Exhibit 10.40
Certain confidential portions of this Exhibit have been omitted and filed
separately with the Commission pursuant to a request for confidential treatment.
IPA PERCENTAGE OF PREMIUM SERVICE AGREEMENT
This Agreement is made and entered into as of June 1, 1996 (the
"Effective Date"), by and between CHESAPEAKE HEALTH PLAN, INC., A UNITED
HEALTHCARE COMPANY, a Maryland corporation (hereinafter referred to as "HMO"),
and Doctors Health System, a Maryland corporation (hereinafter referred to as
"IPA").
RECITALS
WHEREAS, HMO is organized and operates in Maryland as a state-licensed
health maintenance organization under the Maryland Health Maintenance
Organization Act.
WHEREAS, the purpose of HMO is to offer prepaid health care benefits
through a coordinated system of arrangements with various health care providers
that will afford a reasonable choice of primary care physicians, assure access
to medical services and health care resources, and monitor the quality of health
care provided to HMO's enrollees, in groups or as individuals.
WHEREAS, IPA has the capacity to provide or arrange for the provision
of health care services to Members as are specified herein.
WHEREAS, IPA desires to enter into an agreement with HMO to provide or
arrange for the provision of health services to the Members of the HMO.
NOW, THEREFORE, in consideration of the premises and the mutual
promises herein stated, the receipt and sufficiency of which are hereby
acknowledged, it is agreed by and between the parties hereto as follows:
ARTICLE I - DEFINITIONS
As used in this Agreement, the following terms shall have the meanings
indicated:
1.1 Capitation Fee - means the amount per Covered Member (hereinafter
defined) per month specified in Attachments G, H & I, payable to IPA in
consideration for rendering Medical Services (hereinafter defined) and
Utilization Review Program Services (hereinafter defined) pursuant to this
Agreement.
1.2 Clean Claim - means a form HCFA-1500 which includes the Member Name
and Address, subscriber name (if different than patient), HMO ID Number or Other
Insurance ID Number, Date of Birth, Diagnosis Code/Description, CPT/HCPCS/
Description, Dates of Service, Place of Service, Charges/Quantity, Type of
Service, Authorization Number and copy of Authorization, if applicable, Primary
Care Physician who referred patient, if applicable, Provider's Name, Provider
Number and authorization number or other identifiers.
1.3 Copayment - means a charge or an amount authorized under the
applicable Subscription Agreement (hereinafter defined) which may be collected
directly by IPA or its contracted providers or facilities from a Covered Member
and which amount is the financial responsibility of the Covered Member.
1.4 Covered Member - means any person entitled to Covered Services
(hereinafter defined) under the terms of one or more Subscription Agreements
(hereinafter defined). Covered Member includes, but is not limited to, Medical
Assistance Members and Medicare Members.
1.5 Covered Services - means the medical services, hospital services,
and other health care services to which a Member is entitled under the
Subscription Agreement and any applicable supplemental benefit riders.
1.6 Department - means the Maryland Department of Health and Mental
Hygiene, or its designee.
1.7 Emergency - means those health care services that are provided in a
hospital emergency facility after the sudden onset of a medical condition that
manifests itself by symptoms of sufficient severity, including severe pain, that
the absence of immediate medical attention could reasonably be expected by a
prudent layperson who possesses an average knowledge of health and medicine, to
result in: (1) placing the patient's health in serious jeopardy; (2) serious
impairment to bodily functions; or (3) serious dysfunction of any bodily organ
or part.
1.8 External Providers - means any physician, health professional, or
other health care provider, including IPA Physicians, Health Service
Contractors, and Health Centers contracted with IPA to provide Covered Services
to all Members of the HMO.
1.9 HCFA - means Healthcare Financing Administration.
1.10 Health Center - means the Health Center(s) listed in Attachment A
operated by IPA for the provision of certain outpatient health care services to
Members pursuant to this Agreement.
1.11 IPA Physician - means a duly licensed doctor of medicine or
osteopathy who practices in the Health Center(s) and who has by contract agreed
with IPA to provide certain health care services or is otherwise bound by the
terms of such contracts as IPA may enter into to arrange for the provision of
health care services.
1.12 Medical Assistance Contract ("MA Contract")(if applicable) - means
the agreement then in effect between HMO and the Department pertaining to the
provision of services by HMO and its subcontractors to MA Members (hereinafter
defined) under the Maryland Medical Assistance Program. The terms of the Medical
Assistance Contract are incorporated by reference herein.
1.13 Medical Assistance Member ("MA Member")(if applicable) - means any
Member enrolled in HMO who is entitled to receive benefits and services under
the MA Contract.
1.14 Medical Services - means those professional, emergency, hospital,
and referral services which IPA has agreed to provide to or arrange for Members
and which are set forth in Attachments B, C & D.
1.15 Medicare Member - means any Member enrolled in HMO who is entitled
to benefits under the Medicare Risk Contract (hereinafter defined).
1.16 Medicare Risk Contract - means the agreement between HMO and the
Health Care Financing Administration pertaining to the provision of services by
HMO to Medicare Members under the Medicare Risk Contract.
1.17 Member - means any person voluntarily enrolled in the prepaid
medical care program of the HMO, including Medical Assistance and Medicare
Members or any employee, subscriber, enrollee, beneficiary, insured,
policyholder or any other person including spouse or dependents, who are
eligible to receive benefits under a plan of a purchaser.
1.18 Non-MAMember - means any Member enrolled in HMO who is not
receiving services and benefits under the MA Contract.
1.19 Non-Medicare Member - means any Member enrolled in HMO who is
not receiving services and benefits under the Medicare Risk Contract.
1.20 Out of Area - means that the Member is more than thirty (30) miles
from his place of residence and experiences an "Emergency" as defined above.
1.21 Participating Provider - means any duly licensed hospital, skilled
nursing facility, home health agency, or other health provider entity which has
contracted with, or on whose behalf a contract has been entered into with, IPA
to provide Covered Services to Members. Attachment A provides a current list of
"Participating Providers".
1.22 Primary Care Physician ("PCP") - means a physician in family
practice, general practice, internal medicine or pediatrics who provides initial
and primary care to enrollees; who supervises, coordinates, and maintains
continuity of patient care; and who initiates referrals to specialist care.
1.23 Provider Manual - means the manual of rules and regulations
promulgated by HMO with which IPA is required to comply, as such manual may be
established, enhanced, amended, or modified from time to time. A copy of the
Provider Manual is attached hereto as Attachment F.
1.24 Referral Physician - means a duly licensed doctor of medicine or
osteopathy who is not a member of the IPA medical staff and to whom a Member is
referred by an IPA Physician for Medical Services.
1.25 Service Area - means a particular geographic area in which HMO is
licensed to conduct business. On thirty (30) days advance notice to IPA, the
Service Area may be expanded as deemed necessary by HMO.
1.26 Subscriber - means a Member of the Group who meets all applicable
eligibility requirements and for whom the premium payment required has been
actually received by the Health Plan.
1.27 Subscription Agreement - means the Group Master Contract,
Conversion Contract and any other agreement between the HMO and Member which
constitutes the Agreement regarding benefits, exclusions, and other conditions
between the HMO and Member, which includes the MA and Medicare Contracts.
1.28 Utilization Review Program - means the program established for
daily or frequent review and monitoring of Covered Services being managed and/or
arranged by IPA. This review includes precertification, concurrent and
retrospective review and may include telephonic review as well as on-site
review.
ARTICLE II - GENERAL
2.1 IPA Service Area. The service area of the IPA shall be generally
defined as an area within a radius of thirty (30) minutes travel time from the
location of each IPA Health Center or Primary Care Physician's office. The
purpose of the service area designation will be for the determination of the
appropriateness of each HMO Member's selection of IPA as his/her provider of
Medical Services. IPA acknowledges that the Member shall have the absolute right
to select his/her provider of medical services, and that this service area
designation is for purposes of guidance only and does not entitle IPA to the
assignment of any particular member. The HMO will screen Applications to
determine the ability of the applicant to use the IPA properly and efficiently.
The applicant's place of residence, place of employment, and access to
transportation to a Health Center or Primary Care Physician's office will be
considered in the screening process. For MA Members, the IPA's service area
shall be the service area approved by the Department. For Medicare Members the
IPA's service area shall be the service area approved by HCFA.
2.2 Relationship of IPA and HMO.
2.2.1 Each party to this Agreement retains its own identity
and full autonomy for carrying out its responsibilities hereunder and in the
management of its affairs. Except as specifically provided herein, neither the
IPA nor the HMO is authorized to bind the other with any third party(s). Neither
the IPA nor the HMO shall be liable to any other party for any act, or failure
to act, of the other party to this Agreement except for the liability of both
the HMO and the IPA to the Department and HCFA for the provision of services and
benefits to MA & Medicare Members, as provided for in the MA and Medicare
Contracts.
2.2.2 None of the provisions of this Agreement is intended to
create nor shall be deemed nor construed to create any relationship between IPA
and HMO other than that of independent entities contracting with each other
solely for effecting the provisions of this Agreement. Neither of the parties
hereto nor any of their respective representatives shall be construed to be the
agent, employer, or representatives of the other.
2.3 Indemnification. IPA shall indemnify and hold HMO, its employees
and agents, harmless from any and all claims, lawsuits, settlements, and
liabilities incurred as a result of the services provided or not provided by IPA
or IPA's employees, agents or subcontractors pursuant to this Agreement. HMO
shall indemnify and hold IPA harmless from any and all claims, lawsuits,
settlements, and liabilities incurred as a result of actions taken or not taken
by HMO in the administration of the Covered Services under this Agreement.
2.4 Cooperation. IPA and HMO shall maintain effective liaison and close
cooperation with each other in order to provide medical and health maintenance
services compatible with community standards of medical care and medical ethics.
Each party shall cooperate to freely and fully exchange information necessary to
the other party's performance of this Agreement.
2.5 Maintenance of Records. The HMO and IPA will maintain records of
account for all financial transactions pertaining to the HMO. Billing,
collection, receipt and reconciliation of all revenues, and appropriate
disbursement of required moneys will be recorded and maintained in accordance
with generally accepted accounting principles, consistently applied.
2.6 Proprietary Information. IPA and HMO each recognize that all
material provided to each by the other party is the proprietary property of the
party providing the information and neither party shall disclose or release such
material to any third party without the prior written consent of the party
providing the information, except as otherwise required by law or regulation.
Upon termination or expiration of this Agreement, each party shall promptly
return all such proprietary information to the party who provided the
information.
2.7 Confidential. IPA and HMO shall use their best efforts to preserve
the confidentiality of the pricing terms contained in this Agreement. Both
parties acknowledge that all information obtained from the other in negotiating
and completing the transaction contemplated therein is strictly confidential.
Both parties agree not to use any information obtained from the other in any
manner whatsoever which does not directly relate to the transaction contemplated
herein. Where IPA is required to disclose any of the above information to
stockholders or potential investors, IPA will seek HMO's approval and not
disclose the above information without obtaining a signed confidentiality
agreement.
ARTICLE III - COMPENSATION
3.1 IPA Capitation Payment.
3.1.1 Subject to the provisions of Section 3.2 regarding
withholds, the HMO will pay to the IPA a monthly capitation payment for each
Non-MA Member selecting the IPA as set forth in Attachment G, for each MA Member
as set forth in Attachment H and for each Medicare Member as set forth in
Attachment 1.
3.1.2 The capitation payment shall be made on the tenth (10th)
day of each month, or on the next business day if the tenth (10th) is a weekend
day or legal holiday.
3.1.3 IPA agrees to accept from the HMO the mutually agreed
upon monthly capitation payments set forth in Attachment G (for Commercial
Members), Attachment H (for MA Members) and Attachment I (for Medicare Members)
as payment in full for all Covered Medical Services to be provided by IPA,
except for any authorized copayments. HMO and IPA mutually agree to adjust the
capitations set forth in Attachments G, H, and I, in the event that said
services and/or premiums are materially increased, reduced, or changed. If the
parties are unable to agree on the amount of such adjustments, either party may
terminate this Agreement upon ninety (90) days prior written notice, subject to
provisions contained in Section 6.3.2.
3.1.4 Capitation rates for Members who select IPA for a
fraction of a month will be as follows: for Members enrolling between the first
(1st) and fifteenth (15th) day of the month, IPA will be capitated for the full
month. For Members enrolling between the sixteenth (16th) and the end of the
month, capitation payments and IPA service obligations for said Members shall
begin on the first day of the following month.
3.1.5 Capitation rates for Members who disenroll from IPA
during a month will be as follows: for Members who disenroll between the first
(1st) and fifteenth (15th) day of the month, IPA will not receive any capitation
payments. For Members who disenroll between the sixteenth (16th) day to the end
of the month, IPA will receive a capitation payment on behalf of such Members
for the full month.
3.1.6 The HMO shall produce and/or make available to the IPA
by the fifteenth day of each month a listing of the following:
(a) Members who have chosen the IPA as provider
of care, and whose membership is effective during the month following the month
in which the listing is provided to IPA;
(b) Members whose enrollment was effective prior
to the first day of the following month and whose enrollment was not reported on
previous listings;
(c) Members who are enrolled as of the date of
the listing and whose enrollment is to be terminated; and
(d) Any corrections or adjustments to prior
months listings.
3.1.7 IPA, in consideration of said capitation payments, shall
provide or arrange for all those physician services as required in this
Agreement and shall assume the responsibility for the costs of said services, as
specifically defined in the Subscription Agreement. Regardless of the number of
External Providers rendering service to a Member during any month, only one
capitation payment will be made to IPA each month for each Member. The
capitation payment shall be made regardless of the type or amount of service
rendered to the Member during a given month. Although services not covered by
the Member's agreement with the HMO may be provided by the IPA, the HMO shall
have no responsibility to pay for benefits not included in the Subscription
Agreement and applicable benefit riders.
3.2 Reserve. Pursuant to Maryland Health-General 19-713.2, upon
contract signature IPA shall provide HMO with reasonably acceptable collateral
to secure an amount equal to the immediately preceding sixty (60) days of IPA
capitation. The purpose of such Reserve is to ensure that sufficient funds are
on hand to reimburse HMO for any payment made to External Providers, as required
by law, if IPA fails to make any such payments. HMO agrees that a Standby Letter
of Credit from a commercial bank shall be deemed reasonably acceptable
collateral for such purposes. Such Standby Letter of Credit shall be delivered
upon such standard commercial terms and conditions as the Bank, HMO and IPA may
agree.
3.3 Ineligible for Coverage. In the event an individual ceases to be a
Member or becomes ineligible for HMO coverage while receiving Covered Services,
HMO shall promptly notify IPA of such ineligibility. Neither IPA nor HMO shall
be responsible for the cost of any Covered Services rendered to an individual
after that individual has ceased to be a Member. IPA may xxxx the individual
directly for any such services provided to a person who is not a Member.
3.4 Retroactive Adjustments. Any errors in the calculation of the
number of Members resulting from termination or miscalculation of membership
will be retroactively adjusted by HMO for a period not to exceed 90 days from
the date the error occurred. Notwithstanding such time period, HMO shall use
best efforts to adjust any miscalculation of the number of Members within thirty
(30) days following the date that a Capitation Fee payment is made. Any mistakes
not adjusted within such thirty (30) day period, however, shall be adjusted when
discovered; provided, however, that no overpayments to IPA shall be adjusted
more than ninety (90) days after such payment is made. In the event that, as a
result of the failure of HMO to use such best efforts, an underpayment to IPA is
not adjusted within the ninety (90) day period, such underpayment shall be
adjusted when discovered.
3.5 Non-Covered Services. In the event a Member desires services which
are beyond the scope or duration of Covered Services under this Agreement, IPA
shall verify with HMO that HMO has no obligation to provide those non-covered
services and, if such verification is obtained, IPA shall inform the Member that
such services are not Covered Services and thereafter may xxxx the Member for
such Non-Covered Services.
3.6 External Providers.
3.6.1 IPA shall promptly and fully pay all External Providers
who provide Medical Services to Members which were arranged or referred by IPA,
in accordance with the terms of its applicable understandings, contracts and
agreements, and as required by law and which are also Covered Services. IPA
shall pay an External Provider providing services to all Members no later than
thirty (30) days after receipt of a complete and undisputed claim for Medical
Services, unless a longer period of time has been agreed to by HMO.
3.6.2 HMO shall have the right to contact External Providers
directly to verify whether IPA is current in its payment to them. As required by
Section 5.8 below, IPA must certify to HMO on a quarterly basis as to its
payments to External Providers.
ARTICLE IV - HMO RESPONSIBILITIES
4.1 Administration of Agreement. HMO agrees to perform or have
performed all necessary accounting, marketing, enrollment, date base management,
reporting and other functions appropriate to the administration of the HMO and
this Agreement. HMO shall promote the availability of IPA to Members in at least
the same manner that other medical groups and primary care providers who are
under contract with HMO are promoted. HMO agrees to use sound underwriting
criteria in its selection of group accounts. HMO further agrees that such
underwriting requirements shall not differ from those established by HMO for
prospective group accounts that will be offered other physicians or medical
groups with which HMO contracts.
4.2 Eligibility and Benefit Determinations.
4.2.1 HMO is responsible for making eligibility and benefit
determinations regarding Covered Services. HMO will strive to issue HMO
identification cards to each Member within thirty (30) days of enrollment and
HMO shall confirm eligibility of Members by telephone inquiry from IPA. HMO will
provide on-line systems capabilities for eligibility determination within six
(6) months of contract signing, providing both systems are compatible. HMO will
provide a monthly membership list to IPA for Members in accordance with Section
3.1.6. In the event a dispute arises between the parties as to any eligibility
or benefit determination made by HMO, the parties agree to act in good faith to
resolve their dispute and either party may submit the dispute to arbitration in
accordance with Section 7.16 if they are unable to resolve their disagreement to
their mutual satisfaction. All communications to Members regarding final benefit
determinations and eligibility shall be made by HMO.
4.3 Medical Services. HMO acknowledges that IPA and External Providers
shall maintain a professional relationship with Members and shall have the right
and obligation to treat Members in accordance with sound medical practice and
medical ethics. IPA acknowledges, however, that HMO may, pursuant to this
Agreement and the Provider Manual, impose certain restrictions on benefit
coverage and the provision of services including, but not limited to,
determinations made pursuant to the HMO's utilization review or quality
assurance programs.
4.4 Collections of Premiums and Other Income. HMO agrees to collect all
premiums and other items of income to which the HMO is entitled except for any
copayments, coinsurance, or deductibles which may be required of Members at the
time of service. Such copayments, coinsurance or deductibles, if any, will be
collected by IPA's External Providers when Covered Services requiring copayments
are rendered. HMO will develop reasonable policies regarding the termination of
enrollment of Members who fail to make copayments.
4.5 Staff Assistance. HMO shall appoint a Medical Director who will
provide continued staff assistance to IPA. This assistance shall include but not
be limited to advising on the development of: referral protocols for Physician
services; a system for peer and utilization review structure established by the
IPA; a system for the maximum sharing of medical records consistent with
applicable confidentiality requirements to ensure that appropriate information
will travel with the patient throughout the health delivery system; protocols
for referrals to Referral Physicians; and length-of-stay determination,
pre-admission testing, and other criteria necessary to authorize and approve
inpatient admissions prior to hospitalization.
4.6 HMO's Professional Liability Insurance. HMO, at its sole cost
and expense, shall procure and maintain such policies of general liability and
professional liability insurance and other insurance as shall be necessary to
insure HMO and its employees against any claim occasioned directly, or
indirectly, in connection with the performance of any service by HMO, the use of
any property, facilities or equipment provided by HMO, and the activities
performed by HMO in connection with this Agreement. Said insurance limits shall
not be less than ($1,000,000) individual and ($3,000,000) aggregate.
ARTICLE V - IPA RESPONSIBILITIES
5.1 Medical Services. IPA agrees to provide those Covered Services
which are Medical Services and are set forth in Attachments B, C, & D to each
Member who selects IPA as his/her provider of care. For MA and Medicare Members,
IPA also agrees to provide those services required by the current MA and
Medicare Contracts which IPA has the capacity to provide. Any other services
require the prior written consent of IPA. A copy of the current Subscription
Agreements and supplemental benefit riders are provided as Attachment E and may
be revised by HMO from time to time as changes are required. HMO shall provide
IPA with ninety (90) days prior written notice of any modifications to the
Subscription Agreement or the MA and Medicare Contracts provided that no
modification that changes IPA's responsibilities or otherwise increases IPA's
financial risk hereunder shall become effective unless consented to in writing
by IPA.
5.2 Referral Physician Services. In consideration of the capitation
payments set forth in Attachments G, H & I hereto, IPA agrees to arrange and pay
for all those Referral Physician and other health professional services which
HMO is required to provide as Covered Services and which are Medical Services.
IPA agrees to identify and arrange with Referral Physicians and other referral
health professionals who are duly licensed in a manner designed to implement an
efficient system of referrals and consultations, to facilitate the coordination
of medical services, to ensure continuity of care, and to provide accessibility
to the Member. Referral Physicians shall be either Board Certified or determined
by IPA to be Board Eligible for certification and meet other requirements as may
be established by HMO and agreed to by IPA. For usual and frequently used
Medical Services, IPA shall enter into a written agreement with Referral
Physicians or health professionals.
5.3 Participating Providers. Except in cases of Emergency or medical
necessity, External Providers shall agree to use only those inpatient
facilities, skilled nursing facilities, home health agencies, and other
institutional providers which are Participating Providers, or have been approved
by HMO. HMO delegates credentialling of these providers to IPA, but reserves
right to disallow a specific provider due to quality of care criteria. However,
the parties agree that unless services are not available or accessible to
Members, Members will be required to secure Covered Services only from those
Participating Providers to whom a referral is made by the Primary Care
Physician.
5.4 Standard of Medical Care.
5.4.1 IPA agrees to use its best efforts in rendering Medical
Services in order to provide medical care in conformity with accepted medical
and surgical practices prevailing in the community, and to arrange for medical
treatment as promptly as practicable, consistent with sound medical practice.
Further, the IPA agrees to establish mechanisms to: provide for internal peer
review of Members records; evaluate the quality of health care provided to
Members; and evaluate the utilization of Medical Services rendered by IPA to
Members. Such mechanisms shall be in conformance with applicable state and
federal requirements and the requirements set forth in the Provider Manual.
5.4.2 IPA and all of their External Providers shall not
differentiate or discriminate in the treatment of Members as to the quality of
services delivered because of race, sex, age, religion, national origin, or
health status. The rights of Members as patients shall be observed, protected
and promoted. Health care services shall be rendered to Members in the same
manner, in accordance with the same standards, and with the same time
availability as offered to all other patients.
5.4.3 Transportation Expenses. IPA shall be responsible for
the arrangement of and costs associated with: (1) all ambulance transportation
preauthorized by IPA for the provision of Medical Services, (2) transportation
when necessary for all Members to a provider located outside the 30-mile travel
radius from the Member's place of residence, excluding Member's Primary Care
Physician.
5.5 Selection of IPA Primary Care Physician or Health Center. IPA
agrees that each Member seeking care shall be required to select a specific
Primary Care Physician or Health Center as his/her personal physician for
providing and/or arranging for his or her overall health care needs. Except in
cases of Emergency, referrals to referral health professionals and obtaining a
Medical Service from any other provider, shall only be a Covered Service when
authorized by the Member's Primary Care Physician. Except in cases of Emergency,
referrals to Referral Physicians or other referral health professionals and the
obtaining of a Medical Service from any other provider shall only be a Covered
Service when authorized by the Member's Primary Care Physician. Except in an
Emergency, IPA shall not be responsible for any Medical Service that is not
authorized by a Member's Primary Care Physician.
5.6 Designated Physician to Authorize Referral and Hospitalization. IPA
agrees to designate a Physician, who shall be on call 24 hours per day, each and
every day, to authorize appropriate hospital services or other referrals for
Members. IPA agrees to ensure that one or more Health Centers or Primary Care
Physicians within the IPA service area shall be available to Members who may
require emergency care. HMO and IPA shall, from time to time, jointly review
methods and details of coverage and scheduling to ensure adequate emergency
coverage and adequate medical coverage at the Health Centers or Primary
Physician's offices at all times the facilities and/or physician offices are
open.
5.7 Coordination of Benefits and Subrogation. IPA and HMO shall
establish and implement a system for coordination of benefits and subrogation,
in accordance with those rules established under the HMO's policies and
procedures and applicable federal and state laws. If known to IPA, IPA shall
identify and inform HMO of Members for whom coordination of benefits and
subrogation opportunities exist. HMO hereby authorizes IPA to seek payment, on a
fee-for service basis or otherwise, from any insurance carrier, organization, or
government agency which is primarily responsible for the payment or provision of
medical services provided by IPA under this Agreement which can be recovered by
reason of coordination of benefits, motor vehicle injury, worker's compensation,
temporary disability, occupational disease, or similar exclusionary or limiting
provisions, to the extent authorized by the applicable and not otherwise
prohibited by law.
5.8 Reporting Requirements.
1. IPA shall deliver to HMO, on a monthly basis, within 30
days after the end of the month, unless otherwise specified, written reports as
follows:
(a) IPA shall electronically transmit
Member-specific encounter data in the format of Attachment L to HMO on a monthly
basis within ten (10) days after the end of the month for which data was
collected.
(b) IPA shall submit financial data reflecting
total IPA medical loss ratio for arranging for the provision of Medical Services
to HMO on a quarterly basis (every three months) in a format mutually agreed to
by HMO and IPA.
(c) IPA shall submit quarterly reports within 45
days after the quarter identifying payments made or owed to External Providers.
These reports will be in a format satisfactory to HMO. The cost of any
subsequent changes or deletions to this reporting requirement which
requires customization to IPA systems will be paid for by HMO. The reports will
be certified by the Chief Executive Officer and Chief Financial Officer of IPA.
HMO shall have the right to contact IPA's External Providers directly to
verify whether IPA is current in its payment to them.
(d) IPA shall submit a current annual financial
statement to HMO within ninety (90) days following the close of IPA's fiscal
year or an interim financial statement upon request by HMO.
(e) IPA shall submit complaint and grievance
information to HMO, to meet the requirements of HMO and appropriate regulatory
agencies; such information shall include, but not be limited to that which is
required to be included in HMO's annual HEDIS Report on medical service
measures, Quality Improvement and Utilization Management Delegation
Reports. A copy of the complaint and grievance procedure is annexed hereto as
Attachment J, and made a part hereof.
(f) IPA shall submit Member information to HMO
in conformance with Attachment L, as well as additional information as may be
needed and in compliance with relevant state and federal laws which include,
but shall not be limited to, the laws regarding the confidentiality of
medical records.
(g) For MA Members, if applicable, IPA shall
submit outcome data in a form and format mutually acceptable to the parties of
patient and IPA access to include, but not be limited to, (i) the time
within which an initial call to access care is answered, (ii) call
abandonment rate, (iii) call on-hold rate, (iv) number of appointments
scheduled per week and (v) number of kept appointments per week.
5.9 Provider Agreements. IPA shall enter into written service
arrangements with all External Providers providing care under this Agreement.
IPA shall provide HMO with a pro forma copy of such agreements and
changes, amendments, or additions to such agreement. Such agreements, at a
minimum, shall provide for the following:
5.9.1 External Providers shall provide services in
accordance with the compensation arrangement accepted by the IPA.
5.9.2 To the extent feasible, External Providers will share
records, equipment, and the professional, technical and administrative staff.
5.9.3 External Providers shall comply with and maintain
standards under IPA's credentialing standards. HMO retains the right to audit
the IPA's credentialling standards. IPA shall establish and maintain programs
for the continuing education for its External Providers or otherwise require
them to obtain continuing education credits as set forth in IPA's credentialing
standards.
5.9.4 External Providers will look solely to the IPA for
compensation for Covered Services provided to Members, except for any approved
and applicable copayments, coinsurance or deductibles to be collected by the
External Providers.
5.9.5 External Providers shall not, under any circumstances,
including nonpayment of moneys owed to the External Provider by IPA, insolvency
of IPA or HMO, or breach of the Agreement between IPA and the External
Providers, xxxx, charge, collect a deposit, seek compensation, remuneration or
reimbursement from or have any recourse against any Member, or any person (other
than IPA) acting on the Member's behalf, for Covered Services provided by the
External Providers pursuant to their contracts with IPA; provided, however, that
External Providers may collect from Members any approved and applicable
copayments or supplemental charges or charges for non-Covered Services. Each
such agreement must provide that this provision will survive the termination of
the agreement, regardless of the cause of the termination.
5.9.6 In the event a Member desires services which are beyond
the scope or duration of Covered Services under this Agreement, External
Providers shall verify with HMO that HMO has no obligation to provide those
non-covered services and, if such notice is given, IPA may xxxx the Member for
such non-covered services. External Provider shall not be prohibited from
collecting from Members any charges for items or services not covered under this
Agreement.
5.9.7 External Providers shall provide Medical Services
consistent with community standards of medical care and medical ethics. Such
medical care shall be accessible and shall at all times be rendered to Members
in a reasonable, dignified and nondiscriminatory manner.
5.9.8 Continuation of Services. In the event of HMO's or IPA's
inability to pay a capitation or fee for services rendered, including, without
limitation, in the event of insolvency, IPA and its External Providers shall
continue to provide Medical Services to Members for the duration of the period
(not to exceed thirty (30) days) for which a Capitation Fee has been paid to
IPA, and shall continue for the same period to provide Medical Services to
Members who are admitted in an inpatient health care facility on the date of
insolvency or inability to pay until the date of discharge from the facility
(but not to exceed one year thereafter). IPA shall cause provisions to this
effect to be included in all agreements with its External Providers. Each such
agreement must provide that this provision shall survive the termination of the
agreement, regardless of the cause of the termination.
5.9.9 External Providers shall make referrals to Referral
Physicians and health care facilities only in accordance with the guidelines set
forth in the Provider Manual.
5.9.10 External Providers shall provide at their sole cost and
expense, such policies of malpractice insurance as shall be necessary to insure
themselves and their employees against any claim or claims for damages arising
by reason of personal injury or death occasioned directly or indirectly in
connection with the performance of any service by the External Providers. The
amounts and extent of such insurance coverage shall be at least one million
dollars ($1,000,000) per year for each occurrence and three million dollars
($3,000,000) in the aggregate per year for each External Provider. Any
reductions or termination of such coverage shall require the approval of the
HMO.
IPA agrees to produce, at HMO's request at any point
in time during this Agreement, a certificate of insurance from an External
Provider's insurance carrier manifesting compliance with all provisions of
this section of this Agreement.
5.9.11 External Providers shall maintain adequate medical
records on Members and make such records available to other providers and HMO in
accordance with Sections 5.19 and 5.21 of this Agreement.
5.10 Compensation from HMO Solely. IPA shall not, under any
circumstances, including non-payment of moneys owed to the IPA by HMO,
insolvency of HMO, or breach of this Agreement, xxxx, charge, collect a deposit,
seek compensation, remuneration or reimbursement from, or have any recourse
against any Member, or any person (other than HMO) acting on the Member's
behalf, for Covered Services provided by IPA pursuant to this Agreement;
provided, however, that IPA may collect from the Members any applicable
copayments or supplemental charges or charges for non-Covered Services in
accordance with the Subscription Agreement.
IPA agrees to look solely to HMO for compensation for Covered Services
provided to MA and Medicare Members, and not to seek any compensation from the
Department, HCFA, or from the MA or Medicare Members (other than applicable
copayments or deductibles).
5.11 Payment of Claims. Notwithstanding any other provision in this
Agreement to the contrary, in instances where patient care, the reputation of
the HMO, and/or the relationship between HMO and its Members is jeopardized by
the IPA's nonpayment or late payment to subcontractors or providers for services
provided to HMO enrollees, HMO shall have the right to make these payments
directly to the subcontractor provider and to recover from the IPA the full
amount of any such payments as outlined under Section 3.2. In order to exercise
its rights, HMO must give IPA ten (10) days prior notice of HMO's intention to
pay the subcontractor or provider directly.
5.12 Sharing of Facilities. Subject to applicable confidentiality
requirements, IPA shall provide for a system which, to the extent feasible and
to the extent permitted by law, permits maximum sharing of equipment and
professional, technical and administrative staff by IPA's External Providers.
5.13 IPA Medical Director. IPA will designate an IPA Medical
Director who, among other duties will:
5.13.1 Participate as specified in the complaint and
grievance procedure of the HMO.
5.13.2 Monitor the IPA's peer review, quality assurance, and
utilization review processes.
5.13.3 Assist the HMO Medical Director in determining final
rulings regarding medical necessity of referrals to Referral Physicians,
inpatient, hospital outpatient, emergency room, or other treatments or services.
5.14 Malpractice Insurance and Professional Liability. IPA shall
provide and maintain such policies of malpractice insurance as shall be
necessary to insure IPA against any claim or claims for damages arising by
reason of personal injuries or death occasioned directly or indirectly in
connection with the performance of any service by IPA. The amounts and extent of
such insurance shall not be less than [$1,000,000] per claim and [$3,000,000]
per year.
5.15 Review of Staffing & Scheduling. IPA agrees to maintain on record
with the HMO a current schedule of all providers categorized by name, board
status, facility status, hospital affiliation, and relationship to IPA.
HMO and IPA shall, from time to time, jointly review methods and
details of staffing and scheduling to ensure adequate coverage at all times. IPA
shall, from time to time and upon request of HMO at any time, submit medical
policies, procedures, and regulations to HMO for review in order to ensure the
quality and availability of care. The same shall be reviewed and revised
periodically in the light of experience and advances in medical practice.
5.16 IPA/Patient Ratio and Waiting Times. IPA shall at all times
maintain a sufficient number of External Providers to ensure a reasonable
IPA/patient ratio, so that there shall be no unreasonable waiting periods for
appointments or waiting periods for services for Members upon arrival for a
scheduled appointment.
5.17 Credentialling of Providers and Facilities. IPA shall perform
credentialling and selection of its External Providers, and facilities using the
standards developed by the National Committee for Quality Assurance ("NCQA") as
outlined in the letter of Agreement which was previously sent to IPA for
signature. HMO shall have the right to review the credentials of the External
Providers and facilities for compliance with HMO's own credentialling standards.
IPA shall thereafter use its best efforts to ensure that all External Providers
and facilities perform in accordance with the customary rules of ethics,
conduct, and practice of their respective professions.
[Confidential Treatment Requested]
5.18 IPA Physician Requirements and Responsibilities. IPA and IPA
Physicians will adhere to the following requirements:
5.18.1 All IPA providers shall be duly licensed to practice
medicine or osteopathy in the State of Maryland. Evidence of such licensing
shall be submitted to HMO upon request. In addition, IPA providers, where
appropriate, must meet all qualifications and standards for membership on the
medical staff of at least one hospital that is a Participating Provider or to
which Members are admitted.
5.18.2 All physicians and nurse practitioners will have, where
appropriate, a current narcotics number issued by the appropriate authority,
which is currently the United States Drug Enforcement Administration.
5.18.3 All physicians must be Board Eligible or Board
Certified in their areas of specialty, or be able to demonstrate equivalent
training and experience.
5.19 Medical Records. External Providers shall maintain adequate
medical records for Members treated by External Providers. Subject to all
applicable privacy and confidentiality requirements, such medical records shall
be made available to each physician and other External Providers treating the
Member, and upon request, to any proper committee of the IPA or HMO for review,
to determine whether their content and quality are acceptable, as well as for
peer review or grievance review. IPA and HMO agree that medical records of
Members shall be treated as confidential so as to comply with all federal and
state laws and regulations regarding the confidentiality of patient records. IPA
hereby agrees that the HMO has agreed, as part of the MA and Medicare Contracts,
to make medical records of Members available to the Department and HCFA as
appropriate. HMO will secure from Members a release of medical information and
records in accordance with applicable state and federal law. HMO shall indemnify
and hold IPA harmless from any claims by Members relating to IPA's release of
medical information and records to HMO pursuant to this Agreement.
5.20 Advanced Directives. All providers shall discuss with the patient
his/her right under state law to institute or decline Advanced Directives. The
providers shall note in the patient's medical record whether he/she executed or
declined Advanced Directives.
5.21 Inspection of Records and Operations. HMO and IPA shall have the
right to inspect and audit, at all reasonable times, the other party's
accounting, administrative, medical records and operations pertaining to HMO, to
Members, and to its performance under this Agreement. If copies of records are
requested by HMO, HMO agrees to pay IPA a reasonable fee not to exceed the
maximum limits as provided by Maryland law, ss. 4-304(c)(3) of the Health
General Article. IPA further agrees that in the event an examination concerning
the quality of health care services is conducted by appropriate officials, as
required by state law, IPA and External Providers shall submit, in a timely
fashion, any required books and records and shall facilitate such examination.
IPA and HMO agree to facilitate on-site inspection of Health Centers, and
External Providers and their records by representatives of the Department and
HCFA or other authorized agencies.
As required by the MA and Medicare Contracts, the parties agree that
the Department and HCFA may require the HMO to furnish information regarding its
procedure to be followed to monitor or coordinate IPA's activities.
5.22 Duration of Maintenance of Medical Records. IPA shall maintain all
medical and financial records of the Members for the greater of, the time
required under HCFA guidelines or Maryland law, or until all audits in process
hereunder are completed, whichever is longer.
5.23 Utilization Review. If Utilization Review is the responsibility of
the IPA, IPA agrees to provide Utilization Review Services as outlined in the
delegated Utilization Management Agreement. If Utilization Review is not
delegated, IPA agrees to abide by HMO's policies and procedures.
5.24 IPA Quality Management Program. IPA is required to comply
with HMO's Quality Management Program which shall include and not be limited to:
1. Systematic peer review relating to utilization and
quality of care rendered hereunder, including establishment of an appropriate
enforcement mechanism for all final peer review decisions and consultation;
2. Review of the process followed in the provision of
Medical Services;
3. Systematic data collection of performance and patient
results, provides interpretation of such data to the practitioners, and
institutes needed change; and
4. Written procedures for taking appropriate remedial action
whenever it is determined that inappropriate, unnecessary or substandard
services have been provided or that services which should have not been
provided.
5.25 Referral to Social Services Agency (if applicable). (This section
applies to Medical Assistance Members) In the event a Member fails to attend a
scheduled appointment, without giving prior notice, IPA shall send written
notice of the same with a new appointment to the Member or to a responsible
party. If the Member falls to attend the second scheduled appointment, without
giving prior notice, IPA shall send to the Member or responsible party a second
letter instructing the Member or responsible party to contact the IPA
immediately. If the Member or responsible party fails to respond to the second
notice, IPA shall refer the Member, if appropriate, to the appropriate social
services agency (such as Protective Services, Social Services, etc.). A Member
that has demonstrated noncompliance (e.g., has not taken prescribed medication)
shall be referred, as appropriate, to the appropriate social services agency.
5.26 Compliance with HMO Administrative Policies and Procedures. IPA
shall require that all External Providers shall comply with all HMO
administrative policies and procedures relating to the delivery of medical
services and any new policy and procedure which may be enacted by HMO and state
and federal laws and regulations, including cooperation in any external review
conducted by appropriate state and federal agencies, and/or the Joint Commission
on Accreditation of Health Care Organizations. All services shall be rendered
subject to the terms and conditions of this Agreement. In the event that HMO
changes any policies or procedures, whether such change is a result of a change
in state or federal laws or regulations, a change in JCAHO standards, NCQA
standards, or otherwise, and such change materially impacts IPA's cost of
providing services under this Agreement, the IPA and HMO shall negotiate in good
faith a change in the Capitation Fee that fairly and adequately compensates IPA
for such change, or if Agreement cannot be reached, may be cause for termination
after the initial contract term.
5.27 Provider Manual. IPA hereby agrees to comply with all
provisions of the Provider Manual attached hereto as Attachment F.
5.28 MA Contract (if applicable). IPA hereby agrees to comply with
all provisions of the MA Contract.
5.29 Medicare Contract. IPA hereby agrees to comply with all
provisions of the Medicare Contract.
ARTICLE VI - TERM AND TERMINATION
6.1 Term. This Agreement shall commence on the Effective Date noted on
page one (1) and shall remain in effect for an initial term of one (1) Contract
Year. Thereafter, this Agreement will automatically renew for one year
increments unless ninety (90) days advance notice of termination is provided by
either party. Early termination may only be for cause upon ninety (90) days
prior written notice after an opportunity to cure. Termination without cause may
occur at any time after the initial term with one hundred twenty (120) days
notice by either party. Each twelve (12) month period of this Agreement shall be
referred to as a "Contract Year".
6.2 Termination On the Event of Insolvency. Notwithstanding the
foregoing, this Agreement may be terminated effective upon written notice if
either party: (i) is or becomes insolvent (as defined in Section 101(31) of the
United States Bankruptcy Code) or unable to pay its debts as they mature; (ii)
makes a general assignment for the benefit of creditors; (iii) commences a case
under or otherwise seeks to take advantage of any bankruptcy, reorganization,
insolvency, readjustment of debt, dissolution, or liquidation law, statute, or
proceeding; (iv) by any act indicates its consent to, approval of, or
acquiescence in any such proceeding or the appointment of a receiver of or
trustee for it for a substantial part of its property, or suffers any such
receivership, trusteeship, or proceeding to continue undismissed for a period of
thirty (30) days; (v) becomes a debtor in any case under any chapter of the
United States Bankruptcy Code; or (vi) is dissolved, or there is entered any
order, judgment or decree for dissolution; or there is entered any judgment,
order, award or decree which would have a material adverse effect on the party
or the prospects of the full and punctual performance by the party of its
obligations, if the same shall not have been discharged or execution thereof
stayed within thirty (30) days after entry or discharged within thirty (30) days
after the expiration of any stay, and if the same is not fully covered by
applicable insurance.
6.3 Effect of Termination.
6.3.1 Any termination of this Agreement shall not release
either HMO or IPA of obligations imposed with respect to: third party payors;
incentive payments accrued to IPA or penalty payments due HMO in connection with
existing contracts to provide services to Members; or the obligation of IPA to
persons then receiving treatment.
6.3.2 Upon termination of this Agreement, the rights of each
party hereunder shall terminate provided, however, that IPA will continue to
provide or arrange for Medical Services to Members until the renewal or
expiration date of any agreement between HMO and an employer or other group that
offers HMO's program or with an individual enrollee and which was entered into
prior to the termination date provided that payments are made by HMO to IPA as
set forth below. If pursuant to this paragraph, IPA's responsibilities under
this Agreement are continued beyond the date of termination, all terms and
conditions contained in this Agreement shall remain in full force and effect
(other than Attachments G, H, & I), provided that IPA shall be compensated for
Medical Services provided during the continuation period on a fee-for-service
basis in accordance with IPA's usual and customary fee schedule. Once notice of
termination has been given, HMO shall not use IPA's or their providers' names in
any HMO marketing materials other than as necessary to fulfill the terms of this
Agreement. In no event shall IPA's obligation under this Section 6.3.2 extend
beyond three (3) months after the termination of this Agreement.
6.3.3 Copies of Members' medical records and other data to be
provided in accordance with this Agreement shall be delivered to the HMO, by the
IPA, upon the effective date of termination and/or in accordance with other
provisions of this Agreement, provided that (a) HMO secures the prior written
consent of the Member to such transfer; (b) any copying of medical records shall
only be performed during IPA's regular business hours; and (c) any copying of
medical records shall be performed in such a manner so as to not disrupt IPA's
operations.
6.3.4 Notwithstanding anything herein to the contrary, the
following provisions of this Agreement shall survive termination for whatever
cause: Section 2.3 (Indemnification), 5.14 (Malpractice Insurance and Liability)
Section 3.6 (External Providers), Section 5.8 (Reporting Requirements) for
reports as to any period prior to termination, Section 5.10 (Compensation from
HMO Solely), Section 5.19 (Medical Records), and Section 5.21 (inspection of
Records and Operations).
6.4 Annual Renegotiation of Capitation Rate. Notwithstanding any other
provision of this Agreement, no later than ninety (90) days prior to the end of
each Contract Year, HMO shall present revised capitation amounts and any other
provision related to compensation to be effective for the succeeding Contract
Year.
6.5 Termination-MA Only (if applicable). If the IPA provides Covered
Services to MA Members, termination, either voluntary or as a result of default,
shall not take effect without prior notification to the Department by the HMO.
6.6 Termination - Medicare Only. If the IPA provides Covered Services
to Medicare Members, termination, either voluntary or as a result of default,
shall not take effect without prior notification to HCFA by the HMO.
6.7 [Confidential Treatment Requested]
ARTICLE VII - MISCELLANEOUS
7.1 Binding Effect. This Agreement shall be binding upon and inure to
the benefit of the parties hereto, their respective heirs, successors and
assigns of HMO and IPA.
7.2 Assignment. This Agreement, being intended to secure the personal
services of IPA, shall not be assigned, sublet, delegated or transferred, except
as may be provided herein, without the prior written consent of HMO and any
required regulatory approval; provided, however, that HMO may assign this
Agreement to an affiliate or a successor in interest upon notice to IPA.
If IPA provides services to MA or Medicare Members, no
assignment by IPA shall be effective without prior written notice to the
Department for MA Members, and HCFA for Medicare Members.
7.3 Headings. The headings of the various sections of the Agreement are
inserted merely for the purpose of convenience and do not, expressly or by
implication, limit, define or extend the specific terms of the section so
designated.
7.4 Interpretation. The validity, enforceability and interpretation of
any of the clauses of this Agreement shall be determined and governed by the
applicable laws of the State of Maryland, including those governing health
maintenance organizations.
7.5 Entire Agreement and Modifications. This Agreement together with
any supplements, addenda, amendments or modifications, or attachments,
constitutes the entire Agreement and supersedes all other agreements, oral or
otherwise, regarding the subject matter hereof.
7.6 Amendment. This Agreement may be amended at any time by mutual
agreement of the parties, provided that before any amendment shall be operative
and valid, it shall be reduced to writing and signed by the HMO and IPA. Said
amendments may be added in the form of additional attachments signed by both
parties.
7.7 Medical Ethics. HMO and IPA agree that the administration of the
medical services and this Agreement shall, at all times, be compatible with the
Principles of Ethics and Code of Professional Conduct.
7.8 Relationship of Parties. The relationship between HMO and IPA is
solely that of independent contractors and nothing in this Agreement is intended
to create nor shall be deemed or construed as creating any partnership, joint
venture, master-servant, principal-agent or any other relationship between the
parties hereto other than that of independent entities contracting with each
other hereunder solely for the purpose of effectuating the provisions of this
Agreement. Neither of the parties hereto, nor any of their respective
representatives, shall be construed to be the agent, employer, or representative
of the other and neither party is authorized to or has the power to obligate or
bind the other party by contract, agreement, warranty, representation, or
otherwise in any manner whatsoever.
7.9 Disenrollment. It is understood that Subscription Agreements may be
terminated by HMO in the event that a Member is unable or unwilling to establish
and maintain satisfactory Physician/Patient relationships, including failure to
follow a recommended treatment or procedure. Such termination shall be made in
accordance with the terms and conditions of Subscription Agreements, all
applicable statutory requirements, and the grievance and disenrollment
procedures established by HMO.
7.10 Cooperation. HMO and IPA shall maintain an effective liaison and
close cooperation with each other to provide maximum benefits to each Member at
the most reasonable cost, consistent with high quality standards of medical
practice.
7.11 Severability. The illegality, invalidity or unenforceability of
any provision of this Agreement shall in no way affect the legality, validity or
enforceability of any other provision of this Agreement and its Attachments.
7.12 Notice. Any notice required to be given pursuant to the terms and
provisions hereof shall be in writing and shall be hand delivered, telecopied,
or sent by overnight delivery service or certified mail, return receipt
requested, prepaid to HMO, 000 Xxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxx 00000, Attn:
V.P. General Counsel; and to IPA at 00000 Xxxx Xxx Xxxxxx, 00xx Xxxxx, Xxxxxx
Xxxxx, XX 00000, Attn: V.P. Managed Care Products and Services.
A notice delivered personally will be effective only when acknowledged
in writing by the person to whom it is given. Any notice that is mailed shall be
deemed effective 48 hours after it is mailed. Any notice that is delivered by
overnight delivery service shall be deemed effective 24 hours after delivery to
such service. A notice delivered by telecopy shall be deemed effective
immediately.
7.13 Waiver. No failure or delay of any party to exercise any right or
remedy pursuant to this Agreement shall affect such right or remedy or
constitute a waiver by such party of any right or remedy pursuant hereto. Resort
to one form of remedy shall not constitute a waiver of alternative remedies.
Further, no waiver, express or implied, or any breach of this Agreement shall
constitute a waiver of any right under this Agreement or of any subsequent
breach, whether of a similar or dissimilar nature.
7.14 Further Assurances. The parties shall execute and deliver or cause
to be executed and delivered such further instruments and documents and shall
take such other actions as may be reasonably required to more effectively carry
out the terms and provisions of this Agreement.
7.15 No Third Party Rights. No Member or other person shall have any
rights under this agreement as a third party beneficiary or otherwise, except as
specifically provided herein.
7.16 Arbitration of All Controversies. Any controversy which shall
arise between the parties regarding the rights, duties, or liabilities hereunder
of either party shall be submitted first through the HMO's Provider Grievance
Procedure. If unresolved, such dispute shall be submitted to arbitration under
the rules and regulations of the Maryland Uniform Arbitration Act. Both parties
expressly covenant and agree to be bound by the decision of the arbitrators as a
final determination of the matter in dispute. Each party to this Agreement
agrees to pay for half the cost of any arbitration; provided, however, that each
party to this Agreement shall be responsible for its own attorney's fees and
related costs.
7.17 Interpretation and Governing Law. All rights and remedies
hereunder shall be cumulative and not alternative. This Agreement shall be
construed and governed by the laws of the State of Maryland.
7.18 Department of Insurance Approval. This Agreement is subject to
the approval of the Maryland Insurance Administration. Any changes requested by
the Department of Insurance will be incorporated into this Agreement by
Amendment.
7.19 Equal Employment Opportunity. The parties are concerned that they
fulfill their roles as Equal Opportunity Employers. The parties further agree
that they shall not discriminate against any employee or applicant for
employment because of age, race, sex, creed, color, national origin, or physical
or mental handicap. Utilization of each other's services is predicated upon
compliance with Equal Employment Opportunity policy as expressed above.
IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed by their duly authorized representatives to be effective as of the date
set forth above.
HMO IPA
BY: _______________________(SEAL) By: ____________________(SEAL)
Title: ____________________________ Title: _________________________
Date: ____________________________ Date: _________________________
Witness/Attest:____________________ Witness/Attest:_________________
LIST OF ATTACHMENTS
A Provider Directory of Participating Providers, External Providers, and
Health Service Contractors
B Medical Services for Medical Assistance Members (if applicable)
C Medical Services For Medicare Members
D Medical Services for Commercial Members (if applicable)
E Subscription Agreements
F Provider Manual
G Capitation Rates for Commercial Members
H Capitation Rates for MA Members (if applicable)
I Capitation Rates for Medicare Members (if applicable)
J Complaint, Grievance/Appeals Policy
K Encounter Format
L Member Information Format
M Provider Appeals Policy
Attachment A
Directory of Participating Providers, External Providers, Health Centers
and Health Service Contractors
IPA's Directory of Participating Providers, External Providers and Health
Service Contractors, Health Centers previously submitted is hereby made a part
of this Agreement. Such Directory shall be updated from time to time without
necessity of an amendment to this Agreement.
Attachment B
Medical Assistance Members Medical Services
(If Applicable)
The IPA is responsible for directly providing, arranging, or purchasing, or
otherwise making available as medically necessary, the full scope of services to
which persons are entitled under the current State Plan, as may be amended from
time to time, and all applicable State and federal regulations, guidelines,
transmittals, and procedures, except as specified herein.
At such time when Medical Assistance Members are added to this Agreement, the
Agreement will be amended to reflect the appropriate applicable terms and rates.
Attachment C
Medical Services for Medicare Members
Please refer to the attached documents.
Attachment D
Medical Services For Commercial Members
(If Applicable)
The IPA agrees to provide the following medical services to each Member
selecting assignment to the IPA for the capitation payment as set forth in
Attachment G and to collect from the Member any applicable copayment amounts, if
indicated in Members Subscription Agreement.
At such time when Commercial Members are added to this Agreement, the Agreement
will be amended to reflect the appropriate terms and rates.
Attachment E
(If Applicable)
Subscription Agreements
*See attached
* Federal
* State of Maryland
* City of Baltimore
* Commercial P-1
* Commercial P-2/P-3
* First Option
Attachment F
Provider Manual
The HMO Provider Manual previously provided is hereby made a part of this
Agreement. The manual will be updated from time to time without necessity of a
contract amendment.
Attachment G
Commercial Member Capitation Rates
(If Applicable)
At such time when Commercial Members are added, this Agreement will be amended
to reflect the rates.
Attachment H
Capitation Rates for MA Members (if applicable)
At such time when Medical Assistance Members are added to this Agreement, the
Agreement will be amended to reflect the rate.
Attachment I
Capitation For Medicare Members
At this time, this Agreement applies only to Medicare Members. At such time when
Medical Assistance and/or Commercial Members are added to this Agreement, the
Agreement will be amended to reflect the rates and any additional terms
applicable to this population.
HMO shall pay a capitation amount for Medicare Members who have agreed to have
IPA as their provider of care for such month. In exchange for such capitation,
IPA shall provide, arrange or purchase, or otherwise make available as Medically
Necessary, the full scope of services to which persons are entitled under the
current HMO Medicare Risk Contract, as may be amended from time to time,
including all applicable state and federal regulations, guidelines,
transmittals, and procedures, except those services carved out herein. If a
Member requires a particular type of provider who is not in the IPA network, the
IPA is responsible for securing the provider and is financially liable.
1. On or before the tenth (10th) day of each month, HMO will pay to IPA the
capitation payment set forth in this Attachment for each Member who is enrolled
for that month in the respective benefit plan as set forth in this Attachment.
2. HMO will pay a capitation rate to DHS on a per member per month basis on the
age, sex and Medicaid eligibility of the subscribers enrolled with an IPA
Primary Care Physician in HMO's Advantage 65 Medicare HMO Program. The IPA
capitation schedule is defined in this Attachment. This schedule represents the
amount of capitation IPA will receive AFTER carve out dollars have been
deducted.
3. The payment rates defined in this Attachment have been derived from a
mutually agreed upon formula which is based on HCFA's AAPCC payment methodology.
In the event that AAPCC methodology is changed or discontinued by HCFA, HMO may
propose alternative pricing to IPA during the term of this Agreement. In the
event that IPA does not accept revised payment rates or terms, it may be
considered cause for early termination of this Agreement.
4. The capitation rates to IPA will increase, as defined in this Attachment when
IPA's enrollment of NEW HMO Members reaches enrollment thresholds of
[Confidential Treatment Requested] Members, and again at [Confidential Treatment
Requested] Members.
5. IPA capitation rates in this Attachment reflect a deduction by HMO to pay for
"carve-outs". The carved-out dollars will cover all costs related to the
following services and IPA will have no further responsibility. Changes to
carve-outs costs may be made annually, on the anniversary of the contract term,
and with the mutual consent of both parties. The net premium is total premium
net of the carve outs which are listed below:
Attachment I
(Continuation)
Capitation For Medicare Members
Carve Outs PMPM
Eye Care/Vision - global [Confidential Professional & Facility Services
Ear Care (Hearing Screen Tst., Hearing Aid Eval.,
Ear Mold Impression)
Prescription Drug Treatment (Pharmacy)
Mental Health & Substance Abuse
Dental
Transplants Requested]
Open Heart Surgery
Total
6. Reimbursement rates:
Table A [Confidential Treatment Requested] Members
Male Female
Age Medicaid Non-Medicaid Medicaid Non-Medicaid
85+
80-84
75-79 [Confidential Treatment Requested] [Confidential Treatment Requested]
70-74
65-69
Table B [Confidential Treatment Requested] Members
85+
80-84
75-79 [Confidential Treatment Requested] [Confidential Treatment Requested]
70-74
65-69
Attachment I (continued)
Table C [Confidential Treatment Requested] Members
85+
80-84
75-79 [Confidential Treatment Requested] [Confidential Treatment Requested]
70-74
65-69
Attachment J
HMO's Complaint, Grievance/Appeal Policy
Please refer to the attached documents which may be amended from time to time
without the necessity of a formal contract amendment. HMO will strive to provide
IPA with thirty (30) days notice of any changes prior to the effective date of
the change.
--------------------------------------------------------- --------------------------------------------------
POLICIES & PROCEDURES
SECTION: QUALITY
MANAGEMENT
------------------------------------------------------------------------------------------------------------
TITLE: Medicare Grievance Policy
------------------------------------------------------------------------------------------------------------
Policy Number: Issued: 05-28-96 Last Revision: 05-28-96
---------------------------------------- --------------------------------- ---------------------------------
Committee Review Date: Board Approval Date: N/A
--------------------------------------------------- ----- --------------------------------------------------
Policy Implementation Date:
------------------------------------------------------------------------
POLICY STATEMENT:
Chesapeake Health Plan ("CHP") receives and resolves Medicare enrollees'
grievances in an effective and timely manner.
PURPOSE:
Chesapeake Health Plan is dedicated to ensuring that all Medicare enrollees
receive timely resolution to their questions and/or complaints regarding Health
Plan services or the payment of services. This policy is designed to provide
Medicare enrollees with a full and fair investigation of complaints and
grievances. All Medicare enrollees are informed, upon enrollment, of their right
and the process for filing a grievance.
GOALS:
To promote member satisfaction by identifying opportunities to meet the needs
and expectations of members, and to comply with the requirement of regulatory,
accreditory and other auditing agencies.
SCOPE:
This policy applies to matters subject to the formal HCFA grievance process. The
grievance procedures apply to Medicare enrollee complaints that do not involve
an initial determination. The procedures outline the steps in the grievance
process and the time limits imposed on each step.
Grievance rights belong to the member or the member's legal guardian. In cases
of temporary need, the member may assign their grievance rights to a family
member or representative by completing a CHP Appointment of Representation Form
and submitting it to the CHP Grievance Coordinator.
DEFINITION:
Medicare grievances are disputes or complaints that do not involve an initial
determination. Examples include:
(bullet) Complaints about quality of care or service
(bullet) Complaints about accessibility of care or service
(bullet) Complaints about physician demeanor and behavior or adequacy of
facilities
(bullet) Involuntary disenrollment issues
RESPONSIBILITY:
Member Service Department, Quality Management Department, and Chesapeake Health
Plan Grievance Committee
CONTACT PERSON:
Xxxxxxx Xxxxx
------------------------------------------------------------------------
PROCEDURE:
1. Member calls with inquiry or informal grievance.
2. CHP responds within three (3) working days.
3. If member is still dissatisfied, member files formal grievance in
writing or by telephone within sixty (60) days.
4. CHP acknowledges formal grievance within ten (10) working days
Send letter 18 - Receipt of Formal Grievance Acknowledgment
5. Grievance Coordinator issues decisions within thirty (30) days.
Send letter 19 - Original Formal Grievance Decision
6. If member still not satisfied with decision of Grievance Coordinator,
member submits written request for review by Grievance Committee within
ten (10) days of receipt of Grievance Coordinators decision. The
committee is comprised of:
Medical Director
Director of Compliance
Vice President of Medical Services
7. CHP acknowledges request within ten (10) working days. Send letter 20 -
Acknowledgment of Request for Grievance Committee Review
8. Grievance Committee meets and notifies member of decision within thirty
(30) days of receipt of written request. (Period may be extended for an
additional thirty (30) days if there is a delay in obtaining required
records) Send letter 21 - Grievance Committee Decision
9. If member is still dissatisfied, the member may submit a concern to the
Maryland Insurance Administration. A CHP Member Services Represented
will assist the member.
------------------------------------------------------ -----------------------------------------------------
POLICIES & PROCEDURES
SECTION: QUALITY
MANAGEMENT
------------------------------------------------------------------------------------------------------------
TITLE: Medicare Appeal Policy
------------------------------------------------------------------------------------------------------------
Policy Number: Issued: 05-28-96 Last Revision: 05-28-96
---------------------------------------------------- -- ----------------------------------------------------
Committee Review Date: Board Approval Date: N/A
---------------------------------------------------- -- ----------------------------------------------------
Policy Implementation Date:
---------------------------------------------------- -- ----------------------------------------------------
POLICY STATEMENT:
Chesapeake Health Plan ("CHP") receives and resolves Medicare enrollees' appeals
in an effective and timely manner.
PURPOSE:
Chesapeake Health Plan is dedicated to ensuring that all Medicare enrollees
receive timely resolution to appeals regarding Health Plan services or the
payment of services. This policy is designed to provide Medicare enrollees with
a full and fair investigation of appeals. All Medicare Enrollees are informed,
upon enrollment, of their right and the process for filing an appeal.
GOALS:
To promote member satisfaction by identifying opportunities to meet the needs
and expectations of members, and to comply with the requirement of regulatory,
accreditory and other auditing agencies.
SCOPE:
This policy applies to matters subject to the formal HCFA appeal process. All
disputes by Medicare enrollees about a determination is subject to the appeals
procedure. The procedures outline the steps in the appeal process and the time
limits imposed on each step.
Appeal rights belong to the member or the member's legal guardian. In cases of
temporary need, the member may assign their appeal rights to a family member or
representative by completing a CHP Appointment of Representation form and
submitting it to the CHP Grievance Coordinator.
DEFINITION:
Medicare appeals are disputes regarding a CHP initial determination or requests
by Medicare enrollees for the Health Plan to reconsider an initial decision.
Examples include:
(bullet) Payment for services received.
(bullet) Reimbursement for emergency or urgently needed services.
(bullet) Services not received but were the responsibility of CHP to pay for
or provide.
(bullet) Claims for services for which no written notice has been issued
sixty (60) days after submission.
RESPONSIBILITY:
Member Service Department, Quality Management Department, and Chesapeake Health
Plan Grievance Committee
CONTACT PERSON:
Xxxxxxx Xxxxx
------------------------------------------------------------------------
PROCEDURE:
1. Member requests reconsideration of denied claim or service in writing
within sixty (60) days from date of denial notice.
2. CHP acknowledges receipt of request within five (5) working days. Send
letter 30 - Reconsideration Acknowledgment (If required send Letter 31 -
Request for Release of Additional Information)
3. Medicare Appeals Committee meets. The committee is comprised of:
Medical Director
Vice President, Operations
Vice President, Services
4. Member notified in writing of reconsideration decision within sixty (60)
days from date received.
Decision in member's favor
Claim paid or service rendered by CHP within sixty (60) days
Send letter 32 - Overturn of Initial Denial of Claims Payment
or Denial of Service
Decision against member
Case file sent to HCFA for their decision within 60 days
Send letter 33 - Upholding Initial Denial
Send letter 34 - Notice of Referral to HCFA for Final Determination
HCFA Follows Up After This Point
HCFA notifies Chesapeake of their decision and Chesapeake notifies the member.
Send letter 35 - Acknowledgment of Receipt of Reconsideration Determinations
from HCFA.
Decision for the member by HCFA
CHP pays claims or provides service within 60 days of receipt of HCFA decision.
Send letter 36 - Notification to HCFA of Claims Payment or Service
Authorization.
Decision against member by HCFA
HCFA advises member of right to hearing before Administrative Law Judge (ALJ).
The member has 60 days to request a hearing.
-------------------------------------------------------- ---------------------------------------------------
POLICIES & PROCEDURES
SECTION: QUALITY
MANAGEMENT
-------------------------------------------------------- ---------------------------------------------------
TITLE: Complaint, Grievance/Appeal Policy - For Commercial and Medical Assistance HMO Members
------------------------------------------------------------------------------------------------------------
Policy Number: Issued: 05-28-96 Last Revision: 05-28-96
--------------------------------------- --------------------------------- ----------------------------------
Committee Review Date: Board Approval Date: N/A
---------------------------------------------------- --- ---------------------------------------------------
Policy Implementation Date:
---------------------------------------------------- --- ---------------------------------------------------
POLICY STATEMENT:
Chesapeake receives and resolves all member complaints, grievances in an
effective and timely manner.
PURPOSE:
Chesapeake Health Plan ("CHP") is dedicated to ensuring that all CHP members
receive timely resolution to their questions and/or complaints regarding Health
Plan services or the payment of services. This policy is designed to provide CHP
members with a full and fair investigation of complaints and grievances. All CHP
members are informed, upon enrollment, of their right and the process for filing
a complaint.
GOALS:
To promote member satisfaction by identifying opportunities to meet the needs
and expectations of members, and to comply with the requirement of regulatory,
accreditory and other auditing agencies.
SCOPE:
This policy applies to CHP's Commercial and Medical Assistance-HMO members.
Commercial includes members enrolled in a POS option and those with direct pay
coverage.
Grievance/Appeal rights belong to the member or the member's legal guardian. In
cases of temporary need, the member may assign their grievance/appeal rights to
a family
member or a representative by completing a CHP Appointment of Representative
Form and submitting it to the CHP Grievance Coordinator.
Refer to Medicare Grievance and Medicare Appeals Policies for Advantage 65
Members.
Refer to Provider Appeal Policy for Provider Appeals.
BACKGROUND:
Complaints and Grievances are investigated and trended as required by CHP's
Quality Management program. The results are used to identify components of care
and service that require corrective or improvement intiative.
All Complaint and Grievance activity is documented and maintained in the Member
Services Module (MSM). The Grievance records, which include details of
investigations, are centrally maintained in a secure location by the Grievance
Coordinator.
Refer to Medicare Grievance Policy and Medicare Appeals Policy for members
enrolled in the Advantage 65 product.
DEFINITION:
A. An inquiry is defined as a member's verbal request to the Health Plan
for clarification, additional information or explanation of a plan
service, operations, administration, procedures, or benefits.
Inquiries are processed by the Member Service Department.
B. A complaint is defined as a member's initial request for a
determination or an action. A complaint represents a member's concern
or dissatisfaction with the Health Plan's services, providers of
services, or payment of services. Members may file a complaint if they
perceive that they have been treated unprofessionally or improperly by
CHP staff or a CHP provider. Complaints can be filed verbally or in
writing and are processed by the Member Service Department.
If a Medical Assistance-HMO member disenrolls from the HMO and states
on the disenrollment form that she/he is disenrolling because of
alleged fraudulent marketing conduct, CHP must document this and pursue
it as a complaint.
C. A grievance is defined as a member's complaint regarding a previous
issue that was not resolved to the member's satisfaction. A grievance
is a member's request for reconsideration. Grievances must be
submitted in writing and are processed by the CHP Grievance Coordinator
and Grievance Committee.
Members have one year from denial of a claim to file written request
for consideration.
RESPONSIBILITY:
Member Service Department, Quality Management Department, and Chesapeake Health
Plan Grievance Committee.
CONTACT PERSON:
Xxxxxxx Xxxxx
------------------------------------------------------------------------
PROCEDURE:
To file a complaint, CHP members are instructed to contact the CHP Member
Services Department and speak with a Member Services Representative.
The Member Service Representative is responsible for researching the case and
working with appropriate CHP department(s) to resolve the member's issue. Member
Service Representatives attempt to resolve member issues upon the first contact.
Members must be informed of a resolution to their complaint or provided a status
report regarding their complaint within thirty (30) calendar days.
Medical Assistance-HMO members must be provided with a written copy of their
complaint.
Complaints which pertain to emergency situations and require an expedited
determination are handled accordingly.
The Member Services Representative informs the member of his/her right to file a
grievance if she/he is not satisfied with the resolution. The member is also
informed of his/her right to appear before the Grievance Committee.
The member is instructed to direct his/her grievance to the attention of the CHP
Grievance Coordinator. Grievances must be submitted in writing within sixty (60)
days after the member receives notification of the resolution of his/her
complaint.
The Grievance Coordinator is responsible for acknowledging, in writing, to the
member receipt of his/her grievance within five (5) working days.
The Grievance Coordinator will submit all pertinent documentation to CHP's
Grievance Committee, which consists of the following CHP staff:
Medical Director
Vice President, Services
Vice President, Medical Services
Vice President, Operations
Director, Compliance
Grievances are resolved and the member is notified of the committee's decision
within thirty (30) days of receipt of the member's complete information.
The Grievance Committee is the final level of review within the Health Plan.
The member is advised of his/her right to contact the appropriate state
government regulatory agency if she/he is dissatisfied with the decision of the
Grievance Committee. The Grievance Coordinator supports the activities of the
agency and the member during this review process.
Attachment K
Encounter Format
Please refer to the attached document which may be amended from time to time
without the necessity of a formal contract amendment. HMO will strive to provide
IPA with thirty (30) days notice of any changes prior to the effective date of
the change.
CHESAPEAKE HEALTH PLAN
STANDARD ENCOUNTER LAYOUT
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
FIELD NAME BEGIN LGT NOTES TYPE JUST
H
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Claim Number 1 15 999999999999*99 A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Paid Date 16 6 YYMMDD A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Service from Date 22 6 YYMMDD A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Service to date 28 6 YYMMDD A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 34 2 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Source 36 1 (E)ncounter A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Source Fed ID 37 20 Supplier Federal ID A/N L
Number
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 57 3 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Claimant Last Name 60 20 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Claimant First Name 80 20 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 100 49 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Claimant Medical Record Xx. 000 00 X/X X
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Claimant Membership Xx. 000 00 XXX Internal Number A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 176 51 A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Provider Name 227 40 Last, First A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Provider Tax ID 267 12 A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 279 40 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
1st Diagnosis 319 7 ICD9 Code A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
2nd Diagnosis 326 7 ICD9 Code A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
3rd Diagnosis 333 7 ICD9 Code A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
UB82 Revenue Code 340 4 A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Type of Service 344 2 See Value List A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
CPT Procedure Code 346 6 A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Procedure Modifier 352 2 A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Place of Service 354 2 See Value List A/N L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 356 6 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Units of Service 362 5 N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Submitted Amount 367 9 N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Ineligible Amount 376 9 * N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Ineligible Reason 385 5 See Value List* A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 390 9 Submitted-UCR Amount A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
UCR Cutback 399 9 N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 408 9 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Deductible 417 9 * N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
COB 426 9 * N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Copayment 435 9 N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
COB Savings 444 9 * N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
COB Status 453 1 M = Medicare A L
R = Regular
W = Workmen's Comp.
A = Accident
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Amount Paid 454 9 N R
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
Filler 463 37 A L
--------------------------------------- ------------ ----------- -------------------------- ------------ --------
* Does not apply to Encounters
RECORD LENGTH: 500 TAPE DENSITY: 1600
Chesapeake Health Plan
Standard Encounter Layout
BLOCK FACTOR: 10 FORMAT: ASCII
BLOCK FACTOR: 5000 UNLABELED:
Text File Layout
3/2/95
This layout is based on the standard CHP Eligibility Tape layout.
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
Start End Length Just Description Format
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
1 15 15 Left Subscriber's Member Number NNNNNN*01
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
16 30 15 Left Member Number NNNNNN*NN
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
31 39 9 Left Member's Social Security Number NNNNNNNNN
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
40 59 20 Left Member's Last Name Text
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
60 79 20 Left Member's First Name Text
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
80 80 1 Left Member's Middle Initial X
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
81 83 3 Left Member's Suffix SR, JR, III, etc.
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
84 91 8 Left Member's Date of Birth YYYYMMDD
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
92 92 1 Left Member's Sex M or F
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
93 93 1 Left Relationship Code P, S, or D
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
94 123 30 Left Subscriber's Address, Line 1 Text
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
124 153 30 Left Subscriber's Address, Line 2 Text
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
154 173 20 Left Subscriber's City Text
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
174 175 2 Left Subscriber's State XX
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
176 184 9 Left Subscriber's Zip Code NNNNN
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
185 194 10 Right Subscriber's Home Phone NNNNNNNNNN
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
195 204 10 Right Subscriber's Work Phone NNNNNNNNNN
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
205 212 8 Left Coverage Begin Date YYYYMMDD
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
213 220 8 Left Coverage End Date YYYYMMDD
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
221 223 3 Left Coverage End Reason Code XXX
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
224 253 30 Left Employer Group Number 30X
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
254 263 10 Left Primary Care Physician Code 10X
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
264 273 10 Left Region Code 10X
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
274 300 27 Left Filler Blank
--------------- ------------- ------------- ---------------- -------------------------------------- -----------------------
Notes:
(bullet) An entire family (subscriber and all dependents) should be
included in this file if any member of the family is or has been
assigned to a network PCP.
(bullet) If a subscriber (member "01") is included in this file, and the
subscriber is not assigned to a network PCP, then that subscriber
should be considered enrolled, and the PCP code field should be left
blank.
(bullet) If a dependent (not member "01") is included in this file, and
the dependent is not assigned to a network PCP, then that dependent
should be considered disenrolled.
(bullet) Network PCPs can be identified by their PCN code. (Currently, "CMC",
"DH", and "SHMC").
Attachment L
Member Information Format
Please refer to the attached document which may be amended from time to time
without the necessity of a formal contract amendment. HMO will strive to provide
IPA with thirty (30) days notice of any changes prior to the effective date of
the change.
Attachment M
Provider Appeals Policy
The IPA's Provider Appeals Policy previously submitted for review is hereby made
a part of this Agreement.
