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Exhibit 10.18
Portions of this Exhibit have been omitted pursuant to a request for
confidential treatment. The omitted portions, marked by an * and [ ], have been
separately filed with the Commission.
AGREEMENT BETWEEN
UNITED HEALTHCARE OF GEORGIA, INC.
AND
ATLANTA ENT CENTER, INC.
THIS AGREEMENT, effective June 1, 1995, ("Effective Date"), is made
between United HealthCare of Georgia, Inc. ("Plan") and Atlanta ENT Center,
Inc., ("Corporation") for the purpose of setting forth the terms and conditions
under which Corporation shall arrange for Providers to render otolaryngology
health care services to Members. Provider and Member are defined in this
Agreement. For Health Services provided on or after the Effective Date, this
Agreement supersedes and replaces any existing agreements between the parties
relating to the provision of health care services to Members.
Corporation represents and warrants that (1) it has been and will
continue to be properly formed pursuant to the laws of the jurisdiction in which
the services in the Agreement are rendered; (2) it has the unqualified authority
to and shall bind itself and Providers to all of the terms and conditions of
this Agreement, including any Appendices, Attachments and Exhibits, as
applicable; and (3) all documents reviewed by Plan prior to execution of this
Agreement, including any agreements Corporation has in place with Providers,
shall remain substantially similar to those reviewed by Plan, and if Corporation
intends to make any substantial changes which would materially affect this
Agreement, Corporation shall submit to Plan any proposed changes for Plan's
prior review and/or approval. Corporation agrees that any such changes
implemented without Plan's prior review and/or approval shall not take effect
with respect to this Agreement at Plan's sole discretion. Corporation also
agrees that if any terms in any Corporation document conflict or appear to
conflict with this Agreement, including any Appendices, Attachments and
Exhibits, as applicable, the terms of this Agreement shall prevail.
SECTION 1
DEFINITIONS
BENEFIT CONTRACT: A benefit plan which includes health care coverage, is
sponsored or issued by a Payor, and contains the terms and conditions of a
Member's coverage
COPAYMENT: The amount a Member is required to pay for certain Health Services in
accordance with the Member's Benefit Contract.
CUSTOMARY CHARGE: The reasonable and customary fees charged by Provider which do
not exceed the fees Provider would charge any other person regardless of whether
the person is a Member.
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DEDUCTIBLE: The annual amount of charges for Health Services, as provided in the
Member's Benefit Contract, which the Member is required to pay before any
payment is due from Payor.
HEALTH SERVICES: The health care services and supplies covered by the Member's
Benefit Contract, and generally described in Appendix A.
MEMBER: An individual who is properly enrolled for coverage under a Benefit
Contract.
PARTICIPATING PROVIDER: A health care professional or facility, including
Provider, that has or is governed by a participation agreement which is in
effect with Plan to provide Health Services to Members
PAYOR: The entity or person authorized by Plan to access one or more of Plan's
network of Participating Providers and has the financial responsibility for
payment of Health Services covered by that Payor's Benefit Contracts.
PROVIDER: An otolaryngologist who (1) is duly licensed and qualified under the
laws or the jurisdiction in which services are rendered; (2) has an agreement in
effect with Corporation; (3) has a health care services participation agreement
in effect with Plan, the form of which is attached as Appendix D (the
"Participation Agreement"); and (4) is subject to credentialing and ongoing
recredentialing by Plan.
SECTION 2
OBLIGATIONS OF CORPORATION
SECTION 2.1 PROVISION OF HEALTH SERVICES. Corporation shall arrange for
Providers to provide Health Services to all Members in accordance with the terms
set forth in Participation Agreement.
SECTION 2.2 UTILIZATION MANAGEMENT AND QUALITY ASSESSMENT. Corporation shall
cooperate with all utilization management, quality assessment, peer review,
Member grievance, on-site concurrent review, or other similar programs
established by Plan.
SECTION 2.3 SERVICE AREA. Corporation shall assure that Provider's offices are
distributed throughout Plan's service area as described in Appendix C, in a
manner acceptable to Plan and in locations which are reasonably accessible to
all Members. Plan shall provide written notification to Corporation of any
changes to Plan's current service area. Corporation shall provide 30 days prior
written notification to Plan of any changes in its office locations.
SECTION 2.4 PROVIDER PARTICIPATION. Corporation shall cause any otolaryngologist
located within Plan's service area who is or becomes associated with Corporation
to submit to Plan two originally executed Participation Agreements and a
participation application. All otolaryngologists who are associated with
Corporation as of the date this Agreement is executed
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by Corporation shall submit these documents within 30 days of that date. All
otolaryngologists who become associated with Corporation after the date this
Agreement is executed by Corporation shall submit the documents within 15 days
of the date such otolaryngologist become associated with Corporation. Plan shall
have the right to review and apply its credentialing criteria to determine
acceptance of the applications of all otolaryngologists, and shall notify
Corporation upon acceptance or rejection by Plan of any application.
SECTION 3
OBLIGATIONS OF PLAN
SECTION 3.1 PAYMENT FOR HEALTH SERVICES. During the term of this Agreement,
Payor shall pay Corporation for Health Services rendered to Members by Providers
pursuant to the Appendices. The obligation for payment under this Agreement for
Health Services rendered to a Member is solely that of Payor, although Plan may
provide or arrange for claims processing services. During the term of this
Agreement, Corporation shall be solely responsible for compensating Providers
for all Health Services rendered to Members, and Corporation and Providers shall
hold harmless and indemnify Plan and Payor against any claims for compensation
by a Provider.
SECTION 3.2 PARTICIPATION AGREEMENTS. Plan shall enter into Participation
Agreements with all Providers who are also under contract with Corporation and
who meet Plan's credentialing and contracting standards. Corporation shall be
notified of any amendments to the Participation Agreement. To the extent any
Providers are currently under contract with Plan through another agreement, the
Participation Agreement shall supersede and replace that other agreement. If
this Agreement terminates, all Participation Agreements shall remain in effect,
unless all or any of the Participation Agreements are also terminated, and the
providers will be paid pursuant to Appendix A of the Participation Agreement. If
any Provider's contractual relationship with Corporation terminates, that
Provider's Participation Agreement shall also terminate on the date that
Provider's agreement with Corporation terminates, or later if applicable
statutes and regulations require that the termination be effective only after a
specific notice period has been given. Corporation shall notify Plan immediately
upon giving notice of termination to a Provider, or upon receiving notice of
termination from a Provider
SECTION 3.3 PAYMENT IN FULL. Corporation shall accept as payment in full for
Health Services rendered to Members such amounts as are paid by Payor pursuant
to this Agreement. In no event shall Corporation or Provider xxxx a Member for
the difference between Provider's Customary Charges and the amount Corporation
has agreed to accept as full reimbursement under this Agreement. Provider may
collect from the Member Copayments, Deductibles, or charges for services not
covered under the Member's Benefit Contract.
SECTION 3.4 FINANCIAL RESPONSIBILITY. Plan shall notify Corporation in writing
in the event Plan determines that a Payor has failed to maintain its
responsibility to pay for services rendered. Any services which have been
rendered by Provider prior to and after such notification, and which
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have not been paid for by Payor, shall be considered ineligible for
reimbursement under this Agreement, and Provider may xxxx the Member directly
for such services.
SECTION 3.5 MEMBER PROTECTION PROVISION. This provision supersedes and replaces
Sections 3.3 and 3.4 in all instances where (1) Plan is the Payor, or (2) a
specific Payor requires, or any applicable statutes and regulations require that
the Member be held harmless from any and all costs which are the legal
obligation of the Payor.
Corporation shall accept as payment in full for Health Services rendered to
Members such amounts as are paid by Payor pursuant to this Agreement. In no
event, including, but not limited to, non-payment by Payor for Health Services
rendered to Members by Provider, insolvency of Payor, or breach by Plan of any
term or condition of this Agreement, shall Corporation or Provider xxxx, charge,
collect a deposit from, seek compensation, remuneration or reimbursement from,
or have any recourse against any Member or persons acting on behalf of the
Member for Health Services eligible for reimbursement under this Agreement;
provided, however, that Provider may collect from Member Copayments, Deductibles
or charges for services not covered under the Member's Benefit Contract.
The provisions of this Section shall (1) apply to all Health Services rendered
while this Agreement is in force; (2) with respect to Health Services rendered
while this Agreement is in force, survive the termination of this Agreement
regardless of the cause of termination; (3) be construed to be for the benefit
of the Members; and (4) supersede any oral or written agreement, existing or
subsequently entered into, between Corporation or Provider and a Member or
person acting on a Member's behalf, that requires the Member to pay for such
Health Services.
SECTION 4
HOLD HARMLESS, INDEMNIFICATION, AND LIABILITY INSURANCE
SECTION 4.1 HOLD HARMLESS AND INDEMNIFICATION. Each party shall be responsible
for any and all claims, liabilities, damages or judgments which may arise as a
result of its own negligence or intentional wrongdoing. Each party shall hold
harmless and indemnify the other party against any claims, liabilities, damages
or judgments which may be asserted against, imposed upon or incurred by the
other party as a result of the first party's negligence or intentional
wrongdoing.
SECTION 4.2 CORPORATION LIABILITY INSURANCE. Corporation shall procure and
maintain, at Corporation's sole expense (1) medical malpractice insurance in the
amounts of One Million Dollars ($1,000,000.00) per occurrence and Three Million
Dollars ($3,000,000.00) aggregate, and (2) comprehensive general and/or umbrella
liability insurance in the amounts of One Million Dollars ($1,000,000.00) per
occurrence and aggregate. Corporation shall also assure that all health care
professionals employed by or under contract with Corporation to render Health
Services to Members procure and maintain medical malpractice insurance, unless
they are covered under Corporation's insurance policies. Corporation's and other
health care professionals' medical malpractice insurance shall be either
occurrence or claims made with an extended period reporting
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option under such terms and conditions as may be reasonably required by Plan.
Prior to or within 30 days following execution of this Agreement by Corporation
and at each policy renewal thereafter, Corporation shall submit to Plan in
writing evidence of insurance coverage. Corporation shall notify Plan in writing
within 10 days of any changes in carriers, termination of, renewal of or any
material changes in Corporation's liability insurance, including reduction of
limits, erosion of aggregate, changes in retention or non-payment of premium.
SECTION 5
LAWS, REGULATIONS AND LICENSES
SECTION 5.1 LAWS, REGULATIONS AND LICENSES. Corporation shall maintain all
federal, state and local licenses, certifications, and permits, without
restriction, which are required to arrange for the provision of health care
services according to the laws of the jurisdiction in which Health Services are
provided, and shall comply with all applicable statutes and regulations.
Corporation shall notify Plan in writing within 10 days of any knowledge of a
suspension, revocation, condition, limitation, qualification or other
restriction on Corporation's licenses, certifications and permits by any state
in which is authorized to arrange for the provision of health care services.
SECTION 6
BOOKS AND RECORDS
SECTION 6.1 PLAN ACCESS TO AND RELEASE OF BOOKS AND RECORDS. Corporation shall
maintain, in accordance with standard and accepted practices, such financial,
accounting and claims records as shall be necessary, appropriate or convenient
for Plan to monitor Corporation's services under this Agreement. During the term
of this Agreement, and for 3 years following its termination, Plan and its duly
authorized agents, during regular business hours and upon reasonable advance
notice, shall have access to and the right to audit all records or copies of
records related to the services provided under this Agreement. Provider shall,
at the time of the audit, give Plan access to all records or copies of records
related to such Health Services being audited. Corporation shall provide records
or copies of records requested by Plan within 14 days from the date such request
is made, except in the case of an audit by Plan where records or copies of
records shall be provided at the time of the audit.
SECTION 6.2 COMPLIANCE WITH STATUTES AND REGULATIONS. The federal, state and
local government and any of their authorized representatives shall have access
to, and Plan, Corporation and Providers are authorized to release, in accordance
with all applicable statutes and regulations, all information and records or
copies of such, within their possession, which are pertinent to and invoice
transactions related to this Agreement, and access which is necessary to comply
with statutes and regulations applicable to Plan, Corporation or Providers.
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SECTION 6.3 PRIVACY OF RECORDS. Plan and Corporation shall maintain the
confidentiality of all information regarding Members in accordance with any
applicable statutes and regulations.
SECTION 7
RESOLUTION OF DISPUTES
SECTION 7.1 RESOLUTION OF DISPUTES. In the event a dispute between Plan or Payor
and Corporation arises out of or is related to this Agreement, the parties to
the dispute shall meet and negotiate in good faith to attempt to resolve the
dispute. In the event the dispute is not resolved within 30 days of the date one
party sent written notice of the dispute to the other party, and if any party
wishes to pursue the dispute, it shall be submitted to binding arbitration in
accordance with the rules of the American Arbitration Association. In no event
may arbitration be initiated more than one year following the sending of written
notice of the dispute. Any arbitration proceeding under this Agreement shall be
conducted in DeKalb County, Georgia. The arbitrators shall have no authority to
award any punitive or exemplary damages, or to vary or ignore the terms of this
Agreement, and shall be bound by controlling law. If the dispute pertains to a
matter which is generally administered by certain Plan procedures, such as a
credentialing or quality assessment plan, the procedures set forth in that plan
must be fully exhausted by Corporation before Corporation may invoke its right
to arbitration under this section.
SECTION 8
TERM AND TERMINATION
SECTION 8.1 TERM. The term of this Agreement shall commence on the Effective
Date and it shall remain in effect until May 31, 1998.
SECTION 8.2 TERMINATION. This Agreement may be terminated as follows:
(1) by either party upon 120 days prior written notice to the other party.
(2) by either party, in the event of a material breach of this Agreement by
the other party, upon 60 days prior written notice to the other party.
(3) by Plan immediately due to Corporation's loss or suspension of
licensure or loss of liability insurance required under this Agreement.
(4) by Corporation upon written notice to Plan 60 days prior to the
effective date of any amendment made to this Agreement pursuant to
Section 9.1.
SECTION 8.3 CONSEQUENCES OF TERMINATION. The following shall apply in the event
this Agreement terminates:
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(1) Continued Provision of Health Services. During the period after notice
of termination and before the effective date of termination,
Corporation's status with Plan shall remain in full force and effect,
except to the extent Plan determines that such status shall be
restricted or otherwise controlled by Plan (a) to assure that Health
Services are available and provided to Members in a manner consistent
with (i) the obligations of Plan under its Benefit Contracts or under
any state or federal law or regulation; or (ii) other standards for
provision and availability of Health Services as are established by
Plan from time to time; or (b) actions by Corporation which Plan
determines negatively affect Plan's relationship with its Members. Plan
shall notify Corporation upon imposition of any such restriction.
(2) Information to Members. Corporation acknowledges the right of Plan to
inform Members of Corporation's termination and agrees to cooperate
with Plan in deciding on the form of such notification.
SECTION 9
MISCELLANEOUS
SECTION 9.1 AMENDMENT. Plan may amend this Agreement by sending a copy of the
proposed amendment to Corporation at least 60 days prior to the effective date
of the amendment. In the event of such an amendment, Corporation may elect to
terminate this Agreement pursuant to Section 8.2.4.
SECTION 9.2 REGULATORY AMENDMENT. Plan may also amend this Agreement to comply
with applicable statutes and regulations, and shall give notice to Corporation
of such amendment and its effective date. The amendment will not require
agreement by Corporation.
SECTION 9.3 ASSIGNMENT. Plan may assign all or any of its rights and
responsibilities under this Agreement to any entity controlling, controlled by,
or under common control with Plan. Corporation acknowledges that persons and
entities under contract with Plan may perform certain administrative services
under this Agreement. Corporation may not assign any of its rights and
responsibilities under this Agreement to any person or entity without the prior
written consent of Plan, which consent shall not be unreasonably withheld.
SECTION 9.4 RELATIONSHIP BETWEEN PLAN AND CORPORATION. The relationship between
Plan and Corporation is solely that of independent contractors and nothing in
this Agreement or otherwise shall be construed or deemed to create any other
relationship, including one of employment, agency or joint venture.
SECTION 9.5 NAME, SYMBOL AND SERVICE XXXX. During the term of this Agreement,
Corporation, Plan and Payor shall have the right to use each other's name and
make public reference to Corporation as a Participating Provider. Corporation,
Plan and Payor shall not otherwise use each other's name, symbol or service xxxx
without prior written approval.
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SECTION 9.6 ENTIRE AGREEMENT. This Agreement constitutes the entire agreement
between the parties in regard to its subject matter.
SECTION 9.7 MEDICARE. Corporation agrees to provide Health Services to members
who are enrolled in a Benefit Contract for Medicare recipients. The Health Care
Financing Administration shall be notified by Plan if there is any change to
this Agreement with respect to the continuation provision of the Continued
Provision of Health Services section.
SECTION 9.8 GOVERNING LAW. This Agreement shall be governed by and construed in
accordance with the laws of the State of Georgia.
THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY
THE PARTIES.
UNITED HEALTHCARE OF GEORGIA, INC. ATLANTA ENT CENTER. INC.
0000 Xxxxxxxxx Xxxx 5555 Peachtree Dunwoody Road
Suite 300 Suite 201
Atlanta, Georgia 30329-1634 Xxxxxxx, Xxxxxxx 00000
By: ____________________________ By: __________________________
Its: ____________________________ Its: __________________________
Date: ____________________________ Date: __________________________
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
APPENDIX A
CAPITATION PAYMENT
APPLICABILITY
The provisions of this Appendix A apply to Health Services which Corporation
arranges for Providers to render to Members covered by Benefit Contracts
sponsored or issued by all Payors to the extent such Benefit Contracts cover the
services Corporation is obligated to provide or arrange for the provision of,
pursuant the Agreement and this Appendix A.
SECTION 1
DEFINITIONS
CPI. The U.S. City Average Consumer Price index, All Items, as published by the
Department of Labor, Bureau of Labor and Statistics.
GATEKEEPER BENEFIT CONTRACT. A Benefit Contract requiring the Member to receive
all or any Health Services from or upon referral by a primary care physician.
SECTION 2
PAYMENT
SECTION 2.1 CAPITATION PAYMENT. On or before the 15th day of each month, Payor
shall pay Corporation for Health Services rendered to Members by Providers, a
payment of [*] per Member per month ("Capitation Payment"), beginning July 15,
1995. Services which are included in the Capitation Payment are identified in
Appendix B. The Capitation Payment shall be calculated based on the total number
of Members enrolled in the Plan for the previous month. Adjustments to the
Capitation Payment shall be reflected in subsequent calculations as deemed
necessary by Plan, and as provided for in Section 2.2 below.
In the second year of the contract term, and each year thereafter, Plan shall
increase the Capitation Payment by an amount equal to the percentage change CPI
for the previous year.
SECTION 2.2 ADJUSTMENT OF CAPITATION PAYMENTS. Approximately 270 days after
Members who are covered by a Gatekeeper Benefit Contract are initially eligible
to receive such Health Services, the capitation payments made to Corporation by
Payor shall be adjusted. Such adjustment shall be made based upon the
utilization of the Members who are covered under a
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Gatekeeper Benefit Contract compared to the utilization of the Members who are
not covered under a Gatekeeper Benefit Contract.
Such adjustment shall be made based upon the experience of the initial 180 days
of the above period. Plan will determine the adjustment by comparing the two
Member groups based on the number of Medicare Relative Value Units per Member
per month utilized by each Member group. (Relative Value Units will be
determined by multiplying each CPT code used by the number of times such code is
recorded from the Checkwrite or encounter data system.) The ratio of Relative
Value Units per Member per month for the two Member groups will be applied to
the capitation payment for Members covered by a Gatekeeper Benefit Contract in
order to establish a capitation payment for this Member group. This adjusted
payment will be applied retroactively to all payments made to this point and
shall determine per Member per month payment for all payments going forward.
However, at 90 day intervals, after the initial adjustment outlined in the
paragraph directly above, the procedure described in the paragraph above shall
be applied again to all the data accumulated to that time and adjustments made
to the per Member per month payment of that group of Members covered by a
Gatekeeper Benefit Contract. When adjustments have been made in the per Member
per month payment in this manner for a period of one year, no further
retroactive adjustments will be made. Adjustments made in future calculations
will be continue to be based on accumulated data even though no retroactive
adjustments in payments will be made after a year has ended.
Such adjustment described above shall continue until the later of (1) 18 months
of data have been accumulated for calculating the adjustment in the per Member
per month payment, or (2) the number of Members covered by a Gatekeeper Benefit
Contract used to determine the adjusted rate reaches 10,000 Members. At such
time, the per Member per month payment shall be permanently established.
SECTION 2.3 REDUCTION IN CAPITATION PAYMENTS. Adjustments to the Capitation
Payment shall be reflected in subsequent calculations as deemed necessary by
Plan, and shall occur under the following circumstances:
1. Eligible claims submitted to Plan for services rendered by
non-Participating Providers for services (including laboratory and
radiology services) referred by Provider shall reduce the Capitation
Payment by the amount paid by Plan for services rendered by
nonParticipating Providers.
2. Eligible claims submitted to Plan for services rendered by
non-participating hospitals for non-emergency services referred by
Provider shall reduce the Capitation Payment by the amount paid by Plan
for those non-emergency services.
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3. In the event that fines and/or sanctions are imposed upon Corporation
or any Provider, the amount of such fines and/or sanctions shall be
deducted from the Capitation Payment paid to Corporation.
4. Emergency and urgent Health Services rendered by non-Participating
Physicians in and out-of-service area for Members covered by Plan.
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
APPENDIX B
MEDICARE PAYMENT
The provisions of this Appendix apply to Health Services rendered by Provider to
Members covered by Plan pursuant to its TEFRA risk contract on a capitation
basis with the Health Care Financing Administration to the extent such Benefit
Contracts cover the services Corporation is obligated to provide or arrears for
the provision of, pursuant the Agreement and this Appendix B.
SECTION 1
DEFINITIONS
CPI. The U.S. City Average Consumer Price Index, All Items, as published by the
Department of Labor, Bureau of Labor and Statistics.
SECTION 2
PAYMENT
SECTION 2.1 CAPITATION PAYMENT. On or before the 15th day of each month, Plan,
on behalf of Payor, shall pay Corporation for Health Services rendered to
Members covered by Plan pursuant to its TEFRA risk contract on a capitation
basis with the Health Care Financing Administration by Providers, a payment of
[*] per Member per month ("Capitation Payment"), beginning July 15, 1995.
Services which are included in the Capitation Payment are identified in Appendix
C. The Capitation Payment shall be calculated based on the total number of
Members enrolled in the Plan for the previous month Adjustments to the
Capitation Payment shall be reflected in subsequent calculations as deemed
necessary by Plan, and as provided for in this Appendix.
In the second year of the contract term, and each year thereafter, Plan shall
increase the Capitation Payment by an amount equal to the percentage change in
the CPI for the previous year.
SECTION 2.2 REDUCTION IN CAPITATION PAYMENTS. Adjustments to the Capitation
Payment shall be reflected in subsequent calculations as deemed necessary by
Plan, and shall occur under the following circumstances:
1. Eligible claims submitted to Plan for services rendered by
non-Participating Providers for services (including laboratory and
radiology services) referred by Corporation
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Provider shall reduce the Capitation Payment by the amount paid by Plan
for services rendered by non-Participating Providers.
2. Eligible claims submitted to Plan for services rendered by
non-participating hospitals for non-emergency services referred by
Corporation Provider shall reduce the Capitation Payment by the amount
paid by Plan for those non-emergency services.
3. In the event that fines and/or sanctions are imposed upon Corporation
or any Corporation Provider, the amount of such fines and/or sanctions
shall be deducted from the Capitation Payment paid to Corporation.
4. Emergency and urgent Health Services rendered by non-Participating
Physicians in and out-of-service area for Members covered by Plan.
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APPENDIX C
HEALTH SERVICES COVERED UNDER THE CAPITATION PAYMENT
SERVICES WHICH ARE COVERED UNDER THE CAPITATION PAYMENT INCLUDE THE FOLLOWING:
(1) Provider services, including inpatient and outpatient health care
services;
(2) laboratory and radiology services rendered in Provider's facility, and
laboratory and radiology services referred by Provider to a
non-Participating Provider;
(3) medical supplies used or dispensed in Provider's office, including, but
not limited to routinely used office supplies, outpatient surgical
supplies, casts and sterile material;
(4) emergency and urgent services rendered by Provider and
non-Participating Physicians in and out-of-service area for Members
covered by Plan;
(5) Durable Medical Equipment (DME) items dispensed by Provider.
(6) all other ancillary Health Services rendered by Provider or Provider's
staff, including in-office audiology.
SERVICES WHICH ARE NOT COVERED UNDER THE CAPITATION PAYMENT ARE AS FOLLOWS:
(1) Non-emergency or non-urgent services of non-Participating Providers if
Provider did not make referral;
(2) facility charges for authorized Admissions to participating facilities;
(3) charges for pharmaceutical dispensed by non-Corporation providers;
(4) Outside consultation, related therapies and audiology and vestibular
testing services when the services are rendered by non-otolaryngology
providers who contract independently with Plan. Corporation will assist
Plan in negotiating favorable rates with registered speech and hearing
therapists and other providers of related testing.
(5) Durable Medical Equipment (DME) dispensed by Plan's contracted vendors.
(6) Services of speech therapists, physiotherapists and occupational
therapists in provider's office. However, such services must be
contracted for separately by Plan to receive payment.
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APPENDIX D
SERVICE AREA
Xxxxx Xxxxxxxx
Banks Xxxxxx
Xxxxxx Heard
Xxxxxxxx Xxxxx
Xxxxx Xxx
Xxxxxxx Xxxxxx
Xxxxxxx Xxxxxxxxxx
Chattahoochee Xxxxxxxx
Chattooga Muscogee
Cherokee Xxxxxx
Xxxx Paulding
Xxxxxxx Xxxxxxx
Xxxx Pike
Columbia Polk
Coweta Pulaski
Xxxxxxxx Xxxxxxx
Xxxxxx Xxxxxxxx
DeKalb Richmond
Dooly Rockdale
Xxxxxxxxx Spalding
Xxxxxxx Xxxxxxx
Fayette Xxxxxx
Xxxxx Xxxxxxx
Xxxxxxx Xxxxxx
Xxxxxx Xxxxxx
Xxxxxx Xxxxxxx
Gwinnett Xxxxxx
Hall Worth
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