"ALL SECTIONS MARKED WITH TWO ASTERISKS ("**") REFLECT PORTIONS WHICH HAVE
BEEN REDACTED AND FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE
COMMISSION BY PROSPECT MEDICAL HOLDINGS, INC. AS PART OF A REQUEST FOR
CONFIDENTIAL TREATMENT."
CALIFORNIACARE
MEDICAL SERVICES AGREEMENT
This AGREEMENT is effective on JANUARY 1, 0000 xxxxxxx XXXX XXXXX XX XXXXXXXXXX
and Affiliates (jointly and severally "BLUE CROSS") and PROSPECT MEDICAL GROUP
("PARTICIPATING MEDICAL GROUP").
I. RECITALS
1.01 BLUE CROSS is a California Corporation licensed by the California
Commissioner of Corporations to operate a health care service plan
pursuant to the Xxxx-Xxxxx Health Care Service Plan Act of 1975 and
the Rules of the California Commissioner of Corporations promulgated
thereunder (California Health & Safety Code, Sections 1340 to 1399.64
and California Code of Regulations, Sections 1300.43 to 1300.99,
collectively, the "Xxxx-Xxxxx Act"), including without limitation to
issue Benefit Agreements covering the provision of health care
services and to enter into agreements with PARTICIPATING MEDICAL
GROUP.
1.02 PARTICIPATING MEDICAL GROUP is a PROFESSIONAL CORPORATION, a legal
entity organized under the laws of the State of California and
comprised of physicians who desire to provide and arrange for health
services to persons who are enrolled in BLUE CROSS' CALIFORNIACARE
programs.
II. DEFINITIONS
2.01 "ADJUSTED PER MEMBER PER MONTH NON-CAPITATED EXPENSE" means the
PARTICIPATING MEDICAL GROUP's Per Member Per Month Non-Capitated
Expense after adjustments for the PARTICIPATING MEDICAL GROUP's mix of
Member age/sex and plan, and the PARTICIPATING MEDICAL GROUP's
stop-loss and regional relativities for use in identifying the
PARTICIPATING MEDICAL GROUP's Non-Capitated Performance Settlement.
2.02 "AFFILIATE" means a corporation or other organization owned or
controlled, either directly or through parent or subsidiary
corporations, by BLUE CROSS, or under common control with BLUE CROSS.
2.03 "AGE/SEX FACTORS" means the factors used to adjust PARTICIPATING
MEDICAL GROUP's Per Member Per Month Non-Capitated Expenses to account
for cost variations attributable to the mix of Member age and sex.
2.04 "ALTERNATIVE BIRTHING CENTER SERVICES" means services rendered by an
Alternative Birthing Center. Alternative Birthing Center Services
include related services such as equipment, surgical and anesthetic
supplies, oxygen and drugs, blood and blood processing, laboratory
procedures and diagnostic imaging.
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2.05 "AMBULANCE SERVICES" means transportation services provided by a
licensed ambulance company.
2.06 "ATTACHMENT POINT" is the point at which no settlement shall be made
if the PARTICIPATING MEDICAL GROUP's Adjusted Per Member Per Month
Non-Capitated Expense equals or exceeds that amount. The Attachment
Point is shown in the Non-Capitated Performance Settlement Schedule as
set forth in Exhibit F.
2.07 "AWAY FROM HOME CARE" means urgent care, Away from Home Emergency
Care, routine care, and follow-up care as defined in the HMO-USA
member's plan certificate or benefit agreement.
2.08 "BENEFIT AGREEMENT(S)" means the written agreement(s) entered into
between BLUE CROSS and groups or individuals, under which BLUE CROSS
provides, indemnifies, or administers health benefits to persons
enrolled in BLUE CROSS programs including, but not limited to, the
CALIFORNIACARE programs or the BLUE CROSS PLUS program. "Benefit
Agreement(s)" also mean arrangements established by BLUE CROSS and/or
one or more of its Affiliates, or by persons or entities utilizing the
BLUE CROSS Managed Care Network pursuant to a contract with BLUE CROSS
and/or one or more of its Affiliates. Subject to the terms hereof,
BLUE CROSS and/or one or more of its Affiliates may contract, on
PARTICIPATING MEDICAL GROUP's behalf, with Other Payors wishing to
utilize the services of the BLUE CROSS Managed Care Network,
incorporating the terms and conditions of this Agreement.
2.09 "BLUE CROSS MANAGED CARE NETWORK" means the network of health care
providers that have entered into contracts with BLUE CROSS and/or one
or more of its Affiliates pursuant to which those providers have
agreed to participate in the CALIFORNIACARE, BLUE CROSS PLUS and other
programs that are to be conducted pursuant to Benefit Agreements.
2.10 "BLUE CROSS PLUS" means a point of service option benefit plan offered
by BLUE CROSS under which enrolled Members may, at the time benefits
are selected, elect to receive benefits from either a CALIFORNIACARE
provider or another licensed provider.
2.11 "CALIFORNIACARE" means direct care prepayment plan(s) offered by BLUE
CROSS.
2.12 "CALIFORNIACARE CASE MANAGER" means a CALIFORNIACARE employee charged
with assisting PARTICIPATING MEDICAL GROUPs in case management.
2.13 "CALIFORNIACARE COORDINATOR" means an employee of PARTICIPATING
MEDICAL GROUP as set forth in Section 4.08B.
2.14 "CALIFORNIACARE HOSPITAL" means a hospital which has entered into an
agreement with BLUE CROSS to provide Hospital Services to Members.
2.15 "CALIFORNIACARE QUALITY MANAGEMENT REPRESENTATIVE" means an employee
of BLUE CROSS responsible for the CALIFORNIACARE Quality Management
Program.
2.16 "CAPITATION" means a uniform prepayment fee per Member per month,
adjusted by age-sex, based on the Benefit Agreement issued to each
Subscriber and the services due thereunder.
2.17 "CAPITATION SERVICES" means all CALIFORNIACARE Covered Medical
Services which are not otherwise defined in this Agreement or in the
Division of Financial Responsibilities (Exhibit A-1 hereto) as
Non-Capitated Services.
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2.18 "CASE MANAGEMENT PROGRAM" means a program that assesses the Member's
medical needs and includes working with PARTICIPATING MEDICAL GROUP
and other Participating Providers to explore and coordinate treatment
alternatives that may (1) be more cost effective; (2) result in better
medical outcomes; (3) achieve benefit savings; and (4) increase Member
satisfaction.
2.19 "CASE MANAGEMENT STOP-LOSS THRESHOLD" means the level at which
stop-loss under Section 9.03 herein shall apply to PARTICIPATING
MEDICAL GROUP's Non-Capitated Performance Settlement.
2.20 "COVERED MEDICAL SERVICES" means the services and benefits covered
under the Benefit Agreements. A matrix of those services and benefits
is set forth in Exhibit A (incorporated by reference herein).
2.21 "COVERED PERSONS" means Members, enrollees, dependents and other
beneficiaries who are covered by an Affiliate's Benefit Agreement or
by an Other Payor.
2.22 "CUSTOMARY AND REASONABLE CHARGES" (C&R) means:
A. "Customary" means the fee that falls within the range of
prevailing fees charged by physicians and surgeons or other
licensed providers of the same service within the same area for
the performance of a specific service or procedure, and
B. "Reasonable" means the fee that meets the requirements of
Customary and is justified, considering complications or special
circumstances with respect to the performed services or
procedure.
C&R charges are determined by BLUE CROSS.
2.23 "EMERGENCY" means a sudden unexpected onset of a medical condition
manifesting itself by acute symptoms of sufficient severity
(including, without limitation, sudden and unexpected severe pain)
such that the absence of immediate medical attention could reasonably
result in any of the following:
A. Placing the patient's health in serious jeopardy,
B. Serious impairment to bodily functions,
C. Other serious medical consequences, or
D. Serious and/or permanent dysfunction of any bodily organ or part.
2.24 "ENROLLMENT PROTECTION" is a program to limit PARTICIPATING MEDICAL
GROUP's risk with respect to any individual Member who requires
Capitation Services in excess of the limit of liability per individual
Member per calendar year, as set forth in Article VIII, ENROLLMENT
PROTECTION, below.
2.25 "EXTENSION OF BENEFITS" means extended benefits which may be available
to Members who are totally disabled on the date of termination of
their Benefit Agreement. Extended benefits shall have the meaning set
forth in the group coverage agreement applicable to the Member.
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2.26 "HEALTH PROFESSIONAL" means any of the following: A doctor of medicine
or osteopathy, licensed to practice medicine or osteopathy where the
care is received, or a dentist, an optometrist, a podiatrist or
chiropodist, a clinical psychologist, a chiropractor, a clinical
social worker, a marriage family and child counselor, a physical
therapist, a speech pathologist, an audiologist, an occupational
therapist, a physician assistant, a registered nurse, a nurse
practitioner and/or nurse midwife providing services within the scope
of practice as defined by the appropriate clinical license and/or
regulatory board.
2.27 "HEMODIALYSIS SERVICES" means services rendered by a Medicare
certified hemodialysis provider. Hemodialysis Services include
facility charges, use of facility equipment and supplies, laboratory
tests and drugs administered in conjunction with on-site treatment.
2.28 "HMO-USA" means a nationwide network of Blue Cross and Blue Shield
Plan HMOs (Participating Plans) sponsored by Blue Cross and Blue
Shield Association (BCBSA). BCBSA Participating Plan HMOs have entered
into Agreements to provide each other's members with guest
memberships, urgent care and Emergency care, routine care, and
follow-up care as preapproved and authorized by BLUE CROSS when the
member is traveling away from his or her Home HMO-USA participating
plan.
2.29 "HOME HMO" means the participating plan in which a HMO-USA
participating plan member is enrolled.
2.30 "HOSPICE SERVICES" means services rendered to terminally ill patients,
by a Medicare certified hospice provider that are (a) covered by a
Benefit Agreement and (b) ordered or authorized by PARTICIPATING
MEDICAL GROUP.
2.31 "HOSPITAL SERVICES" means Medically Necessary acute and sub-acute care
inpatient and hospital outpatient services and supplies which are both
(a) covered by a Benefit Agreement, and (b) ordered or authorized by a
PARTICIPATING MEDICAL GROUP Physician. Hospital Services do not
include long-term non-acute care.
2.32 "HOST HMO" means any participating plan in whose Service Area a
HMO-USA participating plan member temporarily stays except the
member's Home HMO.
2.33 "INDEPENDENT PRACTICE ASSOCIATION" means an incorporated association
of independent physicians which has entered into an agreement with
BLUE CROSS to provide and arrange for health services to Members.
2.34 "INPATIENT HOSPITAL SERVICES" means services which include inpatient
hospital days for semi-private accommodations, or special treatment
units, or private room accommodations if specifically authorized as
Medically Necessary by PARTICIPATING MEDICAL GROUP Physician.
2.35 "MEDICALLY NECESSARY" means services or supplies which, under the
provisions of this Agreement, are determined to be:
A. Appropriate and necessary for the symptoms, diagnosis or
treatment of the medical condition;
B. Provided for the diagnosis or direct care and treatment of the
medical condition;
C. Within standards of good medical practice within the organized
medical community;
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D. Not primarily for the convenience of the Member, the Member's
physician, or another provider; and
E. The most appropriate supply or level of service which can safely
be provided. For hospital stays, this means that acute care as an
inpatient is necessary due to the kinds of services the Member is
receiving or the severity of the Member's condition, and that
safe and adequate care cannot be received as an outpatient or in
a less intensified medical setting.
2.36 "MEMBER" means a Subscriber or enrolled dependent covered by a Benefit
Agreement.
2.37 "MEMBER MONTHS" means a count that records one Member month for each
month the Member is enrolled in the CALIFORNIACARE program or the BLUE
CROSS PLUS program.
2.38 "NON-CAPITATED EXPENSES" means the actual expenses incurred by BLUE
CROSS to provide Non-Capitated Services to Members, as ordered,
authorized or referred by PARTICIPATING MEDICAL GROUP Physicians.
2.39 "NON-CAPITATED PERFORMANCE SETTLEMENT" means amount paid to
PARTICIPATING MEDICAL GROUP for managing Non-Capitated Services.
2.40 "NON-CAPITATED PERFORMANCE SETTLEMENT SCHEDULE" means a schedule of
PMPM Non-Capitated Performance Settlement amounts associated with
varying PMPM Non-Capitated Expenses. The Non-Capitated Performance
Settlement Schedule is set forth in Exhibit F.
2.41 "NON-CAPITATED SERVICES" means the designated services set forth in
Article IX and Exhibit A-1.
2.42 "OPERATIONS MANUAL" means the CaliforniaCare PMG Operations Manual.
2.43 "OTHER PAYOR" means persons or entities utilizing the BLUE CROSS
Managed Care Network pursuant to an agreement with BLUE CROSS,
including without limitation, other Blue Cross and/or Blue Shield
Plans, self-administered or self-insured programs providing health
care benefits, or employers or insurers.
2.44 "OUT-OF-AREA EMERGENCY SERVICES" means Emergency services which are
rendered to a Member at a distance of more than twenty (20) mile
radius from the medical offices of PARTICIPATING MEDICAL GROUP or the
Satellite Facility to which the Member is assigned. When PARTICIPATING
MEDICAL GROUP is organized as an Independent Practice Association,
Out-of-Area Emergency Services are those Emergency services which are
rendered to a Member at a distance of more than twenty (20) mile
radius from a hospital designated in Exhibit B as a Service Area
hospital. Out-of-Area Emergency Services shall also include Out of
Area urgently needed services to prevent serious deterioration of a
Member's health resulting from unforeseen illness or injury for which
treatment cannot be delayed until the Member returns to the Service
Area.
2.45 "OUTPATIENT HOSPITAL SERVICES" means services which include the
facility component of outpatient surgery, pre-admission testing,
laboratory and radiology services.
2.46 "OUTPATIENT PRESCRIPTION DRUG EXPENSE" means the benefit amount paid
by BLUE CROSS for a Member's covered outpatient prescription drugs.
2.47 "OUTPATIENT PRESCRIPTION DRUG SETTLEMENT" means an amount paid to
PARTICIPATING MEDICAL GROUP for managing Outpatient Prescription Drug
Expenses.
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2.48 "OUTPATIENT PRESCRIPTION DRUG SETTLEMENT SCHEDULE" means a schedule of
outpatient prescription drug settlement amounts associated with
varying Per Member per Month Outpatient Prescription Drug Expenses.
The Schedule is set forth in Exhibit H.
2.49 "PARTICIPATING MEDICAL GROUP PHYSICIAN" means a duly licensed
physician who is a shareholder, partner, associate, contractor or
employee of PARTICIPATING MEDICAL GROUP.
2.50 "PER MEMBER PER MONTH (PMPM) NON-CAPITATED EXPENSE" means the average
monthly medical Non-Capitated Expense per Member attributable to the
PARTICIPATING MEDICAL GROUP.
2.51 "PER MEMBER PER MONTH (PMPM) OUTPATIENT PRESCRIPTION DRUG EXPENSE"
means the average monthly Outpatient Prescription Drug Expenses per
Member for PARTICIPATING MEDICAL GROUP's Members with outpatient
prescription drug benefits.
2.52 "PLAN FACTORS" means factors used to adjust the PARTICIPATING MEDICAL
GROUP's PMPM Non-Capitated Expense to account for cost variations
attributable to the mix of Member Benefit Agreements. The
Non-Capitated Expense Plan Factors include a durational factor for the
durational plans.
2.53 "PRIMARY CARE PHYSICIAN" means the PARTICIPATING MEDICAL GROUP
Physician responsible for coordinating and controlling the delivery of
Covered Medical Services to the Member. Primary Care Physicians
include general and family practitioners, internists and
pediatricians, and such other specialists as BLUE CROSS may approve in
writing to be designated Primary Care Physicians.
2.54 "QUALITY MANAGEMENT COMMITTEE" means a committee of physicians and
other licensed health care providers, at least fifty percent of whom
participate in CALIFORNIACARE, which meets regularly to review the
Quality Management Program.
2.55 "QUALITY MANAGEMENT PROGRAM" means a program which provides review by
physicians and other health professionals of the appropriateness and
adequacy of the delivery of health services.
2.56 "RELATED HOSPITAL SERVICES" means services rendered to Members as part
of, and concurrent with Inpatient Hospital Services, Outpatient
Hospital Services, Hemodialysis Services, Skilled Nursing Facility
Services, Alternative Birthing Center Services and Hospice Services,
including the use of facility equipment, surgical and anesthetic
supplies, oxygen and drugs except for takehome drugs, blood and blood
processing, laboratory procedures and diagnostic imaging.
2.57 "REFERRAL SERVICES" means Capitation Services which are rendered to
Members through a process established by PARTICIPATING MEDICAL GROUP.
2.58 "REGION FACTOR" means the factors used to adjust PARTICIPATING MEDICAL
GROUP's PMPM Non-Capitated Expense to account for cost variations
across BLUE CROSS' corporate regions.
2.59 "SATELLITE FACILITY" means a medical facility separate from
PARTICIPATING MEDICAL GROUP's principal place of business, which is
dependent upon, and responsible to, PARTICIPATING MEDICAL GROUP. It is
a facility that meets the CALIFORNIACARE Satellite Criteria set forth
in the Operations Manual and is approved by BLUE CROSS prior to being
designated a CALIFORNIACARE Satellite Facility.
6
2.60 "SERVICE AREA" means the geographical area within a thirty (30) mile
radius of the medical offices of PARTICIPATING MEDICAL GROUP or any
Satellite Facility to which the Member is assigned, or, in the case of
an Independent Practice Association, the medical office of the
PARTICIPATING MEDICAL GROUP Physician. The designation of a particular
geographical area shall not be construed as giving PARTICIPATING
MEDICAL GROUP an exclusive right to that Service Area.
2.61 "SKILLED NURSING FACILITY SERVICES" means inpatient and related
services provided by a licensed skilled nursing facility. Skilled
Nursing Facility Services excludes custodial care.
2.62 "STOP-LOSS FACTOR" means the factor used to adjust the PARTICIPATING
MEDICAL GROUP's PMPM Non-Capitated Expense to account for cost
variations due to different Case Management Stop-Loss thresholds.
2.63 "SUBSCRIBER" means an individual who has qualified for and is covered
under a Benefit Agreement.
2.64 "URGENT CARE CENTER" is a facility that meets CALIFORNIACARE's Urgent
Care Center criteria as set forth in the Operations Manual, and is
approved by BLUE CROSS prior to being designated as a CALIFORNIACARE
Urgent Care Center.
2.65 "UTILIZATION MANAGEMENT PROGRAM" means a program approved by BLUE
CROSS and designed to review and manage the utilization of Covered
Medical Services.
III. RELATIONSHIP BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP
3.01 BLUE CROSS and PARTICIPATING MEDICAL GROUP are independent entities.
Nothing in this Agreement shall be construed, or be deemed to create,
a relationship of employer and employee or principal and agent, or any
relationship other than that of independent parties contracting with
each other solely for the purpose of carrying out the provisions of
this Agreement.
3.02 BLUE CROSS and PARTICIPATING MEDICAL GROUP agree that PARTICIPATING
MEDICAL GROUP Physicians shall maintain a physician-patient
relationship with each Member assigned to PARTICIPATING MEDICAL GROUP.
PARTICIPATING MEDICAL GROUP shall be solely responsible to the Member
for treatment and medical care with respect to the provision of
Capitation Services and arrangements for Non-Capitated Services.
3.03 Except as specifically provided herein, nothing in this Agreement is
intended to be construed, or be deemed to create, any rights or
remedies in any third party, including, but not limited to, a Member
or a provider of services, other than PARTICIPATING MEDICAL GROUP.
3.04 PARTICIPATING MEDICAL GROUP consents to the memorializing of its legal
obligations with BLUE CROSS and each particular Affiliate in one or
more separate written agreements that shall not alter the substance of
those obligations.
3.05 PARTICIPATING MEDICAL GROUP agrees that each arrangement by which
PARTICIPATING MEDICAL GROUP performs services for Covered Persons that
utilize the BLUE CROSS Managed Care Network shall constitute an
independent legal relationship between PARTICIPATING MEDICAL GROUP and
that Affiliate or Other Payor.
7
3.06 PARTICIPATING MEDICAL GROUP hereby expressly acknowledges its
understanding that this Agreement constitutes a contract between
PARTICIPATING MEDICAL GROUP and BLUE CROSS as an independent
corporation, operating under a license with the Blue Cross and Blue
Shield Association, an association of independent Blue Cross and Blue
Shield Plans (the "Association"), permitting BLUE CROSS to use the
Blue Cross service xxxx in the State of California and that BLUE CROSS
is not contracting as the agent of the Association. PARTICIPATING
MEDICAL GROUP further acknowledges and agrees that it has not entered
into this Agreement based upon representations by any person other
than BLUE CROSS and that no person, entity, or organization other than
BLUE CROSS, or the applicable Affiliate, shall be held accountable or
liable to PARTICIPATING MEDICAL GROUP for any of BLUE CROSS', or the
applicable Affiliate's, obligations to PARTICIPATING MEDICAL GROUP
created under this Agreement. This section shall not create any
additional obligations whatsoever on the part of BLUE CROSS, other
than those obligations created under other provisions of this
Agreement.
IV. PARTICIPATING MEDICAL GROUP SERVICES AND RESPONSIBILITIES
PARTICIPATING MEDICAL GROUP and PARTICIPATING MEDICAL GROUP Physicians
agree as follows:
4.01 Provision of Services.
A. To promptly provide, arrange through referral, or authorize all
Capitation Services, and to authorize or arrange for the
provision of all Non-Capitated Services, and further, to accept
full financial responsibility for all Capitation Services
provided, authorized or arranged through referral, by
PARTICIPATING MEDICAL GROUP in accordance with the provisions of
this Agreement.
B. To provide a Primary Care Physician selected by the Member to
oversee the continuity of care for each Member who appears on
PARTICIPATING MEDICAL GROUP'S Eligibility Report.
C. To maintain a sufficient number of Primary Care Physicians to
guarantee that there is the equivalent of at least one full-time
Primary Care Physician to each [ ** ] Members served by
PARTICIPATING MEDICAL GROUP. All Primary Care Physicians shall
be PARTICIPATING MEDICAL GROUP Physicians.
D. To assure that privileges of PARTICIPATING MEDICAL GROUP
Physicians at CALIFORNIACARE Hospitals shall be adequate to meet
the requirements for the CALIFORNIACARE Hospital Services to
which Members are entitled under the terms of the Benefit
Agreement(s).
E. To engage the Referral Services of duly licensed board certified
consultants, specialists and duly certified allied health
professionals, responsible for delivering Covered Medical
Services to Members. A list of all referral physicians to whom
PARTICIPATING MEDICAL GROUP refers Members for Referral Services
shall be provided to BLUE CROSS upon request.
F. To ensure that all PARTICIPATING MEDICAL GROUP Physicians and all
PARTICIPATING MEDICAL GROUP employees responsible for delivering
Covered Medical Services to Members, continually meet all
applicable federal and state laws and regulations and all legal
standards of care.
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G. That if BLUE CROSS determines in good faith that any
PARTICIPATING MEDICAL GROUP Physician(s):
(1) does not meet the requirements specified herein; or
(2) that the health, safety or welfare of Members is jeopardized
by continuation of any PARTICIPATING MEDICAL GROUP Physician
to provide services to Members; or
(3) if PARTICIPATING MEDICAL GROUP Physician(s) furnishes false,
incomplete, or inaccurate information to BLUE CROSS in the
application to participate; or
(4) at any time during the term of this Agreement, a
PARTICIPATING MEDICAL GROUP Physician(s) suffers revocation,
termination or suspension of Physician's medical license or
medical staff privileges; or
(5) the ability of the PARTICIPATING MEDICAL GROUP Physician(s)
to perform the services covered by this Agreement is
otherwise impaired;
PARTICIPATING MEDICAL GROUP warrants that upon written request of
BLUE CROSS said PARTICIPATING MEDICAL GROUP Physician(s) shall be
excluded from providing services to Members under this Agreement.
PARTICIPATING MEDICAL GROUP and PARTICIPATING MEDICAL GROUP
Physician(s) may present to BLUE CROSS for further consideration
any additional information or explanation regarding PARTICIPATING
MEDICAL GROUP Physician's compliance with the requirements set
forth herein. However, BLUE CROSS retains the right to make the
final decision regarding a PARTICIPATING MEDICAL GROUP
Physician's participation under this Agreement.
4.02 Accessibility and Continuity of Care.
A. To promptly provide or arrange for available and accessible
Covered Medical Services for each Member assigned to
PARTICIPATING MEDICAL GROUP, in accordance with that Member's
Benefit Agreement and this Agreement, and to provide those
services in and through facilities designated in Exhibit J
(incorporated by reference herein).
B. That all Covered Medical Services, (including consultation and
Referral Services), ambulatory care services, diagnostic
laboratory, diagnostic imaging and therapeutic radiology
services, home health services and preventive health services,
shall be available to Members a minimum of forty (40) hours per
week, except for weeks including holidays. The foregoing services
shall be available beyond normal business hours during additional
hours to be scheduled by PARTICIPATING MEDICAL GROUP.
C. To promptly provide, arrange or authorize all Emergency services
for each Member assigned to PARTICIPATING MEDICAL GROUP.
Authorization of any Emergency services, as set forth in Section
2.23 herein, shall not be withheld by PARTICIPATING MEDICAL GROUP
regardless of whether PARTICIPATING MEDICAL GROUP is notified
within forty eight (48) hours from the time such Emergency
services were rendered. PARTICIPATING MEDICAL GROUP shall comply
with all requirements set forth in California Health and Safety
Code Section 1371.4(a) - (d).
D. That PARTICIPATING MEDICAL GROUP shall manage and facilitate
access to Emergency services within a twenty (20) mile radius of
each Satellite Facility and PARTICIPATING MEDICAL GROUP's main
facility at all times, twenty-four (24) hours a day, seven (7)
days a week. In the event that PARTICIPATING MEDICAL GROUP is an
Independent Practice Association, PARTICIPATING MEDICAL GROUP
shall manage and facilitate access to Emergency services within a
twenty (20) mile radius of the Hospital(s) designated in Exhibit
B (incorporated by reference herein) as the CALIFORNIACARE
Hospital(s) within PARTICIPATING MEDICAL GROUP's Service Area.
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E. To admit, or authorize admission of, Members solely to the
CALIFORNIACARE Hospitals listed in Exhibit B, except (a) when
Medically Necessary in an Emergency situation or (b) when Covered
Medical Services are not available in a CALIFORNIACARE Hospital
or (c) as otherwise required under Section 4.02F or (d) when
requested to do so in writing by the Member, with the written
understanding that admission to a hospital, other than those
listed in Exhibit B, is not a Covered Medical Service, except as
stated above in this Section 4.02E.
F. Notwithstanding Section 4.02E, for those Members that require
transplant services (solid organ and bone marrow/stem cell) that
are Covered Medical Services, PARTICIPATING MEDICAL GROUP agrees
to admit, or authorize the inpatient admission or outpatient
treatment of Members, solely at those CALIFORNIACARE Hospitals
whose transplant programs have been approved by BLUE CROSS and
identified as such in the Operations Manual.
PARTICIPATING MEDICAL GROUP will provide notification to BLUE
CROSS of all potential transplant cases, including deferred or
denied cases, when such cases are considered by PARTICIPATING
MEDICAL GROUP's Utilization Management Program Committee or other
similar PARTICIPATING MEDICAL GROUP functional committee, except
for Emergencies, in which case PARTICIPATING MEDICAL GROUP shall
provide notification within two (2) business days of the
admission. The format of such notification is provided in the
Operations Manual.
G. That in circumstances where a Member requires specialized
tertiary care or because of bed unavailability in a
CALIFORNIACARE Hospital, the Member must be admitted to a
non-CaliforniaCare in-area or out-of-area facility for Hospital
Services, then until the Member is transferred to a
CALIFORNIACARE Hospital, the PARTICIPATING MEDICAL GROUP will be
financially responsible for care the same as if care had been
provided in a CALIFORNIACARE Hospital, and the Non-Capitated
Services arrangement as set forth in Article IX. of this
Agreement will apply.
H. To use a referral request process by which Capitation Services
are to be rendered by Health Professionals other than the
Member's Primary Care Physician, including PARTICIPATING MEDICAL
GROUP Physicians or other Health Professionals who do not belong
to PARTICIPATING MEDICAL GROUP. This process shall assure that:
(1) All Health Professionals who provide Referral Services
follow appropriate billing procedures.
(2) That the Health Professional must look only to PARTICIPATING
MEDICAL GROUP for payment of Covered Medical Services and
shall not xxxx the Member, except for applicable co-payments
and for non-Covered Medical Services.
(3) Primary Care Physicians who determine that a referral is
necessary, may issue a referral without the prior
authorization of PARTICIPATING MEDICAL GROUP's Utilization
Management Program to physicians in the following
specialties: Cardiology, Dermatology, Endocrinology, Ear,
Nose and Throat, Gastroenterology, General Surgery,
Hematology, Neurology, Obstetrics-Gynecology, Oncology,
Ophthalmology, Orthopedic Surgery, Podiatry, Routine
Laboratory, Routine X-ray and Urology.
(4) For referrals to specialists or providers, or services other
than those listed in (3) above, PARTICIPATING MEDICAL GROUP
shall review and issue an authorization or denial of a
request for referral within five (5) business days of
receipt of such request or admission to hospital.
I. That visits to the Member's home within the PARTICIPATING MEDICAL
GROUP Service Area, by a Primary Care Physician, shall occur as
necessary within that Physician's discretion.
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J. To assure that Members shall not be subject to discrimination in
access to Covered Medical Services.
K. That PARTICIPATING MEDICAL GROUP facilities shall be reasonably
accessible to the physically handicapped.
L. To provide health education and wellness programs for Members
within the guidelines indicated in the "CaliforniaCare Health
Education and Wellness Manual." Programs are to be delivered in
accordance with these guidelines which provide for disease
prevention and management and the promotion of healthier
life-styles.
4.03 Utilization/Quality Management and Grievance Procedures.
To cooperate with BLUE CROSS' administration of its internal quality
of care review and grievance procedures. The parties acknowledge and
agree that authority to perform Utilization Management Program
activities and Quality Management Program activities under this
Agreement is a delegation of BLUE CROSS authority pursuant to Sections
1370 and 1370.1 of the Health and Safety Code, and all or part of this
authority may be revoked at any time. The scope of delegated authority
shall be as set forth in the Utilization Management Program guidelines
and the Quality Management Program guidelines issued by BLUE CROSS and
provided to PARTICIPATING MEDICAL GROUP. The proceedings of the
Utilization Management and Quality Management Committees shall be
strictly confidential between BLUE CROSS and PARTICIPATING MEDICAL
GROUP and are subject to the protections set forth in Sections 1370
and 1370.1.
4.04 Quality Management Program.
To adopt and maintain a Quality Management Program consistent with
BLUE CROSS standards and approved by BLUE CROSS. This program will
cover all Covered Medical Services provided or arranged by
PARTICIPATING MEDICAL GROUP for Members. PARTICIPATING MEDICAL GROUP
agrees to allow on-site review of its Quality Management Program by
BLUE CROSS staff.
A. The Quality Management Program shall:
(1) Provide for Quality Management review by PARTICIPATING
MEDICAL GROUP Physicians and other Health Professionals.
(2) Provide for review of all services provided to Members by
PARTICIPATING MEDICAL GROUP.
(3) Stress health outcomes by providing health education and
wellness programs for Members.
B. The Quality Management Program shall include, but not be limited
to the following activities:
(1) Credentialing and recredentialing of all PARTICIPATING
MEDICAL GROUP Physicians and allied Health Professional
providers.
(2) Credentialing and recredentialing of all Health
Professionals or providers under contract with or employed
by PARTICIPATING MEDICAL GROUP.
(3) Incident identification and risk management.
(4) Member grievance resolution.
(5) General and focused health care audits.
(6) Development and implementation of appropriate
recommendations.
11
(7) Documentation of remedial procedures for instances of
inappropriate or substandard service(s) and/or failure to
provide needed Medically Necessary Covered Medical
Service(s).
C. BLUE CROSS shall validate PARTICIPATING MEDICAL GROUP's
development and implementation of the Quality Management Program
through regular audit activities as follows:
(1) The CALIFORNIACARE Quality Management Department shall
review PARTICIPATING MEDICAL GROUP's Quality Management
Program on an annual basis through a scheduled on-site
audit.
(2) The CALIFORNIACARE Quality Management Representative shall
notify PARTICIPATING MEDICAL GROUP of any deficiencies or
areas needing improvement.
(3) PARTICIPATING MEDICAL GROUP shall take corrective action to
eliminate any deficiencies in areas needing improvement
within a reasonable period of time.
(4) BLUE CROSS shall conduct follow-up reviews as necessary.
D. PARTICIPATING MEDICAL GROUP shall:
(1) Make available to BLUE CROSS summaries of all minutes and
notes from any and all Quality Management Committees and/or
activities which specifically relate to Members.
(2) Provide BLUE CROSS with access to all PARTICIPATING MEDICAL
GROUP Quality Management data directly or indirectly
relating to Members.
(3) Make available to BLUE CROSS all composite Quality
Management Program data which include Members in the
composite data set and provide such detail as is available
regarding those Members.
(4) Make known to BLUE CROSS any and all adverse actions taken
against a PARTICIPATING MEDICAL GROUP Physician when such
action is the result of deficiencies in quality of medical
care.
(5) Provide the CALIFORNIACARE Medical Director (or the Medical
Director's clinical designee) with a schedule designating
the time and place of all Quality Management Committee
meetings that relate to Members, in order that he or she
shall, in the Medical Director's discretion, attend. The
CALIFORNIACARE Medical Director shall notify the
PARTICIPATING MEDICAL GROUP in advance of his or her
attendance and shall not be excluded from any deliberation
on activities related to Members.
(6) Permit BLUE CROSS to evaluate and utilize the data obtained
from the CALIFORNIACARE Quality Management Program in a
manner that satisfies BLUE CROSS' requirements for quality
assurance, for BLUE CROSS internal use only.
(7) Implement any necessary changes in procedures, in order to
fully comply with all quality assurance standards, as
mutually agreed by the parties, and provide BLUE CROSS with
the minutes of Quality Management Committee meetings and
reviews that relate to Members.
(8) Report to BLUE CROSS quarterly on activities or actions of
PARTICIPATING MEDICAL GROUP's Quality Management Committee
as such activities or actions relate to Members.
4.05 Utilization Management Program.
To adopt and maintain a Utilization Management Program consistent with
BLUE CROSS standards and approved by BLUE CROSS. This program will
cover all Covered Medical Services provided or arranged by
PARTICIPATING MEDICAL GROUP for Members. PARTICIPATING MEDICAL GROUP
agrees to allow on-site review of Utilization Management Program by
BLUE CROSS.
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A. The Utilization Management Program shall:
(1) Include the development and implementation of appropriate
recommendations.
(2) Include documentation of remedial procedures for instances
of inappropriate or substandard services(s) and or failure
to provide Medically Necessary Covered Medical Services.
(3) Assure that PARTICIPATING MEDICAL GROUP's primary
consideration is the quality of services rendered to
Members.
(4) Assure that all services provided to Members are Medically
Necessary.
(5) Work closely with CALIFORNIACARE Hospitals.
(6) Encompass inpatient, outpatient, and ancillary care.
(7) Utilize prospective, concurrent, and retrospective review.
(8) Assure that all adverse utilization review decisions are
made by a licensed physician, and no denial of a requested
service shall be made except by a licensed physician,
experienced in the area being reviewed. Denial decisions
shall be provided to Members in writing.
(9) Permit BLUE CROSS to have access to all PARTICIPATING
MEDICAL GROUP Utilization Management data directly or
indirectly relating to Members.
B. BLUE CROSS shall validate PARTICIPATING MEDICAL GROUP's
development and implementation of the Utilization Management
Program through regular audit activities as follows:
(1) The CALIFORNIACARE Quality Management Department shall
review PARTICIPATING MEDICAL GROUP' Utilization Management
Program on an annual basis through a scheduled on-site
audit.
(2) The CALIFORNIACARE Quality Management Representative shall
notify PARTICIPATING MEDICAL GROUP of any deficiencies or
areas needing improvement.
(3) PARTICIPATING MEDICAL GROUP shall take corrective action to
eliminate any deficiencies in areas needing improvement
within a reasonable period of time.
(4) BLUE CROSS shall conduct follow-up reviews as necessary.
C. PARTICIPATING MEDICAL GROUP shall:
(1) Make available to BLUE CROSS summaries of all minutes and
notes from any and all Utilization Management Committees
and/or activities which relate to Members.
(2) Make available to BLUE CROSS upon request all composite
Utilization Management data which include Members in the
composite data set and provide such detail as is available
regarding those Members.
(3) Provide the CALIFORNIACARE Medical Director (or the Medical
Director's clinical designee) with a schedule designating
the time and place of all Utilization Management Committee
meetings that relate to Members, in order that he or she
shall, in the Medical Director's discretion, attend. The
CALIFORNIACARE Medical Director shall notify the
PARTICIPATING MEDICAL GROUP in advance of his or her
attendance and shall not be excluded from any deliberation
on activities related to Members.
4.06 Records and Reserves.
A. BLUE CROSS shall have access at reasonable times upon demand to
the books, records and papers of PARTICIPATING MEDICAL GROUP
relating to the services PARTICIPATING MEDICAL GROUP provides to
Members, to the cost thereof, and to payments PARTICIPATING
MEDICAL GROUP receives from Members or others on their behalf.
PARTICIPATING MEDICAL GROUP shall maintain such records and
provide such information to BLUE CROSS and the Commissioner of
Corporations as may be necessary
13
for BLUE CROSS' compliance with the requirements of the
Xxxx-Xxxxx Act. PARTICIPATING MEDICAL GROUP shall maintain such
records for at least five (5) years, and such obligations shall
not be terminated upon a termination of this Agreement, whether
by rescission or otherwise.
B. PARTICIPATING MEDICAL GROUP agrees to provide BLUE CROSS with
audited financial statements of PARTICIPATING MEDICAL GROUP no
later than three (3) months after the end of its fiscal year, and
BLUE CROSS shall maintain strict confidentiality of said records.
Audited financial statements shall illustrate net operating
surplus or profit (after taxes). Documents shall include the
following:
(1) Balance sheets
(2) Statements of revenues and expenses
(3) Statements of cash flow
PARTICIPATING MEDICAL GROUP further agrees that BLUE CROSS shall
have the right to require audited financial statements, in
addition to the latest fiscal year, at any time, upon request,
with reasonable notice, if BLUE CROSS pays for the audit.
C. To maintain financial reserves adequate to cover all risks
assumed by PARTICIPATING MEDICAL GROUP hereunder, including, but
not limited to, unanticipated claims for Referral Services that
are the potential responsibility of PARTICIPATING MEDICAL GROUP.
D. That all information shall be provided to each party to this
Agreement pursuant to procedures designed to protect the
confidentiality of patient medical records in accordance with
applicable legal requirements, recognized standards of
professional practice and generally accepted procedures followed
by health maintenance organizations (HMOs).
E. Upon termination of this Agreement, PARTICIPATING MEDICAL GROUP
shall, upon advance written notice from BLUE CROSS, make
available to BLUE CROSS and permit BLUE CROSS to copy the medical
records of each Member who has been assigned to PARTICIPATING
MEDICAL GROUP.
4.07 Insurance Programs or Policies.
PARTICIPATING MEDICAL GROUP agrees to maintain professional liability
insurance, or other risk protection program, acceptable as defined
under A. and B. below to BLUE CROSS. Notification by PARTICIPATING
MEDICAL GROUP of cancellation or material modification of the coverage
under such professional liability insurance or other risk protection
program is to be made to BLUE CROSS within thirty (30) days prior to
any cancellation or modification. Copies of the agreements or
documents evidencing professional liability insurance or other risk
protection required under this section shall be provided to BLUE CROSS
upon execution of this Agreement.
A. PROFESSIONAL LIABILITY INSURANCE
The coverage to be provided under this section shall be in
minimum amounts of ONE MILLION DOLLARS ($1,000,000.00) for any
one (1) incident, THREE MILLION DOLLARS ($3,000,000.00) annual
aggregate. PARTICIPATING MEDICAL GROUPs which are organized as
Independent Practice Associations shall ensure that PARTICIPATING
MEDICAL GROUP Physicians maintain professional liability
insurance in minimum amounts of ONE MILLION DOLLARS
($1,000,000.00) for any one incident and THREE MILLION DOLLARS
($3,000,000.00) annual aggregate. Furthermore, PARTICIPATING
MEDICAL GROUPS organized as Independent Practice Associations
shall maintain directors and
14
officers liability in minimum amounts of ONE MILLION DOLLARS
($1,000,000.00) for any one incident, ONE MILLION DOLLARS
($1,000,000.00) annual aggregate.
B. OTHER INSURANCE
(1) GENERAL LIABILITY INSURANCE. In addition to Subsection A.,
above, PARTICIPATING MEDICAL GROUP shall also maintain a
policy or program of comprehensive general liability
insurance (or other risk protection) with minimum coverage
including no less than ONE HUNDRED THOUSAND DOLLARS
($100,000.00) for PARTICIPATING MEDICAL GROUP's property,
together with combined single limit bodily injury and
property damage insurance of not less that SIX HUNDRED
THOUSAND DOLLARS ($600,000.00).
(2) WORKERS' COMPENSATION. PARTICIPATING MEDICAL GROUP's
employees shall be covered by Workers' Compensation
Insurance in an amount and form meeting all requirements of
applicable provisions of the CALIFORNIA LABOR CODE.
4.08 Administrative Responsibilities.
A. To comply with all CALIFORNIACARE administrative policies and
procedures in the areas listed in Exhibit C (incorporated by
reference herein) and as set forth in the Operations Manual
(incorporated by reference herein) and to comply with all
applicable state and federal laws and regulations relating to the
delivery of Covered Medical Services.
B. To provide a CALIFORNIACARE Coordinator who will create a liaison
with BLUE CROSS and assist Members in accordance with the
procedures set forth in the Operations Manual, and who will be
available to Members during all regular office hours of
PARTICIPATING MEDICAL GROUP for the purpose of assisting Members
to resolve any problems which may arise or be perceived by the
Member.
C. To notify BLUE CROSS within Fifteen (15) days concerning:
(1) Any material change in the bylaws, membership, ownership or
officers of PARTICIPATING MEDICAL GROUP which might affect
BLUE CROSS or this Agreement.
(2) Any legal or governmental action initiated against a
PARTICIPATING MEDICAL GROUP Physician or against
PARTICIPATING MEDICAL GROUP which might affect BLUE CROSS or
this Agreement including, but not limited to, any change in
PARTICIPATING MEDICAL GROUP Physician(s) licensure,
insurance, certification, malpractice, disciplinary
experience or physical or mental health status.
(3) Any other situation that may interfere with PARTICIPATING
MEDICAL GROUP's or PARTICIPATING MEDICAL GROUP Physician's
duties and obligations under this Agreement.
D. To obtain BLUE CROSS' prior written approval for any literature
related to CALIFORNIACARE and intended for Members.
E. To continually meet all criteria for PARTICIPATING MEDICAL
GROUPS, set forth in the Operations Manual, and to continually
meet all criteria for Satellite Facilities (if applicable) set
forth in the Operations Manual.
15
F. To provide BLUE CROSS, on a monthly basis, all ambulatory
encounter data either directly or through PARTICIPATING MEDICAL
GROUP's billing agent in the file format as shown in the
Operations Manual.
G. To comply with BLUE CROSS programs related to the management of
pharmaceutical expenses.
H. That all financial terms of this Agreement shall be and remain
confidential and shall not be disclosed to any third party,
except as required by law or as required to supply information
required by any financial institution.
4.09 Payments and Member Billing.
A. To accept the monthly Capitation payment from BLUE CROSS as
payment in full for Capitation Services (including all Referral
Services) provided or arranged hereunder, and not to seek
additional payments or compensation from Members for Covered
Medical Services. The foregoing restriction shall not apply to
co-payments, which may be collected by PARTICIPATING MEDICAL
GROUP in accordance with the applicable provisions of the Benefit
Agreement(s), nor shall it apply to xxxxxxxx and collections with
respect to non-Covered Medical Services rendered to Members by
PARTICIPATING MEDICAL GROUP. However, to the extent that the
PARTICIPATING MEDICAL GROUP's billing office is aware of the
Member's payment responsibility, PARTICIPATING MEDICAL GROUP
agrees to advise the Member of that payment responsibility prior
to rendering any service requiring a co-payment, or any
non-Covered Medical Service.
If PARTICIPATING MEDICAL GROUP should receive any surcharge or
payment from a Member, in addition to those permissible charges
set forth above, PARTICIPATING MEDICAL GROUP shall promptly
refund the full amount thereof to the Member.
B. To never charge any Member for any health service which has been
deemed not Medically Necessary or not appropriate after
utilization review by PARTICIPATING MEDICAL GROUP, unless the
Member specifically requests the service and acknowledges in
writing that the service is not a Covered Medical Service under
the Member's Benefit Agreement.
C. That BLUE CROSS and PARTICIPATING MEDICAL GROUP respectively
acknowledge that the authority and responsibility for
coordination of benefits shall be carried out in accordance with
the provisions set forth in the Benefit Agreements and the
Operations Manual.
D. That PARTICIPATING MEDICAL GROUP shall promptly notify, in
writing, the CALIFORNIACARE Case Management Department of all
cases that reach the Enrollment Protection or Case Management
Stop-Loss levels specified herein.
E. To pay all Health Professionals and hospitals who have rendered
authorized Referral Services or Out-of-Area Emergency Services to
Members, within forty-five (45) working days following receipt of
a clean, undisputed claim, consistent with the regulations of the
Commissioner of Corporations governing BLUE CROSS.
4.10 Membership.
A. To accept any and all Members who select PARTICIPATING MEDICAL
GROUP until such time as PARTICIPATING MEDICAL GROUP shall have
provided ninety (90) days prior written notice to BLUE CROSS that
it has reached its maximum capacity as set forth in Section 16.08
herein, or that it anticipates reaching such maximum within
ninety (90) days from the date of the notice to BLUE CROSS. The
maximum capacity of PARTICIPATING
16
MEDICAL GROUP designated in Section 16.08 shall be reduced only
upon ninety (90) days written notice to BLUE CROSS. The parties
acknowledge their understanding that enrollment from individual
accounts, or changes in selection of PARTICIPATING MEDICAL GROUP
by Members, are not entirely within the control of BLUE CROSS.
B. That PARTICIPATING MEDICAL GROUP will not request, demand,
require or otherwise seek the transfer or removal of any Member
from the care of PARTICIPATING MEDICAL GROUP, based on that
Member's need of, or utilization of, Medically Necessary
services.
C. PARTICIPATING MEDICAL GROUP agrees that, in the event a Member
who is covered for workers' compensation benefits by a workers'
compensation carrier affiliated with BLUE CROSS, seeks services
for a work-related illness or injury, PARTICIPATING MEDICAL GROUP
shall have the option to (a) provide such Medically Necessary
medical services or (b) refer such Member to a provider that
participates in the Prudent Buyer Comp provider network or the
CalCare Comp provider network, whichever is applicable. In the
event that PARTICIPATING MEDICAL GROUP elects to treat such
Member, PARTICIPATING MEDICAL GROUP shall complete a Doctor's
First Report of Injury as defined in the California Labor Code.
As payment for such medical services rendered, PARTICIPATING
MEDICAL GROUP agrees to accept, as payment in full, compensation
in accordance with the fee schedule set forth in Exhibit E of the
Agreement (incorporated by reference herein). PARTICIPATING
MEDICAL GROUP further agrees that, in the event such Member
requires medical services in connection with such work-related
illness or injury beyond the treatment provided at the initial
visit, PARTICIPATING MEDICAL GROUP shall refer such Member only
to a provider that participates in the Prudent Buyer Comp
provider network or the CalCare Comp provider network, whichever
is applicable.
D. That unless agreed to in writing by BLUE CROSS, this Agreement
shall not apply to organized physician groups (including, but not
limited to, Independent Practice Associations) that PARTICIPATING
MEDICAL GROUP acquires, manages or affiliates with subsequent to
the effective date of this Agreement.
E. When the BLUE CROSS Managed Care Network is utilized by an
Affiliate or Other Payor, PARTICIPATING MEDICAL GROUP agrees to
provide services to Covered Persons of that Affiliate or Other
Payor in accordance with the terms of this Agreement. BLUE CROSS
shall compensate PARTICIPATING MEDICAL GROUP in accordance with
the terms of this Agreement for services provided to Covered
Persons of any such Other Payor. When an Other Payor utilizes the
Managed Care Network, such Other Payor shall comply with the
terms of this Agreement.
In the event the BLUE CROSS Managed Care Network is to be
utilized by an Other Payor that has operational requirements that
are materially different from those required under this
Agreement, BLUE CROSS agrees to notify PARTICIPATING MEDICAL
GROUP in writing thirty (30) days prior to the commencement of
such utilization. PARTICIPATING MEDICAL GROUP may decline to
provide services to such Other Payor by providing written notice
of such decision to BLUE CROSS within ten (10) days of receipt of
notice by BLUE CROSS referenced above.
17
V. BLUE CROSS SERVICES AND RESPONSIBILITIES
BLUE CROSS agrees:
5.01 To perform, or arrange for the performance of, all necessary
accounting and enrollment functions with respect to marketing and
administering the CALIFORNIACARE program, and to issue an
identification card to each Subscriber or to each Subscriber and one
additional eligible Member covered under a two-party or family
contract as described in the Operations Manual.
5.02 To provide PARTICIPATING MEDICAL GROUP with Member Eligibility
Reports, as set forth in Article VI.
5.03 That, to the extent compatible with its obligations to BLUE CROSS
hereunder, PARTICIPATING MEDICAL GROUP reserves the right to provide
professional services to persons who are not Members.
5.04 To provide PARTICIPATING MEDICAL GROUP with claims paid and
Non-Capitated Services data as described in the Operations Manual.
5.05 To make trained personnel available to PARTICIPATING MEDICAL GROUP to
assist in Quality Management activities, the establishment of
procedures for pre-admission medical review and concurrent medical
review of Members who require, or may require, hospitalization.
5.06 To notify PARTICIPATING MEDICAL GROUP of any CALIFORNIACARE Group
Benefit Agreements between BLUE CROSS and employers, government
agencies, or any other groups, which may substantially affect
enrollment at PARTICIPATING MEDICAL GROUP.
5.07 To undertake reasonable efforts, in accordance with a standard of good
faith, to assure that Members assigned to PARTICIPATING MEDICAL GROUP
will live or work within the Service Area defined in this Agreement.
However, BLUE CROSS reserves the right to assign any Members to
PARTICIPATING MEDICAL GROUP at the Member's open enrollment period, or
when the Member changes residence, or when BLUE CROSS determines such
transfer to be in the Member's best interest due to special
circumstances under the terms of the Member's Benefit Agreement.
5.08 To exercise reasonable efforts to negotiate special rates with
hospitals and other providers who contract with BLUE CROSS to render
Non-Capitated Services to Members and to pay hospitals in accord with
those agreements.
5.09 To notify and consult with PARTICIPATING MEDICAL GROUP with respect to
the development of any material changes, as determined by BLUE CROSS,
or amendments to the Benefit Agreements, and to obtain PARTICIPATING
MEDICAL GROUP's consent to changes that BLUE CROSS believes may
materially affect PARTICIPATING MEDICAL GROUP, except for changes
required by law. The foregoing consent will not be unreasonably
withheld by PARTICIPATING MEDICAL GROUP, so long as Capitation
payments are adjusted as mutually agreed to reflect any additional
services which may be required due to any amendment or change in
Member benefits.
5.10 To accept sole responsibility for filing reports, obtaining approvals,
and complying with the applicable laws and regulations of state,
federal, and other regulatory agencies having jurisdiction over BLUE
CROSS, on the condition that PARTICIPATING MEDICAL GROUP cooperates in
providing BLUE CROSS with any information and assistance reasonably
required. PARTICIPATING MEDICAL GROUP is not required to provide
information which is confidential in any other existing contract of
PARTICIPATING MEDICAL GROUP.
18
5.11 That nothing contained in this Agreement is intended to interfere with
the professional relationship between any Member and the Member's
PARTICIPATING MEDICAL GROUP Physician(s).
5.12 To collect, or arrange to have collected, all premiums, Member
payments and other items of income to which BLUE CROSS is entitled
under its group and individual contracts or otherwise, except for (a)
co-payments, (b) payments for non-Covered Medical Services, (c)
coordination of benefits payments for professional services which may
be collected by PARTICIPATING MEDICAL GROUP under the conditions set
forth in the Member's Benefit Agreement, and (d) third party liability
payments for professional services. Pursuant to the Benefit
Agreement(s) BLUE CROSS may hold a lien on third party liability
payments in the amount of benefits paid by BLUE CROSS and the value of
medical care provided under CALIFORNIACARE for the treatment of the
illness, injury or condition for which a third party is liable. BLUE
CROSS shall assign to PARTICIPATING MEDICAL GROUP that portion of any
such lien related to professional services rendered under this
Agreement by PARTICIPATING MEDICAL GROUP. PARTICIPATING MEDICAL
GROUP's methods of collection of such payments shall be conducted in a
reasonable and nonegregious manner and only proper legal procedures
may be used to enforce such payment.
5.13 To consult with PARTICIPATING MEDICAL GROUP regarding any material
changes, as determined by BLUE CROSS, in operating procedures and
policies, as set forth in the Operations Manual, and to provide
PARTICIPATING MEDICAL GROUP with an opportunity to comment on any
policy and procedural changes which may have a substantial impact on
PARTICIPATING MEDICAL GROUP.
VI. ELIGIBILITY LISTINGS
6.01 Eligibility listings of Members of employer groups who have personally
selected, or been assigned to, PARTICIPATING MEDICAL GROUP shall be
provided in the following manner:
A. BLUE CROSS shall maintain, update and distribute monthly, Member
Eligibility Reports listing the persons who are eligible to
receive Covered Medical Services during the applicable month.
B. PARTICIPATING MEDICAL GROUP shall receive a copy of the
Eligibility Reports at PARTICIPATING MEDICAL GROUP's main
site. Should PARTICIPATING MEDICAL GROUP request reports in
an electronic format, paper reports will continue to be
provided for an additional ninety (90) days only. As
described in the Operations Manual, BLUE CROSS will charge a
fee of between [ ** ] and [ ** ] per report, for each of
the following:
(1) duplicate copies of paper reports,
(2) copies of paper reports delivered in addition to reports in
electronic format after the ninety (90) day parallel
reporting period (tape, diskette, NDM or other electronic
medium),
(3) duplicate reports for prior months.
C. BLUE CROSS will discourage retroactive cancellation by an
employer group of more than ninety (90) days from BLUE CROSS'
applicable monthly billing process date. However, when no
services have been rendered, BLUE CROSS may make occasional
exceptions due to legitimate administrative processing
requirements. Notwithstanding any retroactive cancellation of a
Member by an employer group of more than ninety (90) days, BLUE
19
CROSS shall not be entitled to any refund of Capitation payments
made for such Member beyond the ninety (90) day period. BLUE
CROSS will attempt to discourage retroactively adding any Member
after the applicable billing is reconciled. In the event BLUE
CROSS finds it necessary to assign, up to ninety (90) days
retroactively, a new Member to PARTICIPATING MEDICAL GROUP,
Capitation payment for that Member shall be made, and
PARTICIPATING MEDICAL GROUP agrees to be responsible for all
Covered Medical Services due that Member under the terms of the
Member's Benefit Agreement which were provided or arranged by
PARTICIPATING MEDICAL GROUP, from the date the Member was
assigned.
D. In the event care is provided to an ineligible person, based on
an erroneous or delayed Eligibility Report, BLUE CROSS shall be
financially responsible for all care provided by PARTICIPATING
MEDICAL GROUP prior to the time PARTICIPATING MEDICAL GROUP
received notice of that person's ineligibility and, on the
condition that PARTICIPATING MEDICAL GROUP shall supply BLUE
CROSS with evidence that PARTICIPATING MEDICAL GROUP has
unsuccessfully sought payment for all or a portion of the charges
from the ineligible person, or the person having legal
responsibility for the ineligible person, through two billing
cycles, or through a period of sixty (60) days, whichever is
greater. In that event, BLUE CROSS' responsibility for physician
compensation shall be measured as set forth in Exhibit E or the
actual billed amount, whichever is less. The obligations of BLUE
CROSS unclear this Subsection D shall be conditioned upon the
exercise of prudent judgment by PARTICIPATING MEDICAL GROUP,
evidenced by reasonable efforts to contact BLUE CROSS for
verification of the eligibility of each Member prior to providing
or arranging Covered Medical Services.
VII. COMPENSATION TO PARTICIPATING MEDICAL GROUP
7.01 Exhibits D, G and G-1 (all incorporated by reference herein), set
forth Capitation payments for new and renewing business. The
applicable Capitation payment for each Member assigned to
PARTICIPATING MEDICAL GROUP, shall be paid monthly, prorated in
accordance with Member eligibility.
Such Capitation payment shall be adjusted for Member age, sex and
Benefit Agreement in accordance with age, sex and plan relativities
that have been developed by BLUE CROSS based upon actuarial
assumptions and BLUE CROSS' utilization experience. BLUE CROSS
reserves the right to adjust such relativity factors, upon contract
renewal, based upon BLUE CROSS' experience.
7.02 Capitation shall be paid in consideration for providing Capitation
Services and arranging NonCapitated Services for each Member assigned
to PARTICIPATING MEDICAL GROUP, and in consideration for all
Capitation Services arranged through referral for Members by
PARTICIPATING MEDICAL GROUP. The Capitation payment shall be made by
the tenth of each month and shall be computed on the basis of the most
current group and individual information available. In the event that
an error is made in the computation of the Capitation payment,
resulting in an overpayment or underpayment to PARTICIPATING MEDICAL
GROUP, BLUE CROSS reserves the right to adjust subsequent Capitation
payments to PARTICIPATING MEDICAL GROUP to offset such overpayment or
underpayment.
Each Capitation payment shall be accompanied by a remittance summary.
The remittance summary identifies the total Capitation amount payable,
including retroactivity and identifies those Members whose
retroactivity had a financial impact on the total Capitation payment.
A complete listing of Members that are eligible for Capitation
Services is provided in the monthly Eligibility Report, as set forth
in Article VI.
20
7.03 PARTICIPATING MEDICAL GROUP agrees that in no event shall any
allowable co-payment or reimbursement amount, or sum thereof, due
PARTICIPATING MEDICAL GROUP, exceed the cost to PARTICIPATING MEDICAL
GROUP of providing the service or item which was billed.
7.04 PARTICIPATING MEDICAL GROUP agrees to continue to provide or arrange
for all Covered Medical Services and benefits to any Member, or former
Member, who is eligible for coverage under the Extension of Benefits
provision of the Benefit Agreements, in exchange for the then current
Capitation amount per Member per month of the Benefit Agreement type
under which the Member is, or was, enrolled. Under the circumstances
described in this Section 7.04 BLUE CROSS shall be financially
responsible for Non-Capitated Services.
7.05 PARTICIPATING MEDICAL GROUP agrees to be responsible for professional
and technical charges, as described in Exhibit A-1 (incorporated by
reference herein), for laboratory, radiology and diagnostic testing
procedures and diagnostic imaging examinations rendered to Members, as
a part of, and concurrent with benefits set forth in this Agreement,
whether billed by the hospital or by a qualified health professional
7.06 In the event a referral provider has not been reimbursed for
authorized Referral Services or that any other provider has not been
reimbursed by PARTICIPATING MEDICAL GROUP as required under their
agreement for services provided to Members within forty-five (45)
working days following receipt of a clean, undisputed claim, then
after notice BLUE CROSS shall have the option to pay a clean and
uncontested claim and deduct such payment (including any interest
payable under Health & Safety Code Section 1371), plus an
administrative charge equal to [ ** ] of the claim amount,
from any money due from BLUE CROSS to PARTICIPATING MEDICAL GROUP. If
a total of five (5) or more instances occur where any provider
associated with PARTICIPATING MEDICAL GROUP bills a Member in
violation of this Agreement during any calendar year, BLUE CROSS may,
in its sole discretion, suspend the assignment of new Members to
PARTICIPATING MEDICAL GROUP until such time as PARTICIPATING MEDICAL
GROUP has rectified the problem to BLUE CROSS' satisfaction.
VIII. ENROLLMENT PROTECTION
8.01 Enrollment Protection is a program designed to limit PARTICIPATING
MEDICAL GROUP's liability for Capitation Services expense.
8.02 For PARTICIPATING MEDICAL GROUPs with less than [ ** ] Members, on
the effective date of this Agreement, the liability of PARTICIPATING
MEDICAL GROUP for expenses for Capitation Services rendered to any
single Member during the calendar year shall be limited to the first
[ ** ] of such expenses.
8.03 If PARTICIPATING MEDICAL GROUP's assigned CALIFORNIACARE and BLUE
CROSS PLUS enrollment is [ ** ] or more Members, on the effective
date of this Agreement, PARTICIPATING MEDICAL GROUP agrees to accept
risk under either Subsection A or Subsection B, as indicated below.
A. The liability of PARTICIPATING MEDICAL GROUP for expenses for
Capitation Services rendered to any single Member during the
calendar year, shall be limited to the first [ ** ] of
Capitation Services expenses, which have been incurred by
PARTICIPATING MEDICAL GROUP for that Member, or
21
B. The liability of PARTICIPATING MEDICAL GROUP for expenses for
Capitation Services rendered to any single Member during the
calendar year, shall be limited to the first [ ** ] of
Capitation Services expenses which have been incurred by
PARTICIPATING MEDICAL GROUP for that Member.
PARTICIPATING MEDICAL GROUP hereby elects to accept risk pursuant
to Section 8.03.
/ / A. / / B. (Check one).
8.04 Notwithstanding Section 8.02 or 8.03 above, the liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services for
Members who have been diagnosed as having Acquired Immune Deficiency
Syndrome (AIDS) shall be limited to [ ** ] for any Member who has
been diagnosed as having AIDS according to the most current criteria
established by the Center for Disease Control (CDC) at the time of
the diagnosis.
8.05 The total expenses of PARTICIPATING MEDICAL GROUP for Capitation
Services rendered to any single Member during the calendar year shall
be calculated according to the fee schedule set forth in Exhibit E. In
the event the foregoing calculation for any given procedure results in
a figure greater than the actual cost of the procedure as billed by a
third party, then the actual cost for that procedure shall be deemed
to be the amount actually paid by PARTICIPATING MEDICAL GROUP.
8.06 Expenses in connection with the following services shall not be
included as Capitation Services expenses incurred by PARTICIPATING
MEDICAL GROUP in reaching the Enrollment Protection level:
A. Services rendered in connection with Workers' Compensation cases.
B. Services for which payment is obtained from third-party sources.
C. Services for which payment is obtained from BLUE CROSS through
any coverage other than CALIFORNIACARE.
All co-payments applicable to Capitation Services rendered to Members
shall be subtracted from Capitation Services expenses. When the
PARTICIPATING MEDICAL GROUP is capitated by two coverages for one
Member, the PARTICIPATING MEDICAL GROUP agrees to coordinate all
related co-payments under the Coordination of Benefits rules in the
Member's Benefit Agreement.
8.07 PARTICIPATING MEDICAL GROUP shall maintain records necessary to
evidence having reached the Enrollment Protection level. After
reaching the Enrollment Protection level with regard to any Member,
during the remainder of the calendar year PARTICIPATING MEDICAL GROUP
shall xxxx BLUE CROSS for [ ** ] of services rendered, or provided,
to that Member by PARTICIPATING MEDICAL GROUP, calculated in
accordance with Sections 8.02, 8.03, 8.04, 8.05 and 8.06.
Reimbursement to PARTICIPATING MEDICAL GROUP for Enrollment
Protection shall be made by BLUE CROSS in accordance with the lesser
of actual billed charges or the fee schedule set forth in Exhibit E,
on a monthly basis, within forty-five (45) working days of submission
of complete and accurate documentation by PARTICIPATING MEDICAL GROUP.
Services which are not set forth in Exhibit E shall be reimbursed by
BLUE CROSS at the actual charges paid by PARTICIPATING MEDICAL GROUP.
22
8.08 PARTICIPATING MEDICAL GROUP and BLUE CROSS acknowledge and agree that
PARTICIPATING MEDICAL GROUP limitations of liability as set forth in
this Article VIII shall be conditioned upon submission of clean
undisputed claims to BLUE CROSS no later than twelve (12) months after
the date of the service rendered to Members. Any claims under the
Enrollment Protection program which would otherwise be the
responsibility of BLUE CROSS under this Agreement shall be the
financial responsibility of PARTICIPATING MEDICAL GROUP if a clean
undisputed claim is not submitted within twelve (12) months of the
date of service. For the purpose of this Agreement, a clean claim
shall mean a claim that meets all BLUE CROSS requirements with respect
to back-up information.
IX. NON-CAPITATED SERVICES
9.01 Non-Capitated Services, as defined in this Article, shall include
Covered Medical Services, as set forth in the applicable Benefit
Agreement and as authorized or referred by PARTICIPATING MEDICAL
GROUP.
The Covered Medical Services encompassed in Non-Capitated Services are
delineated in Exhibit A(1) and include, but are not limited to:
A. Inpatient Hospital Services (exclusive of professional charges).
B. Outpatient Hospital Services (exclusive of professional charges).
C. Hemodialysis Services (exclusive of professional charges).
D. In-Area Emergency Room Facility Services (exclusive of
professional charges).
E. Related Hospital Services.
F. Skilled Nursing Facility Services.
G. Ambulance Services.
H. Home Health Services.
I. Alternative Birthing Center Services (exclusive of professional
charges).
J. Ten percent (10%) of expenses related to Out-of-Area Emergency
Services (Facility and Professional Expenses).
K. Durable Medical Equipment and prosthetic devices.
L. Hospice Services.
M. [ ** ] of the average wholesale price (AWP) related to
chemotherapy drugs (intravenously administered) and injectable
medications administered during a visit to the physician's office
(excluding take-home insulin).
N. Mammography Services.
23
9.02 Billing for Non-Capitated Services shall be as follows:
A. The provider of Non-Capitated Services may xxxx BLUE CROSS
directly, in which case, BLUE CROSS shall reimburse said provider
within forty-five (45) working days following receipt of a clean
undisputed claim accompanied by an authorization from
PARTICIPATING MEDICAL GROUP; or,
B. The provider of Non-Capitated Services may xxxx PARTICIPATING
MEDICAL GROUP, in which case, PARTICIPATING MEDICAL GROUP shall
xxxx BLUE CROSS for reimbursement. BLUE CROSS shall reimburse
PARTICIPATING MEDICAL GROUP within forty-five (45) working days
following BLUE CROSS's receipt of a clean undisputed claim from
PARTICIPATING MEDICAL GROUP, on the condition that such claim
shall be submitted to BLUE CROSS no later than twelve (12) months
after the date of service. This section shall only apply for the
following Non-Capitated Services: mammography services, DME,
prosthetics and injectable medications (including chemotherapy
drugs and infused substances).
In either case described above, BLUE CROSS shall pay contracting
providers at the rate negotiated between BLUE CROSS and said
provider. In the case of non-contracting providers, BLUE CROSS
shall pay the lesser of: the actual billed charges, or the
maximum allowable rate according to the BLUE CROSS Customary and
Reasonable charges, or the rate arranged for by a CALIFORNIACARE
Case Manager.
9.03 Case Management Stop-Loss.
A. The Case Management Program is a program in which a Member's
medical needs are assessed by PARTICIPATING MEDICAL GROUP in
conjunction with a CALIFORNIACARE Case Manager to explore and
coordinate treatment alternatives. PARTICIPATING MEDICAL GROUP
should notify the CALIFORNIACARE Case Manager prior to the Member
achieving the applicable Case Management Stop-Loss Threshold, as
described below.
B. For PARTICIPATING MEDICAL GROUPs with enrollment of [ ** ] or
more Member Months for the calendar year, the Case Management
Stop-Loss Threshold for an individual Member shall be [ ** ]
of Non-Capitated Expenses.
For PARTICIPATING MEDICAL GROUPs with enrollment of less than
[ ** ] Member Months, the Case Management Stop-Loss Threshold
shall be [ ** ] of Non-Capitated Expenses.
C. Authorized expenses for Member's Non-Capitated Services, up to
the Case Management Stop-Loss Threshold specified above will be
accrued toward PARTICIPATING MEDICAL GROUP's PMPM Non-Capitated
Expenses. Additionally, [ ** ] of expenses between the
applicable Case Management Stop-loss Threshold and [ ** ]
incurred by an individual Member will be accrued toward
PARTICIPATING MEDICAL GROUP's PMPM Non-Capitated Expenses.
Non-Capitated expenses greater than [ ** ] for any individual
Member will not be included in PARTICIPATING MEDICAL GROUP's PMPM
Non-Capitated Expenses.
24
D. The Case Management Stop-loss Thresholds described above will
apply to Members whose treatment includes transplants (solid
organ and bone marrow/stem cell), except in those cases where
PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as
described in Section 4.02F. When PARTICIPATING MEDICAL GROUP
fails to provide such notice, all of that Member's Non-Capitated
Expenses will be included in PARTICIPATING MEDICAL GROUP's PMPM
Non-Capitated Expenses.
9.04 Calculating PARTICIPATING MEDICAL GROUP PMPM Non-Capitated Expenses.
The Non-Capitated Expenses shall include actual expenses incurred by
BLUE CROSS to provide Non-Capitated Services to Members, as authorized
or referred by the PARTICIPATING MEDICAL GROUP. Expenses above the
Case Management Stop-Loss Threshold, as set forth in Section 9.03, and
expenses incurred by Members or former Members covered under the
Extension of Benefits provision of the Benefit Agreements are excluded
from PARTICIPATING MEDICAL GROUP's Non-Capitated Expenses for purposes
of determining the Non-Capitated Performance Settlement.
BLUE CROSS shall accrue Non-Capitated Expenses by each PARTICIPATING
MEDICAL GROUP by the calendar year the services were incurred and paid
through one hundred and twenty (120) days (April 30) after year-end.
Beginning in year two (2) of this Agreement, any claims received after
calculation of the final Non-Capitated Performance Settlement will be
charged to the following year's Non-Capitated Expenses. Any
Non-Capitated Services treatments that begin in one calendar year and
extend into the next year shall accrue to the year the treatment
began. Notwithstanding the aforementioned, any claims for
Non-Capitated Services or Shared Risk Services (as defined in the
CALIFORNIACARE Medical Services Agreement in effect for years prior to
1997) paid after April 30, 1997 will be charged to the 1997
Non-Capitated Expense.
PARTICIPATING MEDICAL GROUP's PMPM Non-Capitated Expense is the
quotient of PARTICIPATING MEDICAL GROUP's Non-Capitated Expenses
divided by PARTICIPATING MEDICAL GROUP's calendar year Member Months.
BLUE CROSS shall provide PARTICIPATING MEDICAL GROUP with quarterly
reports advising them of their Non-Capitated Expenses. The Operations
Manual describes the PARTICIPATING MEDICAL GROUP reports.
9.05 Non-Capitated Performance Settlement Schedule.
Non-Capitated Performance Settlement Schedule shall mean a schedule
that will be the basis for determining the Non-Capitated Performance
Settlement. This schedule presents BLUE CROSS's prior year aggregate
PMPM Non-Capitated Expenses adjusted by factors to account for medical
inflation. Exhibit F (incorporated by reference herein) sets forth the
Non-Capitated Performance Settlement Schedule.
9.06 Calculating the Non-Capitated Performance Settlement.
A. PARTICIPATING MEDICAL GROUP's Adjusted PMPM Non-Capitated
Expense.
PARTICIPATING MEDICAL GROUP's Adjusted PMPM Non-Capitated
Expenses is the quotient of PARTICIPATING MEDICAL GROUP's PMPM
Non-Capitated Expenses divided by the composite of PARTICIPATING
MEDICAL GROUP's Age/Sex, Plan, Stop-Loss and Region Factors.
25
The PARTICIPATING MEDICAL GROUP's PMPM Non-Capitated Expense is
adjusted to account for the PARTICIPATING MEDICAL GROUP's mix of
Members and make the PARTICIPATING MEDICAL GROUP's PMPM
Non-Capitated Expenses comparable to the Non-Capitated
Performance Settlement Schedule, as set forth in Exhibit F.
B. Non-Capitated Performance Settlement.
If the PARTICIPATING MEDICAL GROUP's Adjusted PMPM Non-Capitated
Expense is equal to or greater than the Attachment Point, the
PARTICIPATING MEDICAL GROUP will not receive a Non-Capitated
Performance Settlement. If the PARTICIPATING MEDICAL GROUP's
Adjusted PMPM Non-Capitated Expense is less than the Attachment
Point, the PARTICIPATING MEDICAL GROUP will receive a
Non-Capitated Performance Settlement.
The PMPM Non-Capitated Performance Settlement is determined by
allocating a portion of the difference between the Attachment
Point and the PARTICIPATING MEDICAL GROUP's Adjusted PMPM
Non-Capitated Expense. The proportion of the difference allocated
to the PMPM Non-Capitated Performance Settlement is according to
the Non-Capitated Performance Settlement Schedule, set forth in
Exhibit F. The PMPM Non-Capitated Performance Settlement amount
multiplied by the PARTICIPATING MEDICAL GROUP's calendar year
Member Months determines the total Non-Capitated Performance
Settlement.
Within forty-five (45) working days after April 30, BLUE CROSS
shall pay the Non-Capitated Performance Settlement if a
Non-Capitated Performance Settlement amount is due to the
PARTICIPATING MEDICAL GROUP.
Notwithstanding the above, in the event this Agreement is
terminated, BLUE CROSS shall calculate the Non-Capitated
Performance Settlement in accordance with this Article IX and
shall pay PARTICIPATING MEDICAL GROUP a preliminary Non-Capitated
Performance Settlement equal to [ ** ] of any amount due
PARTICIPATING MEDICAL GROUP based upon this calculation. Twelve
(12) months following the calculation and payment of the
preliminary Non-Capitated Performance Settlement, BLUE CROSS
shall calculate a final Non-Capitated Performance Settlement in
accordance with this Article IX and shall pay any amount due
PARTICIPATING MEDICAL GROUP, less any amounts paid at the time
of preliminary Non-Capitated Performance Settlement. In the
event monies paid PARTICIPATING MEDICAL GROUP at the time of
the preliminary Non Capitated Performance Settlement exceed the
final Non-Capitated Performance Settlement, PARTICIPATING MEDICAL
GROUP shall reimburse BLUE CROSS any amounts owed within
forty-five (45) working days of notification from BLUE CROSS.
X. OUTPATIENT PRESCRIPTION DRUG EXPENSE
10.01 Calculating PARTICIPATING MEDICAL GROUP PMPM Outpatient Prescription
Drug Expenses ("PMPM OPDE").
The Outpatient Prescription Drug Expense ("OPDE") shall include
expenses incurred by BLUE CROSS to provide covered outpatient
prescription drugs to Members assigned to PARTICIPATING MEDICAL GROUP.
BLUE CROSS shall accrue OPDE for each PARTICIPATING MEDICAL GROUP by
the calendar year the services were incurred and paid through one
hundred and twenty (120) days after yearend. Beginning in year two (2)
of this Agreement, any claims received after calculation of the final
Outpatient Prescription Drug Settlement will be charged to the
following year's OPDE. Notwithstanding the aforementioned, any claims
for outpatient prescription drug services
26
incurred prior to 1997 but paid after the final Non-Capitated
Performance Settlement calculation for 1996 and if applicable, for
subsequent years, will be charged to the following year's OPDE.
PARTICIPATING MEDICAL GROUP's PMPM OPDE is the quotient of
PARTICIPATING MEDICAL GROUP's OPDE divided by the PARTICIPATING
MEDICAL GROUP's calendar year Member Months for Members with
outpatient prescription drug benefits.
BLUE CROSS shall provide PARTICIPATING MEDICAL GROUP with quarterly
reports advising them of their OPDE. Report formats are described in
the Operations Manual.
10.02 Outpatient Prescription Drug Settlement Schedule.
The Outpatient Prescription Drug Settlement Schedule set forth at
Exhibit H (incorporated by reference herein) will be the basis for
determining PARTICIPATING MEDICAL GROUP's Outpatient Prescription Drug
Settlement.
10.03 Calculating the Outpatient Prescription Drug Settlement.
If PARTICIPATING MEDICAL GROUP's PMPM OPDE is less than the Outpatient
Prescription Drug Expense Target, the PARTICIPATING MEDICAL GROUP will
receive an Outpatient Prescription Drug Settlement. If the
PARTICIPATING MEDICAL GROUP's PMPM Outpatient Prescription Drug
Expense is equal to or greater than the Outpatient Prescription Drug
Expense Target, the PARTICIPATING MEDICAL GROUP will not receive an
Outpatient Prescription Drug Settlement.
A. Outpatient Prescription Drug Settlement.
The PMPM Outpatient Prescription Drug Settlement is determined by
allocating a portion of the difference between the OPDE Target,
and the PARTICIPATING MEDICAL GROUP's PMPM Outpatient
Prescription Drug Expense. The proportion of the difference
allocated to the PMPM Outpatient Prescription Drug Settlement is
determined in accordance with the Outpatient Prescription Drug
Schedule, set forth in Exhibit H.
B. Formulary Utilization Incentive.
If PARTICIPATING MEDICAL GROUP's use of the BLUE CROSS Outpatient
Prescription Drug Formulary (the "Formulary") is equal to or
greater than [ ** ], as described in Exhibit H, and
PARTICIPATING MEDICAL GROUP's PMPM OPDE is less than the OPDE
Target, an additional [ ** ] PMPM will be added to
PARTICIPATING MEDICAL GROUP's PMPM Outpatient Prescription Drug
Settlement.
The amount of the Outpatient Prescription Drug Settlement and
Formulary utilization incentive will be based on the applicable PMPM
Settlement calculation under Exhibit H multiplied by PARTICIPATING
MEDICAL GROUP's Member Months for Members with outpatient prescription
drug benefits. Within forty-five (45) working days after April 30,
BLUE CROSS will pay any Outpatient Prescription Drug Settlement that
is due PARTICIPATING MEDICAL GROUP for the previous year.
Notwithstanding the above, in the event this Agreement is terminated
BLUE CROSS shall calculate the Outpatient Prescription Drug Settlement
in accordance with this Article X and shall pay PARTICIPATING MEDICAL
GROUP a preliminary Outpatient Prescription Drug Settlement equal to
[ ** ] of any amount due PARTICIPATING MEDICAL GROUP based upon
this calculation. Twelve (12) months following the calculation and
payment of the preliminary Outpatient Prescription Drug Settlement,
BLUE CROSS shall calculate a final
27
Outpatient Prescription Drug Settlement in accordance with this
Article X and shall pay any amount due PARTICIPATING MEDICAL GROUP.
less any amounts paid at the time of preliminary Outpatient
Prescription Drug Settlement. In the event monies paid PARTICIPATING
MEDICAL GROUP at the time of the preliminary Outpatient Prescription
Drug Settlement exceed the final Outpatient Prescription Drug
Settlement, PARTICIPATING MEDICAL GROUP shall reimburse BLUE CROSS any
amounts owed within forty-five (45) working days of notification from
BLUE CROSS.
XI. QUALITY MANAGEMENT BONUS
Blue Cross will evaluate PARTICIPATING MEDICAL GROUP's Quality
Management Program and Member quality of care using a scorecard.
PARTICIPATING MEDICAL GROUP will be notified of the scorecard
parameters and scoring methodology prior to the start of each year, as
described in the Operations Manual.
PARTICIPATING MEDICAL GROUP must meet minimum eligibility criteria to
receive a scorecard score and therefore to be eligible for a Quality
Management Bonus. These criteria include a minimum of [ ** ] Member
months for a calendar year and submission to BLUE CROSS of all
necessary encounter data.
A Quality Management Bonus will be paid if PARTICIPATING MEDICAL
GROUP's performance on the scorecard is average or above average. No
Quality Management Bonus will be paid if PARTICIPATING MEDICAL GROUP's
scorecard performance is below average. BLUE CROSS will notify
PARTICIPATING MEDICAL GROUP of the scorecard results sixty (60) days
following the end of the calendar year.
The Quality Management Bonus paid to PARTICIPATING MEDICAL GROUP,
should a payment be due in accordance with the PMPM Quality Management
Bonus Schedule shown in Exhibit I (incorporated by reference herein),
will be made by the fifteenth of June following the end of the
calendar year for which it is based.
XII. BILLING FOR HMO-USA AWAY FROM HOME CARE SERVICES
12.01 PARTICIPATING MEDICAL GROUP agrees to render or refer urgent care,
Emergency services, follow-up care and routine services, as Host HMO
to out-of-state members of HMO-USA participating plans, when such care
is prearranged by BLUE CROSS. Urgent care as it relates to the HMO-USA
Away From Home Care Program means outpatient medical care which the
Host HMO determines is required for an unexpected illness or injury
that is not life threatening, but which cannot reasonably be postponed
until the HMO-USA participating plan member returns to the service
area of the member's Home HMO.
All medical services rendered at PARTICIPATING MEDICAL GROUP or
Satellite Facilities and all Referral Services rendered to members of
HMO-USA participating plans, due to unavailability of the required
services at PARTICIPATING MEDICAL GROUP, shall be paid by BLUE CROSS.
For services PARTICIPATING MEDICAL GROUP provides directly to members
of HMO-USA participating plans, BLUE CROSS shall reimburse
PARTICIPATING MEDICAL GROUP at PARTICIPATING MEDICAL GROUP's invoiced
amount, not to exceed reimbursement in accordance with Exhibit E of
this Agreement. For Referral Services, PARTICIPATING MEDICAL GROUP may
instruct providers of Referral Services to xxxx BLUE CROSS directly
or, such providers may xxxx PARTICIPATING MEDICAL GROUP, in which
case, PARTICIPATING MEDICAL GROUP shall be reimbursed by BLUE CROSS.
In all cases, PARTICIPATING MEDICAL GROUP or provider of Referral
Services shall note on the claim that services were
28
rendered to a member of an HMO-USA participating plan. Neither
PARTICIPATING MEDICAL GROUP nor provider of Referral Services shall
xxxx members of HMO-USA participating plans.
12.02 BLUE CROSS agrees to pay PARTICIPATING MEDICAL GROUP within forty-five
(45) working days of receipt of a completed professional services
claim form for authorized services rendered to members of HMO-USA
participating plans.
XIII. TERM OF AGREEMENT, TERMINATION
13.01 This Agreement shall be in effect for a THREE (3) year period (the
"Initial Term") from the date noted on page 1. Unless written notice
of intent not to renew or of intent to modify this Agreement is
provided at least one hundred twenty (120) days prior to completion of
the Initial Term or any subsequent renewal period, this Agreement
shall renew upon the same terms and conditions for consecutive one
year periods each year thereafter.
13.02 Should this Agreement be terminated pursuant to Section 13.01 above,
PARTICIPATING MEDICAL GROUP agrees to continue to provide Capitation
Services and to arrange NonCapitated Services for all Members assigned
to PARTICIPATING MEDICAL GROUP, including any Members who become
eligible during the notice period set forth in Section 13.01 above;
and to provide these services consistent with the terms and conditions
of the applicable Benefit Agreements. In such case, Capitation
Services rendered to Members shall be compensated at the applicable
rates set forth in Exhibit E, until the annual anniversary dates of
the Benefit Agreements of Members assigned to PARTICIPATING MEDICAL
GROUP.
In the event this Agreement is terminated, BLUE CROSS shall have the
right, but not the obligation, to directly pay any bills for expenses
for Referral Services rendered to Members assigned to PARTICIPATING
MEDICAL GROUP which remain outstanding on the date of termination.
BLUE CROSS shall immediately be notified in writing of all such
outstanding bills for Referral Services and BLUE CROSS shall have the
right to set off the amount of such payments against any amount due
PARTICIPATING MEDICAL GROUP for Capitation and NonCapitated Services
pursuant to Article IX, or any other payments due PARTICIPATING
MEDICAL GROUP.
The right to set off such payments against any amounts due under this
Agreement shall be in addition to any other rights BLUE CROSS may have
under this Agreement, or in law or in equity.
13.03 Termination of this Agreement shall not affect any rights or
obligations hereunder which shall have previously accrued, or shall
thereafter arise, with respect to any occurrence prior to termination,
and such rights and obligations shall continue to be governed by the
terms of this Agreement.
Without limiting the foregoing, if this Agreement is terminated,
PARTICIPATING MEDICAL GROUP shall continue to provide and be
compensated under the terms of this Agreement for Covered Medical
Services provided to each Member who is under the care of
PARTICIPATING MEDICAL GROUP at the time of that termination, until the
services being rendered to that Member are completed or reasonable and
medically appropriate provision is made for the assumption of such
services by another contracting provider.
29
13.04 In the event of a material breach of this Agreement the party claiming
the breach shall give written notice to the other, with registered or
certified mail. The notice shall specify the breach with as much
detail as possible. The party receiving the notice shall then have
thirty (30) days to commence curing the breach. If the breach is not
cured to the satisfaction of the complaining party within sixty (60)
days after the notice is received by the other party, this Agreement
shall terminate at the end of the sixtieth (60th) day or, if the
breach is by PARTICIPATING MEDICAL GROUP, BLUE CROSS may in the
alternative freeze enrollment of PARTICIPATING MEDICAL GROUP and/or
withhold [ ** ] of the Capitation until such breach is cured to
BLUE CROSS' satisfaction.
XIV. ARBITRATION OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL
GROUP
14.01 PARTICIPATING MEDICAL GROUP and BLUE CROSS agree to meet and confer in
good faith to resolve any problems or disputes that may arise under
this Agreement.
14.02 Any problem or dispute arising under this Agreement and/or concerning
the terms of this Agreement that is not satisfactorily resolved under
Section 14.01 shall be arbitrated. The arbitration shall be initiated
by either party making a written demand for arbitration on the other
party. Arbitration shall be conducted by the American Arbitration
Association (AAA) under the Commercial Rules of the AAA. The
arbitration shall also be subject to California Code of Civil
Procedure, Title Nine, Section 1280, ET. SEQ., unless otherwise
mutually agreed. The parties agree that the decision of the arbitrator
shall be final and binding as to each of them, except to the extent
that California or Federal law provide for the review of arbitration
proceedings. Issues as to whether malpractice was committed by a
physician shall not be subject to Arbitration by the AAA unless
otherwise agreed in writing by the parties and the AAA.
14.03 ARBITRATION FEE. In all cases submitted to AAA, the parties agree to
share equally the AAA administrative fee as well as the arbitrator's
fee, if any, unless otherwise assessed by the arbitrator. The
administrative fee shall be advanced by the initiating party.
14.04 ENFORCEMENT OF AWARD. The parties agree that the arbitrator's award
may be enforced in any court having jurisdiction thereof by the filing
of a petition to enforce said award. Costs of filing may be recovered
by the party that initiates the action to have an award enforced.
14.05 ALTERNATIVE DISPUTE SETTLEMENT TECHNIQUES. Should the parties, prior
to submitting a dispute to arbitration, desire to utilize other
impartial dispute settlement techniques, such as mediation or
fact-finding, a joint request for such services may be made to the
AAA, or the parties may initiate such other procedures as they may
mutually agree upon.
14.06 LIMITATION. Nothing contained herein is intended to create, nor shall
it be construed to create, any right of any Member to independently
initiate the arbitration procedure established in this Article. This
limitation shall not prevent BLUE CROSS from initiating such
procedures as the representative of its Members, or PARTICIPATING
MEDICAL GROUP from initiating such procedures on behalf of Members for
whom they have assumed responsibility for the provision of Capitation
Services, and for arranging Non-Capitated Services provided that in
any such case BLUE CROSS or PARTICIPATING MEDICAL GROUP, respectively,
shall be considered the initiating party for the purposes of Section
14.03 hereof.
14.07 Each party hereto agrees to notify the other at the earliest
reasonable time in the event of any dispute which may be arbitrated,
and in the event either party becomes aware of facts or circumstances
which indicate a reasonable possibility of litigation with any third
person or entity, and which are relevant to any rights, obligations,
or other responsibilities under this Agreement.
30
XV. CALIFORNIACARE MEMBER GRIEVANCE SYSTEM
15.01 In the event a Member perceives a problem which the CALIFORNIACARE
Coordinator is unable to satisfactorily resolve, the Member shall be
advised to complete a Grievance Form and submit it to the
CALIFORNIACARE Coordinator. The grievance shall be reviewed and
resolved if possible, by the PARTICIPATING MEDICAL GROUP's Quality
Management Committee.
15.02 PARTICIPATING MEDICAL GROUP shall maintain a log of all grievances
heard by PARTICIPATING MEDICAL GROUP's Quality Management Committee
filed by Members who are assigned to PARTICIPATING MEDICAL GROUP and
shall, on a quarterly basis, forward a copy of each grievance to the
CALIFORNIACARE Quality Management Representative.
15.03 PARTICIPATING MEDICAL GROUP shall provide a written response to Member
within fifteen (15) working days of receipt of grievance. In the
event a grievance cannot be resolved by the PARTICIPATING MEDICAL
GROUP's Quality Management Committee to the complaining Member's
satisfaction within fifteen (15) working days of receipt, the Member
may appeal to BLUE CROSS using the procedures in the Member's Benefit
Agreement and in the Operations Manual. In the event that the Member
appeals to BLUE CROSS, PARTICIPATING MEDICAL GROUP agrees to provide
BLUE CROSS with a response to the grievance and the pertinent medical
records within ten (10) days from the date of such request by BLUE
CROSS.
15.04 The Member shall be notified of the disposition of the complaint by
BLUE CROSS within fifteen (15) working days of making the appeal.
XVI. MISCELLANEOUS PROVISIONS
16.01 AMENDMENT. This Agreement or any part or section of it may be amended
at any time during the term of the Agreement by mutual written consent
of duly authorized representatives of BLUE CROSS and PARTICIPATING
MEDICAL GROUP.
16.02 ASSIGNMENT. BLUE CROSS and PARTICIPATING MEDICAL GROUP, pursuant to
mutual written agreement, may assign rights and duties established
under this Agreement, provided that no such assignment shall adversely
affect the rights or duties of Members or be in conflict with the
requirements of state or federal laws or regulations under which BLUE
CROSS is licensed or regulated.
16.03 MARKETING, ADVERTISING AND PUBLICITY. BLUE CROSS shall have the right
to use the name of PARTICIPATING MEDICAL GROUP for purposes of
informing Members and prospective Members of the identity of
PARTICIPATING MEDICAL GROUP.
Except as provided above, BLUE CROSS and PARTICIPATING MEDICAL GROUP
each reserve the right to control the use of their respective names
and all symbols, trademarks or service marks presently existing, or
later established. In addition, except as provided above, neither BLUE
CROSS nor PARTICIPATING MEDICAL GROUP shall use the other party's
name, symbols, trademarks or service marks in advertising or
promotional materials, or otherwise, without the prior written consent
of that party, and shall cease any such usage immediately upon written
notice of the party, or on termination of this Agreement, whichever
first occurs.
16.04 SOLE AGREEMENT. This Agreement with its Exhibits and the Operations
Manual, represents the entire agreement between the parties hereto and
supersedes any and all prior or contemporaneous, written or oral
agreements, representations or understandings.
31
16.05 INDEPENDENT CONTRACTORS. PARTICIPATING MEDICAL GROUP shall furnish
care or other benefits to Members as an independent contractor, and
BLUE CROSS shall not be liable for any claim or demand on account of
damages arising out of, or in connection with, any injuries suffered
by any Member while receiving care from, or care authorized by,
PARTICIPATING MEDICAL GROUP or any of its Member Physicians.
16.06 SEVERABILITY. If any term, provision, covenant or condition of this
Agreement is held by a court of competent jurisdiction to be invalid,
void or unenforceable, the remainder of the provisions hereof shall
remain in full force and effect and shall in no way be affected,
impaired, or invalidated as a result of such decision.
16.07 NOTICES. Any notice which is required or permitted to be given
pursuant to this Agreement shall be in writing and shall either be
personally delivered, or sent by registered or certified mail, in the
United States Postal Service, return receipt requested, postage
prepaid, addressed to each party at its principal office or at the
address provided in writing to the other. Notices shall be effective
when received.
16.08 MAXIMUM CAPACITY. The Maximum Capacity of PARTICIPATING MEDICAL GROUP
during the term of this Agreement shall be UNLIMITED Members.
16.09 XXXX-XXXXX ACT. BLUE CROSS is subject to the requirements of the
Xxxx-Xxxxx Act and any provision required to be in this Agreement
thereunder shall bind BLUE CROSS and PARTICIPATING MEDICAL GROUP,
whether or not expressly provided in this Agreement.
16.10 SOLICITATION OF MEMBERS. The business relationship between BLUE CROSS
and its Members, and BLUE CROSS and the employer groups with which it
contracts, shall be deemed the property of BLUE CROSS. Similarly, all
lists of Members accepted by PARTICIPATING MEDICAL GROUP under the
provisions of this Agreement and of the employer groups to which they
belong, shall be deemed the property of BLUE CROSS. During the term of
this Agreement or any renewal thereof, and for a period of one (1)
year from the date of termination, PARTICIPATING MEDICAL GROUP agrees
and will require its PARTICIPATING MEDICAL GROUP Physicians and all
other contracted Health Professionals to agree, that they will not,
within the service area of BLUE CROSS: (1) interfere with BLUE CROSS'
contract and/or property rights; (2) advise or counsel any Member or
employer groups to dissenroll from BLUE CROSS; (3) solicit such Member
or employer group to become enrolled with any other health maintenance
organization, preferred provider organization or any other similar
hospitalization or medical payment plan or insurance company; or (4)
disclose proprietary BLUE CROSS information. This section shall not
apply to general mailings unless the mailings specifically target BLUE
CROSS Members and as long as the mailings do not violate the intent of
this section.
16.11 CONFIDENTIALITY. PARTICIPATING MEDICAL GROUP and BLUE CROSS agree to
keep confidential, except as otherwise required by applicable law or
this Agreement, the terms and conditions of this Agreement and any
amendments thereto. Violation of the above shall be deemed a material
breach.
16.12 WAIVER. The waiver by either party of a failure to perform any
covenant or condition set forth in this Agreement shall not act as a
waiver of performance for a subsequent breach of the same or any other
covenant or condition set forth in this Agreement.
32
16.13 GOVERNING LAW. This Agreement shall be construed and enforced in
accordance with the laws of the State of California.
BLUE CROSS OF CALIFORNIA PARTICIPATING MEDICAL GROUP
Signature: /s/ Xxxxxx Xxxxxxxxx Signature: /s/ Xxxxx XxXxxxxx
-------------------------------- -----------------------
Name: Xxxxxx Xxxxxxxxx Name: Xxxxx XxXxxxxx
-------------------------------- -----------------------
Title: Vice President Title: President
-------------------------------- -----------------------
Network Development & Manaqement
-------------------------------- -----------------------
Date: 2/13/97 Date: 11-26-96
-------------------------------- -----------------------
33
EXHIBIT A
COVERED MEDICAL SERVICES
I. MEDICAL AND SURGICAL SERVICES
A. Physician's services at the:
(1) Physician's office; the Member shall pay any copayment directly
to the physician for each such visit
(2) Hospital or Skilled Nursing Facility
B. Professional services of an anesthetist or anesthesiologist
C. Diagnostic X-ray examinations
D. Laboratory tests
E. Radiation therapy in Physician's office, including use of X-ray,
radium, cobalt and other radioactive substances
F. Professional services of other participating Health Professionals
G. Professional services of a physician at the Member's home when the
Member is too ill or disabled to be seen during regular office hours.
The Member shall pay the amounts set forth in the Member's Benefit
Agreement to the physician for each such visit.
II. PSYCHIATRIC CARE BENEFITS
A. Inpatient Visits
Physician's hospital visits shall be limited as set forth in the
Member's Benefit Agreement during each calendar year and the Member
shall pay the amounts set forth in the Member's Benefit Agreement to
the physician for each such visit.
B. Outpatient Visits or Sessions
Outpatient care shall be provided for short-term evaluation of the
Member's condition when such care is ordered by the attending
PARTICIPATING MEDICAL GROUP Physician. Charges and limitations as set
forth in the Member's Benefit Agreement. This care shall not include
visits for psychoanalysis.
III. COVERED PREVENTIVE CARE BENEFITS
The following services shall be provided when performed by, authorized by,
or deemed appropriate by the Member's Primary Care Physician. The Member
shall pay any copayment listed in the Member's Benefit Agreement directly
to the physician for each service performed.
A. Well baby care through age 2 years, including immunizations.
B. Scheduled physical examinations as set forth in the Member's Benefit
Agreement.
C. Pediatric and adult immunizations.
D. Eye examinations
E. Infertility studies for Members aged 18 or over.
A-1
F. Ear examinations.
G. Health education services as follows:
(1) Health education services and education in the appropriate use of
health services and in the contribution each Member can make to
the maintenance of his/or her own health.
(2) Instruction in personal health care measures.
(3) Information about services provided, including recommendations on
generally accepted medical standards for use and frequency of
such services.
H. Services such as pre- and post-hospitalization planning; referral to
services provided through community health and social welfare agencies
and related family counseling for the physical, emotional and economic
impact of illness and disability.
I. Allergy testing and administration of injections.
A-2
EXHIBIT A(1) CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
ACUPUNCTURE
AIDS
Inpatient Facility Component
Professional Component
ALLERGY TESTING & TREATMENT
Professional Component
Serums
AMBULANCE: Air or Ground
In-Area [ ** ](1)
Out-of-Area
AMNIOCENTESIS
Outpatient Facility Component
Professional Component
ANESTHETICS, Administration of
ARTIFICIAL EYE
* ARTIFICIAL INSEMINATION
ARTIFICIAL LIMBS (Prosthetic Device)
BIOFEEDBACK
BLOOD AND BLOOD PRODUCTS
From Blood Bank
Autologous Blood Donation
* CHEMICAL DEPENDENCY REHABILITATION
Inpatient Facility Component
Inpatient Professional Component
Outpatient Facility Component
Outpatient Professional Component
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-1
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
CHEMOTHERAPY DRUGS (intravenously administered)
Professional Component
Chemotherapy Drugs
CHIROPRACTIC (REFERRED SERVICE ONLY)
CIRCUMCISION
COLOSTOMY SUPPLIES
Inpatient Facility Component
Outpatient Dispensing
In Conjunction with Home Health
DENTAL SERVICES
(ACCIDENTAL INJURY TO SOUND NATURAL TEETH AND DENTAL WORK
NECESSARY FOR THE CONSTRUCTION OF NON-DENTAL STRUCTURES)
Inpatient Facility Component
Professional Component
DETOXIFICATION
Inpatient Facility Component
Professional Component [ ** ](1)
* DURABLE MEDICAL EQUIPMENT (DME)
EMERGENCY ADMISSIONS: In-Area
Facility Component
Professional Component
EMERGENCY ADMISSIONS: Out-of-Area
Facility Component
Professional Component
EMERGENCY ROOM: In-Area
Facility Component
Professional Component
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-2
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
EMERGENCY ROOM: Out-of-Area
Facility Component
Professional Component
EMPLOYMENT PHYSICAL EXAMS
ENDOSCOPIC STUDIES
Inpatient / Outpatient Facility Component
Professional Component
EXPERIMENTAL PROCEDURES
FAMILY PLANNING SERVICES [ ** ](1)
Inpatient Facility Component
Outpatient Clinic or Non-Hospital Facility Component
Professional Component
FETAL MONITORING
Inpatient Facility Component
Professional Component
GENETIC TESTING
HEALTH EDUCATION
**HEALTH EVALUATIONS / PHYSICALS
(REQUIRED BY THIRD PARTY OR OUTSIDE AGENCY)
* HEARING AIDS
HEARING SCREENING
HEMODIALYSIS
Inpatient / Outpatient Facility Component
Professional Component
* As set forth in the applicable Benefit Agreement
** Routine physical examinations or tests which do not directly treat an actual
illness, injury or condition unless authorized by a Primary Care Physician,
except in no event will any physical examination or test required by
employment or government authority, or at the request of a third party such
as a school, camp or sport affiliated organization be covered.
(1) All references to division of responsibility have been deleted.
A(1)-3
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
HEPATITIS B VACCINE/ GAMMA GLOBULIN
HOME HEALTH (including medications)
HOSPICE (in lieu of acute inpatient or SNF care)
Inpatient Facility Component
Professional Component
HOSPITAL BASED PHYSICIANS
Anesthesiology
Audiology
Cardiology
Emergency Medicine
General Surgery
Neonatology
Nephrology
Neurology [ ** ](1)
Neurosurgery
Obstetrics / Gynecology
Orthopedic Surgery
Pathology
Pediatrics
Physical Medicine
Pulmonary Medicine
Radiology
Radiation Oncology
Urology
* HOSPITALIZATION / INPATIENT SERVICES,
SUPPLIES & TESTING
In-Area
Out-of-Area (Emergency)
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-4
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
IMMEDIATE CARE
Facility Component
Professional Component
IMMUNIZATION SERUMS (pediatric)
IMMUNIZATION SERUMS (Adult)
INFANT APNEA MONITOR (DME)
(IN CONJUNCTION WITH OR CONCURRENT WITH AUTHORIZED INPATIENT
ADMISSION)
OUTPATIENT INFANT APNEA MONITOR
* INFERTILITY (Diagnosis / Treatment)
*Inpatient Facility Component
*Professional Component
INFUSION THERAPY [ ** ](1)
Inpatient / Outpatient Facility Component
Professional Component
Infused Substances
INJECTABLE MEDICATIONS: Outpatient
(EXCLUDING TAKE-HOME INSULIN)
LABORATORY SERVICES
Inpatient Facility Component
Outpatient Hospital Facility Component
Outpatient Clinic or Non-Hospital Facility Component
Professional Component
* LITHOTRIPSY
Inpatient / Outpatient Hospital Facility Component
Professional Component
MAMMOGRAPHY
Technical Component
Professional Component
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-5
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
MENTAL HEALTH
*Inpatient Facility Component
*Inpatient Professional Component
*Outpatient Professional Component
NUTRITIONIST / DIETITIAN
OBSTETRICAL SERVICES
Inpatient Facility Component
Inpatient Professional Component
Outpatient Diagnostic Services
OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES,
DRESSINGS etc.
ORGAN TRANSPLANTS (non-experimental) [ ** ](1)
Inpatient Facility Component
Professional Component
* OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS
Primary Care Physicians
Specialty Physicians
OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY COMPONENT
FOR DIAGNOSTIC SERVICES & TREATMENTS
These services include, but are not limited to the following:
Angiograms
CAT Scan
2-D Echo
EEG
EKG (aka: ECG)
EMG
Xxxxxx Monitor
MRI
Treadmill
Ultrasound
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-6
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS
Professional Component for:
Anesthesiology
Audiology
Cardiology
Emergency Medicine
General Surgery
Neonatology
Nephrology
Neurology
Obstetrics / Gynecology [ ** ](1)
Orthopedics
Pathology
Pediatrics
Physical Medicine
Pulmonary Medicine
Radiation Oncology
Radiology
Urology
OUTPATIENT SURGERY
Facility Component
Professional Component for:
Anesthesiology
Audiology
Cardiology
Emergency Medicine
Neonatology
Neurology
Nephrology
Orthopedics
Pathology
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-7
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
OUTPATIENT SURGERY: Professional Component
CONTINUED
Pediatrics
Physical Medicine
Pulmonary Medicine
Radiation Oncology
Radiology
Urology
PEDIATRIC SERVICES (newborn)
PHYSICAL THERAPY
Inpatient Facility Component
Outpatient Clinic or Non-Hospital Facility Component
Inpatient / Outpatient Professional Component
PHYSICIAN VISITS
To Hospital
To Skilled Nursing Facility
To Patient Home
PHYSICIAN OFFICE VISITS [ ** ](1)
Consultations
Specialty Visits
PODIATRY SERVICES
PREADMISSION TESTING
Inpatient Facility Component
Outpatient Hospital Facility Component
Outpatient Clinic or Non-Hospital Facility Component
Inpatient / Outpatient Professional Component
PRE-EXISTING PREGNANCY
Inpatient Facility Component
Professional Component
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-8
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
PREGNANCY SERVICES
Inpatient Facility Component
Professional Component
PROSTHETIC DEVICES
RADIATION THERAPY
Inpatient Facility Component
Outpatient Hospital Facility Component
Outpatient Clinic Facility Component
Professional Component
RADIOLOGY SERVICES
Inpatient Facility Component
Outpatient Hospital Facility Component [ ** ](1)
Outpatient Clinic or Non-Hospital Facility Component
Professional Component
RECONSTRUCTIVE SURGERY
Inpatient Facility Component
Professional Component
REFRACTIONS
REHABILITATION SERVICES
(SHORT TERM: PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH
THERAPY, CARDIAC THERAPY)
Inpatient Facility Component
Inpatient Professional Component
Outpatient Clinic or Non-Hospital Facility Component
Outpatient Professional Component
ROUTINE PHYSICAL EXAMINATIONS
SKILLED NURSING FACILITY (SNF)
SPECIALIST CONSULTATIONS
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-9
EXHIBIT A(1)
CALIFORNIACARE
DIVISION OF FINANCIAL RESPONSIBILITIES
NON-
LIST OF BENEFITS / SERVICES CAPITATION CAPITATED
--------------------------- ---------- ---------
SURGICAL SUPPLIES
Inpatient Facility Component
Outpatient Facility Component
TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ)
Dental Treatment
Professional Component
(FOR THE DIAGNOSIS AND MEDICALLY NECESSARY CORRECTION)
Inpatient Facility Component
TRANSFUSIONS
From Blood Bank
Autologous Blood Donations
URGENT CARE: In-Area [ ** ](1)
Facility Component
Professional Component
URGENT CARE: Out-of-Area
Facility Component
Professional Component
VISION SCREENING
VISION CARE
Medically Necessary Care
Refraction
Lenses / Frames (covered by optional rider)
Contact lenses (fitting only)
* As set forth in the applicable Benefit Agreement
(1) All references to division of responsibility have been deleted.
A(1)-10
HIQPVHD CORPORATE SYSTEMS P 2/12/97 08:46:20 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
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_ 0PY017 PCP G 00066822 XXXX,XXXXXXX D 12/01/94 S Y FAMILY PRACTICE
_ 0PY018 PCP C 00024394 HALL,RUBLE S 12/01/94 S Y FAMILY PRACTICE
_ 0PY019 PCP C 00034125 XXXXX,XXXX M 12/01/94 S Y FAMILY PRACTICE
_ 0PY020 PCP G 00058879 XXXXXX,XXXX M 12/01/94 S Y FAMILY PRACTICE
_ 0PY021 PCP A 00021159 XXXXXXXX,XXXXXXX C 12/01/94 S Y FAMILY PRACTICE
_ 0PY022 PCP G 00023941 XXXXXXX,XXXXX R 12/01/94 S Y INTERNAL MEDICINE
_ 0PY023 PCP 20A00004456 XXXXXX,XXXXXX X 12/01/94 S Y FAMILY PRACTICE
_ 0PY024 PCP G 00058421 MAY,XXXXXX L 12/01/94 S N FAMILY PRACTICE
_ 0PY025 PCP C 00027117 XXXXXXX,XXXXXXX R 12/01/94 S Y FAMILY PRACTICE
_ 0PY026 PCP G 00048075 XXXXXXX,XXXX I 12/01/94 S Y FAMILY PRACTICE
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PHYSICIAN CROSS REFERENCE
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_ 0PY031 PCP G 00024260 XXXXX,XXXXXX W 12/01/94 S Y FAMILY PRACTICE
_ 0PY032 PCP A 00036922 XXX,XXXXXX K 12/01/94 S N FAMILY PRACTICE
_ 0PY033 PCP G 00044401 XXX,XXXXXXX X 12/01/94 S Y FAMILY PRACTICE
_ 0PY034 PCP G 00047710 XXXXX,XXXXX R 01/01/95 S N FAMILY PRACTICE
_ 0PY035 PCP A 00045020 XXXX,XXXXXXX C 03/01/95 S Y INTERNAL MEDICINE
_ 0PY037 PCP A 00037201 EL-ZAYAT,SAID L 03/01/95 S Y FAMILY PRACTICE
_ 0PY038 PCP A 00046536 XXXXXXXXX,XXXXXXXX L 03/01/95 S Y INTERNAL MEDICINE
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_ 0PY042 PCP G 00063280 XXXXXXXX,XXXX A 03/01/95 S Y INTERNAL MEDICINE
_ 0PY043 PCP A 00032367 XXXXXX,XXXXXXX 03/01/95 S Y PEDIATRICS
_ 0PY044 PCP A 00036482 XXXXXX,XXXXXXXX D 03/01/95 S Y FAMILY PRACTICE
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PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
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PHYSICIAN CROSS REFERENCE
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_ 0PY087 PCP A 00045658 XXXXXX,XXXX X 03/01/95 S Y FAMILY PRACTICE
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_ 0PY107 PCP G 00011142 XXXX,XXXXXXX V 03/01/95 S Y FAMILY PRACTICE
_ 0PY108 PCP A 00024610 XXXXXXXX,XXXXX R 03/01/95 S Y FAMILY PRACTICE
_ 0PY109 PCP A 00049740 XXXXXX,XXXXXXX H 03/01/95 S Y FAMILY PRACTICE
_ 0PYll0 PCP 20A00005021 XXXXXXXX,XXXXXXX X 03/01/95 S Y FAMILY PRACTICE
_ 0PYlll PCP A 00052391 XXX,UN S 03/01/95 S Y FAMILY PRACTICE
_ 0PYll2 PCP C 00024935 XXXXXXX,XXX D 03/01/95 S Y PEDIATRICS
_ 0PYll4 PCP G 00067093 XXXXXXX,XXXXXXX 03/01/95 S Y FAMILY PRACTICE
NEXT XXXX: ________ NEXT KEY: _______________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 2/12/97 08:46:42 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================ ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYll5 PCP G 00049359 XXXXXX,XXXXX X 03/01/95 S Y INTERNAL MEDICINE
_ 0PYll6 PCP A 00036414 XXXXXXX,XXXX A 01/01/95 S Y PEDIATRICS
_ 0PYll7 PCP G 00061762 XXX,XXXXX G 01/01/95 S Y INTERNAL MEDICINE
_ 0PYll9 PCP A 00037985 XXXXX,XXXXX 05/01/95 S Y INTERNAL MEDICINE
_ 0PY121 PCP A 00034095 XXXXXX,XXXX X 08/01/95 S Y FAMILY PRACTICE
_ 0PY122 PCP 20A00006510 XXXXX,XXXXXXXX 08/01/95 S Y INTERNAL MEDICINE
_ 0PY123 PCP G 00068455 XXXX,XXXX B 09/01/95 S Y PEDIATRICS
_ 0PY124 PCP A 00045651 XXXXXXXXXX,XXXXXX C 10/01/95 S Y FAMILY PRACTICE
_ 0PY125 PCP G 00070251 XXXX,XXXXX A 10/01/95 S Y INTERNAL MEDICINE
_ 0PY126 PCP A 00031479 XXXXXX,XXXX M 11/01/95 S Y FAMILY PRACTICE
_ 0PY129 PCP G 00034800 XXXXXX,XXXXXXX R 11/01/95 S Y FAMILY PRACTICE
_ 0PY131 PCP G 00025942 XXXXXXX,XXXXXXX T 01/01/96 S Y FAMILY PRACTICE
_ 0PY132 PCP A 00051549 XXXXXX,XXXXXXX D 01/01/96 S Y INTERNAL MEDICINE
_ 0PY133 PCP A 00043752 XXXXX,JYOTINKUMAR K 06/15/96 S Y PEDIATRICS
NEXT XXXX: ________ NEXT KEY: _______________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:46:46 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================ ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PY134 PCP A 00022838 XXXXXX,XXXXXX S 06/15/96 S Y PEDIATRICS
_ 0PY135 PCP A 00030945 XXXX,XXXXX Y 07/01/96 S Y PEDIATRICS
_ 0PY136 PCP C 00039890 XXXXX,XXXXXXX X 07/01/96 S Y PEDIATRICS
_ 0PY137 PCP A 00037744 XXXXXX,XXXXX C 07/01/96 S Y FAMILY PRACTICE
_ 0PY139 PCP G 00074232 TAN,KWAN T 06/01/96 S Y INTERNAL MEDICINE
_ 0PY140 PCP A 00015117 XXXXXX,XXXXXX R 06/01/96 S Y PEDIATRICS
_ 0PY141 PCP A 00052561 XXXXXX,XXXXXX Y 06/01/96 S Y FAMILY PRACTICE
_ 0PY142 PCP G 00066916 XXXXXXXX,XXXX E 06/01/96 S Y INTERNAL MEDICINE
_ 0PY143 PCP A 00050474 XXXX,XXXXXX K 06/01/96 S Y FAMILY PRACTICE
_ 0PY144 PCP A 00049335 XXXXX,XXXXXX Q 06/01/96 S Y FAMILY PRACTICE
_ 0PY146 PCP G 00011220 XXXXXXX,XXXXXXXX I 09/01/96 S Y INTERNAL MEDICINE
_ 0PY147 PCP A 00045267 XXXXX,BAKULKUMAR K 09/01/96 S Y INTERNAL MEDICINE
_ 0PY148 PCP A 00032006 WOLSZTEJN,XXXXXX 10/01/96 S Y PEDIATRICS
_ 0PYA02 SPC G 00015113 XXXXX,XXXXXXX P 01/01/95 M Y HEMATOLOGY
NEXT XXXX: ________ NEXT KEY: ______________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:46:50 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYA03 SPC G 00017298 XXXXXXXX, XXXXXXX 01/01/95 M Y GENERAL PRACTICE
_ 0PYA04 SPC G 00011836 PADOVA, XXXXX A 01/01/95 M Y HEMATOLOGY
_ 0PYA05 SPC G 00010122 XXXXXXX, XXXXXXXX A 01/01/95 M Y HEMATOLOGY
_ 0PYA06 SPC C 00041528 XXXXXXX, XXXX K 01/01/95 M Y NEUROLOGY
_ 0PYA07 SPC A 00025731 SRINIVASAN, NATHAPET 03/01/95 M Y INTERNAL MEDICINE
_ 0PYA08 SPC G 00012458 XXXXXX, X X 03/01/95 M Y PEDIATRIC CARDIOL0
_ 0PYA09 SPC G 00028788 DALLAS, XXXX G 03/01/95 M N ORTHOPEDIC SURGERY
_ 0PYA10 SPC G 00071049 VASSALLI, LUCA 03/01/95 M Y OTOLARYNGOLOGY
_ 0PYA11 SPC G 00022754 XXXXXX, XXXX M 03/01/95 M Y PLASTIC SURGERY
_ 0PYA12 SPC DDS 00025236 XXXX, XXXXXXX X 03/01/95 M Y ORAL MAX FACIAL SU
_ 0PYA13 SPC A 00029509 XXXXXXXXX, XXXXXXXXX 03/01/95 M Y INTERNAL MEDICINE
_ 0PYA14 SPC G 00022888 XXXXXXXXX, XXXXXX F 06/01/95 M Y DERMATOLOGY
_ 0PYA15 SPC A 00036842 XXXXXX, XXXXX U 06/01/95 M Y ORTHOPEDIC SURGERY
_ 0PYA16 SPC C 00040813 XXXX, XXX T 06/01/95 M Y PEDIATRIC NEUROLOG
NEXT XXXX: ____________ NEXT KEY: ____________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:46:54 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYA17 SPC G 00023626 XXXXXX, XXXXXXXX J 06/01/95 M Y SURGERY
_ 0PYA18 SPC A 00024898 XXXXXXX, XXXXXXX A 06/01/95 M Y DERMATOLOGY
_ 0PYA19 SPC A 00025829 XXXXXXX, XXXXXXX S 06/01/95 M Y INTERNAL MEDICINE
_ 0PYA20 SPC G 00053769 XXXXXXX, XXXXXXX X 06/01/95 M Y DERMATOLOGY
_ 0PYA21 SPC C 00036534 XXX, XXXXXXX X 06/01/95 M Y NEONATAL MEDICINE
_ 0PYA22 SPC G 00034562 XXXX, XXXXXX J 06/01/95 M Y ORTHOPEDIC SURGERY
_ 0PYA23 SPC PSY 00011468 XXXX, XXXXXXX X 06/01/95 M Y PSYCHOLOGY
_ 0PYA24 SPC G 00038575 XXXXX, XXXXXX K 06/01/95 M Y PHYSICAL MED & REH
_ 0PYA25 SPC A 00031698 XXXXXXXXX, XXXXX J 06/01/95 M Y SURGERY
_ 0PYA26 SPC G 00064401 THAI, DIEUMY 06/01/95 M Y PHYSICAL MED & REH
_ 0PYA27 SPC A 00019323 XXXXXX, XXXXX L 06/01/95 M Y ORTHOPEDIC SURGERY
_ 0PYA28 SPC G 00069571 XXXXX, XXXXXXX D 06/01/95 M Y PHYSICAL MED & REH
_ 0PYA29 SPC MFC 00025197 XXXXXXX, XXXXX T 06/01/95 M Y MFCC
_ 0PYA30 SPC G 00049428 XXXXXXX, XXXXX X 05/01/95 M Y GASTROENTEROLOGY
NEXT XXXX: ____________ NEXT KEY: ____________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:46:57 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYA31 SPC C 00041671 DHAR, NAVEEN 05/01/95 M Y THORACIC SURGERY
_ 0PYA32 SPC G 00042457 XXXXXXXX, XXXXXX J 05/01/95 M Y OBSTETRICS & GYNEC
_ 0PYA33 SPC A 00036111 HUR, IN H 05/01/95 M Y OBSTETRICS & GYNEC
_ 0PYA34 SPC DC 00021346 XXXXX, XXXXX X 08/01/95 M Y CHIROPRACTOR
_ 0PYA35 SPC A 00019731 XXXXX, XXXXX P 08/01/95 M Y OBSTETRICS & GYNEC
_ 0PYA36 SPC A 00021727 XXXXXXX, XXXX I 08/01/95 M Y UROLOGY
_ 0PYA37 SPC C 00041897 XXXXXXXXX, XXXXXX X 08/01/95 M Y OBSTETRICS & GYNEC
_ 0PYA38 SPC G 00058799 XXXXXXXXXX, XXXXXXX X 08/01/95 M Y ORTHOPEDIC SURGERY
_ 0PYA39 SPC G 00049280 XXXX, XXXXXXX G 08/01/95 M Y ORTHOPEDIC SURGERY
_ 0PYA40 SPC G 00054069 FIELD, XXXXX T 06/01/95 M Y ORTHOPEDIC SURGERY
_ 0PYA42 SPC DC 00022259 XXXX, XXXXX H 08/01/95 M Y CHIROPRACTOR
_ 0PYA44 SPC G 00014971 XXXXX, XXXX W 08/01/95 M Y OTOLARYNGOLOGY
_ 0PYA46 SPC A 00034425 XXXXXX, XXXXXXXXXXXX 08/01/95 M Y OTOLARYNGOLOGY
_ 0PYA47 SPC E 00003412 XXXXXXXXX, XXXXX L 08/01/95 M Y PODIATRISTS
NEXT XXXX: ____________ NEXT KEY: ____________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:47:00 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYA48 SPC G 00073749 NANDA, MOHIT 08/01/95 M Y OPHTHALMOLOGY
_ 0PYA49 SPC A 00044723 XXXXXXXX, XXXXX E 08/01/95 M Y ANESTHESIOLOGY
_ 0PYA50 SPC C 00037346 XXXXXXXXXX, XXXX M 08/01/95 M Y UROLOGY
_ 0PYA51 SPC PSY 00014165 XXXXXXX, XXXXXX 08/01/95 M Y PSYCHOLOGY
_ 0PYA52 SPC DC 00023131 XXXXX, XXXX H 08/01/95 M Y CHIROPRACTOR
_ 0PYA53 SPC E 00002539 XXXXXX, XXXXXX L 08/01/95 M Y PODIATRISTS
_ 0PYA54 SPC E 00003833 XXX, XXXXXXX R 08/01/95 M Y PODIATRISTS
_ 0PYA55 SPC A 00036380 XXXXXXXX, XXXX 08/01/95 M Y PHYSICAL MED & REH
_ 0PYA56 SPC G 00071898 XXXXX, XXXX M 10/01/95 M Y GASTROENTEROLOGY
_ 0PYA58 SPC A 00033138 XXXXXX, XXXXXXX N 11/01/95 M Y INTERNAL MEDICINE
_ 0PYA59 SPC G 00034099 XXXXXXXXXX, XXXXXX W 11/15/95 M Y UROLOGY
_ 0PYA60 SPC E 00003792 LIN, PARKSON J 11/15/95 M Y PODIATRISTS
_ 0PYA62 SPC G 00072693 XXXXX, XXXXX A 11/15/95 M Y INTERNAL MEDICINE
_ 0PYA63 SPC PSY 00012071 XXXXXXXXXX, XXXXXX 11/15/95 M Y PSYCHOLOGY
NEXT XXXX: ____________ NEXT KEY: ____________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:47:04 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYA64 SPC G 00054162 XXXXXXX, XXX M 11/15/95 M Y OBSTETRICS & GYNEC
_ 0PYA65 SPC DC 00019076 XXXXXXXXXXX, XXXXXXX 11/15/95 M Y CHIROPRACTOR
_ 0PYA66 SPC C 00041445 XXXXX, XXXX X 11/15/95 M Y PEDIATRICS
_ 0PYA67 SPC G 00016543 XXXXXXX, XXXXXXX A 11/15/95 M Y ALLERGY & IMMUNOLO
_ 0PYA68 SPC A 00034163 CHAMBI, ISRAEL P 01/01/96 M Y NEUROLOGICAL SURGE
_ 0PYA69 SPC A 00029781 BHASKAR, BIRBAL S 01/01/96 M Y INTERNAL MEDICINE
_ 0PYA70 SPC C 00028212 XXXXX, XXXXX L 01/01/96 M Y PSYCHIATRY
_ 0PYA71 SPC G 00039256 XXXXX, XXXXX I 03/01/96 M Y OTOLARYNGOLOGY
_ 0PYA72 SPC A 00021894 XXXX, XXXXXX 03/01/96 M Y RADIOLOGY
_ 0PYA73 SPC G 00050355 XXXXX, XXXXXXX A 03/01/96 M Y DERMATOLOGY
_ 0PYA74 SPC G 00055330 XXXXXXXXXX, XXXXXX P 03/01/96 M Y OBSTETRICS & GYNEC
_ 0PYA75 SPC G 00047629 XXXXXX, XXXXXX A 03/01/96 M Y NEONATAL MEDICINE
_ 0PYA76 SPC A 00019070 XXXXXXX, XXXX M 03/01/96 M Y OPHTHALMOLOGY
_ 0PYA77 SPC G 00042276 XXXXXX, XXXX A 03/01/96 M Y OBSTETRICS & GYNEC
NEXT XXXX: ____________ NEXT KEY: ____________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:47:07 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYA78 SPC A 00041163 XXXXX,XXXX S 03/15/96 M Y OBSTETRICS & GYNEC
_ 0PYA79 SPC A 00051302 XXXXX,XXXXXXX X 04/01/96 M Y SURGERY
_ 0PYA80 SPC A 00032247 XXXXX,XXXXXX L 04/01/96 M Y RHEUMATOLOGY
_ 0PYA81 SPC G 00067568 DEYAN,ALEXANDER 04/01/96 M Y OBSTETRICS & GYNEC
_ 0PYA82 SPC G 00044062 XXXXXXXXX,XXXXXX B 04/01/96 M Y INTERNAL MEDICINE
_ 0PYA83 SPC G 00071549 XXXXXXXX,XXXXX A 04/01/96 M Y OBSTETRICS & GYNEC
_ 0PYA84 SPC A 00045786 XXX,XXXX-I 04/01/96 M Y ALLERGY & IMMUNOLO
_ 0PYA85 SPC A 00048188 XXXXXXXXX,XXXXXX 05/01/96 M Y OBSTETRICS & GYNEC
_ 0PYA86 SPC A 00025746 XXXXXXXXXXX,XXXXX A 05/01/96 M Y INTERNAL MEDICINE
_ 0PYA88 SPC A 00044025 XXXXXX,XXXXXXXXX J 06/01/96 M Y INTERNAL MEDICINE
_ 0PYA89 SPC G 00047680 XXXXXX,XXXXX S 06/01/96 M Y INTERNAL MEDICINE
_ 0PYA90 SPC A 00041039 XXXXXXXX,XXXXXX 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYA91 SPC A 00030819 XXXXXXXX,XXXXXX A 06/01/96 M Y OPHTHALMOLOGY
_ 0PYA92 SPC A 00038941 XXXXX-XXXXXXX,SHAHPO 06/01/96 M Y OBSTETRICS & GYNEC
NEXT XXXX:________ NEXT KEY:________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:47:10 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYA93 SPC G 00057651 XXXXXXXXX,XXXXXX R 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYA94 SPC A 00049758 SHAH,MITA H 06/01/96 M Y PEDIATRICS
_ 0PYA95 SPC G 00062616 XXXXXXXX,XXXXXXX R 06/01/96 M Y PEDIATRICS
_ 0PYA96 SPC G 00076417 XXXXXXXXX,XXXXXXXXX 07/01/96 M Y OBSTETRICS & GYNEC
_ 0PYA97 SPC DC 00018565 XXXXX,XXXXXXX R 07/01/96 M Y CHIROPRACTOR
_ 0PYA98 SPC G 00073198 XXXXXX,XXXX A 07/01/96 M Y OPHTHALMOLOGY
_ 0PYA99 SPC A 00046389 XXXXXX,XXXXXX J 07/01/96 M Y NEPHROLOGY
_ 0PYB01 SPC G 00041537 XXXXXXXXX,XXXXXXXXX 07/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB02 SPC G 00050776 XXXXXX,XXXXXXX L 07/01/96 M Y ORTHOPEDIC SURGERY
_ 0PYB03 SPC G 00017825 XXXXXX,XXXXXXX J 07/01/96 M Y OPHTHALMOLOGY
_ 0PYB04 SPC G 00037045 XXXXXXXXX,XXXXXX R 07/01/96 M Y ORTHOPEDIC SURGERY
_ 0PYB05 SPC G 00039051 XXXXXXX,XXXX R 07/01/96 M Y ORTHOPEDIC SURGERY
_ 0PYB06 SPC A 00023526 XXXXXXXX,XXXXXXX K 06/01/96 M Y CARDIOVASCU DISEAS
_ 0PYB07 SPC G 00028746 XXXXXXX,XXXX L 06/01/96 M Y CARDIOVASCU DISEAS
NEXT XXXX:________ NEXT KEY:________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU J PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS 02/12/97 08:47:13 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYB08 SPC LCS00012523 XXXXXXXX,XXXXXXX R 06/01/96 M Y LCSW
_ 0PYB09 SPC A 00029368 XXXXXXXX,XXXXXXX L 06/01/96 M Y SURGERY
_ 0PYB10 SPC A 00045410 XXXXXXX,XXXXX 06/01/96 M Y UROLOGY
_ 0PYB11 SPC A 00029687 XXX,XXXXXXX C 06/01/96 M Y NEUROLOGICAL SURGE
_ 0PYB12 SPC G 00043398 XXXXXX,XXXXXXX C 06/01/96 M Y PEDIATRIC CARDIOLO
_ 0PYB13 SPC PSY00010977 XXXX,XXXX T 06/01/96 M Y PSYCHOLOGY
_ 0PYB14 SPC G 00067377 XXXXXXX,XXXXXXXX M 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB15 SPC G 00047957 YORK,XXXXX C 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB16 SPC A 00038317 XXXXX,XXXX W 06/01/96 M Y INTERNAL MEDICINE
_ 0PYB17 SPC A 00052121 XXXX,XXXXXX R 06/01/96 M Y INTERNAL MEDICINE
_ 0PYB18 SPC OPT00003828 XX XXXX,XXXXX L 06/01/96 M Y OPTOMETRY
_ 0PYB19 SPC C 00035334 XXXX,XXXXX C 06/01/96 M Y CARDIOVASCU DISEAS
_ 0PYB20 SPC MFC00029953 XXXXXXXX-XXXXXXXX,MA 06/01/96 M Y MFCC
_ 0PYB21 SPC PSY00012070 XXXXXXXXXX,XXXXXXX L 06/01/96 M Y PSYCHOLOGY
NEXT XXXX:________ NEXT KEY:________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:47:17 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYB22 SPC MFC00016388 XXXXXX,XXXXXXXXXX S 06/01/96 M Y MFCC
_ 0PYB23 SPC G 00064918 XXXXXXXX,XXXX J 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB24 SPC A 00043562 XXXXXXXX,XXXXXX X 06/01/96 M Y NEPHROLOGY
_ 0PYB25 SPC G 00017470 XXXXX,XXXXX X 06/01/96 M Y PATHOLOGY
_ 0PYB26 SPC G 00044536 XXXXXX,XXXX 06/01/96 M Y PSYCHIATRY
_ 0PYB27 SPC G 00044673 XXXXXXXX,XXXXXX X 06/01/96 M Y PSYCHIATRY
_ 0PYB28 SPC A 00044904 XXXXXX,XXXXXXX E 06/01/96 M Y ANESTHESIOLOGY
_ 0PYB29 SPC A 00044552 XXXXXXXX,XXXXXXXX M 06/01/96 M Y NEPHROLOGY
_ 0PYB30 SPC A 00040197 XXXXXXX-XXXXXX,XXXX 06/01/96 M Y UROLOGY
_ 0PYB31 SPC G 00053241 XXX,XXXXX S 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB32 SPC G 00028735 XXXXXXX,XXXXXXX R 06/01/96 M Y SURGERY
_ 0PYB33 SPC G 00042829 XXXXXXX,XXXXX R 06/01/96 M Y DIAGNOSTIC RADIOLO
_ 0PYB34 SPC G 00074511 XXXXXXXX,XXXX H 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB35 SPC G 00070407 XXXXXXX,XXXXXX E 06/01/96 M Y ORTHOPEDIC HAND SU
NEXT XXXX:________ NEXT KEY:________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:47:20 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYB36 SPC A 00000000 XX XX XXXX,XXXXXX E 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB37 SPC A 00038493 XXXXXX,FERNAND0 06/01/96 M Y INTERNAL MEDICINE
_ 0PYB38 SPC A 00043518 XXXXXXXX,XXXX L 06/01/96 M Y OBSTETRICS & GYNEC
_ 0PYB39 SPC C 00033575 XXXXXX,XXXX G 06/01/96 M Y ORTHOPEDIC SURGERY
_ 0PYB40 SPC C 00038037 XXXXXXX,XXXXX X 06/01/96 M Y MEDICAL ONCOLOGY
_ 0PYB41 SPC G 00045372 XXXXXX,XXXXX S 06/01/96 M Y CARDIOVASCU DISEAS
_ 0PYB42 SPC A 00033853 XXXXX,XXXX X 06/01/96 M Y THORACIC SURGERY
_ 0PYB43 SPC C 00041397 KAVOOSSI-SHARIFABAD, 06/01/96 M Y PHYSICAL MED & REH
_ 0PYB44 SPC DC 00016644 XXXXXXX,XXXXXXX P 06/01/96 M Y CHIROPRACTOR
_ 0PYB45 SPC A 00044650 XXXXXX,XXXXXX B 06/01/96 M Y ANESTHESIOLOGY
_ 0PYB47 SPC A 00025157 XXXXXXXXXX,XXXXXX A 06/01/96 M Y NEUROLOGY
_ 0PYB48 SPC A 00029007 XXXXXXX,XXXXXX X 06/01/96 M Y RHEUMATOLOGY
_ 0PYB49 SPC G 00037056 SHEAR,STUART L 06/01/96 M Y DERMATOLOGY
_ 0PYB50 SPC A 00039226 SEE,XXXXXXXX C 06/01/96 M Y INFECTIOUS DISEASE
NEXT XXXX:________ NEXT KEY:________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
PLEASE ENTER "S" NEXT TO DESIRED PHYSICIAN
HIQPVHD CORPORATE SYSTEMS P 02/12/97 08:47:20 0000
XXXX00 XXX00000 XXXXX XXX DATA INQUIRY VERSION 001
PHYSICIAN CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
============================================================== ALL PHYSICIANS
DR NO. P/S LICENSE NO. NAME EFF DATE PRC/ACC SPECIALTY
_ 0PYB51 SPC G 00051075 XXXXX,XXXX T 06/01/96 M Y OPHTHALMOLOGY
_ 0PYB52 SPC G 00043480 XXXXXX,XXXXXX 06/01/96 M Y INTERNAL MEDICINE
_ 0PYB53 SPC A 00030158 XXXXXXX,XXXXXXXXX M 06/01/96 M Y PLASTIC SURGERY
_ 0PYB54 SPC A 00039778 SUCHOV,MORDO 06/01/96 M Y INTERNAL MEDICINE
_ 0PYB55 SPC G 00045202 XXXXXXX,XXXXX 06/01/96 M Y ORTHOPEDIC SURGERY
_ 0PYB56 SPC G 00027036 XXXXXXX,XXXXXXX 06/01/96 M Y ORTHOPEDIC SURGERY
_ 0PYB57 SPC E 00003593 XXX,XXXXX W 06/01/96 M Y PODIATRISTS
_ 0PYB58 SPC G 00032178 XXXXXXX,XXXX P 06/01/96 M Y RADIATION ONCOLOGY
_ 0PYB59 SPC G 00020647 LAW,XXXX C 09/01/96 M Y EMERGENCY MEDICINE
_ 0PYB60 SPC G 00035526 XXXXX,XXXX X 09/15/96 M Y ORTHOPEDIC SURGERY
_ 0PYB61 SPC A 00025389 XXXXXX,XXXXXX M 11/15/96 M Y OBSTETRICS & GYNEC
NEXT XXXX:________ NEXT KEY:________ SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
NO MORE PHYSICIAN RECORDS FOR THIS SITE
HIQPVHG CORPORATE SYSTEMS
HPCT26 BCNMS HMO DATA INQUIRY VERSION 001
AFFILIATED HOSPITAL CROSS REFERENCE
SITE CODE: 0PY000
SITE NAME: PROSPECT MEDICAL GROUP
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MEDICARE ID HOSPITAL NAME EFFDATE ENDDATE
_ 050065 ** WESTERN MEDICAL CENTER-SANTA XXX 10/01/96 99/99/99
_ 050168 ** ST JUDE MEDICAL CENTER 12/01/94 99/99/99
_ 050282 ** XXXXXX XXXXXX HOSPITAL MEDICAL CENTER 10/01/96 99/99/99
_ 050535 ** COASTAL COMMUNITIES HOSPITAL 10/01/96 99/99/99
_ 050567 ** MISSION HOSPITAL REGIONAL
MEDICAL CENTER 10/01/96 99/99/99
_ 050603 __ SADDLEBACK MEMORIAL MEDICAL CENTER 10/01/96 99/99/99
_ 050693 ** IRVINE MEDICAL CENTER 10/01/96 99/99/99
NEXT XXXX: NEXT KEY: SVC DATES: 02/12/97 02/12/97
PF3: HMO MAIN PF5: SYSRETRN PF6: CORPMENU PF7: PAGEBACK PF8: PAGENEXT
NO MORE HOSPITAL RECORDS FOR THIS SITE
EXHIBIT C
ADMINISTRATIVE RESPONSIBILITIES OF PARTICIPATING MEDICAL GROUP
This exhibit lists the areas in which PARTICIPATING MEDICAL GROUP and
PARTICIPATING MEDICAL GROUP Physicians will have administrative
responsibility. The extent and type of responsibility to be undertaken will
be agreed upon by the PARTICIPATING MEDICAL GROUP and BLUE CROSS through an
annual audit process.
A. PROFESSIONAL SERVICES ADMINISTRATION
Professional Services - Schedule, control, process and report encounter
information
Outside Referrals - Control, process and report encounter information
Ancillary - Control, process and report encounter information
B. INSTITUTIONAL SERVICES ADMINISTRATION
Preadmission certification process
Medical Review of claims
Length-of-stay (monitoring and control)
C. UTILIZATION REVIEW
D. PEER REVIEW, EDUCATION AND CREDENTIALING
E. QUALITY MANAGEMENT
F. GRIEVANCE PROCEDURE COMPLIANCE
G. MONITOR AND REVISE SPECIALIST/OTHER REFERRAL CONTRACTS
H. PATIENT EDUCATION
I. CASE MANAGEMENT
C-1
CALIFORNIACARE HEALTH PLANS
SCHEDULE D
Intentionally omitted. Confidential Treatment Requested.
Effective December 1, 0000 Xxxx Xxxxx xx Xxxxxxxxxx
Prudent Buyer Plan
EXHIBIT E
PHYSICIAN PAYMENT STRUCTURE
AREA 5
Blue Cross of California establishes and, from time to time, revises unit
values based on observed charge patterns by CPT-4 procedure code. The maximum
allowable for physician claims shall be calculated using the unit values as
in effect, multiplied by the following conversion factors: *
CONVERSION FACTORS
------------------
Anesthesia [ ** ]
Medicine [ ** ]
Pathology
CPT codes 88100-88399 [ ** ]
All other CPT codes [ ** ]
Radiology [ ** ]
Surgery
CPT-4 codes 59400-59622 [ ** ]
All other CPT-4 codes [ ** ]
When PHYSICIAN does not submit claims electronically in a format specified
by BLUE CROSS, a handling fee of [ ** ] per OCR scannable claim and
[ ** ] per paper claim will be deducted from payment due PHYSICIAN.
PHYSICIAN will not charge Members for the handling fee.
REIMBURSEMENT FOR HCPCS LEVEL II CODES
PHARMACY (INCLUDING INFUSION THERAPY DRUGS): Maximum Allowable reimbursement
based on Average Wholesale Price (AWP) according to published market data
(such as DRUG TOPICS RED BOOK, AMERICAN DRUGGIST BLUE BOOK, OR MEDISPAN).
Oral prescription drugs dispensed in the physician's office will be denied as
not payable, and the Member may not be billed by physician.
DURABLE MEDICAL EQUIPMENT, SUPPLIES (INCLUDING, BUT NOT LIMITED TO, INFUSION
THERAPY SUPPLIES), PROSTHETICS AND ORTHOTICS: Maximum Allowable Reimbursement
not to exceed the lesser of the average retail price or the Medicare regional
allowable reimbursement rates applied to California for the appropriate code
ranges. The average retail price will be determined annually from claims data
and/or external data. Reimbursement rates will be based on whether the
equipment is new, used or rented as identified by the CPT code modifier.
Codes not identified by modifier will be considered as rentals.
ALL OTHER HCPCS CODES: For all other HCPCS codes the Maximum Allowable will
be determined by Blue Cross using claims data and/or external data.
EXHIBIT F
NON-CAPITATED PERFORMANCE SETTLEMENT SCHEDULE
FOR NON-CAPITATED MEDICAL SERVICES
Based on Plan C, $60,000 Stop Loss,
Age/Sex Factor = 1.00 and Regional Factor = 1.00
NON-CAPITATED PERFORMANCE SETTLEMENT CALCULATION METHOD:
1) Identify the payment band that contains the PARTICIPATING MEDICAL GROUP's
Adjusted PMPM Non-Capitated Expense
2) Subtract the PARTICIPATING MEDICAL GROUP's PMPM Non-Capitated Expense from
the high value of the payment band
3) Multiply the result from Step 2 by the multiplier column for the payment
band
4) Add the result from Step 3 to the minimum payment amount for the payment
band to get the PMPM Non-Capitated Performance Settlement
5) Multiply the PMPM Non-Capitated Performance Settlement from Step 4 by the
PARTICIPATING MEDICAL GROUP's Member Months to calculate the Non-Capitated
Performance Settlement
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Non-Capitated Expense Ranges
Payment Bands (PMPM Non-Capitated Expense) Multiplier Minimum Payment Amount
----------------------------
Low High
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1 $31.63 > $31.63 [ ** ] [ ** ]
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2 $30.30 $31.62* [ ** ] [ ** ]
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3 $28.97 $30.29 [ ** ] [ ** ]
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4 $27.64 $28.96 [ ** ] [ ** ]
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5 $26.31 $27.63 [ ** ] [ ** ]
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6 $24.98 $26.30 [ ** ] [ ** ]
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7 $23.65 $24.97 [ ** ] [ ** ]
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8 $22.32 $23.64 [ ** ] [ ** ]
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9 $20.99 $22.31 [ ** ] [ ** ]
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10 < $20.98 $20.98 [ ** ] [ ** ]
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* Attachment Point
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Example of Non-Capitated Performance Settlement Calculation
Assume: PARTICIPATING MEDICAL GROUP has an PMPM Non-Capitated Expense of
$26.63; and there are 100,000 member months
(1) Identify the payment band that contains the PARTICIPATING MEDICAL GROUP's
Adjusted PMPM Non-Capitated Expense.
The PARTICIPATING MEDICAL GROUP's PMPM Non-Capitated Expense of $26.63
falls between the low and high values of payment band 5
(2) Subtract the PARTICIPATING MEDICAL GROUP's PMPM Non-Capitated Expense from
the high value for the payment band.
$27.63 - $26.63 = $1.00
(3) Multiply the result from Step 2 by the multiplier for the payment band.
$1.00 x [ ** ] = [ ** ]
(4) Add the result from Step 3 to the minimum payment amount for the payment
band to get the PMPM Non-Capitated Performance Settlement.
[ ** ] + [ ** ] = [ ** ] PMPM Non-Capitated Performance Settlement
(5) Multiply the PMPM Non-Capitated Performance Settlement from Step 4 by the
PARTICIPATING MEDICAL GROUP's Member Months to calculate the Non-Capitated
Performance Settlement.
[ ** ] PMPM Non-Capitated Performance Settlement x 100,000 member months
= [ ** ] Non-Capitated Performance Settlement
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F-1
EXHIBIT G
COMPENSATION FOR SERVICES TO BLUE CROSS PLUS MEMBERS
In consideration for the mutual promises herein set forth, PARTICIPATING MEDICAL
GROUP and BLUE CROSS hereby agree as follows:
I. DEFINITIONS
A. "ADVANCE SUPPLEMENTAL CAPITATION PAYMENT" means a supplemental
Capitation payment apportioned monthly and paid in advance of the
date it is earned. Advance Supplemental Capitation Payments are
subject to recoupment by BLUE CROSS if not actually earned prior to
the end of the calendar quarter.
B. "BASELINE CAPITATION PAYMENT" means the monthly Capitation payment for
each Member covered by a BLUE CROSS PLUS Benefit Agreement and
assigned to PARTICIPATING MEDICAL GROUP.
C. "IN-NETWORK SERVICES" means those services which are provided,
arranged by, referred or authorized by PARTICIPATING MEDICAL GROUP for
BLUE CROSS PLUS Members and which would be CALIFORNIACARE Capitation
Services if they had been rendered under the Agreement to a
CALIFORNIACARE Member.
D. "IN-NETWORK UTILIZATION FACTOR" means the quotient of the Baseline
Capitation Payment, divided by the sum of Baseline Capitation Payments
plus expenses for Out-of-Network Services, modified each calendar
quarter to allow for incurred but not reported expenses (IBNR) based
on BLUE CROSS's overall BLUE CROSS PLUS experience, as follows:
Baseline Capitation Payment = A
Expenses for Out-of-Network Services = B
(Modified to allow for IBNR)
In-Network Utilization Factor = C
A
C = -------
A + B
E. "NON-PARTICIPATING PROVIDER" means a Health Professional, hospital,
emergency facility, skilled nursing facility, ambulance service, home
health agency, or Alternate Birthing Center that has rendered services
to a BLUE CROSS PLUS Member without authorization from the
PARTICIPATING MEDICAL GROUP to which the Member is assigned.
F. "OUT-OF-NETWORK SERVICES" means those services rendered to BLUE CROSS
PLUS Members by a Non-Participating Provider, and which would be
Capitation Services if rendered by PARTICIPATING MEDICAL GROUP under
the Agreement to CALIFORNIACARE Members, except for Out-of-Area
Emergency Services.
G. "SUPPLEMENTAL CAPITATION PAYMENT" means a Capitation payment per BLUE
CROSS PLUS Member per month, which may be earned based on the
In-Network Utilization Factor as set forth in Exhibit G-1.
G-1
CALIFORNIACARE HEALTH PLANS
SCHEDULE G-1
Intentionally omitted. Confidential Treatment Requested.
EXHIBIT H
OUTPATIENT PRESCRIPTION DRUG SETTLEMENT SCHEDULE
PMPM Outpatient Prescription Drug Expense Target: $10.45 PMPM
PMPM EXPENSE RANGE SETTLEMENT CALCULATION
Greater than $10.45 [ ** ]
$9.60 to $10.45 [ ** ]
$8.75 to $9.59 [ ** ]
Less than $8.75 [ ** ]
If PARTICIPATING MEDICAL GROUP's PMPM OPDE is less than the OPDE Target, an
additional [ ** ] PMPM will be due to PARTICIPATING MEDICAL GROUP if
PARTICIPATING MEDICAL GROUP's Formulary utilization is equal to or greater
than 95%.
Formulary Utilization: Is the quotient of the number of prescriptions for
Members with outpatient prescription drug benefits
assigned to PARTICIPATING MEDICAL GROUP using drugs
listed in the Blue Cross of California Outpatient
Prescription Drug Formulary divided by the total
number of prescriptions for Members with outpatient
prescription drug benefits assigned to PARTICIPATING
MEDICAL GROUP.
H-1
EXHIBIT I
QUALITY MANAGEMENT BONUS SCHEDULE
Quality Management Scorecard Rating PMPM Quality Bonus Settlement
Below Average [ ** ]
Average [ ** ]
Above Average [ ** ]
Where:
"Average" is the numeric average of all PARTICIPATING MEDICAL GROUP
scorecard scores plus or minus one standard deviation.
"Above Average" is a score that is greater than one standard deviation above
the numeric average of all PARTICIPATING MEDICAL GROUP scorecard scores.
"Below Average" is a score that is less than one standard deviation below the
numeric average of all PARTICIPATING MEDICAL GROUP scorecard scores.
I-1
