EX-10.30 9 dex1030.htm HERITAGE PHYSICIAN NETWORKS ANCILLARY PARTICIPATION AGREEMENT HERITAGE PHYSICIAN NETWORKS ANCILLARY PARTICIPATION AGREEMENT NOTICE: THIS AGREEMENT IS SUBJECT TO BINDING ARBITRATION PURSUANT TO THE TEXAS GENERAL ARBITRATION ACT...
Exhibit 10.30
HERITAGE PHYSICIAN NETWORKS
ANCILLARY PARTICIPATION AGREEMENT
NOTICE: THIS AGREEMENT IS SUBJECT TO BINDING ARBITRATION
PURSUANT TO THE TEXAS GENERAL ARBITRATION ACT AND THE
COMMERCIAL ARBITRATION RULES OF THE
AMERICAN ARBITRATION ASSOCIATION
THIS ANCILLARY PARTICIPATION AGREEMENT (the “Agreement”) is made and entered into as of the 1st day of March, 2004, by and between Heritage Physician Networks, a Texas non-profit corporation certified pursuant to Section 162.001 et seq. of the Texas Medical Practice Act (hereinafter referred to as “HPN”) and CDS Health Management Inc. (d/b/a Certified Diabetic Supplies) a legal entity licensed to provide health care services in the State of Texas (hereinafter referred to as “Provider”), who are collectively referred to hereinafter as “the Parties.”
WHEREAS, Provider is duly licensed (and the members of such entity are duly licensed) to provide health care services in the State of Texas, whose licenses are without limitation or restriction, and who desire to participate in the health care provider panel described herein;
ARTICLE 1
1.1 ADA shall mean the Americans with Disabilities Act.
1.2 Advance Directives shall mean a Member’s written instructions, recognized under State law, relating to the provision of health care when the Member is incapacitated.
1.3 Centers for Medicare and Medicaid Services (“CMS”) shall mean the administrative agency of the U.S. Government responsible for administering the Medicare program. Formerly known as the Health Care Financing Administration (HCFA).
1.4 Clean Claim shall mean, as defined by the Texas Insurance Code, a claim submitted by Provider for medical care or health care services rendered to a Member under a Payer Plan with documentation reasonably necessary for HPN or a Payer to process the claim, which contains: (i) the required data elements set forth in §21.2803(b); (ii) the attachments of which Provider has been properly notified as necessary for processing pursuant to §21.2803(c); (iii) any additional elements of which Provider has been properly notified pursuant to §21.2803(b) relating to this title and in §21.2805 relating to disclosure of additional clean claim elements; (iv) the amount paid by the primary plan or valid coverage pursuant to §21.2803(e) relating to this title; and (v) any revised data elements, attachments, and additional Clean Claim elements which Provider has been properly notified pursuant to §21.2806 of this title. HPN’s requirements for a Clean Claim are outlined in Exhibit E of this Agreement.
1.5 Covered Services shall mean the health care services, including Emergency Care, that are within Provider’s capabilities, which Provider is licensed to provide, and that are rendered to a Member by Provider for which a Payer is obligated to pay or reimburse pursuant to a Payer Plan.
1.6 Department shall mean the Texas Department of Insurance.
1.7 Emergency Care shall mean services furnished in order to evaluate and stabilize medical conditions of a recent onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe his or her condition, sickness, or injury is of such nature that failure to get immediate medical care could result in: (i) serious impairment to bodily functions; (ii) serious dysfunction of any body organ or part; (iii) placing a Member’s health in serious jeopardy; (iv) serious disfigurement; or (v) in the case of a pregnant woman, serious jeopardy to the health of the fetus. In no event will “Emergency Care” be interpreted under this Agreement so as to conflict with emergency service obligations under State or federal law.
1.8 HEDIS shall mean the Health plan Employer Data and Information Set.
1.9 HIPAA shall mean the Health Insurance Portability and Accountability Act of 1996 and as amended and as implemented by CMS and the U. S. Department of Health and Human Services pursuant to which the Parties agree to the terms and conditions of the Business Associate Addendum, attached hereto as Exhibit F and made a part of this Agreement.
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1.10 Hospitalist shall mean a provider contracted by HPN to oversee inpatient Covered Services, including authorizing all inpatient provider consultations, participating in discharge planning, and assisting in-the documentation of such inpatient care as required by HPN.
1.11 Medically Necessary, means those health care services provided to a Member that are (i) appropriate and necessary for the symptoms, diagnosis, or treatment of the Member’s injury or disease; (ii) provided for the diagnosis or direct care and treatment of the Member’s injury or disease; (iii) within standards of good medical practice established by the organized medical community; (iv) not primarily for the convenience of the Member, Provider, or another provider; and (v) provided at an appropriate supply or level of service needed to provide safe and adequate care. The final determination of whether a service, supply or benefit was Medically Necessary shall be made by Payer or its designee, subject to appeal under the applicable grievance and appeals procedures.
1.12 Medicare Advantage (MA) means the comprehensive managed care program for Medicare created under the Balanced Budget Act of 1997 and contained -in Title XVIII; Part C of the Social Security Act (§§ 1851-1859; 42 U.S.C.A. §§ 1395w-21 to -28 (West Supp. 1999)) and the rules and regulations promulgated thereunder and as amended by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DIMA), or as may be amended from time to time. Medicare Advantage program requirements are set forth in Exhibit D attached to and made part of this Agreement. MA is foimerly known as the Medicare+Choice Program.
1.13 Members shall mean those employees or members and their dependents who have elected to receive health care services from Participating Providers and who are eligible to receive such services under a Payer Plan.
1.14 NCOA shall mean the National Committee on Quality Assurance.
1.15 Open Access Payer shall mean Risk Payers that allow Members the right to seek certain health care services from network providers without Prior Authorization or notification by another network provider.
1.16 Out-of-Area Services shall mean those Urgently Needed Services (as defined in Exhibit D related to the Medicare Advantage program) and Emergency Care provided while a Member is outside Provider Service Area.
1.17 Participating Facility shall mean a hospital or other licensed acute care facility, skilled nursing facility or other health care facility that has entered into a written agreement with HPN or Payer to provide Covered Services to Members within the scope of the facility’s license.
1.18 Participating Provider shall mean a Participating Facility, physician, or legal entity duly licensed to provide health care services, or other licensed health care professional, practitioner, provider or facility that has entered into an agreement, directly or indirectly, with HPN or a Payer to provide Covered Services to Members.
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1.19 Payer shall mean any entity, including, but not limited to, employers, unions, associations, insurers, health maintenance organizations, Medicare (CMS), Medicaid (Title XIX) agency, or provider service organization/network that has contracted with HPN to arrange for Covered Services to be provided to Members of their Payer Plans.
1.20 Paver Plan, shall mean the health benefit programs for which a Payer is obligated to provide, arrange, administer, and/or finance health care services, provider networks, administrative or other related services pursuant to a written agreement between a public or private employer, governmental entity or other entity and a Payer.
1.21 Payer Agreements shall mean those agreements entered into, directly or indirectly, by and between HPN and Payers that describe the terms and conditions under which Payer shall have access to HPN’s panel of health care providers.
1.22 Primary Care Physician “PCP”), also referred to as a personal physician, shall mean a Participating Provider who accepts responsibility for rendering Primary Care Physician Services and coordinating referral care for specified Members under an agreement with HPN. Unless otherwise determined by HPN, Primary Care Physician shall only include physicians in family practice, general practice, internal medicine, or pediatrics.
1.23 Primary Care Physician Services are the Covered Services, comprising initial and continuing health care, including basic or initial diagnosis and treatment, health supervision, management of chronic conditions and preventive health services, and ongoing management of referrals to consultants, other ancillary providers and community resources.
1.24 Provider Service Area shall mean the geographic area within which Provider is responsible for providing Covered Services to Members.
1.25 Risk Payer shall mean Payers that have contracted with HPN for the provision of Covered Services to Members where HPN has been assigned financial risk for the cost of professional and/or institutional services.
1.26 State shall mean the State of Texas.
1.27 Subcontractor means an entity or person with whom Provider has contracted directly or indirectly for the provision of Covered Services under this Agreement as set forth in Section 2.18.
1.28 Urgent Care Services shall mean health care services, other than Emergency Care, which are typically provided in settings such as a physician or provider’s office or urgent care center, as a result of an acute injury or illness that is severe or painful enough to lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, illness or injury is of such a nature that failure to obtain treatment within a reasonable period of time would result in serious deterioration of the condition of his or her health.
1.29 Utilization/Quality Management Committee shall mean a committee designated by HPN to monitor and review the provision of Covered Services to Members.
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ARTICLE 2
DUTIES AND OBLIGATIONS OF PROVIDER
2.1 Participation in Payer Plan. Provider shall participate in Payer Plans according to Section 5.1 hereof and shall provide Covered Services to Members’ in accordance with (i) the terms and conditions of this Agreement; (ii) Payer Plans; (iii) Payer Agreements; and (iv) all laws, rules and regulations, policies and procedures applicable to Provider, HPN or a Payer. Provider acknowledges that the Payers contracting with HPN, in coordination with the Hospitalist, have the right to immediately withdraw Members from the care of Provider in the event the health or safety of a Member is endangered by the actions of Provider or by reason of the Provider’s failure to provide Covered Services in accordance with the quality improvement and utilization management programs of the Payer and/or HPN.
2.4 Cooperation with Utilization Management, Quality Improvement and Other Managed Care Requirements. Provider shall participate in and comply with quality improvement activities, credentialing activities, utilization management activities, Hospitalist program, member grievance and appeal procedures, member satisfaction activities, medical records review, formulary programs, preventive health policies and programs and other related policies and programs as established by HPN and/or Payer. Provider shall comply with all additional policies and procedures of the applicable Payer, including, without limitation, those relating to Advance Directives. Provider shall provide information regarding treatment options in a culturally competent manner. The parties agree that all activities conducted by HPN and Provider pursuant to the utilization management and quality improvement programs and in connection with provider credentialing by HPN shall be conducted, to the extent practicable, in such a manner as to be subject to and obtain the privileges and immunities of applicable laws pertaining to peer review activities.
2.5 Managed Care Efforts. Provider shall utilize the managed care methods and practices consistent with sound health care practices as determined in accordance with accepted community professional standards for rendering quality care. Provider shall abide by the procedures and criteria adopted by HPN and/or Payer to monitor the necessity and quality of Covered Services provided to Members and cooperate fully with HPN and Payer in the development of appropriate approaches to manage care consistent with sound health care practice.
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2.10 Out-of-Area Services. Provider shall cooperate fully with HPN in HPN’s activities relating to management and coordination of Out-of-Area Services.
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2.18.6 Access to Other Administrative and Financial Information. Provider further agrees to submit such additional reports and information as HPN or a Payer Plan deems necessary for HPN or such Payer Plan to monitor the financial and administrative viability of Provider.
Provided, further, each Subcontractor shall provide HPN or each Payer Plan access to all financial records as is required of Provider under this Section 2.18.
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such provision(s), as reasonably determined by HPN or Payer. If Provider fails to comply with such provision(s) by the date specified on the notice, HPN and such Payer shall have the right to (i) cease marketing efforts on behalf of Provider; (ii) discontinue referral of Members to Provider until such time as Provider complies with such provision(s), as reasonably determined by HPN and/or terminate Provider’s participation under one or more Payer Plans; and/or (iii) terminate this Agreement in accordance with the provisions of Section 13.4. In addition, HPN shall have the right to either (a) collect from Provider; or (b) recoup against amounts due Provider under this Agreement, any penalties or other monetary amounts payable by HPN to government agencies, Members or groups of Members, Participating Providers or any other health care providers as a result of Provider’s failure to comply with any provision(s) of this Agreement or the policies or procedures of HPN or a Payer. HPN’s rights and remedies under this Section shall be in addition to all other rights and remedies available to HPN to enforce this Agreement, including the right of termination.
2.21 Existing and Future Contractual Relationships with Payers. HPN and Provider agree that in addition to this Agreement that includes payment rates and other general terms and conditions under which Covered Services will be provided to Members covered by Payer Plans, HPN has or will enter into additional or revised Payer Agreements and Provider has or will enter into other agreements with Payers (“Provider-Payer Contracts”) that may cover the same subject matter as this Agreement as hereinafter provided.
2.21.1 Payer Agreements. HPN has directly or indirectly entered into the Payer Agreements listed on Exhibit C that include general terms and conditions, the scope of which is limited solely to the specific products reflected in Exhibit C which exhibit shall be amended from time to time by HPN to include each new Payer Agreement, and the specific products included, entered into by HPN as of the effective date of said additional Payer Agreement. Provider acknowledges and agrees that regardless of any existing or future Provider-Payer Contracts that may cover the same subject matter as the Payer Agreements listed on Exhibit C, if a Payer has entered into as of the Effective Date of this Agreement, or in the future enters into, a valid and existing Payer Agreement, the Payer Agreement is the agreement that is primary and controls (the “Primary Agreement”) with respect to the specific products reflected on Exhibit C unless HPN and Provider agree otherwise pursuant to a written agreement between HPN and Provider.
2.21.2 Additional Acts. Provider agrees to use its best efforts to take whatever action is necessary to effectuate the parties’ understanding under this Agreement, including without limitation, amendment, assignment or termination of one or more Provider-Payer Contracts, to cause a Payer Agreement to serve as the Primary Agreement as set forth in this Section 2.21. The parties acknowledge and agree that this Section 2.21 is not intended to circumvent or interfere with existing contractual relationships; rather, the intent of the parties is to avoid any potential misunderstandings or disagreements that may necessarily arise when there is one or more agreements with a Payer that cover the same subject matter as this Agreement by creating a common understanding as to which agreement is the Primary Agreement that controls.
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2.21.3 HPN Notice Requirements. HPN shall (i) on the date of execution of this Agreement by HPN, provide Provider in writing a completed Exhibit C identifying existing Payer Agreements as of the Effective Date of this Agreement (“Notice of Existing Payer Agreements”); and (ii) thereafter, provide written notice of amendments to Exhibit C reflecting future Payer Agreements entered into after the Effective Date of this Agreement (“Notice of Future Payer Agreements”).
2.21.4 Notice of Exception. Provider shall have fifteen (15) business days from receipt of a Notice of Existing Payer Agreements or Notice of Future Payer Agreements to provide HPN with written notice (the “Notice of Exception”) in the event Provider is unable to effectuate the parties’ understanding under this Section 2.21 with respect to a Payer Agreement serving as the Primary Agreement when there is one or more Payer Agreements that cover the same subject matter as this Agreement. The Notice of Exception shall clearly identify the Payer Agreement and state the reasons why such Payer Agreement does not control as a Primary Agreement in accordance with the parties’ understanding under this Section 2.21. Receipt of Notice of Exception by HPN shall automatically operate to create an exception to the parties’ understanding under this Section 2.21 concerning such Payer Agreement.
2.21.5 Participating Providers Bound. Provider shall cause each Subcontractor to comply with the provisions of this Section 2.21, including the provision of a Notice of Exception to Provider and/or HPN in the event Subcontractor cannot cause a Payer Agreement to serve as the Primary Agreement when there is one or more agreements with a Payer that cover the same subject matter as this Agreement.
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ARTICLE 3
3.5 Complaint Process. In accordance with the provisions Article 3.70-3C(3)(f) of the Texas Insurance Code, HPN or Payer shall provide a mechanism for the resolution of complaints initiated by Members or Provider and shall furnish Provider a copy of the review process. Such mechanism shall provide for reasonable due process which includes, in an advisory role only, a review panel selected in the manner described in Article 3.70-3C(3)(b)(3) of the Texas Insurance Code.
ARTICLE 4
PROVIDER REPRESENTATIONS AND WARRANTIES
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4.3 Qualifications. Provider represents and warrants that:
4.3.1 Provider has and will maintain the appropriate current and unrestricted licenses, registrations and/or certificates to provide Covered Services required by State and federal law or by HPN or Payers in order to provide Covered Services to Members;
4.3.2 Provider provides Covered Services in compliance with all applicable local, State, and federal laws, rules, regulations and institutional and professional standards of care;
4.3.3 Provider is certified to participate in Medicare under Title XVIII of the Social Security Act, and in Medicaid under Title XIX of the Social Security Act or other applicable State law pertaining to Title XIX of the Social Security Act;
4.3.4 Provider is accredited by the appropriate accreditation organization(s) as specified by HPN; and
Provider shall maintain such licensure, compliance, certification and accreditation throughout the term of this Agreement. Provider shall notify HPN immediately if there is any action against Provider with respect to, or a change in the status of any of, the foregoing.
4.4.1 any action taken to restrict, suspend or revoke Provider’s license to provide the services required by this Agreement;
4.4.2 any suit or arbitration action for malpractice against Provider (provide a summary of the final disposition of such action);
4.4.3 any felony indictment naming Provider (provide a summary of the final disposition of such action);
4.4.4 any disciplinary proceeding or action involving Provider before any administrative agency;
4.4.5 any cancellation or material modification of Provider’s general liability insurance; or
4.4.6 any other material adverse change to Provider’s ability to perform under this Agreement.
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In addition, Provider shall also report all such actions as they apply to Provider’s agents, employees, and Subcontractors. All such notices shall include copies of any complaints, petitions, lawsuits or other documents filed or prepared in connection with such proceeding.
ARTICLE 5
ACCEPTANCE OF PAYER AGREEMENTS
5.2.1 make payments for Covered Services rendered by Provider to Members;
5.2.2 make payments for Covered Services on the basis of a compensation system negotiated by HPN and communicated to and accepted by Provider in accordance with Article 6 hereof;
5.2.3 make best efforts to make payments to Provider, as applicable, in accordance with Section 6.1 hereof; and
5.2.4 agree, in the event payment is denied, to provide Provider and/or HPN with notice thereof and an opportunity to substantiate the right of payment.
ARTICLE 6
PROVIDER COMPENSATION AND XXXXXXXX
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6.7 Patient Identification. HPN shall cause Payer to provide Members with appropriate identification indicating their participation in a Payer Plan.
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6.9 Encounter Data/Claims for Risk Payers. Provider shall submit to HPN, no later than forty-five(45) calendar days from the date of service claims for any services to be paid at fee-for-service rates per this Agreement. Such information shall be in such form as prescribed by HPN. Provider agrees that HPN and Payers shall be permitted to prepare and disclose to a third party a report of “quality data.” For purposes of this Section 6.10, quality data shall be limited to: (i) utilization data of HPN and Participating Providers in the aggregate; (ii) HEDIS reporting data; (iii) Member satisfaction data; (iv) overall compliance with NCQA or other comparable quality standards; and (v) Member disenrollment data; provided, however, that quality data shall not include any information that identifies an individual Member or that is privileged or confidential under applicable peer review or patient confidentiality laws.
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ARTICLE 7
7.2.1 The Payer as Primary Carrier. Where a Payer, pursuant to applicable coordination of benefits rules, is the primary payer, HPN will pay the amount due under this Agreement.
7.2.2 The Payer as Other Than Primary Carrier. Where a Payer is other than the primary payer, HPN will pay only that amount which, when added to amounts owed from other sources, equals one hundred percent (100%) of the amount required under this Agreement.
ARTICLE 8
COMPLIANCE WITH HPN AND PAYER PLAN RULES
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ARTICLE 9
MEDICAL RECORDS AND CONFIDENTIALITY
9.2 Transferability. Provider agrees, upon request of a Member or another HPN Participating Provider caring for the Member, subject to applicable disclosure and confidentiality laws, to transfer the medical records of the Member to the HPN Participating Provider. Following termination of this Agreement, at the request of the applicable Payer, Provider shall copy all requested Member medical records in its possession and forward such files to another provider of Covered Services designated by the applicable Payer, provided such copying and forwarding is not otherwise objected to by such Members. The copies of such medical files may be in summary form. The cost of copying the patient medical files shall be borne by Provider. This Section 9.2 shall survive the termination or expiration of this Agreement.
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Provider shall not disclose to any other person, entity, or party not related to either party, any of such proprietary information without the prior written authorization of HPN or Payer, except as set forth in Section 2.11, unless such disclosure is required by State or federal statute, regulation or court order, This provision shall survive any termination or expiration of this Agreement. Such proprietary information includes, without limitation: (i) information containing the names, addresses and telephone numbers of Members which has been compiled by HPN or Payers; (ii) lists or documents compiled by HPN or Payer which include the names, addresses and telephone number of employers, employees of such employers responsible for health benefits, and the officers and directors of such employers, responsible for health benefits; (iii) HPN and Payer provider manuals and any of HPN’s or Payer’s member, employer and administrative service . manuals and all forms related hereto; (iv) the financial arrangements between Payer and HPN, any of Payer and HPN’s Participating Providers, and between HPN and Provider; (v) Payer’s underwriting and rating information and any other information utilized by Payers for determining eligibility rates; and (vi) any other information compiled or created by Payer or HPN which is proprietary. Provider shall not use the name, service xxxx, logo or other business product of HPN or Payer without the written consent of HPN or Payer.
ARTICLE 10
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Notwithstanding any other provision to the , contrary, HPN shall, in addition to any other remedies provided for under this Agreement, have the right to seek a judicial temporary restraining order, preliminary injunction, or other equitable relief against Provider to enforce its rights under this Section.
ARTICLE 11
ARTICLE 12
ADVERTISING REFERENCES TO PROVIDER
Provider agrees that HPN may use Provider’s name, address, telephone number, and a description of Provider’s credentialed specialty in any roster of Participating Providers published by HPN or Payer, Member handbooks, other materials distributed to Members, or any other marketing materials. The roster may be inspected by and is intended for the use of prospective and existing participants as well as for advertising purposes.
ARTICLE 13
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appeals procedures, including but not limited to grievance procedures for resolving disputes regarding the necessity for continued treatment. HPN may extend this Agreement by giving written notice to Provider until the termination of such Payer Agreement but for no more than twelve (12) months. Provider shall be compensated by HPN at the rates in effect between HPN and Provider as of the date of termination.
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ARTICLE 14
14.2 Nondiscrimination and other Material Laws. Provider agrees to comply with all applicable provisions of State and federal law. Provider shall meet the standards for participation and all applicable requirements for providers of health care services under the Medicare program. In addition, Provider shall require that all facilities and offices utilized by Provider to provide Covered Services to Medicare Members shall comply with facility standards established by CMS. Provider shall not unlawfully discriminate against employees or applicants for employment or against any Members on the basis of race, color, creed, national origin, ancestry, religion, sex, marital status, age (except as provided by law), or physical or mental handicap, sexual orientation, source of payment, utilization of health services, or other unlawful basis. Provider shall ensure that the evaluation and treatment of its employees and applicants for employment and of Members are free of such discrimination. In addition to the foregoing, Provider shall comply with Title VI of the Civil Right Act of 1964, as amended (42 U.S.C. § 2000d, et seq.), Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794) and the regulations thereunder, Title IX of the Education Amendments of 1972, as amended (20 U.S.C. § 1681, et seq.), the Age Discrimination Act of 1975, as amended (42 U.S.C. § 9849), the Americans with Disabilities Act (P.L. 101-365) (ADA) and all implementing regulations, guidelines and standards as are now or may be lawfully adopted under the above statutes. Without limiting the foregoing, Provider shall assure that Members with disabilities are provided with Provider and Provider’s agents as required by the ADA or other applicable law.
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HERITAGE PHYSICIAN NETWORKS
By: | /s/ Xxxxxxxx Xxxxxxxxx | |
Name: | Xxxxxxxx Xxxxxxxxx | |
Title: | Executive Vice President and C.O.O. |
Address for Notices:
Heritage Physician Networks
0000 Xxxx Xxxxxxx Xxxxx, Xxxxx 000
Xxxxxxx, Xxxxx 00000
Attn: Executive Director
Telephone Number:
713/000-0000
PROVIDER | ||
By: | /s/ Grant M. Gables | |
Name: | Grant M. Gables | |
Title: | V.P. Managed Care |
Address for Notices:
0000 Xxxxxxxxx Xxxxx X. # 000
Xxxxxx, Xxxxxxx 00000
Attn: Grant M. Gables
Telephone Number:
000-000-0000
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EXHIBIT A
PROVIDER COMPENSATION FOR RISK PAYERS
All services performed or supplied provided by Provider shall be compensated at the rates identified herein.
Consultation and Education: | Cost: | ||||||
G0108 | Individual consultation | [R | ]* | ||||
G0109 | Group class education (billed in thirty minute units.) | [R | ]* | ||||
* Each unit represents thirty (30) minutes of time. | |||||||
Diabetes Supplies: | Cost: | ||||||
E0607 | Home Blood Glucose Monitor | [R | ]** | ||||
A4253 | Blood Glucose Strips - 50 count per box | [R | ] | ||||
A4254 | Replacement Battery | [R | ] | ||||
A4256 | Normal, High Low Calibration solution | [R | ] | ||||
A4258 | Spring Powered Lancet Device | [R | ] | ||||
A4259 | Lancets – 100 count per box | [R | ] | ||||
A4206 | Syringes | [R | ] | ||||
** Each member who utilizes Provider’s services shall be given a preferred Bayer glucose monitor (Elite, Breeze, etc.) free of charge either to the Member or HPN. If a Member requests a non-preferred glucose monitor, then Provider will be compensated according to the rate identified herein.
Provider may, at its sole discretion, offer additional non-covered supplies, to Member and agree that Provider shall be compensated directly by the Member for such supplies at [R] of the then current Medicare allowable rates for the county in which supplies are delivered.
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Examples: | |||||||
A5119 | Skin Barrier Wipes | [R | ] | ||||
A6257 | Transparent Film - 16 sq. In | [R | ] | ||||
A6258 | Transparent Film - 16-48 sq. In | [R | ] | ||||
K0601 | Pump Batteries | [R | ] | ||||
K0552 | Insulin Pump Cartridges | [R | ] | ||||
L7900 | Male Vacuum Erection System | [R | ] |
[R] | Redacted materials have been omitted pursuant to a Confidential Treatment Request filed under 17 C.F.R. § 230.406. The omitted materials have been filed separately with the Office of the Secretary of the Securities and Exchange Commission. |
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Additional Services (at no additional cost):
For Diabetes Education Solution:
1. | Provide an American Diabetes Association recognized program consisting of no less than ten (10) important self management topics. |
2. | Utilize Dynamic and Engaging instructors consisting of Certified Diabetic Educators (CDEs), RN’s, Registered Dieticians (RDs). Bilingual as available. |
3. | Individual goal setting for each class attendee. |
4. | Follow up with attendee at 3 and 6 month intervals, and evaluate performance against goals. |
5. | Spouses or other household support members attend free of charge. |
6. | Provide high quality take home materials accompanies by a PowerPoint presentation. |
7. | Flexible site locations to accommodate Member location requirements. |
For Diabetes Member Support Solution:
1. | Assign a personal care coach to each member (the Care Coach Program). |
2. | Ask a series of diabetes self management questions every 90 days. |
3. | Take and send a supply order via mail. No shipping expense. |
4. | Provide the member with access to our clinical diabetes professionals including CDEs, RD and RNs. |
5. | Send targeted education materials with approval of Members. |
6. | Handle all billing and insurance issues on behalf of Members. |
7. | Provide annual trend reports for accreditation activities. |
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EXHIBIT B
HPN’S CONTRACT AUTHORITY
1. | Provider hereby grants HPN the authority to negotiate and enter into and amend Payer Agreements for the provision of Covered Services to Members by Provider in accordance with the following terms and conditions. |
2. | In the event the terms and conditions of a Payer Agreement, or amendment thereto, are substantially similar to this Agreement as it may be amended from time to time, HPN shall notify Provider not less than fifteen (15) days in advance of the effective date of any such Payer Agreement or amendment. Provider shall be automatically bound to such Payer Agreement or amendment upon such effective date.\ |
3. | In the event of the terms and conditions of the Payer Agreement or amendment do not meet the terms and conditions set forth in this Agreement, HPN shall notify Provider of such terms and conditions. Unless HPN receives timely written notice from Provider rejecting such Payer Agreements on or before fifteen (15) days after Provider’s notice, Provider shall be deemed to have accepted such Payer Agreement or amendment and to have agreed to provide Covered Services to Members in accordance with the terms of such Payer Agreement; provided however, in the event the compensation terms under a Payer Agreement or amendment are lower than or otherwise inconsistent with the terms of this Agreements, Provider shall be required to affirmatively accept such compensation terms in writing within the period of time specified in HPN’s notice, or such Payer Agreement shall be construed as rejected by Provider. |
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EXHIBIT C
EXISTING CONTRACTS
The following Risk Payer(s), as modified from time to time, and their designated products are contacted with HPN:
Medicare Advantage HMO
SelectCare of Texas, LLC (product=TexanPlus)
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EXHIBIT D
MEDICARE ADVANTAGE PROGRAM REQUIREMENTS
Unless otherwise expressly provided herein, all defined terms used herein shall have the same meanings ascribed to such terms in the Agreement. The following additional paragraphs, or amendments or additions to existing paragraphs are hereby made a part of the Agreement:
ARTICLE 1
DEFINITIONS
For purposes of this Exhibit D, the following terms shall have the meanings ascribed thereto unless another meaning is clearly required by the context in which such term is used. Definitions respecting the matters set forth below shall not differ from the definitions set forth in Title XVIII, Part C of the Social Security Act (“1851-1859; 42 U.S.C.A.” 1395w-21 to -28 (West Supp. 1999)) and the rules and regulations promulgated thereunder.
1.1 Continuation Area means an additional area outside of the Payer Plan’s service area within which Payer furnishes or arranges for the furnishing of Covered Services to Medicare Members who move outside of the Payer Plan’s service area.
1.2 CMS Contract means the contract between Payer and CMS under the Medicare Advantage Program.
1.3 Medicare Member means a Member who is eligible to receive Covered Services under a Payer Plan that is offered under the Medicare Advantage Program.
1.4 Urgently Needed Services means Covered Services under a Payer Plan provided when a Medicare Member is temporarily absent from the Payer Plan’s service area {or, if applicable, Continuation Area) (or, under unusual and extraordinary circumstances, provided when a Medicare Member is in the Payer Plan’s service area or Continuation Area, but Payer’s provider network is temporarily unavailable or inaccessible) when such services are Medically Necessary and required without delay in order to prevent the serious deterioration of a Medicare Member’s health as a result of an unforeseen illness, injury, or condition and it was not reasonable given the circumstances to obtain the services through Payer’s provider network.
ARTICLE 2
RESPONSIBILITIES OF PROVIDER
2.1 Provision of Services. Provider agrees to provide Covered Services in a manner consistent with professionally recognized standards of health care. Provider agrees further to (i) provide Covered Services in a culturally competent manner to all Medicare Members by making a particular effort to ensure that those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities receive the health care to which they are entitled; (ii) provide Medicare
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Members information regarding treatment options in a culturally competent manner, including the option of no treatment; and (iii) ensure that Medicare Members with disabilities have effective communications with participants throughout Provider in making decisions regarding treatment options.
2.2 Access to Benefits. Provider shall make Covered Services available and accessible to Medicare Members on a 24-hours per day, 7-day per week basis and with reasonable promptness and in a manner which assures continuity in the provision of Covered Services.
2.3 Discrimination Prohibited. Provider shall not deny, limit, or condition the furnishing of benefits to a Medicare Member on the basis of any factor that is related to health status, including, but not limited to the following: (i) medical condition, including mental as well as physical illness; (ii) claims experience; (iii) receipt of health care; (iv) medical history; (v) genetic information; (vi) evidence of insurability, including conditions arising out of acts of domestic violence; or (vii) disability.
2.4 Screening Mammography, Influenza Vaccine, Pneumococcal Vaccine, and Woman’s Health Services. Provider acknowledges that Medicare Members may directly access (through self-referral) Covered Services constituting screening mammography, influenza vaccine and women’s routine and preventative health care services provided by a women’s health specialist Participating Provider. Provider may not xxxx or collect from Medicare Members copayments, or any other type of cost sharing for influenza vaccine and pneumococcal vaccine.
2.5 Subcontractors. Prior to entering into a subcontract whereby Provider arranges to provide any of its services hereunder through a Subcontractor, Provider (i) shall obtain HPN’s written approval of such subcontract; and (ii) agrees, and shall cause such Subcontractor to agree, that such services shall be performed in accordance with the terms and conditions of the Agreement and the CMS Contract. If Provider carries out any responsibilities under the Agreement through the use of a Subcontractor, including any organization related by ownership or control to Provider when the subcontract is worth or costs Ten Thousand Dollars ($10,000) or more over a twelve (12) month period, Provider shall obtain and forward to HPN the Subcontractor’s written promise to be bound as Provider under the Agreement. Subject to and in accordance with the foregoing, Provider shall make available to government agencies and accreditation organizations all Medicare Member medical information required for assessing the quality of care or investigating Medicare Member’s grievances or complaints.
2.6 Reporting Requirements. Provider agrees to provide to HPN or Payer all documents and information necessary for Payer to comply with Payer’s requirements for submitting information under the respective CMS Contract, as determined in the sole discretion of Payer. Provider further agrees, as a condition to receiving payment under the Agreement, to provide a monthly certification certifying, to the best of Provider’s knowledge, information, and belief, the accuracy, completeness, and truthfulness of the encounter data Provider submits to HPN or Payer under this Section 2.6 and in accordance with the provisions of 42 C.F.R. 422.502(1), as may be amended from time to time.
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2.7 Accountability. Provider hereby acknowledges and agrees that Payer shall oversee and be accountable to CMS for any of Payer’s functions or responsibilities under the Medicare Advantage Program. Provider agrees to cooperate with Payer and assist Payer in such oversight and accountability activities as part of the program integrity requirements under the Medicare Advantage Program.
2.8 Excluded Providers. Provider acknowledges that Payer is prohibited from employing or contracting with an individual who is excluded from participation in the Medicare program (or with an entity that employs or contracts with such an individual) for the provision of any of the following: (i) health care; (ii) utilization review; (iii) medical social work; or (iv) administrative services. Provider agrees to immediately notify HPN and Payer in the event Provider, or any of its employees, Subcontractors, or agents is excluded from participation in the Medicare program or any administrative or regulatory proceedings is initiated that could lead to the exclusion of Provider or any of its employees, agents or Subcontractors from the Medicare program. In such event, HPN or Payer may immediately terminate Provider’s participation under such Payer’s Plan.
2.9 Physician Incentive Plans. In the event Provider enters into an agreement with any individual physician or physician group related to the performance of Provider’s duties under this Exhibit D that includes a physician incentive plan as defined in 42 C.F.R. §422.208, Provider agrees that such physician incentive plan shall comply with the rules and regulations set forth under the Medicare Advantage Program and agrees to the following:
2.9.1 no payments shall be made directly or indirectly to any physician as an inducement to reduce or limit Medically Necessary services;
2.9.2 Provider agrees, and shall cause such physician to agree, to disclose the terms and conditions of any and all physician incentive plan arrangements entered into by Provider, including without limitation: (i) whether the amount of compensation under such arrangement covers physician referrals; (ii) the amount of the financial incentives, stated as a percentage of withhold or bonus; (iii) the amount of stop loss coverage maintained by Provider and physicians; and (iv) the number of covered lives under each physician incentive plan submitted in accordance with this Exhibit D or as otherwise required by HPN or Payer; and
2.9.3 Provider agrees, and shall cause each physician and physician group to agree, to cooperate with any patient satisfaction survey and any other efforts of HPN and Payer to comply with federal and state regulations, including disclosure requirements.
2.10 Advance Directives. Provider shall: (i) document in a prominent part of each Medicare Member’s medical record whether or not the Medicare Member has executed an advance directive; (ii) not condition the provision of care or otherwise discriminate against a Medicare Member based on whether or not the individual has executed an advance directive; (iii) comply with HPN’s and Payer’s policies and procedures regarding advance directives; and (iv) comply with requirements of state and federal law regarding advance directives, including without limitation the rules and regulations under the Medicare Advantage Program.
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2.11 Notice of Discharge. Provider shall (i) comply with the Medicare Advantage Program requirements and HPN and Payer’s policy and procedures regarding review of noncoverage of inpatient hospital care, including without limitation, the submission of medical records and other pertinent information in a timely manner; and (ii) provide Notice of Discharge to Provider Members in accordance with HPN and Payer’s policies and procedures and the requirements of the Medicare Advantage Program; provided, however, Provider shall not give Notice of Discharge to any Member without first notifying HPN and Payer of the proposed discharge and obtaining HPN and Payer’s approval of such Notice of Discharge. Provider shall cooperate with HPN and Payer with respect to the proposed discharge. Provider shall cooperate with the Member and HPN and Payer to arrange an orderly discharge, including without limitation providing all medical information related to the Member’s care, subject to and in accordance with state and federal laws and regulations regarding the confidentiality of patient medical records. Provider agrees to pay the copying costs of any such medical information.
2.12 Continuation of Covered Services.
2.12.1 Payer shall develop a system to provide Provider with reasonable advance notice of impending ineligibility of a Medicare Member who is currently undergoing treatment from Provider. Upon receipt of notification of ineligibility of a Medicare Member, Provider shall use reasonable efforts (i) to advise such Medicare Member of alternative health care providers, programs or arrangements, if any, available to such Medicare Member; and (ii) to assist in the transfer of such Medicare Member whose responsibility for treatment is assumed by another health care provider. Nothing in the Agreement removes the obligation of Provider to not abandon any Member who is a patient.
2.12.2 Notwithstanding any other provision to the contrary, in the event a Medicare Member under a Payer Plan becomes ineligible or a Payer Plan terminates, Provider will continue to provide Covered Services to: (i) all such Medicare Members through the period for which payment from CMS to Payer has been paid; (ii) Medicare Members who are inpatients on the date of such event until their discharge.
2.123 Provider acknowledges that in the event of HPN’s or Payer’s insolvency or other cessation of operations, Provider will continue to provide covered services to Medicare Members through the period for which payment from CMS to Payer has been made and to Medicare Members who are inpatients in a hospital on the date of insolvency or other cessation of operations until their
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discharge. No changes in the insolvency protection or continuation of benefits provisions under this Section shall be made without prior written approval of CMS, if applicable. In the event Provider violates this Section, Provider agrees to pay any penalties or sanctions imposed by CMS or other government agency.
ARTICLE 3
COORDINATION OF CARE
3.1 Coordination of Care. Provider hereby agrees to the following:
3.1.1 Consultation with PCP. Provider shall consult with and periodically update the Member’s PCP as regards the treatment being provided to the Member under the referral from the PCP.
3.1.2 Treatment Referral. Provider agrees that Covered Services to be provided under this Agreement will be compensated by HPN only on proper referral by a PCP, unless the Payer Plan specifically authorizes Provider to provide Covered Services other than through referral by a PCP.
3.1.3 Treatment Updates. If applicable, Provider agrees to provide the PCP of each Member referred to Provider not later than five (5) working days after the initial consultation with Member, a report concerning the treatment being provided to the Member. If the treatment exceeds ten (10) working days following the date of referral to Provider, Provider shall provide treatment updates to the PCP not less than every fifteen (15) working days beginning on the tenth (10th) day until such treatment is concluded. Provider’s patient records must be properly noted as to the communication of the required information to the PCP.
3.1.4 Specialist Referrals. If Provider determines after examination of a Member that the treatment required for the Member will require specialist services of a Participating Facility which are outside the area of specialization of Provider, Provider shall consult with the PCP regarding the needed treatment and the needed services of an additional Participating Facility, and if the PCP considers such referral necessary, the PCP shall make an additional referral of the Member to the appropriate Participating Facility as determined to be necessary as a result of the discussions with Provider, in accordance with the referral policies of HPN and Payer.
3.2 Exchange of Information. Provider shall cooperate and participate in all HPN and Payer Plan requirements designed to ensure that there is a confidential exchange of information among Participating Providers.
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ARTICLE 4
MANAGED CARE SERVICES
4.1 Quality Assurance.
4.1.1 Quality Management and Improvement Program. Provider agrees to comply with the quality management and improvement program of each Payer Plan and to consult with HPN and Payer regarding such activities.
4.1.2 External Review. Provider acknowledges that Payer is required under the Medicare Advantage Program to have an agreement with an independent quality review and improvement organization approved by CMS to perform an external review of the quality management and improvement program. Provider agrees to comply with the activities of Payer’s independent quality review and improvement organization in accordance with the applicable Medicare Advantage Program requirements, including, without limitation, (i) allocating adequate space at Provider’s facilities for use of the review organization whenever it is conducting review activities; and (ii) providing all pertinent data, including without limitation, patient care data, at the time the review organization needs the data to carry out the review and make its determination.
4.1.3 Policies and Procedures. Provider agrees to comply with Payer’s policies and procedures, including without limitation written standards for the following: (i) timeliness of access to care and member services; (ii) policies and procedures that allow for individual Medical Necessity determinations (e.g., coverage rules, practice guidelines, payment policies); and (iii) provider consideration of Medicare Member input into Provider’s proposed treatment plan.
4.1.4 Grievance, Organization, Determinations, and Appeals. Provider agrees to comply with Payer’s procedures for Medicare Member grievances, organization detenuinations, and Medicare Member appeals, including gathering and forwarding to HPN and Payer information related to such appeals. Provider shall maintain a contract with a Peer Review Organization (a “PRO”) operating in the area in which Provider is located, in accordance with the provisions of 42 C.F.R. § 466.70 et seq. and 42 C.F.R. §422.622.
ARTICLE 5
FINANCIAL ARRANGEMENT
5.1 Special Payment Rules for Inpatient Provider Stays.
5.1.1 Provider shall not be entitled to payment from Payer for Covered Services provided to a Medicare Member who is receiving inpatient hospital services from Provider as of the effective date of the Medicare Member’s election of the Payer Plan until after the date of the Medicare Member’s discharge. In the event a Medicare Member’s eligibility to receive Covered Services ends, Provider shall be entitled to payment from Payer for Covered Services provided to a Medicare Member who is receiving inpatient hospital services from Provider as of the effective date of the end of such coverage after such date and until the date of the Medicare Member’s discharge.
5.1.2 Provider acknowledges and agrees that after Payer determines that inpatient hospital services are not, or are no longer, covered under the Payer Plan, Payer is responsible for payment to Provider for services rendered in connection with the
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continued hospital stay until noon of the calendar day following the day Payer notifies Medicare Member of its determination regarding coverage for the continued hospital stay only if (i) Payer authorized the inpatient stay directly or by delegation; and (ii) Medicare Member makes a timely request for Peer Review Organization (PRO) review. Provider further acknowledges and agrees that if Payer did not authorize the inpatient stay directly or by delegation, Payer will only pay Provider for the continued stay if it is determined by PRO or Payer on appeal that the hospital stay should have been a Covered Service.
5.2 Services Furnished Under a Private Contract. Provider shall not be entitled to payment from Payer for Covered Services (other than Emergency Services or Urgently Needed Services) provided by a physician or other practitioner, including an employee or Subcontractor, who has filed with the Medicare carrier an affidavit promising to furnish Medicare-covered services to Medicare beneficiaries only through private contracts under Section 1802(b) of the Social Security Act with the beneficiaries.
5.3 Incorrect Collections. Provider agrees to refund any amounts incorrectly collected from a Medicare Member (or from others on behalf of a Medicare Member), and to pay any other amounts due to a Medicare Member (or others on a Medicare Member’s behalf), in accordance with the provisions of 42 C.F.R. § 422.309, as may be amended from time to time. Provider further agrees to notify HPN and Payer of any amounts Provider owes under this Section 5.3.
5.4 Medicare as Secondary Payer. Provider shall not be entitled to payment by Payer for the provision of Covered Services to the extent that the Medicare Advantage Program is not the primary Payer, as determined in accordance with the relevant provisions of Section 1862(b) of the Social Security Act and 42 C.F.R. Part 411.
ARTICLE 6
ACCESS TO BOOKS AND RECORDS
6.1 Access to Records. Notwithstanding any other provision to the contrary, Provider hereby agrees to the following: the Department of Health and Human Services (ADHHS), the Comptroller General or other government agencies, or their designee may evaluate, through inspection or other means: (i) the quality, appropriateness, and timeliness of services furnished to Medicare Members; and (ii) the facilities of Provider. Provider further agrees that DHHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, patient care documentation, and other records of Provider (or its assignee) that pertain to any aspect of services performed, reconciliation of benefit liabilities, and determination of amounts payable under CMS Contract, or as the Secretary may deem necessary to enforce the CMS Contract. Provider agrees to: (i) retain for a period of six (6) years from the final date of the contract period of the CMS Contract; and (ii) to make available, for the purposes specified in this Section 6.1, its premises, physical facilities and equipment, records relating to Medicare Members, and any additional relevant information that CMS may require. Provider further agrees that DHHS, the Comptroller General, or their designee’s right to inspect, evaluate, and audit extends through six (6) years from the final date of the contract period of CMS Contract or completion of any audit, whichever is later.
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6.2 Confidentiality of Records. For any medical records or other infonnation Provider maintains with respect to Medicare Members, Provider must establish procedures to: (i) safeguard the privacy of any information that identifies a Medicare Member; (ii) release information from, or copies of, records only to authorized individuals; (iii) ensure that unauthorized individuals cannot gain access to or alter Medicare Member records; (iv) release original medical records only in accordance with state and federal laws, court orders, or subpoenas; (v) maintain the records and information in an accurate and timely manner; (vi) ensure timely access by Medicare Members to the records and information that pertain to them; and (vi) abide by all state and federal laws regarding confidentiality and disclosure for mental health records, medical records, other health information and Medicare Member information.
6.3 Exchange of Information. Provider shall maintain each Medicare Member medical record in accordance with standards established by Payer and shall cooperate with Payer to ensure that there is appropriate and confidential exchange of information among provider network components.
ARTICLE 7
MISCELLANEOUS
7.1 Compliance with Laws. Provider and Payer agree to comply with: (i) Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 C.F.R. part 84; (ii) The Age Discrimination Act of 1975 as implemented by regulations at 45 C.F.R. part 91; (iii) The Rehabilitation Act of 1973; (iv) The Americans With Disabilities Act; and (v) all other applicable laws and rules, including, without limitation, all applicable Medicare rules and regulations and CMS instruction. Provider acknowledges that Payer receives federal funds and that as a subcontractor of Payer, the payments Provider receives under the Agreement are, in whole or in part, from federal funds. Provider agrees to comply with all laws, rules, and regulations applicable to entities receiving federal funds.
7.2 Notice to Provider. In the event Provider’s participation in a Payer Plan is denied, suspended, or terminated, HPN br Payer shall provide Provider the notice required under 42 C.F.R. 422.204 (c)(1).
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EXHIBIT E
REQUIREMENTS OF A CLEAN CLAIM
Description CMS 1500 | CMS 1500 field number | |
The following data elements must be complete, legible, and accurate: | ||
Patient’s ID Number | 1a | |
Patient’s Name | 2 | |
Patient’s Date of Birth and gender | 3 | |
Subscriber’s Name | 4 | |
Patient’s Address (street or P.O. Box, city, zip) | 5 | |
Patient’s relationship to Subscriber | 6 | |
Subscriber’s address (street or P.O. Box, city, zip) | 7 | |
Other insured’s or enrollee’s name if patient is covered by more than one health benefit plan | 9 | |
Other insured’s or enrollee’s policy/group number | 9a | |
Other insured’s or enrollee’s date of birth | 9b | |
Other insured’s or enrollee’s plan name (employer, school, etc.) | 9c | |
Other insured’s or enrollee’s health plan name | 9d | |
Whether patient’s condition is related to employment, auto accident, or other accident | 10a-c | |
Subscriber’s policy number | 11 | |
Subscriber’s birth date and gender | 11a | |
Subscriber’s plan name (employer, school, etc.) | 11b | |
Health Plan name | 11c | |
Disclosure of any other health benefit plans; if respond “yes” to 11d, then complete 9 through 9d; if respond “no” to 11d, then data elements 9 through 9d are not essential to the claim | 11d | |
Patient’s or authorized person’s signature or notation that the signature is on file with the physician or provider | 12 | |
Subscriber’s or authorized person’s signature or notation that the signature is on file with the physician or provider | 13 | |
Date of current illness, injury, or pregnancy | 14 | |
First date of previous same or similar illness | 15 | |
Referring physician’s name | 17 | |
Referring physician’s UPIN number, if applicable | 17a | |
Valid diagnosis code(s) to the fifth digit when applicable | 21 | |
Prior authorization number, if services require prior authorization | 23 | |
Date(s) of service | 00x | |
Xxxxx xxxxx of service codes | 24b | |
Valid type of service code | 24c | |
Valid procedure/modifier code | 24d | |
Diagnosis code pointer by specific service | 24e | |
Charge for each listed service | 24f | |
Number of days or units | 24g | |
Reserved for local use (performing provider number), required if group practice group practice | 24k |
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Description CMS 1500 | CMS 1500 field number | |
Physician’s or provider’s federal tax ID number | 25 | |
Whether assignment was accepted (applicable when assignment under Medicare is accepted) | 27 | |
Total charge | 28 | |
Amount paid is required if (1) an amount has been paid to the physician or provider submitting the claim by the patient or subscriber or (2) an amount of a covered claim was paid by a primary payor plan | 29 | |
Balance due is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber | 30 | |
Signature of physician or provider or notation that the signature is on file with the health plan | 31 | |
Name and address of facility where services ‘rendered (if other than home or office) | 32 | |
Physician’s or provider’s billing name, address, zip code, and telephone # | 33 | |
Additional Requirements when applicable: | ||
Operative reports or description of services on all claims with procedure codes that end in -99 (unlisted or undefined procedures) | Attachment | |
Description of supplies when using CPT Code 99070 | Attachment or
Detail on Claim Form | |
Primary carrier Explanation of Benefits | Attachment | |
Clinical notes detailing unusual bil limited to, CPT codes billed with a -25ling procedures including, but not modifier, repeat procedures on the same date of service, and Emergency room services | Attachment | |
For injectables, indicate the NDC number (or drug name) and quantity | Attachment or
Detail on Claim Form |
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EXHIBIT F
BUSINESS ASSOCIATE TO BUSINESS ASSOCIATE AGREEMENT
THIS BUSINESS ASSOCIATE TO BUSINESS ASSOCIATE AGREEMENT is made as of the 1 s1 day of March, 2004 by and between Heritage Physician Networks, (hereinafter referred to as “Primary Business Associate”) and CDS Health Management Inc. (d/b/a Certified Diabetic Supplies), (hereinafter referred to as “Secondary Business Associate”) (collectively the “Parties”) in order to comply with the federal Standards for Privacy of Individually Identifiable Health Information, located at 45 C.F.R. parts 160 and 164 (“HIPAA” or the “Privacy Rule”).
WHEREAS, the purpose of this Agreement is to comply with the requirements of the Privacy Rule.
ARTICLE 1
DEFINITIONS
Terms used herein, but not otherwise defined, shall have meaning ascribed by 45 C.F.R. parts 160 and 164.
1.1 Secondary Business Associate. “Secondary Business Associate” shall mean CDS Health Management Inc. (d/b/a Certified Diabetic Supplies).
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1.2 Primary Business Associate. “Primary Business Associate” shall mean Heritage Physician Networks.
1.3 Designated Record Set. “Designated Record Set” shall mean a group of records maintained by or for a covered entity, as defined by the Privacy Rule, that is: (i) the medical records and billing records about Individuals maintained by or for a covered health care provider; (ii) the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (iii) used, in whole or in part, by or for the covered entity to make decisions about Individuals. For purposes of this definition, the term “record” means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity.
1.4 Individual. “Individual” shall mean the person who is the subject of the protected health information.
1.5 Privacy Rule. “Privacy Rule” shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 C.F.R. parts 160 and 164, subparts A and E.
1.6 Protected Health Information (“PHI”). “Protected Health Information” or PHI shall mean individually identifiable health information that is transmitted or maintained in any form or medium.
1.7 Required by Law. “Required by Law” shall mean a mandate contained in law that compels a use or disclosure of PHI.
1.8 Security Standards. “Security Standards” shall mean the Standards for the Security of Electronic Protected Health Information at 45 C.F.R. part 164, subparts A and C as they may be amended from time to time.
1.9 Secretary. “Secretary” shall mean the Secretary of the Department of Health and Human Services or his or her Designee.
ARTICLE 2
PURPOSES FOR DISCLOSURE
In connection with the services provided by Secondary Business Associate to or on behalf of Primary Business Associate described in this Agreement, Primary Business Associate may disclose PHI to Secondary Business Associate for the purposes of treatment, payment, or healthcare operations as described in 45 CFR part 164.506(a)(b)(c) for standard uses and in 45 CFR part 164.508 for uses and disclosures for which an authorization is required.
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ARTICLE 3
SECONDARY BUSINESS ASSOCIATE OBLIGATIONS
Secondary Business Associate agrees to comply with applicable federal and state confidentiality and security laws, specifically the provisions of the Privacy Rule and Security Standards applicable to business associates (as defined by the Privacy Rule), including:
3.1 Use and Disclosure of PHI. Except as otherwise permitted by this Agreement or applicable law, Secondary Business Associate shall not use or disclose PHI except as necessary to provide services to or on behalf of Primary Business Associate, and shall not use or disclose PHI that would violate the Privacy Rule if used or disclosed by Primary Business Associate. Provided,
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