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PPO AGREEMENT
THIS AGREEMENT is entered into as of this 1st day of October, 1990, between
AFFORDABLE HEALTH CARE CONCEPTS, a California corporation, (hereinafter
referred to as "AFFORDABLE"), and National Association of Letter Carriers
Health Benefit Plan (Non-Group and Staff), (hereinafter referred to as "PLAN").
WHEREAS, AFFORDABLE has established, and/or intends to establish, various
Health Care Provider Networks by entering into contracts with various hospitals
and other health care providers for the provision of health care services which
PLAN is interested in on behalf of its Health Plans for its Covered Persons.
THEREFORE, in accordance with the terms and conditions contained herein, the
parties agree as follows:
ARTICLE 1
DEFINITIONS
1.1 "Chemical Dependency Network" means all of the providers of inpatient or
outpatient care for treatment of alcohol or other substance abuse who
have entered into contracts with AFFORDABLE to provide substance abuse
services.
1.2 "Claims Administrator" means the entity which the PLAN employs to
administer and process its health plan claims.
1.3 "Contract Provider" means a health care provider included within one of
the networks defined herein such as a hospital, residential facility,
clinic, laboratory or physician, or the like, which has contracted with
AFFORDABLE for the provision of health care services.
1.4 "Contract Rate(s)" means the rate(s) specified in the contract between
AFFORDABLE and a Contract Provider, which may be in the form of per
diems, case or procedure rates, discounts off charges, 1974 California
Relative Value Scale (CRVS) value conversion factors or other
reimbursement methods.
1.5 "Covered Person" means a person who is entitled to benefits for health
care services under the Health Plan.
1.6 "Health Care Provider Networks" means the individual networks defined in
this Article 1.
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1.7 "Health Plan" means the contract, certificate, policy, health plan
document or any other document offered or sponsored by PLAN under which
a Covered Person may be entitled to receive reimbursement for health
care services. A Health Plan may include, but is not limited to, an
indemnity plan, a health maintenance organization, an insurance group
health plan, and a Workers' Compensation plan.
1.8 "Hospital Claims Pricing Service" means a service available from
AFFORDABLE to assist PLAN in accurate and timely adjudication of claims
by Covered Persons for health care services obtained from a hospital
which is a Contract Provider.
1.9 "Hospital Network" means all of those general acute care and psychiatric
hospitals which have entered into contracts with AFFORDABLE for the
provision of inpatient and outpatient health care services including
general acute, psychiatric and chemical dependency care services.
1.10 "Implementation Date" means the date on which the Contract Rate(s) became
available to Covered Persons.
1.11 "Outpatient Care Network" means all of those physicians, laboratories,
imaging centers, freestanding outpatient surgery facilities and other
entities who have entered in contracts with AFFORDABLE to provide
outpatient care services.
1.12 "Provider Agreement" means the agreement between AFFORDABLE and a
Contract Provider for the delivery of health care services.
ARTICLE 2
DUTIES OF AFFORDABLE
AFFORDABLE agrees to the following:
2.1 AFFORDABLE establishes and maintains various Health Care Provider
Networks by entering into Provider Agreements with Contract Providers
for the delivery of health care services at negotiated rates for PLAN
and AFFORDABLE's other clients.
2.2 AFFORDABLE agrees to make available to PLAN the Health Care Provider
Networks identified in Appendix A attached hereto upon the terms and
conditions set out in this Agreement.
2.3 AFFORDABLE may at any time, and in its sole discretion, add and/or
delete any Contract Provider(s) from any of its Health Care Provider
Networks.
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2.4 Prior to the Implementation Date, AFFORDABLE will furnish PLAN with a
listing of all Contract Providers and Outpatient Care Network Contract
Rate(s) as applicable to each Health Care Provider Network set out in
Appendix A. This will be provided on hard copy for the Hospital Networks
and magnetic tape for the Outpatient Care Net Works.
Periodically AFFORDABLE may furnish PLAN with updates as to rate changes,
changes in identity of Contract Providers, and changes in Procedure Code
listings. Such updates shall be provided not less than quarterly.
2.5 AFFORDABLE shall provide notice to Contract Providers regarding the
PLAN's selection of Health Care Provider Networks in conjunction with
its quarterly provider bulletin, or earlier as determined practical by
AFFORDABLE.
2.6 AFFORDABLE agrees to make available to PLAN, at PLAN's request, its
personnel for assistance in the implementation of the services
hereunder, including but not limited to, consultation regarding the most
appropriate approach to informing Covered Persons about each Health Care
Provider Network and the most effective means of utilizing each Network.
In those cases where such assistance is beyond the scope of AFFORDABLE's
usual services, AFFORDABLE shall be reimbursed by PLAN on a consultant
basis for its personnel, their travel and other expenses at its
customary rates. However, in each case where AFFORDABLE contemplates
reimbursement, it shall so notify PLAN prior to incurring such fees and
costs.
2.7 AFFORDABLE shall provide instruction to PLAN concerning data and claims
processing to describe how payment of claims is to be made pursuant to
this Agreement.
2.8 AFFORDABLE shall perform Hospital Claims Pricing Services for PLAN.
AFFORDABLE shall compute a reimbursement amount payable for each
contract hospital claim submitted to PLAN for a Covered Person. This
amount will be based on the negotiated rates for hospital services at
the Contract Provider, and the amount will not be based on Plan
benefits. To facilitate this function, PLAN agrees to submit all
Hospital Network claims to AFFORDABLE in a timely manner. AFFORDABLE
will compute the contract rates for each contract hospital claim and
return each claim to PLAN with a transmittal sheet indicating the
computed amount. At the end of each calendar month, AFFORDABLE will
generate a listing of claims processed during the month and the amount
of AFFORDABLE's fees in accordance with Appendix A.
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2.9 AFFORDABLE shall annually, based on the anniversary date of the Health
Care Provider Network(s) selected by PLAN, prepare and deliver up to 20
copies of its standard management information system (MIS) reports which
shall summarize the utilization, cost of health care services provided
to Covered Persons and savings achieved as a direct result of Health
Care Provider Networks over a one year period.
On written request of PLAN, for matters of special interest to PLAN,
AFFORDABLE will provide such special reports as it is capable of
providing and which are requested in writing by PLAN. If additional
expense will be incurred by AFFORDABLE in preparing such reports,
AFFORDABLE will promptly provide a written cost estimate and production
schedule and obtain PLAN's approval of such costs prior to preparing any
such reports.
2.10 Information and records obtained or prepared by AFFORDABLE in performing
its obligations under this Agreement shall be kept confidential in
accordance with applicable state and federal laws.
2.11 AFFORDABLE certifies that it has contracted with Health Care Providers
that meet its credentialing and recredentialing procedures. AFFORDABLE
will provide PLAN in writing any substantial changes to its current
credentialing and recredentialing procedures.
2.12 Effective January 1, 1992, AFFORDABLE agrees to provide a toll-free
telephonic contract provider directory service for use by PLAN's Covered
Persons.
ARTICLE 3
DUTIES OF PLAN
PLAN agrees to the following:
3.1 PLAN shall identify as its Contract Providers all of the Contract
Providers who are part of the Health Care Provider Network(s) identified
in Appendix A who provide services covered under PLAN's Health Plan.
3.2 PLAN shall reimburse directly each Contract Provider for all covered
services according to the effective Contract Rates. Such payment shall
not include any applicable co-payments or charges for non-covered
services which Provider may charge and/or xxxx Covered Person directly.
3.3 PLAN shall pay Contract Providers within thirty (30) days of receipt of
claims that are accurate and complete. Failure to comply with this
provision may result in the penalty set out in 3.5 below.
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3.4 PLAN's Health Plan shall include financial incentives to Covered Persons
to encourage use of Contract Providers for health care services covered
by the Health Plan. Such Health Plan shall be submitted to AFFORDABLE no
later than 30 days after the Implementation Date.
3.5 In the event that PLAN shall default in its obligations or duties set
out in paragraphs 3.2, 3.3 or 3.4, AFFORDABLE shall have the right to
terminate PLAN's right to Contract Rates from one or more Contract
Providers. Provided, however, such termination shall be effective not
earlier than the 20th day after AFFORDABLE shall have provided PLAN
written notice of the specific default(s) and if PLAN has not cured said
default within said 20 day period.
3.6 PLAN agrees to print and distribute to Covered Persons lists and
instructions for use which include names and addresses of all Contract
Providers. These materials shall advise Covered Persons that the list of
Contract Providers may change from time to time and Covered Person is
obligated to confirm with PLAN the Contract Provider status.
3.7 PLAN acknowledges the validity of AFFORDABLE's and AFFORDABLE's Contract
Providers' service marks, trademarks, copyrights, and other proprietary
marks and that the same are the sole property of AFFORDABLE or
AFFORDABLE's Contract Providers, as the case may be. PLAN shall not in
any way infringe upon or harm the rights of AFFORDABLE or AFFORDABLE's
Contract Providers in their proprietary marks.
PLAN shall protect the integrity of both AFFORDABLE's and AFFORDABLE's
Contract Providers' said service and proprietary marks and copyrights to
the extent they are used by PLAN. PLAN shall not, without the prior
written approval of AFFORDABLE, use any xxxx or name in connection with
providing services contemplated under this Agreement.
3.8 PLAN shall promptly notify AFFORDABLE of its inability to meet its
payment obligations to AFFORDABLE and Contract Providers. AFFORDABLE
shall have the right, in its sole discretion, to notify Contract
Providers of PLAN's failure to promptly pay its obligations or of its
inability to pay such obligations so that Contract Providers may cease
providing services to PLAN's Covered Persons at Contract Rates.
3.9 PLAN shall follow the reimbursement procedures relative to payment of
Contract Providers established by AFFORDABLE from time to time.
PLAN shall indicate on the Explanation of Payment (EOP) to the Contract
Provider that reimbursement is pursuant to the AFFORDABLE PPO Agreement.
The EOP
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shall identify the balance owed by Covered Person, the date of service
and provide sufficient information to allow Contract Providers to
reconcile payment with the billed amount.
3.10 PLAN shall provide Covered Persons with ID cards with the AFFORDABLE
logo or such other means which will identify Covered Persons as eligible
to receive Contract Rates.
3.11 Any written or printed material prepared for general circulation by PLAN
relating to AFFORDABLE's services or obligations under this Agreement
which is to be published, disseminated, released or prepared for
distribution by PLAN to Covered Persons or to the general public will be
released only after consultation with and approval by AFFORDABLE which
shall not be unreasonably withheld.
3.12 PLAN shall be responsible for responding to Covered Persons' questions
concerning benefits, and to provide Covered Persons with information
concerning the current status of Contract Providers.
3.13 Because an effective PPO program requires a utilization review program to
prevent provision of unnecessary services, PLAN has retained the
services of HealthCare COMPARE Corp. ("COMPARE") to perform utilization
review. However, AFFORDABLE shall have no responsibility either to the
Covered Person or to PLAN for the delivery or results of such
utilization review program. PLAN agrees that its health plan will
include a hospital utilization review program which will substantially
conform with the hospital utilization review program described in the
Utilization Review Agreement between PLAN and COMPARE dated as of
January 1, 1989.
3.14 PLAN shall maintain a procedure for prompt verification of a Covered
Person's eligibility under the Health Plan. The procedure shall provide
verification of a Covered Person's eligibility during normal working
hours if requested by a Contract Provider.
3.15 PLAN is solely responsible for compliance with all laws, rules and
regulations that are now or hereafter promulgated by any governmental
authority or agency and that govern or apply to the use of the services
contemplated herein.
3.16 PLAN hereby agrees that within the geographic areas covered by
AFFORDABLE's Health Care Provider Networks set out in Appendix A it will
exclusively offer to its Covered Persons only AFFORDABLE's Contract
Providers and Health Care Provider Networks and it will not enter into
any agreement with any other health care networks or provider of health
care networks to provide health care services to its Covered Persons or
in any way compete with or encourage competition with
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AFFORDABLE's Health Care Provider Networks or cause to be provided to
its Covered Persons health care services which are competitive to those
provided in the AFFORDABLE Health Care Provider Network; except that
this shall not prohibit PLAN from independently operating or
participating in an entity which provides the delivery of health care
services or fee-for-service health care insurance business through
non-network type organizations or plans, such as HMOs, which are
noncompetitive to AFFORDABLE's Health Care Network.
3.17 PLAN shall perform OCN Claims Pricing. AFFORDABLE shall review hard copy
outpatient claims from Contract Providers incurred during the initial
three months after the Implementation Date of the Health Care Provider
Network and submitted by PLAN to determine the accuracy of claims
payment pursuant to the Contract Rates. PLAN will indicate what was
paid on the submitted claims. The number of claims subject to this
review will be determined by PLAN and provided at no additional cost.
If it is determined by AFFORDABLE that PLAN is making incorrect
payments, AFFORDABLE will assist PLAN in determining the proper
allowable charge.
ARTICLE 4
DATA REQUIREMENTS
4.1 PLAN shall provide AFFORDABLE with the necessary data and/or
information that is required to process AFFORDABLE's annual Management
Information System (MIS) report for PLAN. The MIS Report shall be based
upon the most current data made available to AFFORDABLE up to a maximum
of the 12 preceding months. All data and/or information must be
submitted to AFFORDABLE in computer readable form and must contain the
data necessary to produce the reports. Data for the MIS Report must be
received and validated no later than 90 days prior to the Health Care
Provider Network anniversary date. AFFORDABLE will, at no cost, make
any initial changes or modifications to its reporting programs to
accept the data and information submitted by the PLAN. All subsequent
changes resulting from PLAN modifying their data format will be
completed, but all services associated with these changes will be
billed to PLAN at AFFORDABLE's standard fees.
4.2 If PLAN elects to submit the above mentioned data and/or information in
non-computer readable format, PLAN will be billed at AFFORDABLE standard
fees for all services and charges associated with the preparation of
submitted data to convert information into a computer readable format.
4.3 Any charge associated with the preparation of the data to be given to
AFFORDABLE shall be the responsibility of the PLAN.
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ARTICLE 5
FEES
5.1 PLAN agrees to pay AFFORDABLE, as a fee for services rendered by
AFFORDABLE, those sums which are arrived at by using the fee schedule
set out in Appendix A. AFFORDABLE shall have the right to amend
Appendix A by adding fee schedules for Health Care Provider Networks
which PLAN hereafter elects to add.
5.2 With respect to the Hospital Network services provided by AFFORDABLE in
accordance with Appendix A, PLAN shall pay AFFORDABLE the fees due
within 10 days of receipt by PLAN of a billing by AFFORDABLE showing
the amount due for services rendered during the preceding calendar
month.
5.3 There shall be added to any fees due AFFORDABLE, as described in
Appendix A, amounts equal to any use or sales tax, or any tax in lieu
thereof, imposed by any governmental agency with respect to services
rendered by AFFORDABLE.
5.4 Additional Services
In addition to routine services described in this Agreement, if
requested by PLAN, AFFORDABLE agrees to provide additional services at
the fees described below:
a. For activities performed by AFFORDABLE including its personnel and
computer services, AFFORDABLE's fees will be at its standard rates.
b. For such other services requested by PLAN, AFFORDABLE will provide
such services at fees agreed to by both parties.
5.5 Price Adjustments
For all fees which are charged on an hourly basis, AFFORDABLE shall
have the right to increase such fees upon ninety (90) days advance
written notice.
5.6 For the Outpatient Care Network ("OCN"), PLAN shall provide a monthly
OCN Savings report and along with said report shall pay to AFFORDABLE
the total fee due AFFORDABLE on or before the 20th of the month.
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ARTICLE 6
TERM
6.1 This Agreement shall commence upon the execution hereof and shall
terminate on December 31, 1993 and shall automatically renew for
consecutive one (1) year terms thereafter, unless terminated or amended
as hereinafter set forth.
ARTICLE 7
TERMINATION
7.1 This Agreement may be terminated by written notice thereof given by
PLAN to AFFORDABLE if any one of the following occurs, but in no event
shall such termination relieve AFFORDABLE from any of its obligations
incurred under this Agreement:
7.1.1 Failure of AFFORDABLE to meet any material covenant, agreement,
or obligation provided for in this Agreement if it has not
commenced to cure any such default within twenty (20) days
after written notice thereof to AFFORDABLE by PLAN.
7.1.2 AFFORDABLE becomes insolvent, or is adjudicated as a bankrupt,
or its business comes into possession or control, even
temporarily, of any trustee in bankruptcy, or a receiver is
appointed for it, or it makes a general assignment for the
benefit of creditors. If any of these events occurs, no
interest in this Agreement shall be deemed an asset of
creditors. No interest in this Agreement shall be deemed an
asset or liability of AFFORDABLE, nor shall any interest in
this Agreement pass by the operation of law without the consent
of PLAN.
7.1.3 Upon the expiration date of the initial term or any extension
of the term with at least ninety (90) days written notice to
AFFORDABLE prior to the end of the Term of this Agreement or
any extension of the Term.
7.2 This Agreement may be terminated by written notice thereof given by
AFFORDABLE to PLAN if any one of the following occurs, but in no event
shall such termination relieve PLAN from any of its obligations incurred
under this Agreement:
7.2.1 Failure of PLAN to meet any material covenant, agreement, or
obligation provided for in this Agreement if it has not
commenced to cure any such
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default within twenty (20) days after written notice thereof to
PLAN by AFFORDABLE.
7.2.2 Failure of PLAN to make payment provided for under this
Agreement when due, and if payment is not made within twenty
(20) days following written notice of non-payment sent by
AFFORDABLE to PLAN.
7.2.3 PLAN becomes insolvent, or is adjudicated as a bankrupt, or its
business comes into possession or control, even temporarily, of
any trustee in bankruptcy, or a receiver is appointed for it,
or it makes a general assignment for the benefit of creditors.
If any of these events occurs, no interest in this Agreement
shall be deemed an asset of creditors. No interest in this
Agreement shall be deemed an asset or liability of PLAN, nor
shall any interest in this Agreement pass by the operation of
law without the consent of AFFORDABLE.
7.2.4 Upon the expiration date of the initial term or any extension
of the term with at least ninety (90) days written notice to
PLAN prior to the end of the Term of this Agreement or any
extension of the Term.
7.3 Upon the effective date of the termination of this Agreement for any
reason:
7.3.1 PLAN shall promptly notify Covered Persons of such termination.
A copy of the Notice to Covered Persons shall be mailed to
AFFORDABLE at the same time it is distributed to Covered
Persons.
7.3.2 PLAN shall immediately cease reimbursing Contract Providers at
the Contract Rates except for those Covered Persons admitted to
a Contract Provider prior to the termination effective date.
7.3.3 Upon termination of this Agreement for PLAN's failure to comply
with the terms of this Agreement, PLAN shall reimburse
AFFORDABLE for the costs incurred in the notification of
Contract Providers as described in Appendix A.
7.3.4 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.
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ARTICLE 8
RECORDS
8.1 AFFORDABLE and PLAN shall maintain such records as shall accurately
reflect the billed charges made for each service rendered and the
difference between such billed charges and the Contract Rate(s). To the
extent practical, such records shall be kept in accordance with
generally accepted accounting principles.
8.2 Subject to Article 9 hereof, AFFORDABLE agrees that at its office,
during normal business hours, and upon not less than seven (7) days
advance notice, or upon reasonable notice in the event of an emergency,
PLAN shall have access to and the right to examine records which
AFFORDABLE has kept which relate directly to PLAN. Such access and right
of examination shall continue to be provided to PLAN for a period of not
less than two (2) years after the date of discharge or the end of the
treatment or other health care service provided to a Covered Person.
Subject to Article 9 hereof, PLAN agrees that at its office, during
normal business hours, and upon not less than seven (7) days advance
notice, or upon reasonable notice in the event of an emergency,
AFFORDABLE shall have access to and the right to examine records which
PLAN has kept which relate directly to AFFORDABLE. Such access and right
of examination shall continue to be provided to AFFORDABLE for a period
of not less than two (2) years after the date of discharge or the end of
the treatment or other health care service provided to a Covered Person.
ARTICLE 9
CONFIDENTIALITY
9.1 The parties agree that the Provider Contract Rates are confidential and
will be kept in strictest confidence. Therefore, PLAN hereby certifies
that such rates shall be disclosed by PLAN only to the extent and only
to such persons or entities as are necessary to carry out the specific
terms of this Agreement. PLAN shall also ensure that each person or
entity to which PLAN discloses Provider Contract rates certifies or
otherwise provides assurance to PLAN that the rates will be treated as
confidential.
9.2 AFFORDABLE agrees to keep in confidence all specific medical patient
information received which by applicable law is deemed confidential.
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9.3 In order for AFFORDABLE to effectively provide services to PLAN, it is
necessary and desirable for AFFORDABLE to disclose to PLAN confidential
and proprietary information relating to AFFORDABLE's past, present and
future activities. Since it is difficult to separate confidential and
proprietary information from that which is not, PLAN will regard all
information obtained from AFFORDABLE as a result of services hereunder
as proprietary information. All confidential information will be
permanently safeguarded and kept confidential by PLAN.
9.4 Neither party will be liable for disclosure of any information received
from the other under this Agreement if:
(1) The information is generally available to or known to the
public or is obtained by PLAN from third parties.
(2) The information was known to PLAN prior to the implementation
of this Agreement.
ARTICLE 10
GENERAL PROVISIONS
10.1 This Agreement is entered by and between the parties signing it and for
their benefit. There is no intent by either party to create or establish
third party beneficiary status or rights or their equivalent in any
Covered Person, subcontractor or other third party which may be affected
by the operation of this Agreement, and no such third party shall have
any right to enforce any right or enjoy any benefit created or
established under this Agreement.
10.2 The relationship of the parties is that of Independent Contractors.
Nothing herein is intended or will be construed to establish any agency,
employment, partnership, or joint venture relationship between the
parties. Each party shall be solely responsible for the direction,
control and management of its agents and employees.
10.3 Neither party will be responsible for, nor deemed to be in default under
this Agreement on account of, any failure or delay in performance
hereunder (except for the failure to make any payment when due) due to
acts of God or governmental authority, strikes or labor disputes, fires
or any other cause beyond the control of the party.
10.4 This Agreement shall be binding upon and inure to the benefit of the
respective parties hereto, and their successors and assigns. This
Agreement constitutes the entire agreement between the parties and
supersedes any prior agreement or
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understandings, whether oral or written.
10.5 This Agreement may be amended only by mutual written agreement between
the parties. Neither party shall have the right or power to assign any
rights or duties pursuant to this Agreement without the express written
consent of the other party.
10.6 The paragraph headings are for convenience only and shall not be deemed
to limit, define, or restrict the meaning or contents thereof.
10.7 The provisions of Articles 2.10, 5, 7.3, 8, 9, and 10 shall survive the
termination of this Agreement.
10.8 This Agreement is executed in and shall be governed by and construed in
accordance with the laws of the State of Illinois.
10.9 In the event any provision of this Agreement conflicts with laws
applicable hereto or under which this Agreement is construed, or if any
provision of this Agreement shall be held illegal or unenforceable or
partially illegal or unenforceable by a court with jurisdiction over the
parties to this Agreement, then this Agreement shall be modified to
conform with said laws or judicial determination and such provision
shall be construed and enforced only to such extent as it may be a legal
and enforceable provision, and all other provisions of this Agreement
shall be given full effect separately therefrom and shall not be
affected thereby.
10.10 Neither the execution of this Agreement nor the performance of its
obligations constitutes an undertaking by AFFORDABLE to guarantee the
results of health care provider services to Covered Persons or that such
will be rendered in accordance with generally accepted medical standards
or procedures; all such services and the results thereof are determined
by the Contract Provider.
10.11 If any legal action is necessary to enforce the terms of this Agreement,
the prevailing party shall be entitled to reasonable attorneys fees and
costs in addition to any other relief to which it may be entitled.
10.12 Notices and Payments: Any notice required pursuant to this Agreement
shall be in writing and sent by registered or certified mail, return
receipt requested, to the addressees of the parties set forth below in
this Agreement. Notice so sent will be deemed effective when delivered
in the mail with postage pre-paid. All notices, payments and other
communications shall be addressed as follows:
to AFFORDABLE:
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(1) AFFORDABLE Health Care Concepts
0000 Xxxxxxx Xxxx Xxxxx, Xxxxx 000
Xxxxxxxxxx, Xxxxxxxxxx 00000
Attn: President
(2) COPY HealthCare COMPARE Corp.
0000 Xxxxxxxx Xxxxxx
Xxxxxxx Xxxxx, Xxxxxxxx 00000
Attn: Vice President of Administration
to PLAN: National Association of Letter PLANs
Health Benefit Plan (Non-Group and Staff)
00000 Xxxxxxx Xxxxx
Xxxxxxx, XX 00000
Attn: Xx. Xxxxx Xxxxxxx
Administrator
10.13 This Agreement may be executed in several counterparts, each of which
shall be deemed an original, but all of which shall constitute one and
the same instrument. The Exhibits and Schedules attached hereto are by
reference deemed incorporated herein.
IN WITNESS WHEREOF the parties have executed this Agreement the day and date
first above written by their duly authorized officers for and on behalf of said
corporation.
National Association of Letter AFFORDABLE Health Care Concepts
Carriers Health Benefit Plan
(Non-Group and Staff)
By: Xxxxxx Vincenze By: Xxxxx X. Xxxxx
--------------------------------- ---------------------------------------
Authorized Signatory
Title: Director Title: as President, Healthcare COMPARE Corp.
------------------------------- -------------------------------------
Date: March 9, 1992 Date: 4/1/92
-------------------------------- -------------------------------------
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PPO AGREEMENT BETWEEN
AFFORDABLE HEALTH CARE CONCEPTS
AND
NATIONAL ASSOCIATION OF LETTER CARRIERS
HEALTH BENEFIT PLAN (NON-GROUP AND STAFF)
APPENDIX A
I. Network(s) Selected:
Health Geo- Implementation % of Fixed Monthly
Plan graphic Date Savings Minimum Fee
---- Area ---- ------- --------------
----
[x] Hospital Network FEHBP AL 06/01/91 23% N/A
AK 02/01/92 23% N/A
(Includes Chemical AR 05/01/91 23% N/A
Dependency Network) AZ 12/01/90 23% N/A
CA 10/01/90 23% N/A
CO 10/01/90 23% N/A
D.C. 10/01/90 23% N/A
FL 10/01/90 23% N/A
GA 10/01/90 23% N/A
IA 06/01/91 23% N/A
ID 02/01/92 23% N/A
IL 10/01/90 23% N/A
IN 12/01/90 23% N/A
KS 10/01/90 23% N/A
KY 10/01/90 23% N/A
LA 05/01/91 23% N/A
MA 12/01/90 23% N/A
MI 06/01/91 23% N/A
MN 05/01/91 23% N/A
MO 10/01/90 23% N/A
MS 09/01/91 23% N/A
MT 01/01/92 23% N/A
NC 05/01/91 23% N/A
NE 09/01/91 23% N/A
NJ 12/01/91 23% N/A
NM 10/01/90 23% N/A
NV 10/01/90 23% N/A
OH 01/01/91 23% N/A
OK 06/01/91 23% N/A
OR 10/01/90 23% N/A
PA 12/01/90 23% N/A
RI 12/01/91 23% N/A
SC 05/01/91 23% N/A
SD 12/01/91 23% N/A
TN 12/01/90 23% N/A
TX 10/01/90 23% N/A
UT 10/01/90 23% N/A
VA 10/01/90 23% N/A
WA 10/01/90 23% N/A
WI 02/01/91 23% N/A
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[x] Outpatient Care FEHBP AL 01/01/92 23% N/A
Network AZ 01/01/92 23% N/A
CA 01/01/92 23% N/A
CO 01/01/92 23% N/A
D.C. 01/01/92 23% N/A
FL 01/01/92 23% N/A
GA 01/01/92 23% N/A
IL 01/01/92 23% N/A
KS 01/01/92 23% N/A
KY 01/01/92 23% N/A
LA 01/01/92 23% N/A
MA 01/01/92 23% N/A
MD 01/01/92 23% N/A
MN 01/01/92 23% N/A
MO 01/01/92 23% N/A
NM 01/01/92 23% N/A
NV 01/01/92 23% N/A
OH 01/01/92 23% N/A
OK 01/01/92 23% N/A
OR 01/01/92 23% N/A
PA 01/01/92 23% N/A
TN 01/01/92 23Z N/A
TX 01/01/92 23% N/A
UT 01/01/92 23% N/A
VA 01/01/92 23% N/A
WA 01/01/92 23% N/A
WI 01/01/92 23% N/A
II. Use of Networks
A. AFFORDABLE agrees to make available to PLAN all new Health Care
Provider Networks developed by AFFORDABLE throughout the United States as
of the effective date of implementation of each such network.
B. PLAN agrees to utilize each new AFFORDABLE Health Care Provider
Network within ninety (90) days of receipt of notification of such
network's existence, provided that PLAN does not have a contract with a
competing health care provider network after first offering AFFORDABLE
the right of first refusal to develop a network in such area, which offer
AFFORDABLE has declined.
III. Compensation to AFFORDABLE
For each Health Care Provider Network selected by PLAN and commencing
with the Implementation Date listed in this Appendix A, PLAN agrees to
pay AFFORDABLE an amount equal to the Percentage of Savings listed in
Section I above.
17
IV. For the Hospital Network, Savings are to be computed as the difference
between Contract Providers' billed charges, net of payments due from
other payors and the Contract Rates at Contract Providers. AFFORDABLE
shall compute the savings by review and pricing of hard copy claims
from Contract Providers and submitted to AFFORDABLE by PLAN in accord
with Article 2.8.
Any adjustments to the savings made by PLAN will be reconciled with
payment on a quarterly basis. When reconciliation performed by
AFFORDABLE or PLAN discloses that adjustment to reimbursement under
this Agreement is appropriate, both parties agree to make the necessary
adjustments under the terms of this Agreement.
For OCN claims incurred during the contract period, PLAN will pay
AFFORDABLE a fee equal to twenty three percent (23%) of OCN Savings
for use of AFFORDABLE's Outpatient Care Networks.
OCN Savings shall be computed as the difference between the 90th
percentile of either HIAA or MDR, or the billed charges at the Contract
Providers, whichever is less, net of payments due from third party
payors and the Contract Rate obligation at Contract Providers.
V. PLAN and AFFORDABLE agree that use of the above-referenced Health Care
Provider Networks is subject to the terms and conditions contained in
this PPO Agreement.
