FACILITY PROVIDER AGREEMENT
This Facility Provider Agreement ("Agreement") is made and entered into as of
the 1st day of June, 1997 by and between Option Care, Inc. ("Provider"), and the
Foundation Health Corporation Affiliate(s) ("Foundation") identified in Addendum
A to this Agreement.
R E C I T A L S
A. Provider is a corporation or other public or private entity that
operates the Facilities listed on the signature page hereto, as
amended from time to time.
B. Foundation is one or more corporations which has the legal
authority to enter into this Agreement, and to perform the
obligations of Foundation hereunder with respect to the Benefit
Programs identified on Addendum A.
C. Foundation desires to enter into this Agreement to arrange for
Provider to render Contracted Services to Beneficiaries of the
various Benefit Programs identified on Addendum A.
D. Provider desires to enter into this Agreement to render
Contracted Services to Beneficiaries of the
various Benefit Programs identified on Addendum A.
A G R E E M E N T
NOW, THEREFORE, in consideration of the above recitals and the covenants
contained herein, the parties hereby agree as follows:
I. DEFINITIONS
Many words and terms are capitalized throughout this Agreement to indicate that
they are defined as set forth in this Article I.
1.1 Affiliate. A company in which Foundation Health Corporation, a
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Delaware corporation, owns 51% or more of the voting stock.
The Affiliates provide, arrange or administer one or more
Benefit Programs covered under this Agreement on behalf of
themselves and Payors. The Affiliates who are parties to this
Agreement are listed on Addendum A, as amended from time to
time by Foundation.
1.2 Beneficiary. (Member) A person who is eligible to receive
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Covered Medical Services under a Benefit Program included in
this Agreement, including a newborn baby who is a dependent of
Beneficiary during the first 31 days following the baby's
birth and/or legal adoption.
1.3 Benefit Program. Foundation's and Payors' performance of its
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obligations to provide, arrange or administer health care,
provider networks, administrative or other related services
pursuant to a written agreement between a public or private
employer or other entity and Foundation. The Benefit Programs
covered under this Agreement are listed on Addendum A hereto,
as amended from time to time.
1.4 Benefit Program Requirements. The rules, procedures,
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policies, protocols and other conditions to be followed by
Participating Providers and Beneficiaries with respect to
providing Covered Medical Services under a particular Benefit
Program.
1.5 Capitated Medical Group/IPA. A Participating Provider having a
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capitation agreement with Foundation, to provide Covered
Medical Services to Beneficiaries.
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1.6 Capitation Compensation. The per Beneficiary (member) per
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month ("PMPM") payment, indicated in the applicable Addenda to
this Agreement, payable monthly for each Beneficiary who has
selected or been assigned to Provider or a Capitated Medical
Group/IPA linked to Provider.
1.7 Contracted Services. All Inpatient Services, Outpatient
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Services, Emergency or other Covered Medical Services listed
on Addendum I, except Excluded Services, to be rendered by
Provider to a Beneficiary in accordance with this Agreement.
Contracted Services are included in Provider Risk Services as
specified in the Division of Financial Responsibility/Matrix
of Foundation, Capitated Medical Group/IPA and Provider Risk
Services exhibit to an applicable Addendum.
1.8 Coordination of Benefits. The allocation of financial
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responsibility between two or more payors of health care
services, each with a legal duty to pay for or provide Covered
Medical Services to a Beneficiary at the same time.
1.9 Copayment. That portion of the cost of Covered Medical
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Services that a Beneficiary is obligated to pay under a
particular Benefit Program, including a deductible and
coinsurance. A Copayment may be either a fixed dollar amount
or a percentage of the applicable Participating Provider
contract rate. Foundation will advise Participating Providers
of the amounts or methods by which Copayments may be
determined.
1.10 Covered Medical Services. (Covered Services) The Medically
-------------------------
Necessary health care services and supplies that are covered
under a Benefit Program.
1.11 Emergency. (Emergency Services) The sudden onset of a medical
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condition manifesting itself by acute symptoms of sufficient
severity, including severe pain, where the absence of
immediate medical attention could reasonably be expected to
result in serious impairment to a bodily function, or serious
and permanent dysfunction of any body organ or body part, or
to cause other serious medical consequences which include
placing a Beneficiary's health in permanent jeopardy.
1.12 Excluded Services. Those health care services and
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supplies which are determined not to be Medically Necessary,
or which otherwise are not Covered Medical Services under the
applicable Benefit Program.
1.13 Facility(ies). The hospitals, health care facility(ies) and
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other service locations operated or subcontracted by Provider
at which Contracted Services are to be provided under this
Agreement. Provider's hospitals, health care facilities and
other service locations are listed on the signature page of
this Agreement, as amended from time to time.
1.14 Inpatient Services. Inpatient Services include, but are not
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limited to: (a) bed and board; (b) medical, nursing, surgical,
pharmacy and dietary services; (c) all diagnostic and
therapeutic services required by a Beneficiary when ordered by
an attending physician with appropriate medical and clinical
staff privileges; (d) use of Facilities, and medical, mental
health and social services furnished for the provision of
Contracted Services; (e) drugs while an inpatient, take-home
drugs, supplies, appliances and equipment; (f) transportation
services subsequent to admission and prior to discharge
required in providing Inpatient Services; (g) services
rendered within 24 hours at the facility prior to
Beneficiary's admission as an inpatient, which are related to
the condition for which the Beneficiary is admitted; (h)
observation services, and (i) Facility physician and other
professional services where such physicians or allied health
professionals are employees or contractors of Provider, and
Provider normally bills for these services on Provider's HCFA
1500 or UB-92 (UB-82) or its successor form. Above services
are included in the
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compensation rates contained in this Agreement and shall not
be billed separately by Provider, physicians or allied health
professionals.
1.15 Medically Necessary. Those Covered Medical Services which
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are determined under the applicable Utilization Review and
Management Program to be:
(a) Appropriate and necessary for the symptoms, diagnosis or
treatment of a medical condition; and,
(b) Provided for the diagnosis or direct care and treatment of
a medical condition; and,
(c) Within standards of good medical practice within the
organized medical community of the treating provider; and,
(d) Not primarily for the convenience of the Beneficiary or
the treating provider; and,
(e) Consistent with the medical policy, the Utilization
Management Program, Quality Management Program and Benefit
Program Requirements applicable to the Benefit Program
under which the Covered Medical Services are rendered;
and,
(f) The most appropriate and cost effective service or supply
consistent with generally accepted medical standards of
care. For inpatient stays, this means that acute care as
an inpatient is necessary due to the kind of services the
Beneficiary is receiving or the severity of the
Beneficiary's condition, and that safe, cost effective and
adequate care cannot be received as an outpatient or in a
less intensified medical setting.
1.16 Outpatient Services. Outpatient services include, but are not
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limited to, Emergency services, outpatient and short stay
surgery, day care, clinic care, and related ancillary
services. Any outpatient services delivered to a Beneficiary
within 24 hours prior of an admission as an inpatient for the
same medical condition are included in the inpatient rate.
1.17 Participating Provider. A hospital, physician, physician
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organization, other health care practitioner or other
organization which has a direct or indirect contractual
relationship with Foundation, a Payor or another Participating
Provider to provide certain Covered Medical Services.
1.18 Payor. Foundation, or any other public or private entity which
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provides, administers, funds, insures or is responsible for
paying Participating Providers for Covered Medical Services
rendered to Beneficiaries under a Benefit Program covered
under this Agreement.
1.19 Preventive Care. Preventive Care aims to remove or reduce
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disease risk factors and promote early detection of disease
or precursor states. Health education and behavior
modification are two of the most effective and economical
means of disease control.
1.20 Primary Care Physician (PCP). The physician who is a
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Participating Provider and who is responsible pursuant to the
applicable Benefit Program for coordinating and managing the
delivery of Covered Medical Services to Beneficiaries selected
or assigned to such physician.
1.21 Prior Authorization. The written approval by Foundation, an
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Affiliate, a Payor, or other permitted person or entity, prior
to admitting a Beneficiary to a hospital, or to providing
certain other Covered Medical Services to a Beneficiary, which
approval is required under the Utilization Management Program
of the applicable Benefit Program.
1.22 Provider Risk Services. Contracted Services and such other
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Covered Medical Services as are described in an Addendum to
this Agreement for which Provider has accepted Capitation
Compensation under the applicable Benefit Programs to which
the Addendum applies.
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1.23 Provider Service Area. The geographic area(s), specified by
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zip codes and/or other descriptive boundaries which are
described in the applicable Addenda to this Agreement.
1.24 Quality Management Program. The functions, including, but not
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limited to, credentialing and certification of providers,
review and audit of medical and other records, outcome rate
reviews, peer review and provider appeals and grievance
procedures performed or required by Foundation, an Affiliate,
a Payor, or any other permitted person or entity, to review
and improve the quality of Covered Medical Services rendered
to Beneficiaries.
1.25 Referral. When required under a Benefit Program, the written
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approval from the Beneficiary's PCP and usually for a
specified number of visits, treatments, or period of time,
required under a Utilization Management Program for a
Beneficiary to receive Covered Medical Services from a
physician (usually a specialist) or other health care
professional or organization. Referral to a non-Participating
Provider requires Prior Authorization.
1.26 Supplemental Medical. A Benefit Program which limits coverage
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to Copayments.
1.27 State. The state or states of licensure and accreditation of
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Facilities at which Contracted Services are to be provided
under this Agreement.
1.28 Utilization Management Program. The functions, including, but
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not limited to Prior Authorization, Referral and prospective,
concurrent and retrospective review, performed or required by
Foundation, an Affiliate, a Payor, or any other permitted
person or entity, to review and determine whether medical
services or supplies which have been or will be provided to
Beneficiaries are covered under a Benefit Program and meet the
criteria as Medically Necessary.
II. PERFORMANCE PROVISIONS
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2.1 Representations and Warranties. Provider represents and
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warrants for each Facility that:
(a) Provider is licensed by the State to operate and
provide Contracted Services at the Facility;
(b) Provider operates and provides Contracted Services
at the Facility in compliance with all applicable
local, State, and federal laws, rules, regulations
and institutional and professional standards of
care;
(c) The Facility 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;
(d) The Facility is accredited by the appropriate
accrediting organization(s) listed on the signature
page of this Agreement; and
(e) Provider shall maintain such licensure, compliance,
certification and accreditation throughout the term
of this Agreement.
2.2 Provision of Services. Provider agrees to render Contracted
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Services to Beneficiaries of the Benefit Programs covered
under this Agreement, in accordance with:
(a) The terms and conditions of this Agreement;
(b) All laws, rules and regulations applicable to
Provider, each Facility, Foundation, Affiliates and
Payors;
(c) The Utilization Management Program, Quality
Management Program, Benefit Program Requirements and
grievance, appeals and other policies and procedures
of the particular Benefit Program under which the
Covered Medical Services are rendered; and
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(d) The same standard of care, skill and diligence as is
customarily used by similar facilities in the
community in which such services are rendered, and in
the same manner, and with the same availability, as
Provider renders services to its other patients.
(e) Provider shall accept the Compensation Rates, as
referenced in Exhibit 1 of the Addenda, from
Foundation Health Affiliates who are not parties to
this Agreement in return for services rendered to
Beneficiaries of Benefit Programs offered by such
Affiliates.
Provider shall maintain such Facilities, equipment, patient
service personnel and allied health personnel as may be
necessary to provide Contracted Services. Provider shall be
responsible for promptly notifying Foundation of any additions
or deletions in the services contained in the Hospital Service
Inventory in Addendum I.
2.3 Non-Discrimination. Provider shall not discriminate against
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any Beneficiary in the provision of Contracted Services
hereunder, whether on the basis of the Beneficiary's coverage
under a Benefit Program, age, sex, marital status, sexual
orientation, race, color, religion, ancestry, national origin,
disability, handicap, health status, source of payment,
utilization of medical or mental health services or supplies
or other unlawful basis including, without limitation, the
filing by such Beneficiary of any complaint, grievance or
legal action against Provider, Foundation, an Affiliate or a
Payor.
2.4 Subcontracting. Provider shall not subcontract for the
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performance of Contracted Services under this Agreement
without the prior written consent of Foundation. If Provider
has agreed to render Provider Risk Services for Capitation
Compensation hereunder, Provider may subcontract for the
provision of such services with entities acceptable to
Foundation. Every subcontract between Provider and a
subcontractor shall be in writing and shall comply with all
applicable local, State and federal laws, be consistent with
the terms and conditions of this Agreement, and be terminable
with respect to Beneficiaries by Provider upon request of
Foundation. Each such subcontract may require the prior
approval of one or more local, State, or federal regulatory
agencies, and shall not become effective until all such
required approvals have been obtained. If any of the Provider
Risk Services are to be provided by a subcontractor, Provider
and the subcontractor shall enter into a written agreement
which expressly provides that the rendering of Provider Risk
Services by the subcontractor is subject to the terms of this
Agreement. Provider shall furnish Foundation with copies of
such subcontracts within ten days of execution of this
Agreement and ten days of execution of any subsequent
subcontracts by Provider. Each such subcontractor shall meet
Foundation's credentialing requirements, prior to the
subcontract becoming effective. Provider agrees to be solely
responsible to pay any subcontractor permitted under this
Agreement, and shall hold, and ensure that subcontractors
hold, Foundation, Affiliates, Payors and Beneficiaries
harmless from and against any and all claims which may be made
by such subcontractors in connection with Contracted Services
rendered to Beneficiaries under any such subcontract.
2.5 Utilization Management Requirements. Provider agrees to
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participate in, cooperate with and comply with all decisions
rendered in connection with Foundation's, an Affiliate's or a
Payor's Utilization Management Program. The hospital shall
submit indicator data relevant to its services to the Joint
Commission on Accreditation of Healthcare Organizations'
(JCAHO) Indicator Measurement System. The data will be
submitted on a timely basis and meet the reasonable standards
set by JCAHO for completeness and reliability. Provider also
agrees to provide such other records and information as may be
required or requested under such Utilization Management
Program. Provider shall notify Foundation's Health Care
Services Department in the event of any inpatient admission,
in addition to any notification required by the Beneficiary's
Capitated Medical Group/IPA.
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2.6 Prior Authorization and Referrals. Unless a particular Benefit
----------------------------------
Program or Utilization Management Program contains no such
requirement, and except in an Emergency, Provider agrees not
to seek payment from Foundation or a Payor for Contracted
Services rendered to a Beneficiary unless Prior Authorization
or a Referral was obtained for the rendering of such services.
Such Prior Authorization or Referral may be issued by
Foundation, the applicable Payor, or a Participating Provider.
In an Emergency, Provider agrees to attempt to obtain Prior
Authorization, by telephone if necessary, before admitting a
Beneficiary either as an inpatient or outpatient, or providing
Contracted Services. If Prior Authorization or Referral cannot
be obtained, Provider agrees to notify Foundation or the
applicable Payor and the appropriate Participating Provider as
applicable, as soon as possible, but no later than 24 hours
after admission, or providing the Contracted Services, or on
the next working day.
2.7 Participating Providers. Except in an Emergency, as otherwise
------------------------
described in the applicable Benefit Program Requirements, or
as otherwise required by law, Provider shall refer
Beneficiaries only to Participating Providers for Covered
Medical Services, and shall use Participating Providers to
provide Facility-based physician and other ancillary services
included in Contracted Services. In the event Provider
knowingly refers a Beneficiary to a nonparticipating provider
without Prior Authorization, Provider agrees to be responsible
for payment of claims incurred for the unauthorized Covered
Medical Service, and Provider agrees, in accordance with
Section 3.7 of this Agreement, to hold harmless the
Beneficiary for such claims. Provider shall assist Foundation
or Payors in their efforts to contract with Provider's
Facility-based physicians. Foundation or a Payor will require
that the most cost effective, qualified Participating Provider
is utilized.
2.8 Quality Management Program. Provider shall be solely
---------------------------
responsible for the quality of Contracted Services rendered to
Beneficiaries. The quality of Contracted Services rendered to
Beneficiaries shall be monitored under the Quality Management
Program applicable to the particular Benefit Program. Provider
agrees to participate in and cooperate in all respects with
the applicable Quality Management Program. Provider also
agrees to comply with all decisions rendered by Foundation or
a Payor in connection with a Quality Management Program.
Provider also agrees to provide such medical and other records
within 10 days of written notice, and such review data and
other information as may be required or requested under a
Quality Management Program, including outcome reporting in
accordance with, but not limited to, the Health Plan Employer
Data and Information Set (HEDIS), Version 2.0, or its
successor. In the event that the standard or quality of care
furnished by Provider is found to be unacceptable under any
Quality Management Program, Foundation shall give written
notice to Provider to correct the specified deficiencies
within the time period specified in the notice. Provider shall
correct such deficiencies within that time period.
2.9 Credentialing of Provider. Provider shall submit to Foundation
-------------------------
the Credentials Application or the same information in a
format used by Provider which meets minimum requirements of
Foundation, contained in Exhibit 1 to Addendum A of this
Agreement. In no event will this Agreement be executed by
Foundation, nor will Provider begin performing Provider's
obligations under this Agreement, until Provider's Credentials
Application has been approved by Foundation.
2.10 Notice of Adverse Action. Provider shall notify Foundation in
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writing, within five days of receiving any written or oral
notice of any adverse action, including, without limitation,
any malpractice suit or arbitration action, or other suit or
arbitration action naming or otherwise involving Provider, a
Facility, Foundation or any Payor, and of any other event,
occurrence or situation which might materially interfere with,
modify or alter performance of any of Provider's duties or
obligations under this Agreement. Provider shall forward to
Foundation any written complaint or grievance of a Beneficiary
against Provider, a Facility, Foundation or any Payor
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within one business day of receipt thereof. Provider shall
maintain a written record of any Beneficiary complaint and
provide such record to Foundation promptly upon request.
Provider also shall notify Foundation promptly of any action
against any Facility license, accreditation, or certification
under Title XVIII or Title XIX or other applicable statute of
the Social Security Act or other State law, and of any
material change in the ownership or business operations of
Provider or a Facility.
2.11 Preventive Care. Provider shall require and assure that its
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Facilities abide by Foundation's policies and procedures
regarding Preventive Care and health education. Provider shall
render Preventive Care and health education to Beneficiaries
during each episode of care and document such in the medical
record.
2.12 Professional Liability Insurance. Provider shall maintain
---------------------------------
professional liability insurance in an amount equal to the
lesser of the highest amount required by law, the accrediting
body having jurisdiction over Provider or, $3,000,000 per
claim and $10,000,000 in the aggregate of all claims per
policy year. Provider agrees to provide Foundation with
written evidence, acceptable to Foundation, of such insurance
coverage within three days of such request by Foundation.
Provider also agrees to notify, or to ensure that its
insurance carriers notify Foundation, at least 30 days prior
to any proposed termination, cancellation or material
modification of any policy for all or any portion of the
coverage provided for above.
2.13 Listing of Provider. Provider agrees that Foundation and
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Payors may list the name, address, telephone number and other
factual information of Provider, each Facility and Provider's
subcontractors and their facilities in its marketing and
informational materials. Provider shall supply all printed
materials and other information relating to its operations
within seven days of Foundation's request.
2.14 Non-Solicitation. Neither Provider nor any employee, agent or
-----------------
subcontractor of Provider shall solicit or attempt to convince
or otherwise persuade any Beneficiary not to participate or to
discontinue participation in any Foundation or Payor Benefit
Program for which Provider renders Contracted Services under
this Agreement. Further, Provider, its employees and
subcontractors, shall treat Beneficiaries promptly, fairly and
courteously.
2.15 Encounter Reporting. For Beneficiaries for which Provider
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receives Capitation Compensation under this Agreement,
Provider shall provide Foundation with the following
information, via personal computer diskette, magnetic tape or
electronic transmission in standard UB-92 (UB-82) form or its
successor format, for each encounter (either at Provider's
Facility, or any other facility at which a Beneficiary
received approved Inpatient Services, and for which Provider
has paid the claim) with a Beneficiary during a calendar
month. Such electronic encounter information materials shall
be complete, accurate and provided to Foundation by the 15th
day of the month following the month in which the encounter
occurred. Encounter reporting shall be in accordance with, but
not limited to, the Health Plan Employer Data and Information
Set (HEDIS), Version 2.0, or its successor. Additionally,
Provider shall promptly provide Foundation with all
corrections to and revisions of such encounter data.
2.16 New or Additional Benefit Programs. Provider acknowledges that
-----------------------------------
Foundation may develop new or additional Benefit Programs in
Provider's Service Area. Provider agrees to participate and
negotiate with Foundation in good faith to amend this
Agreement to include such new or additional Benefit Programs
as requested by Foundation. Where a new Benefit Program falls
under existing Addenda, then the applicable contract rates
shall automatically apply.
2.17 Payment of Applicable Taxes. Provider shall be solely
----------------------------
responsible for the collection and payment of any sales, use
or other applicable taxes on the sale or delivery of medical
services.
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2.18 Timely Assignment of Beneficiaries. Where required under a
-----------------------------------
Benefit Program, Foundation shall require Beneficiaries to
select specified Participating Providers at the time of
enrollment. In the event a Beneficiary does not select a PCP
or other Participating Providers within 60 days, Foundation
shall automatically assign the Beneficiary to the appropriate
PCP and Facility Provider based upon the zip code in which the
Beneficiary resides. Upon automatic assignment of PCP and
Facility Provider, the Beneficiary may change to another PCP
and Facility Provider of choice.
2.19 Requirement that Most Cost Effective Services be Used. Unless
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there is an overriding medical reason, as determined by the
appropriate Medical Director, Provider agrees to utilize the
lowest cost option in circumstances in which there is a
medically appropriate choice of using different services.
2.20 Beneficiary Grievance Procedures. Provider shall abide by the
---------------------------------
determination of the applicable Payor's Beneficiary Grievance
Procedure.
III. COMPENSATION
3.1 Compensation Rates. Provider shall accept as payment in full
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for Contracted Services and all other services (including
payment for any and all sales, use or other applicable taxes
on the sale or delivery of medical services) rendered under
this Agreement to Beneficiaries the amounts payable by
Foundation or a Payor as set forth in the applicable Addendum
to this Agreement, less Copayment amounts payable by
Beneficiaries in accordance with the applicable Benefit
Program. It is expressly understood that, in this context,
Provider acknowledges its obligations to provide care
consistent with the professional standards of care generally
accepted by the medical community.
3.2 Billing and Payment.
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(a) Billing. Unless a Provider is compensated on a
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Capitation Compensation basis, Provider shall submit
to Foundation, via Foundation's electronic claims
submission program [or hardcopy], clean, complete and
accurate claims in a format approved by Foundation
for Contracted Services rendered to a Beneficiary
within 60 calendar days after such services are
rendered. Where Foundation is the secondary payor
under Coordination of Benefits, such 60 day period
shall commence once the primary payor has paid or
denied the claim. Neither Foundation nor any Payor
shall be under any obligation to pay Provider on any
claim not timely submitted. Provider shall not seek
payment from any Beneficiary in the event Foundation
or a Payor fails to pay Provider for a claim not
timely submitted. In the event Provider elects to
purchase reinsurance from Foundation, and is
capitated on a Capitation Compensation basis,
Provider shall submit to Foundation clean, complete
and accurate claims in a format approved by
Foundation for Provider Risk Services in excess of
the stop loss threshold. Provider shall be
responsible for submitting such claims no later than
60 days after the stop loss year ends. Foundation
shall not be under any obligation to pay Provider on
any claim not timely submitted. Provider shall not
seek payment from any Beneficiary in the event
Foundation fails to pay Provider for a claim not
timely submitted.
(b) Payment. Unless the claim is disputed, Foundation or
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a Payor shall make payment on each of Provider's
clean, complete, accurate and timely submitted claims
for Contracted Services rendered to a Beneficiary,
within 30 working days of receipt of such claim, or
within the time required by applicable State, Federal
Law or Regulation or such other period of time as set
forth in the applicable Benefit Program Addendum to
this
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Agreement, or as required by State Occupationally
Ill/Injured or Workers' Compensation law, if
applicable.
(c) Performance Guarantees. If Foundation determines that
-----------------------
deficiencies identified and reported to Provider
relating to the Quality Management Program,
Utilization Review Program, Preventive Care Services,
credentialing, encounter reporting, and financial
reporting are not corrected within 30 working days of
notice to Provider, then Provider's compensation
hereunder shall be reduced at Foundation's discretion
up to 2.5% of the Provider's applicable monthly
compensation or claims reimbursement. Reduction of
compensation shall occur on payments due for the
first month after Provider has been notified and
continue until such identified deficiencies are
remedied.
(d) Appeals. Provider shall abide by Foundation's appeal
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process for disputes regarding denial of coverage.
3.3 Eligibility. Except in an Emergency, Provider shall verify the
------------
eligibility of Beneficiaries before admitting or providing
Contracted Services. When required by the applicable
Utilization Management Program, Provider shall verify the
eligibility of Beneficiaries before admitting or providing
Provider Risk Services. Foundation shall make a good faith
effort to confirm the eligibility of any Beneficiary when such
is in question.
3.4 Reconciliation of Eligibility. When Provider is compensated on
------------------------------
a Capitation Compensation basis, Foundation shall provide
Provider with a monthly list of Beneficiaries for whom
Provider is responsible for rendering Provider Risk Services
during such month. Foundation will use its best efforts to
discourage retroactive cancellation or addition of
Beneficiaries to a Benefit Program. However, in the event
Foundation allows such adjustments, Foundation shall
retroactively adjust Provider's Capitation Compensation as
necessary, provided that the retroactive addition or
cancellation period shall not exceed 90 days (except for
Medicare Risk Benefit Programs, which have no such limits). In
cases where a Beneficiary has utilized a non-participating
hospital, and an appeal of the denial of such utilization by
Foundation or Provider has been approved in favor of the
Beneficiary by a governmental agency or its agent, after such
90 day period, Foundation may disenroll such Beneficiary and
retroactively adjust Provider's Capitation Compensation
accordingly. In the event of allowable retroactive additions,
Provider agrees to be responsible for all Provider Risk
Services rendered to the Beneficiary from the beginning of the
retroactive period. In the event of retroactive cancellations,
Provider may xxxx the Beneficiary for all Provider Risk
Services received by the Beneficiary from the date such
Beneficiary was no longer covered under the applicable Benefit
Program.
3.5 Collection of Copayments. Provider shall collect all
-------------------------
Copayments due from Beneficiaries, and shall not waive or fail
to pursue collection of Copayments from Beneficiaries, without
the prior written consent of Foundation.
3.6 No Surcharges. Provider shall not charge the Beneficiary any
--------------
fees or surcharges for Contracted Services rendered pursuant
to this Agreement (except for authorized Copayments). In
addition, Provider shall not collect a sales, use or other
applicable tax from Beneficiaries for the sale or delivery of
medical services. If Foundation or any Payor receives notice
of any additional charge, Provider shall fully cooperate with
Foundation or such Payor to investigate such allegations, and
shall promptly refund any payment deemed improper by
Foundation or a Payor to the party who made the payment.
3.7 Beneficiary Held Harmless. Provider agrees that in no event,
-------------------------
including, but not limited to, non-payment by Foundation or a
Payor, insolvency of Foundation or a Payor, or breach of this
Agreement, shall Provider xxxx, charge, collect a deposit
from, seek compensation, remuneration, or reimbursement from,
or have any recourse against Beneficiaries or persons other
than Foundation or a Payor acting on their behalf for
Contracted Services provided pursuant to this
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Agreement. This provision shall not prohibit collection of
Copayments on Foundation's or a Payor's behalf made in
accordance with the terms of the applicable Benefit Program.
Provider further agrees that: (a) this provision shall survive
the termination of this Agreement regardless of the cause
giving rise to termination and shall be construed to be for
the benefit of Beneficiaries; and (b) this provision
supersedes any oral or written contrary agreement now existing
or hereafter entered into between Provider and Beneficiaries
or persons acting on their behalf. Any modification, addition,
or deletion mandated by State of or to the provisions of this
clause shall be effective on a date no earlier than 15 days
after the State regulatory agency has received written notice
of such proposed change and has approved such change.
3.8 Conditions for Compensation for Excluded Services. Provider
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may xxxx a Beneficiary for other Excluded Services rendered by
Provider to such Beneficiary only if the Beneficiary is
notified in advance that the services to be provided are not
covered under the Beneficiary's Benefit Program, and the
Beneficiary requests in writing that Provider render the
Excluded Services, prior to Provider's rendition of such
services. Neither a Beneficiary, nor Foundation nor any Payor
shall be liable to pay Provider for any Contracted Service
rendered by Provider to a Beneficiary which is determined
under a Utilization Management Program not to be Medically
Necessary.
3.9 Coordination of Benefits. Provider agrees to conduct
-------------------------
Coordination of Benefits in accordance with the policies and
procedures established by Foundation or a Payor for the
applicable Benefit Program. Provider shall not xxxx
Beneficiaries for any portion of Contracted Services not paid
by the primary carrier when Foundation or Payor is the
secondary carrier, but shall instead look to Foundation or
Payor for such payment. When a Beneficiary has coverage which
is primary through another carrier, then Foundation's or a
Payor's compensation to Provider shall be limited to the
difference between the amount paid by the primary payor and
the negotiated rates, including Copayments, contained in the
applicable Addendum to this Agreement. When Provider is
compensated on a Capitated Compensation basis, Provider shall
be entitled to conduct Coordination of Benefits for those
services where Provider is so paid.
3.10 Third Party Recoveries. When Foundation or a Payor has
-----------------------
compensated Provider for Contracted Services, then Foundation
or a Payor retains the right to recover from applicable third
party carriers covering a Beneficiary, including self-insured
plans, and to retain all such recoveries. Provider agrees to
provide Foundation with such information as Foundation may
require to pursue recoveries from such third party sources,
and to promptly remit to Foundation or a Payor any moneys
Provider may receive from or with respect to such sources of
recovery.
3.11 Occupationally Ill/Injured or Workers' Compensation. Unless a
----------------------------------------------------
beneficiary is covered under the Occupationally Ill/Injured or
Workers' Compensation Benefit Program (Addendum H), Covered
Medical Services shall not include health care services and
supplies rendered to diagnose or treat occupational illnesses
or injuries.
IV. TERM AND TERMINATION
--------------------
4.1 Term. The term of this Agreement shall commence on the date
-----
set forth on the first page of this Agreement and shall
continue for a period of three years thereafter. This
Agreement shall automatically renew for successive three year
periods, unless one party notifies the other in writing of its
intent not to renew this Agreement, at least 120 days prior to
the next scheduled renewal date. Any and all negotiations must
be completed 90 days prior to the anniversary date of the
contract. The renewal date of the term of this Agreement shall
remain the same for all Benefit Programs covered hereunder,
even if this Agreement becomes effective with respect to a
particular Benefit Program after the initial or any renewal
date of this Agreement, due to licensure, contract award or
other reason. Regardless of the effective date or any renewal
date of
10
this Agreement, Provider shall not begin providing Contracted
Services to Beneficiaries and Foundation shall have no
obligation to pay for such services until the completion of
Foundation's or a Payor's credentialing and certification
processes.
4.2 Immediate Termination. Foundation may terminate this Agreement
----------------------
in its entirety, or with respect to specific Facilities,
immediately upon notice to Provider, in the event of: (a)
Provider's violation of any applicable law, rule or
regulation; (b) the revocation or suspension of any of
Provider's licenses, accreditations or certifications; (c)
Provider's failure to maintain the professional liability
insurance coverage specified hereunder; (d) Provider's failure
to comply with the terms, conditions or determinations of any
Utilization Management Program or Quality Management Program
or other Benefit Program Requirements; (e) Provider's breach
of Section 2.1, 2.2, 2.3, 2.5, 2.8, 2.9, 2.10, 2.12, 2.15,
3.6, 3.7 or 3.8 hereof; or (f) Foundation's determination that
the health, safety or welfare of any Beneficiary may be in
jeopardy if this Agreement is not terminated.
4.3 Termination Due to Material Breach. In the event that either
----------------------------------
Provider or Foundation fails to cure a material breach of this
Agreement within 30 days of receipt of written notice to cure
from the other, the non-defaulting party may terminate this
Agreement, effective as of the expiration of said 30 day
period. If the breach is cured within such 30 day period, or
if the breach is one which cannot reasonably be corrected
within 30 days, and the non-defaulting party determines that
the defaulting party is making substantial and diligent
progress toward correction during such 30 day period, this
Agreement shall remain in full force and effect.
4.4 Right of Partial Termination. Provider may only terminate this
-----------------------------
Agreement in its entirety in accordance with Sections 4.1 and
4.3. Foundation may terminate this Agreement, with respect to
one or more Benefit Programs as Foundation indicates in the
notice of termination to Provider. This Agreement shall remain
in full force and effect with respect to all other
Beneficiaries and Benefit Programs.
4.5 Effect of Termination. In the event that a Beneficiary is
----------------------
receiving Contracted Services at the time this Agreement
terminates, Provider shall continue to provide Contracted
Services to the Beneficiary until: (a) the Beneficiary is
discharged; or (b) treatment is completed; or (c) the
Beneficiary is transferred to another Participating Provider.
Compensation for such Contracted Services shall be at the
rates contained in the Addendum that applies to the applicable
Benefit Program.
V. RECORDS, AUDITS AND REGULATORY REQUIREMENTS
-------------------------------------------
5.1 Medical and Other Records. Provider warrants that it prepares
--------------------------
and maintains and will prepare and maintain all medical and
other books and records required by law in a form maintained
in accordance with the general standards applicable to such
book- or recordkeeping. Provider shall maintain such records
for at least seven years after the rendering of Contracted
Services [records of a minor child shall be kept for at least
one year after the minor has reached the age of 18, but in no
event less than seven years]. Additionally, Provider shall
maintain such financial, administrative and other records as
may be necessary for compliance by Foundation and Payors with
all applicable local, State, and federal laws, rules and
regulations.
5.2 Access to Records; Audits. The records referred to in Section
--------------------------
5.1 shall be and remain the property of Provider and shall not
be removed or transferred from Provider except in accordance
with applicable local, State, and federal laws, rules and
regulations. Subject to applicable State and federal
confidentiality or privacy laws, Foundation and Payors, or
their designated representatives, and designated
representatives of local, State, and federal regulatory
agencies
11
having jurisdiction over Foundation or any Payor, shall have
access to Provider's records, at Provider's place of business
on request during normal business hours, to inspect and review
and make copies of such records. Such governmental agencies
shall include, when applicable to the Benefit Programs
identified on Addendum A, the California Department of Health
Services, the California Department of Corporations and the
United States Department of Health and Human Services. When
requested by Foundation, Payors, or representatives of local,
State or federal regulatory agencies, Provider shall produce
copies of any such records for which Provider shall charge no
more than $.10 per page. In no event, however, shall Provider
charge for copying records requested for payment of a claim.
Additionally, Provider agrees to permit Foundation, and its
designated representatives, and designated representatives of
local, State, and federal regulatory agencies having
jurisdiction over Foundation or any Payor, to conduct site
evaluations and inspections of Provider's offices and service
locations.
5.3 Continuing Obligation. The obligations of Provider under
---------------------
Sections 5.1 and 5.2 shall not be terminated upon termination
of this Agreement, whether by rescission or otherwise. After
termination of this Agreement, Foundation and Payors shall
continue to have access to Provider's records as necessary to
fulfill the requirements of this Agreement and to comply with
all applicable laws, rules and regulations.
5.4 Regulatory Compliance. Provider agrees to comply with all
----------------------
applicable local, State, and federal laws, rules and
regulations, now or hereafter in effect, to the extent that
they directly or indirectly affect Provider, Provider's
Facility(ies), Foundation, any Payor, and bear upon the
subject matter of this Agreement.
In addition, Foundation Health, a California Health
Plan is subject to the requirements of Chapter 2.2 of Division
2 of the California Health and Safety Code and of Subchapter
5.5 of Chapter 3 of Title 10 of the California Code of
Regulations. Any provision required to be in this Agreement by
either of the above shall bind the parties whether or not
provided in this Agreement.
VI. GENERAL PROVISIONS
------------------
6.1 Amendments. All amendments to this Agreement or any of its
-----------
Addenda proposed by Provider must be agreed to in writing by
Foundation in advance of the effective date thereof. Any
amendment to this Agreement, including any of its Addenda,
proposed by Foundation shall be effective 20 days after
Foundation has given written notice to Provider of the
amendment, and Provider has failed within that time period to
notify Foundation in writing of Provider's rejection of the
requested amendment. Amendments required because of
legislative, regulatory or legal requirements do not require
the consent of Provider or Foundation and will be effective
immediately on the effective date thereof. Any amendment to
this Agreement requiring prior approval of or notice to any
federal or state regulatory agency shall not become effective
until all necessary approvals have been granted or all
required notice periods have expired. Foundation and Provider
shall amend this Agreement, from time to time, to include
additional Facilities, Affiliates, Benefit Programs, and
Payors.
6.2 Separate Obligations. The rights and obligations of Foundation
---------------------
under this Agreement shall apply to each Affiliate listed on
Addendum A to this Agreement only with respect to the Benefit
Programs of such Affiliate. No such Affiliate shall be
responsible for the obligations of any other Affiliate under
this Agreement with respect to the other Affiliate's Benefit
Programs. The person executing this Agreement on behalf of
Foundation has been duly authorized by each Affiliate listed
on Addendum A to execute this Agreement on its behalf.
12
6.3 Assignment. Neither this Agreement, nor any of Provider's
-----------
rights or obligations hereunder, is assignable by Provider
without the prior written consent of Foundation. Should the
name of Foundation change, due to any merger or other cause,
Provider agrees that this Agreement shall remain in full force
and effect.
6.4 Confidentiality. Foundation and Provider agree to hold all
----------------
confidential or proprietary information or trade secrets of
each other in trust and confidence and agree that such
information shall be used only for the purposes contemplated
herein, and not for any other purpose. Specifically Provider,
as well as Foundation and Payors, shall keep strictly
confidential all compensation rates, set forth in this
Agreement and its Addenda, except that this provision does not
preclude disclosure of the method of compensation, e.g.,
fee-for-service, capitation, shared risk pool, DRG or per
diem. However, Provider agrees that Foundation may extend the
compensation rate set forth in this Agreement and its Addenda
to other participating Providers who may from time to time be
responsible for compensating Provider for Covered Medical
Services rendered by Provider to a Beneficiary of Foundation
or a Payor. Foundation and Provider agree that nothing in this
Agreement shall be construed as a limitation of the Provider's
right or obligation to discuss with the Beneficiaries matters
pertaining to the Beneficiaries' health.
6.5 Binding Arbitration. Provider and Foundation agree to meet and
--------------------
confer in good faith to resolve any problems or disputes that
may arise under this Agreement. Such negotiation shall be a
condition precedent to the filing of any arbitration demand by
either party, and no arbitration demand may be filed until the
exhaustion of Foundation's internal appeal procedures.
The parties agree that any controversy or claim arising out
of or relating to this Agreement, or the breach thereof,
whether involving a claim in tort, contract or otherwise,
shall be settled by final and binding arbitration in
accordance with the provisions of the California Arbitration
Act (California Code of Civil Procedure Sections 1280, et
seq.). The parties waive their right to a jury or court trial.
The arbitration shall be conducted in Sacramento, California
by a single, neutral arbitrator who is licensed to practice
law. These arbitration proceedings are initiated by the
complaining party serving a written demand for arbitration
upon the other party. The written demand shall contain a
detailed statement of the matter and facts supporting the
demand and include copies of all related documents. On receipt
of a timely demand for arbitration, Foundation shall provide
Provider with a list of three neutral arbitrators from which
Provider shall select its choice of arbitrator for the
arbitration. Each party shall have the right to take the
deposition of one individual and any expert witness designated
by another party. At least 30 days before the arbitration, the
parties must exchange lists of witnesses, including any
experts, and copies of all exhibits to be used at the
arbitration. Arbitration must be initiated within six months
after the alleged controversy or claim occurred by submitting
a written demand to the other party. The failure to initiate
arbitration within that period constitutes an absolute bar to
the institution of any proceedings.
The decision of the arbitrator shall be final and binding
upon the parties. The arbitrator shall have no authority to
make materials errors of law or to award punitive damages or
to add to, modify or refuse to enforce any agreements between
the parties. The arbitrator shall make findings of fact and
conclusions of law and shall have no authority to make any
award which could not have been made by a court of law. The
prevailing party, or substantially prevailing party's costs of
arbitration, are to be borne by the other party, including
reasonable attorneys' fees.
13
6.6 Entire Agreement. This Agreement supersedes any and all other
-----------------
agreements, either oral or written, between the parties with
respect to the subject matter hereof, and no other agreement,
statement or promise relating to the subject matter of this
Agreement shall be valid or binding.
6.7 Governing Law. This Agreement shall be governed by and
--------------
construed and enforced in accordance with the laws of the
State, except to the extent such laws conflict with or are
preempted by any federal law, in which case such federal law
shall govern. Federal law shall also govern with respect to
Benefit Programs of federal Benefit Programs.
6.8 Indemnification of Parties. Foundation, any entity contracting
---------------------------
with Foundation (or any of their respective agents or
employees), and Provider are each responsible for their own
acts or omissions, and are not liable for the acts or
omissions of, or the costs of defending, others. Any provision
to the contrary in a contract with providers is void and
unenforceable. Nothing in this section shall preclude a
finding of liability on the part of Foundation, any entity
contracting with Foundation (or any of their respective agents
or employees), or Provider, based on doctrines of equitable
indemnity, comparative negligence, contribution, or other
statutory or common law bases for liability.
6.9 Non-Exclusive Contract. This Agreement is non-exclusive and
-----------------------
shall not prohibit Provider or Foundation from entering into
agreements with other health care providers or purchasers of
health care services.
6.10 No Notice to Beneficiaries. Provider and Foundation reserve
--------------------------
the right to amend this Agreement and any of its provisions,
to waive any rights granted to either party hereunder, and to
terminate this Agreement without notice to or consent of any
Beneficiary.
6.11 No Third Party Beneficiary. Nothing in this Agreement is
---------------------------
intended to, or shall be deemed or construed to create any
rights or remedies in any third party, including a
Beneficiary. Nothing contained herein shall operate (or be
construed to operate) in any manner whatsoever to increase the
rights of any such Beneficiary or the duties or
responsibilities of Provider or Foundation with respect to
such Beneficiaries.
6.12 Notice. Any notice required or desired to be given under this
-------
Agreement shall be in writing and shall be sent by certified
mail, return receipt requested, postage prepaid, or overnight
courier, or facsimile, addressed as follows:
Foundation: 0000 Xxxx Xxxxx
Xxxxxx Xxxxxxx, Xxxxxxxxxx 00000
Attention: Senior Vice President,
Provider Development
Facsimile number: 000-000-0000
Provider:
=============================================
---------------------------------------------
Facsimile number: ____________________________
Notices given hereunder shall be deemed given upon documented
receipt. The addresses to which notices are to be sent may be
changed by written notice given in accordance with this
Section.
14
6.13 Regulation. Foundation is subject to the requirements of
-----------
various local, State, and federal laws, rules and regulations.
Any provision required to be in this Agreement by any of the
above shall bind Provider and Foundation whether or not
provided herein.
6.14 Severability. If any provision of this Agreement is rendered
-------------
invalid or unenforceable by any local, State, or federal law,
rule or regulation, or declared null and void by any court of
competent jurisdiction, the remainder of this Agreement shall
remain in full force and effect.
6.15 Status as Independent Entities. None of the provisions of this
-------------------------------
Agreement is intended to create or shall be deemed or
construed to create any relationship between Provider and
Foundation other than that of independent entities contracting
with each other solely for the purpose of effecting the
provisions of this Agreement. Neither Provider nor Foundation,
nor any of their respective agents, employees or
representatives, shall be construed to be the agent, employee
or representative of the other.
6.16 Addenda. Each Addendum to this Agreement is made a part of
-------
this Agreement as though set forth fully herein. Any provision
of an Addendum that is in conflict with any provision of this
Agreement shall take precedence and supersede the conflicting
provision of this Agreement.
6.17 Regulatory Approval. If Foundation has not been licensed to
--------------------
provide, or provide services in connection with, a particular
Benefit Program in a particular State, or has not received all
required regulatory approvals for use of this Agreement with
respect to a particular Benefit Program in such State prior to
the execution of this Agreement, this Agreement shall be
deemed to be a binding letter of intent with respect to such
Benefit Program in that State. In such event, this Agreement
shall become effective with respect to any such Benefit
Program in that State on the date that the required licensure
and regulatory approvals are obtained. If Foundation does not
obtain such licensure or regulatory approvals after due
diligence, Foundation shall notify Provider and both parties
shall be released from any liability under this Agreement with
respect to the Benefit Program in question in the applicable
State; provided however, that if such licensure or regulatory
approval is conditioned upon amendment of this Agreement, then
this Agreement shall be amended automatically pursuant to
Section 6.1 hereof.
15
IN WITNESS WHEREOF, the parties have executed this Agreement to be effective on
the first day of the month after Foundation has executed this Agreement.
Option Care, Inc. Foundation Health
------------------------------------ -------------------------------------
Signature Signature
------------------------------------ -------------------------------------
Title Title
------------------------------------ -------------------------------------
Date Date
------------------------------------ -------------------------------------
------------------------------------
Federal Tax Identification Number
Provider's Facilities included in this Agreement:
====================================================================================================================================
JCAHO
Facility Name, State Federal Tax Medicare Medi-Cal or other
Address, Telephone and Type of License Identification Provider Provider Accrediting
Facsimile and Phone Facility Number Number Number Number Body
====================================================================================================================================
====================================================================================================================================
====================================================================================================================================
====================================================================================================================================
====================================================================================================================================
Provider's Facilities excluded from this Agreement:
====================================================================================================================================
JCAHO
Facility Name, State Federal Tax Medicare Medi-Cal or other
Address, Telephone and Type of License Identification Provider Provider Accrediting
Facsimile and Phone Facility Number Number Number Number Body
====================================================================================================================================
====================================================================================================================================
====================================================================================================================================
====================================================================================================================================
====================================================================================================================================
16
Addendum A
ADDENDUM A
AFFILIATES, BENEFIT PROGRAMS AND CREDENTIALS APPLICATION
I. AFFILIATES AND BENEFIT PROGRAMS
The Affiliates who are parties to this Agreement and whose Benefit Programs are
included within and covered by this Agreement, are indicated by the typewritten
xxxx "X" below. This Agreement applies only to Affiliates and Benefit Programs
where such check xxxx appears in either the "FEE-FOR-SERVICE" or "CAP" box, and
may be amended from time to time as specified in Section 2.16 of the Agreement.
------------------------------------------------------------------------------------------------------------------
FEE-FOR-
AFFILIATE and Benefit Programs ADDENDUM SERVICE CAP
------------------------------------------------------------------------------------------------------------------
Foundation Health, a California Health Plan
------------------------------------------------------------------------------------------------------------------
HMO (Standard) B X
------------------------------------------------------------------------------------------------------------------
Medi-Cal D X
------------------------------------------------------------------------------------------------------------------
Medicare Risk C X
------------------------------------------------------------------------------------------------------------------
Medicare Supplement and Medicare Select E X
------------------------------------------------------------------------------------------------------------------
Point of Service B X
------------------------------------------------------------------------------------------------------------------
Supplemental Medical E X
------------------------------------------------------------------------------------------------------------------
Occupationally Ill/Injured or Workers' H X
Compensation
------------------------------------------------------------------------------------------------------------------
Foundation Health National Life Insurance Company/
California Compensation Insurance Company
------------------------------------------------------------------------------------------------------------------
Medicare Supplement E X
------------------------------------------------------------------------------------------------------------------
Point of Service G X
------------------------------------------------------------------------------------------------------------------
Preferred Provider Organization G X
------------------------------------------------------------------------------------------------------------------
Supplemental Medical E
------------------------------------------------------------------------------------------------------------------
Occupationally Ill/Injured or Workers' H X
Compensation
------------------------------------------------------------------------------------------------------------------
Foundation Health Federal Services
------------------------------------------------------------------------------------------------------------------
CHAMPUS F X
------------------------------------------------------------------------------------------------------------------
Other Government F X
------------------------------------------------------------------------------------------------------------------
II. CREDENTIALS APPLICATION.
------------------------
The Foundation Provider Credentials Application is included herein as
Exhibit 1 to this Addendum A. Provider shall be responsible for completing the
Credentials Application in its entirety for itself and/or every Facility
rendering Contracted Services under this Agreement, unless Provider's
Credentials Application meets Foundation's requirements.
17
Addendum A, Exhibit 1
EXHIBIT 1 TO ADDENDUM A
CREDENTIALS APPLICATION
(SEE ATTACHMENT)
18
Addendum B
ADDENDUM B
TO FACILITY PROVIDER AGREEMENT
HMO AND POINT OF SERVICE BENEFIT PROGRAMS
Provider understands and agrees that the obligations of Foundation set forth in
this Addendum are the obligations Foundation Health, a California Health Plan,
an Affiliate of Foundation Health Corporation ("FHC"), and not the obligations
of FHC or any other Affiliate of FHC.
A. STANDARD HMO BENEFIT PROGRAMS
-----------------------------
1. Fee-For-Service Contracted Services. Provider shall render
------------------------------------
Contracted Services to Beneficiaries of Foundation's Benefit
Programs covered under this Addendum on a fee-for-service or
per diem basis. As compensation for providing such Contracted
Services, Provider shall be paid the rates set forth in
Exhibit 1 of this Addendum. Such compensation shall be paid
within 30 working days of Foundation's receipt of a complete
and accurate claim for Contracted Services rendered to a
Beneficiary.
[OPTIONAL]
2. Capitation; Provider Risk Services.
-----------------------------------
2.1 Compensation to Provider for Provider Risk Services.
----------------------------------------------------
Provider shall render Provider Risk Services for each
Beneficiary linked to such Capitated Medical
Group/IPA(s) as are delineated on Exhibit 2 of this
Addendum. Provider Risk Services and Foundation Risk
Services are set forth on Exhibit 4 of this Addendum.
As compensation for providing Provider Risk Services,
Foundation shall pay Provider the Capitation
Compensation as set forth in Exhibit 2 of this
Addendum for each Beneficiary eligible to receive
such services from Provider during a particular
month. Notwithstanding any provision in this
paragraph to the contrary, only one Capitation
Compensation shall be paid by Foundation for both a
mother and newborn child during the first 31 days
following the baby's birth. Such payment shall be
made by Foundation on or before the 15th day of such
month. Foundation's payment shall be subject to the
provisions of Sections 2.15 and 3.4 of the Agreement.
2.2 Compensation to Other Providers of Provider Risk
------------------------------------------------
Services. Provider shall compensate all other
---------
providers of Provider Risk Services rendered to
assigned Beneficiaries not available at Provider's
facilities. In the event that Provider does not
process and pay eligible claims submitted by other
providers for Provider Risk Services not rendered by
Provider within the applicable time limits as
specified above, Foundation may pay such claims at
billed charges or Foundation contract rate unless
Provider indicates subcontract terms and deduct the
amounts paid from Provider's monthly Capitation
Compensation.
2.3 Access to Financial Records. In that Provider will be
----------------------------
compensated on other than a fee-for-service or per
diem basis and is responsible for paying claims of
other providers as set forth in Section 2.2 above,
Foundation also shall have access to all financial
records relating to the financial condition of
Provider. Provider agrees to submit such reports and
financial information as is necessary for Foundation
to comply with regulatory requirements to monitor
capitated providers' financial and administrative
viability of capitated providers.
19
2.4 Provider Risk Services Threshold. Provider shall also
---------------------------------
render Contracted Services on a fee-for-service or
per diem basis to Beneficiaries whose utilization of
Provider Risk Services has exceeded $100,000 for the
calendar year. For purposes of calculating the
$100,000 threshold, the following shall apply when
Provider Risk Services are actually provided by:
(a) Provider, the compensation schedule set
forth on Exhibit 1 of this Addendum
shall be utilized to compute such
calculation;
(b) another provider who is subcontracted to
Provider, the subcontract rates shall
be utilized to compute such calculation;
(c) a Participating Provider who is not
subcontracted by Provider, Foundation shall
pay such Participating Provider based upon
Foundation's contract rate with such
Participating Provider, and deduct that
payment amount from Provider's subsequent
capitation payment; or
(d) the actual charges paid by Provider when
none of the above applies.
Provider shall be responsible for identifying such
cases to Foundation, and Foundation shall compensate
Provider for such services exceeding $100,000 in a
calendar year, utilizing the rates set forth on
Exhibit 1 of this Addendum.
2.5 Provider's Service Area. Provider's Service Area as
------------------------
described in Exhibit 2 to this Addendum denotes the
geographic area within which Provider is responsible
for providing and/or paying for all Provider Risk
Services which are rendered on an Emergency basis to
Provider's assigned Beneficiaries. In addition,
Provider is responsible for paying for all Provider
Risk Services rendered by any provider anywhere on a
non-Emergency basis to Provider's assigned
Beneficiaries, unless such services are Excluded
Services.
2.6 Encounter Data. Provider shall provide Foundation
----------------
with all encounter information as required under
Section 2.15 of this Agreement.
2.7 Qualification Process for Capitation Compensation.
--------------------------------------------------
Foundation shall have the right at its option to
review and assess Provider's financial ability and
administrative capacity to perform its obligations
hereunder, including the managed care and other
functions delegated to Provider by Foundation, prior
to implementing Capitation Compensation to Provider.
Such review and assessment may include, but is not
limited to, Provider's general operations and
administration, claims processing and adjudication,
information systems capability and capacity, and
financial viability and reporting, Utilization
Management Program and Quality Management Program. If
Foundation determines that Provider does not meet
Foundation's minimum requirements for Capitation
Compensation, then the implementation of such
prospective payment methodology shall be deferred
until Provider remedies the deficiency(ies). Provider
shall in the meantime be compensated for Contracte
Services on a fee-for-service or per diem basis in
accordance with the rates set forth on Exhibit 1 of
this Addendum. Foundation, at its sole discretion,
may implement Capitation Compensation on a
provisional basis subject to appropriate monitoring
and evaluation of Provider to assess ongoing
viability and capacity.
3. Contracted Services Reciprocity. When a Beneficiary
-----------------------------------
not assigned to Provider under a Capitation Compensation
arrangement receives Contracted Services from Provider, then
Provider shall accept compensation based upon the rates set
forth in Exhibit 1 of this Addendum.
20
4. Report of Reinsurance Claims. Provider shall report
------------------------------
potential reinsurance claims in accordance with Foundation's
reinsurance guidelines. Foundation shall provide Provider with
such guidelines, from time to time.
B. POINT OF SERVICE BENEFIT PROGRAMS
---------------------------------
1. Benefit Program Design. Under a Point of Service Benefit
-----------------------
Program, Beneficiaries may elect, at the time of obtaining
each Covered Medical Service, to utilize either: (1) HMO
coverage through their selected or assigned PCP; (2) other
indemnity coverage through either nonparticipating providers,
or Participating Providers where other Benefit Program
Requirements are not met; or (3) optional Preferred Provider
Organization ("PPO") coverage by self-referring to PPO
Participating Providers.
2. Compensation Method.
--------------------
2.1 Fee-for-Service. Provider shall render
----------------
Contracted Services to Beneficiary of Foundation's
Benefit Programs covered under this Addendum on a
fee-for-service or per diem basis. As compensation
for rendering such Contracted Services, Provider
shall be paid the rates set forth in Exhibit 1 to
this Addendum. Such compensation shall be paid within
30 working days of receipt by Foundation of a
complete and accurate claim for Contracted Services
rendered to a Beneficiary.
[OPTIONAL]
2.2 Capitation; Provider Risk Services. Provider
-----------------------------------
shall render the Provider Risk Services set forth on
Exhibit 4 to this Addendum to Beneficiaries of a
Point of Service Benefit Program and who are linked
to such Capitated Medical Group/IPA(s) as are
delineated on Exhibit 3 of this Addendum. As
compensation for providing such services, Provider
shall be paid the applicable Capitation Compensation
provided for on Exhibit 3 of this Addendum, less a
30% withhold. Notwithstanding any provision in this
paragraph to the contrary, only one Capitation
Compensation shall be paid by Foundation for both a
mother and newborn child during the first 31 days
following the baby's birth. The 30% withhold shall be
placed in an escrow account ("Point of Service
Reserve Fund"). Foundation or its indemnity
Affiliate, as required by law, shall reimburse all
non-network hospitals and optional PPO Participating
Provider hospitals for inpatient care received by
linked Beneficiaries who have selected the indemnity
or PPO options of the Point of Service Benefit
Program for the provision of Covered Medical Services
at the time of service ("Indemnity Loss"). If such
total reimbursement for non-network hospitals and
optional PPO Participating Provider hospitals is less
than the amount withheld in Provider's Point of
Service Reserve Fund after an annual (contract year)
reconciliation, then Provider shall be paid the
difference between the total amount withheld in the
Point of Service Reserve Fund and the amount paid by
Foundation for the Indemnity Loss. To allow adequate
time for claims runout, Foundation shall make such
payments required in this Section within 220 days
after the end of each contract year. Foundation shall
pay Provider the Capitation Compensation for each
Beneficiary entitled to receive such services from
Provider during a particular month on or before the
15th day of such month. Foundation's payment shall be
subject to the provisions of Sections 2.15 and 3.4 of
the Agreement.
3. Other Performance Obligations of Provider. Provider shall
------------------------------------------
comply with Sections A(2.2), A(2.3), A(2.4), A(2.5), A(2.6),
A(2.7), A(3) and A(4) contained above in this Addendum B, with
respect to the Point of Service Benefit Programs.
21
Addendum B, Exhibit 1
EXHIBIT 1 TO ADDENDUM B
FEE-FOR-SERVICE COMPENSATION SCHEDULE
HMO/POS BENEFIT PROGRAMS
ASSIGNED AND UNASSIGNED BENEFICIARIES SERVICES
Compensation to Provider for the delivery of Medically Necessary Covered
Contracted Services will be the lesser of 60% of billed charges or the rate
schedule in Attachment A.
22
Addendum C
ADDENDUM C
TO FACILITY PROVIDER AGREEMENT
MEDICARE RISK PROGRAMS
Provider understands and agrees that the obligations of Foundation set forth in
this Addendum shall be the obligations of Foundation Health, a California Health
Plan, an Affiliate of Foundation Health Corporation, ("FHC"), and not the
obligations of FHC or any other Affiliate of FHC. All references to
"Beneficiaries" in this Addendum are deemed to refer to "Medicare
Beneficiaries".
A. DEFINITIONS
-----------
For purposes of this Addendum, the definitions included herein shall have the
meaning required by law to applicable Medicare Risk Programs.
1. Emergency Services. Covered Medical Services which are
--------------------
needed immediately because of injury or sudden illness such
that not receiving immediate care would risk permanent damage
to the health of the Beneficiary.
2. Senior Value Member. A Medicare beneficiary entitled to
--------------------
receive coverage for certain health care services under the
terms of the Foundation Health Senior Value Combined Evidence
of Coverage, Member Contract and Disclosure Form who has
elected to enroll and whose enrollment in Foundation Health
Senior Value has been confirmed by the Health Care Financing
Administration ("HCFA").
3. In-Area-Out-of-Plan Emergency Care. Emergency services
-----------------------------------
provided for Medicare Risk Beneficiaries which are performed
by an entity other than Provider within 30 miles of Provider's
Facility(ies).
4. Medicare Risk Capitated Medical Group/IPA. A Capitated
------------------------------------------
Medical Group/IPA associated with Provider with whom
Foundation contracts on a capitated compensation basis under
the Medicare Risk Program to provide Capitated Group Risk
Services to the Senior Value Members assigned to both Provider
and Medicare Risk Capitated Medical Group/IPA.
5. Medicare Risk Program. A program to provide services to
----------------------
Medicare Beneficiaries under a contract with HCFA,
authorized by Section 114 of the U.S. Tax Equity and Fiscal
Responsibility Act of 1982.
6. Medicare Risk Service Area. The area approved by HCFA and the
---------------------------
State regulatory agency as being the area in which Foundation
may market and enroll Beneficiaries. At any given time during
the term of this Agreement, the Medicare Risk Service Area
consists of the list of zip codes currently approved by HCFA
and/or the State regulatory agency as the Medicare Risk
service area. This is not necessarily the area for which
Provider shall be responsible for "in-area" care.
7. Out-of-Area Emergency Care. Emergency services performed more
---------------------------
than 30 miles from Provider's Facility(ies).
8. Primary Care Physician (PCP). The physician selected by or
-----------------------------
assigned to a Medicare Risk Beneficiary to provide primary
care services and to serve as a coordinator to manage
utilization and quality of other medical services. Only
physicians who practice as general practitioners or
23
who practice in and are Board eligible or certified in the
specialties of family practice, geriatrics, pediatrics (for
Medicare eligible infants and children only) or internal
medicine, and who are able to directly provide a comprehensive
range of primary care services, shall be eligible for listing
as a Medicare Risk PCP.
9. Provider Service Area. The geographic area within the zip
----------------------
codes as defined by Exhibit 2 this Addendum.
10. Senior Value Combined Evidence of Coverage, Member Contract
-----------------------------------------------------------
and Disclosure Form. A contract, revised annually, between a
--------------------
Senior Value Member and Foundation under which a Senior Value
Member is entitled to receive coverage for certain hospital,
medical and other health services. Foundation shall notify
Provider immediately of any material modifications or
amendments to the contract which would reasonably require
renegotiation of the financial provisions of this Agreement.
11. Urgently Needed Care.
---------------------
(a) In-Area Urgently Needed Care. Non-Emergency, in-area
-----------------------------
Covered Medical Services obtained to treat a
condition where the condition or other circumstances
are such that obtaining a future appointment through
standard procedures would result in severe pain or
might reasonably be judged by the Beneficiary to risk
a serious deterioration of the Beneficiary's health.
(b) Out-of-Area Urgently Needed Care. Non-Emergency
---------------------------------
Covered Medical Services obtained to treat an
unforeseen condition while a Beneficiary is
temporarily outside of the Medicare Risk Service Area
where the condition is such that waiting to return to
the service area would risk a serious deterioration
of the Beneficiary's health.
B. MEDICARE RISK BENEFIT PROGRAMS
------------------------------
1. Provider Obligations. Provider agrees to render Contracted
---------------------
Services or Provider Risk Services to Beneficiaries eligible
for coverage under Title XVIII of the Social Security Act, as
amended, (otherwise known as Medicare), in accordance with the
terms and conditions of Foundation's Medicare Risk Programs.
Foundation shall provide Provider with the Benefit Program
Requirements of such Benefit Programs not set forth in this
Addendum. Such Benefit Program Requirements include the
provisions of the applicable Senior Value Combined Evidence of
Coverage, Member Contract and Disclosure Form, operational
policies and procedures, Utilization Management Program and
Quality Management Program requirements with which Provider
shall comply in rendering Contracted Services or Provider Risk
Services, as applicable, under this Addendum. Provider
acknowledges that the determination of Provider Risk Services
and all other services shall be governed by coverage
guidelines established by Medicare, and the Medicare Risk
Benefit Program and Benefit Program Requirements, with
Foundation being solely responsible for final coverage
determinations, subject to the applicable appeal procedures.
2. Continuation of Services After Termination. After
---------------------------------------------
termination of this Agreement, Foundation shall be liable for
payment of Covered Medical Services rendered by Provider
(other than for Copayments) to a Senior Value Member who
retains eligibility or is under the care of Provider at the
time of termination, until the services being rendered to the
Senior Value Member by Provider are completed, unless
Foundation makes reasonable and medically appropriate
provision for the assumption of such services by another
Participating Provider. Foundation shall reimburse Provider
for all services rendered pursuant to this Section at Medicare
allowable assignment rates and Provider shall accept such
payment, together with any authorized
24
Copayment, as payment in full. Notwithstanding the above or
any other provisions to the contrary, Provider agrees that, in
the event Foundation ceases operations for any reason,
including insolvency, Provider shall provide Contracted
Services and shall not xxxx, charge, collect or receive any
form of payment other than an authorized Copayment, nor shall
Provider collect a deposit from any Senior Value Member or
persons acting on their behalf, nor have any recourse against
a Senior Value Member or persons acting on their behalf, for
Contracted Services provided after Foundation ceases
operations. This continuation of Contracted Services
obligation shall be for the period for which member premium
has been paid, not to exceed a period of 30 days, except for
those Senior Value Members who are hospitalized on an
inpatient basis. Provider shall continue to arrange for
Contracted Services to those Senior Value Members who are
hospitalized on an inpatient basis at the time this Agreement
is no longer in effect until the Senior Value Member is
discharged from the hospital. No amendment or modification of
the provisions of this Section B.(2) shall be allowed without
the prior written approval of the Secretary of the U.S.
Department of Health & Human Services, or the Secretary's
designee.
3. Reconciliation of Eligibility. Notwithstanding the
-------------------------------
provisions contained in Section 3.4 of the Agreement,
Foundation shall assume financial responsibility for care
provided to an ineligible person due to retroactivity or
otherwise erroneous, incomplete or late Eligibility List data
Such care shall be provided at the lesser of the amount which
the Medicare program would have paid plus any applicable
deductible or copayment, or the compensation contained in
Exhibit 1 to Addendum B. However, Foundation shall only be
responsible for such payment in the event that no other payor,
including Medicare, Medi-Cal, or other HMO or insurance plan,
or other individual is responsible for such care, and when
Provider has used Provider's best efforts to verify and
confirm eligibility from Foundation for any patient whose
eligibility is or should have been in question, or who
required institutional or other high cost care.
4. Prohibition on Removal of Plan Assigned Members. Neither
--------------------------------------------------
Provider, Provider's employees nor Provider's subcontractors
under the Agreement shall request, demand, require or
otherwise seek, directly or indirectly, the termination from
the Medicare Risk Benefit Plan of any Beneficiary based upon
the Beneficiary's need for or utilization of medically
required services, or in order to gain financially or
otherwise from such termination. Provider may request that
Foundation terminate coverage of a Beneficiary for reasons of
fraud, disruption of medical services, or failure to follow a
physician's orders, or for any of the reasons for mandator
disenrollment specified by HCFA. However, Provider agrees that
Foundation shall have sole and ultimate authority to terminate
a Medicare Risk Beneficiary's coverage, and Provider
understands that any requested termination is subject to prior
approval by HCFA.
5. Operations Policies and Procedures. Provider shall have or
------------------------------------
develop written administrative and operational policies and
procedures to administer the Medicare Risk Program.
6. Member Services. Provider shall cooperate fully with
----------------
Foundation in the investigation and resolution of complaints
by Senior Value Members regarding Provider, the services
Provider renders or that are provided by subcontractors, in
compliance with HCFA, California Department of Corporations
and California Department of Health Services requirements.
7. Reports and Administration. Foundation shall have sole
responsibility for filing reports, obtaining approval
from, and complying with the applicable laws and
regulations of federal, State and local governmental
agencies having jurisdiction over Foundation. Provider
shall cooperate in providing Foundation with such information
and assistance regarding Senior Value Members and Provider's
performance under this Agreement and Addendum C as
Foundation may reasonably require in filing such reports.
Foundation shall perform all the necessary administrative,
accounting, enrollment and other functions appropriate for
the marketing and administration of its Senior Value Benefit
Programs and this Agreement. Any material change
25
in Foundation's marketing and administrative policies and
procedures affecting Provider shall be promptly communicated
by Foundation.
C. COMPENSATION
------------
1. Fee-For-Service Contracted Services. Provider shall render
------------------------------------
Contracted Services which are not Provider Risk Services to
Beneficiaries of Foundation's Benefit Programs covered under
this Addendum on a fee-for-service, per diem or DRG basis. As
compensation for providing such Contracted Services, Provider
shall be paid the rates set forth on Exhibit 1 of this
Addendum. Such compensation shall be paid within 27 working
days of receipt by Foundation of a complete and accurate claim
for Covered Services rendered to a Beneficiary.
2. Capitation; Provider Risk Services. Provider shall render
-------------------------------------
Provider Risk Services for each Beneficiary linked to such
Capitated Medicare Risk Medical Group/IPA(s) as are delineated
on Exhibit 2 of this Addendum. Provider/Facility Risk
Services, Capitated Group Risk Services and Foundation Risk
Services are set forth on Exhibit 3 of this Addendum. As
compensation for rendering Provider Risk Services, Foundation
shall pay Provider the Capitation Compensation as set forth in
Exhibit 2 of this Addendum for each Beneficiary eligible to
receive such services from Provider during a particular month.
Notwithstanding any provision in this paragraph to the
contrary, only one Capitation Compensation shall be paid by
Foundation for both a mother and newborn child during the
first 30 days following the baby's birth. Such Capitation
Compensation shall be paid by Foundation on or before the 15th
day of such month. Foundation's payment shall be subject to
the provisions of Sections 2.15 and 3.4 of the Agreement.
3. Compensation to Other Providers of Provider Risk Services.
Provider shall compensate all other providers of Provider
Risk Services for services provided to assigned
Beneficiaries. Provider shall process and pay or deny all
"clean" claims submitted by other providers related to
Foundation Medicare Risk Beneficiaries, for Provider Risk
Services not rendered by Provider, within the time limits
specified by HCFA, the State regulatory agency, and State
Department of Health Services. Current HCFA guidelines
specify that "clean" claims be paid or denied within 27 days
of receipt by the plan or its contracted responsible payo
(Provider in this case), and within 60 days for claims
requiring significant medical review. Claims that are denied,
either fully or partially, are subject to appeal to HCFA by
members and/or the provider whose claim is denied. Provider
shall either follow and use the HCFA guidelines and model
denial letters when denying claims or it shall submit
[no later than 20 days of receipt for clean claims and 55 days
for other claims] recommendations to deny a claim to
Foundation for review, determination of coverage and, if
appropriate, preparation of HCFA approved formal denial letter
to the provider or member. If the latter choice is made by
Provider, Foundation shall consult with Provider prior to
overruling a recommendation to deny a claim made by Provider.
Clean claims must be paid by Provider at reasonable rates for
the service in question, or, if negotiations fail within a
reasonable period of time, at least at the rate that the
Medicare program would have paid on a fee-for-service, per
diem or DRG basis, plus Medicare deductible and copayment,
where applicable. Provider shall maintain adequate records and
procedures to record dates of receipt, processing, and payment
of claims from non-contracted providers. Foundation shall
assist Provider in obtaining agreement from such
non-contracted providers to accept payment rates which do not
exceed the Medicare allowable rate. In the event that Provider
does not process and pay eligible claims submitted by other
providers for Provider Risk Services not rendered by Provider
within the applicable time limits as specified above,
Foundation reserves the right to pay such claims and deduct
the amount paid from Provider's monthly Capitation
Compensation.
4. Access to Financial Records. In that Provider will be
----------------------------
compensated on other than a fee-for-service basis and is
responsible for paying claims of other providers as set forth
in Section 3 above, Foundation also shall have access to all
financial records relating to the financial
26
condition of Provider. Provider agrees to submit reports and
financial information as is necessary for Foundation to comply
with regulatory requirements to monitor the financial and
administrative viability of capitated providers.
5. Provider's Service Area. Provider's Service Area as described
------------------------
in Section A above denotes the geographic area within which
Provider is responsible for providing and/or paying for all
Provider Risk Services rendered on an Emergency basis to
Beneficiaries assigned to Provider. In addition, Provider is
responsible for paying for all Provider Risk Services rendered
by any provider anywhere on a non-Emergency basis to
Provider's assigned Beneficiaries, unless such services are
Excluded Services.
6. Encounter Data. Provider shall provide Foundation with all
----------------
encounter information as required under Section 2.15 of this
Agreement.
7. Shared Risk Pool. Foundation shall withhold 15% of Provider's
-----------------
capitation compensation each month and deposit the entire
amount into a Shared Risk Pool. As an incentive to maintain
inpatient utilization within reasonable limits, Provider,
Medicare Risk Capitated Medical Group/IPA and Foundation shall
participate in the Shared Risk Pool Program as set
forth in Section 7.1 below.
7.1 Shared Risk Pool Program. Distribution of the Shared
-------------------------
Risk Pool shall be made to Provider and the Medicare
Risk Capitated Medical Group/IPA(s) based upon the
measurement of actual hospital utilization as
measured each contract year, and in accordance with
the Shared Risk Pool Matrix contained in Exhibit 4 to
this Addendum. For purposes of this measurement,
"hospital days" shall include the following: all
acute inpatient (in and out-of-area) days, all
out-patient surgery days, all skilled nursing
facility (SNF) days and any other subacute days. Each
outpatient surgical episode shall count as one
"hospital day", each SNF day as 0.25 day and other
subacute days as 0.50 day. All days shall be counted
in the month of a Beneficiary's discharge.
Distribution of the Shared Risk Pool for each
contract year shall occur within 120 days following
the end of such contract year. Claims/utilization
applicable to the year in question that are not
received by Foundation within 90 days of the end of
such year shall be carried forward into the
utilization results for the subsequent year. The
amount of the incentive to be paid is determined on
the basis of experience for the entire contract year,
including claims for out-of-plan services received
within 90 days of the end of the contract year.
8. Foundation Medical Risk Fund. Foundation shall establish a
-----------------------------
Medical Risk Fund into which it shall deposit the entire
Medical Risk Fund allocation each month. Foundation shall pay
all Covered Medicare Risk Benefit Program services as
Foundation's responsibility in Exhibit 3 to this Addendum,
"Division of Financial Responsibility" and related
administrative fees and costs from the Foundation Medical Risk
Fund. Any surplus or deficit in this Foundation Medical Risk
Fund shall remain with and be the responsibility of
Foundation.
9. Contracted Services Reciprocity. When a Beneficiary not
----------------------------------
assigned to Provider under a Capitated Compensation method
receives services from Provider, then Provider shall accept
compensation based upon the rates set forth in Exhibit 1 of
this Addendum.
27
Addendum C, Exhibit 1
EXHIBIT 1 TO ADDENDUM C
FEE-FOR-SERVICE COMPENSATION SCHEDULE
MEDICARE RISK BENEFIT PROGRAMS
Compensation to Provider for the delivery of Medically Necessary Covered
Contracted Services will be the lesser of 85% of the Medicare allowable fee
schedule, 60% of billed charges, or the rate schedule in Attachment A.
28
Addendum D
ADDENDUM D
TO FACILITY PROVIDER AGREEMENT
MEDI-CAL PROGRAM
Provider understands and agrees that the obligations of Foundation set forth in
this Addendum shall be the obligations of Foundation Health, a California Health
Plan, an Affiliate of Foundation Health Corporation ("FHC"), and not the
obligations of FHC or any other Affiliate of FHC. Foundation has entered into a
prepaid health plan agreement ("PHP Agreement"), with the State Department of
Health Services ("DHS") under which Foundation has agreed to provide medical
services covered under California's Medi-Cal program, including Provider Risk
Services, to Medi-Cal Beneficiaries enrolled in or otherwise assigned to
Foundation, on a prepaid basis. Pursuant to the requirements of the Medi-Cal
Program, this Agreement and any subcontracts as requested, must be filed with
DHS. All references to "Beneficiaries" in this Addendum are deemed to refer to
"Medi-Cal Beneficiaries".
A. PROVIDER RISK SERVICES
----------------------
1. Provider Risk Services. Provider shall render the Provider
-----------------------
Risk Services set forth in Exhibit 3 to this Addendum to
Beneficiaries eligible for coverage and enrolled in Foundation
under the PHP Agreement, who select or are assigned to
Provider, or who select or are assigned to a Capitated Medical
Group/IPA listed on Exhibit 2 of this Addendum, as of the end
of a particular month. Provider shall provide such services in
accordance with this Agreement, this Addendum and the
applicable Benefit Program Requirements. Foundation shall
provide Provider with Benefit Program Requirements not set
forth in this Addendum. Such Benefit Program Requirements may
include Utilization Management Program and Quality Management
Program requirements.
B. COMPENSATION PROVISIONS
-----------------------
1. Fee-For-Service Contracted Services. Provider shall render
------------------------------------
Contracted Services which are not Provider Risk Services to
Beneficiaries of Foundation's Benefit Programs covered under
this Addendum on a fee-for-service or per diem basis except
for Provider Risk Services rendered to Beneficiaries assigned
to Provider under a Capitation Compensation method. As
compensation for providing such Contracted Services, Provider
shall be paid in accordance with the rates set forth on
Exhibit 1 of this Addendum. Such compensation shall be paid
within 45 working days of receipt of a complete and accurate
claim for Covered Services rendered to a Beneficiary.
2. Provider Risk Services. Foundation shall pay Provider the
------------------------
applicable Capitation Compensation described in Exhibit 2 to
this Addendum for each Beneficiary entitled to receive
Provider Risk Services from Provider during the month to which
the Capitation Compensation applies, on or before the
_______________ (_____) day following Foundation's receipt of
payment for that month from the California Department of
Health Services. Notwithstanding any provision in this
paragraph to the contrary, only one Capitation Compensation
shall be paid by Foundation for both a mother and newborn
child during the child's month of birth and the immediately
following month. Provider shall hold harmless and not seek to
recover against the State of California or any Beneficiary in
the event Foundation fails to make any payment required
hereunder.
3. Contracted Services Reciprocity. When a Beneficiary not
assigned to Provider under a Capitated Compensation method
receives services from Provider, then Provider shall accept
compensation based upon the rates set forth in Exhibit 1
of this Addendum.
29
Addendum D
C. GENERAL PROVISIONS
------------------
1. Subcontracts and Assignment. Any subcontract for the
----------------------------
provision of Contracted Services shall require that the
subcontractor make all applicable books and records available
at all reasonable times for inspection, examination or copying
by Foundation and the California Department of Health
Services, retain such books and records for a term of at least
five years from the close of the California fiscal year in
which the subcontract is in effect, and comply with the
nondiscrimination and compliance provisions set forth in
Section 6, below.
2. Disclosure of Interest. Provider shall submit to Foundation a
-----------------------
Disclosure of Interest form, attached as Exhibit 4 to this
Addendum for officers and other persons associated with
Provider as required by Welfare and Institutions Code, Section
14452 and described in Exhibit 4.
3. Beneficiary Education. Provider shall make health education
----------------------
materials and programs available to Beneficiaries on the same
basis that it makes such materials and programs available to
the general public, and shall use its best efforts to
encourage Beneficiaries to participate in such health
education programs.
4. Grievances. Provider and Foundation agree to cooperate i
-----------
resolving all grievances relating to the provision of services
to Beneficiaries. Copies of complaint forms and Foundation's
grievance procedure will be made available to Provider and all
Beneficiaries. Provider agrees to report any complaint
directly to Foundation within one business day of receipt,
whether resolved directly or not. All complaints will be
logged by Foundation, a form letter acknowledging the
complaint will be sent to the Beneficiary within 20 days of
its receipt, and a brief summary of the resolution of the
complaint will be sent to the Beneficiary within 30 days
thereafter. Provider agrees to comply with Foundation's
grievance procedure and to abide by Foundation's adjudication
process for grievances concerning Provider and Beneficiaries,
including any fair hearing procedure involving the State of
California or Foundation. Beneficiaries may request
disenrollment from the Benefit Plan or a fair hearing from the
State or Foundation.
In the event that complaints from Beneficiaries
regarding Provider Risk Services are received by Foundation,
Foundation shall forward the complaint to Provider, who shall
attempt to resolve the complaint informally. If the complaint
cannot be resolved satisfactorily within a reasonable period
of time by direct communication between Provider and the
Beneficiary, the matter will be submitted for resolution in
accordance with Foundation's grievance procedures.
5. Relationship of the Parties. Provider shall be solely
----------------------------
responsible, without interference from Foundation or its
agent, for providing Provider Risk Services to Beneficiaries,
and shall have the right to object to treating any individual
who makes onerous the relationship between Provider and
Beneficiary. In the event of a breakdown in such relationship,
Foundation shall make reasonable efforts to assign the
Beneficiary to another Participating Provider. If reassignment
is unsuccessful, a request may be filed with the State of
California to permit termination of services to such
Beneficiary. Approval from the State must be obtained before
Provider terminates services to such Beneficiary.
6. Fair Employment Requirements. During the term of
---------------------------------
this Agreement, Provider and its subcontractors shall not
unlawfully discriminate against any employee or applicant for
employment becaus of race, religious creed, color, national
origin, ancestry, physical disability, mental disability,
medical condition, marital status, age (over 40) or sex.
Provider and its subcontractors also shall ensure that the
evaluation and treatment of their employees and applicants for
employment are free of such discrimination. Provider and its
subcontractors shall comply with the provisions of the Fair
Employment & Housing Act (California Government Code, Section
12990 et seq.) and the applicable regulations promulgated
-------
thereunder (California Code of Regulations, Title 2,
Section 7285.0 et seq.). The applicable regulations of the
-------
Fair
30
Employment & Housing Commission implementing Government Code,
Section 12990, set forth in Chapter 5 of Division 4 of Title 2
of the California Code of Regulations are incorporated into
this Agreement by reference and made a part hereof as if set
forth in full. Provider and its subcontractors shall give
written notice of their obligations under this clause to labor
organizations with which they have a collective bargaining or
other agreements.
7. Regulation. Foundation is subject to the requirements of
-----------
Chapter 2.2 of Division 2 of the California Health and Safety
Code, the California Welfare and Institutions Code, and
Subchapter 5.5 of Chapter 3 of Title 10 and other portions of
Title 22 of the California Code of Regulations. Provider and
Foundation agree to be bound by any provision required by any
of such laws or regulations to be in this Agreement or
Addendum, and with all other laws, regulations and contractual
obligations incumbent upon Foundation. Additionally, Provider
shall comply with all standards expressed in the PHP
Agreement, and Chapters 3 and 4 of Subdivision 1 of Division 3
of Title 22 of the California Code of Regulations. Further,
Provider agrees that this Agreement, as it applies to
Beneficiaries covered under this Addendum shall be governed by
and construed in accordance with the contractual obligations
of Foundation under the PHP Agreement, as well as with all
applicable State, federal and local laws, rules and
regulations.
8. Notice. Provider agrees, as long as it provides Contracted
-------
Services to Beneficiaries, to notify the California Department
of Health Services in the event this Agreement is amended or
terminated. Notice to the California Department of Health
Services is considered given when properly addressed and
deposited with the United States Postal Service as first class
certified mail, postage attached.
9. Reports and Information. Provider shall provide Foundation,
------------------------
within the time requested by Foundation, with all such reports
and information as Foundation may require to allow it to meet
the reporting requirements under the PHP Agreement or any
applicable law, rule or regulation.
10. Confidentiality of Information. Notwithstanding any other
---------------------------------
provision of this Agreement or Addendum to the contrary, names
of persons receiving public social services are confidential
and are to be protected from unauthorized disclosure in
accordance with Title 45, Code of Federal Regulations, Section
205.50 and Section 14100.2 of the California Welfare and
Institutions Code and the regulations adopted thereunder. For
the purposes of this Agreement, all information, records,
data, and data elements collected and maintained for or in
connection with performance under this Agreement and
pertaining to Beneficiaries shall be protected by Provider
from unauthorized disclosure. With respect to any identifiable
information concerning a Beneficiary under this Agreement that
is obtained by Provider or its subcontractors, Provider: (i)
will not use any such information for any purpose other than
carrying out the express terms of this Agreement; (ii) will
promptly transmit to Foundation all requests for disclosure of
such information, (iii) will not disclose, except as otherwise
specifically permitted by this Agreement, any such information
to any party other than Foundation without Foundation's prior
written authorization specifying that the information is
releasable under applicable law, and will, at the expiration
or termination of this Agreement, return all such information
to Foundation or maintain such information according to
written procedures provided Provider by Foundation for this
purpose. Provider shall ensure that its subcontractors comply
with the provisions of this paragraph.
11. Coordination of Benefits. Provider shall abide by and
---------------------------
comply with the requirements of Foundation's Coordination
of Benefits policy. The above notwithstanding, Provider
shall make no claim for recovery for Contracted Services
rendered to a Beneficiary when such recovery would result from
recovery from an action involving the tort liability of a
third party or casualty liability insurance, including
workers' compensation awards and uninsured motorist coverage.
Provider shall notify Foundation of cases in which an action
by the Beneficiary involving the tort
31
or workers' compensation liability of a third party could
result in a recovery by the Beneficiary. Additionally,
Provider shall promptly provide: (a) all information requested
by Foundation in connection with the provision of Provider
Risk Services to a Beneficiary who may have an action for
recovery from any such third party; (b) copies of all requests
by subpoena from attorneys, insurers or Beneficiaries for
copies of bills invoices or claims for Provider Risk Services;
and (c) copies of all documents released as result of such
requests. Provider shall ensure that its subcontractors comply
with the provisions of this paragraph.
32
Addendum D, Exhibit 1
EXHIBIT 1 TO ADDENDUM D
MEDI-CAL PROGRAM FEE-FOR-SERVICE COMPENSATION SCHEDULE
Compensation to Provider for the delivery of Medically Necessary Covered
Contracted Services will be the lesser of 100% of the Medi-Cal allowable fee
schedule, 60% of billed charges, or the rate schedule in Attachment A.
33
Addendum D, Exhibit 4
EXHIBIT 4 TO ADDENDUM D
DISCLOSURE FORM
(Required by California Welfare and Institutions Code Section 14452)
(Name of Provider)
The undersigned hereby certifies that the following information regarding:
-------------------------------------------------------------------------------
(the "Organization") is true and correct as of the date set forth below:
Officers/Directors/General Partners:
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
Co-Owner(s):
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
Stockholders owning more than ten percent of the stock of the Organization:
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
Major creditors holding more than five percent of Organization's debt:
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
Form of Organization (Corporation, Partnership, Sole Proprietorship, Individual,
etc.):
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
If not already disclosed above, is Organization, either directly or indirectly
related to or affiliated with the Contracting Health Plan? Please explain:
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
Dated: Signature: _____________________________
--------------------------
Name: ________________________________
(Please type or print)
Title: _________________________________
(Please type or print)
00
Xxxxxxxx X
XXXXXXXX X
TO FACILITY PROVIDER AGREEMENT
MEDICARE SUPPLEMENT, MEDICARE SELECT AND SUPPLEMENTAL MEDICAL BENEFIT
PROGRAMS
Provider understands and agrees that the obligations of Foundation hereunder are
the obligations of:
[X] Foundation Health, a California Health Plan
[X] Foundation Health National Life Insurance Company
[_] Other: __________________________________
as applicable, all of which are Affiliates of Foundation Health Corporation
("FHC"), and not the obligations of FHC or any other Affiliate of FHC.
Provider agrees to provide Contracted Services to Beneficiaries eligible for
coverage under Title XVIII of the Social Security Act, as amended, (otherwise
known as Medicare), or other Beneficiaries in accordance with the terms and
conditions of Foundation's Medicare Supplement, Medicare Select or other
Supplemental Medical Programs.
A. MEDICARE SUPPLEMENT AND MEDICARE SELECT BENEFIT PROGRAMS
1. Fee-for-Service Compensation. Under the Medicare Supplement and
-----------------------------
Medicare Select Programs, Provider shall accept Medicare assignment
from Beneficiaries for Contracted Services covered under Medicare,
and shall xxxx and accept payment from Medicare as payment in full
for such services, except for applicable Copayments and deductibles.
Provider shall xxxx Foundation, and not Beneficiaries, for such
Copayments and deductibles. For Contracted Services rendered that
are not covered under Medicare, but which are covered under the
applicable Medicare Supplement or Medicare Select Program, Provider
shall be paid the lessor of Provider's billed charges or the HMO
fee-for-service or per diem compensation rates set forth on Exhibit
1 to Addendum B, if Provider is not participating in the HMO Benefit
Program Provider shall be reimbursed 80% of Provider's billed
charges. Such compensation shall be paid subject to the billing
requirements set forth in Section 3.2 of the Agreement.
B. SUPPLEMENTAL MEDICAL BENEFIT PROGRAMS
1. Fee-for-Service Compensation. Under a Supplemental Medical
-----------------------------
Benefit Program, Provider shall render Contracted Services
covered under a Beneficiary's primary health care program, and
shall xxxx and accept payment from that primary health care
program as payment in full for such services, except for
applicable Copayments. Provider shall xxxx Foundation, and not
Beneficiaries, for such Copayments. For Contracted Services
rendered that are not covered under the Beneficiary's primary
health care program, but which are covered under the
applicable Foundation Supplemental Medical Program, Provider
shall be paid the lessor of Provider's billed charges or the
HMO fee-for-service or per diem rates set forth on Exhibit 1
to Addendum B, if Provider is not participating in the HMO
Benefit Program Provider shall be reimbursed 80% of Provider's
billed charges. Such copayments and compensation shall be paid
subject to the billing requirements set forth in Section 3.2
of the Agreement.
35
Addendum E, Exhibit 1
EXHIBIT 1 TO ADDENDUM E
MEDICARE SUPPLEMENT, MEDICARE SELECT AND SUPPLEMENTAL MEDICAL BENEFIT
PROGRAMS
FEE-FOR-SERVICE COMPENSATION SCHEDULE
Compensation to Provider for the delivery of Medically Necessary Covered
Contracted Services will be the lesser of 85% of the Medicare allowable fee
schedule, 60% of billed charges, or the rate schedule in Attachment A.
36
Addendum F
ADDENDUM F
TO FACILITY PROVIDER AGREEMENT
CHAMPUS, CHAMPUS SUPPLEMENT AND OTHER GOVERNMENT BENEFIT
PROGRAMS
Provider understands and agrees that the obligations of Foundation hereunder are
obligations of:
[X] Foundation Health Federal Services, Inc.
[X] Foundation Health, a California Health Plan
[X] Foundation Health National Life Insurance Company
[_] Other: __________________________________
as applicable, an Affiliate of Foundation Health Corporation ("FHC"), and not
obligations of FHC or any other Affiliate of FHC. Foundation may contract with
the United States Department of Defense ("DoD"), or with other entities which
contract with DOD, to arrange for the provision of health and administrative
services to certain Beneficiaries of the Civilian Health and Medical Program of
the Uniformed Services ("CHAMPUS"), and may contract with other local, state or
federal agencies to arrange for the provision of health, administrative and
certain other services to the Beneficiaries of other local, state and/or federal
programs.
A. CHAMPUS PROGRAMS AND REGULATIONS
--------------------------------
1. CHAMPUS Programs. CHAMPUS Programs are those services and
-----------------
benefits which require the use of the services of a contracted
medical provider network and are purchased by the United
States Government through the authorized agency pursuant to
Chapter 55 of Title 10 of the United States Code and the
regulations promulgated thereunder.
2. CHAMPUS Regulations. Foundation is obligated to comply with
-------------------
all applicable CHAMPUS regulations, operations manuals,
Automated Data Processing manuals, policy manuals and the
prime contract technical proposals, and with the American
Disabilities Act. These documents provide a comprehensive
description of the applicable CHAMPUS program benefits and
operational requirements. The parties to this Agreement
acknowledge that all services rendered by Provider hereunder
are governed by such requirements. Foundation shall provide
Provider with all information regarding such requirements as
necessary for proper compliance.
3. Fee-for-Service Contracted Services. Provider shall render
------------------------------------
Contracted Services to Beneficiaries of CHAMPUS Programs,
including the TRICARE Prime and TRICARE Extra Programs,
covered under this Addendum on a fee-for-service, per diem or
DRG basis. As compensation for providing such Contracted
Services, Provider shall be paid the rates set forth in
Exhibit 1 of this Addendum. Such compensation shall be paid
within 30 working days of receipt by Foundation of a complete
and accurate claim for Contracted Services rendered to a
Beneficiary in accordance with the provisions of Section
3.2(a) and 3.2(b) of the Agreement.
4. Primary Care Manager (PCM). or Primary Care Physician is a
--------------------------
physician who is a Participating Provider and who is
responsible pursuant to the applicable CHAMPUS Benefit Program
for coordinating and managing the delivery of Covered Medical
Services to Beneficiaries selected or assigned to such
physician.
37
Addendum F
5. Supplemental Care. Foundation will work with MTF Commanders
-----------------
to define Supplemental Care needs and to extend TRICARE
contract rates to the MTF's for those services.
B. CHAMPUS SUPPLEMENT PROGRAMS
---------------------------
1. Fee-for-Service Compensation. Under a CHAMPUS Supplement
----------------------------
Medical Coverage Program, Provider shall render Contracted
Services covered under the Standard CHAMPUS Benefit Program,
and shall xxxx and accept payment from CHAMPUS or its agent as
payment in full for such services, except for applicable
Copayments. Provider shall xxxx Foundation, and not
Beneficiaries, for such Copayments. For Contracted Services
rendered that are not covered under the Standard CHAMPUS
program, but which are covered under the applicable Foundation
CHAMPUS Supplement Medical Program, Provider shall be paid the
compensation rates set forth on Exhibit 1 to Addendum E. Such
Copayments and compensation shall be paid within the time and
subject to the billing requirements set forth in Section 3.2
of the Agreement.
C. OTHER GOVERNMENTAL PROGRAMS. Foundation may contract with local, State
or federal entities to provide medical delivery programs such as
universal health care programs, or other Benefit Programs for which
Foundation has contracted with a Payor to provide Participating
Provider networks, or certain Covered Medical Services. Provider shall
render Contracted Services covered under such other governmental
benefit programs, and shall xxxx and accept payment from Foundation or
a Payor as payment in full for such services, except for applicable
Copayments, in accordance with the HMO fee-for-service or per diem
compensation rates set forth on Exhibit 1 to Addendum B.
D. PROVIDER OBLIGATIONS
--------------------
1. Contracted Services. Provider shall provide Contracted
--------------------
Services to Beneficiaries of CHAMPUS,CHAMPUS Supplement and
other governmental programs in accordance with the terms and
conditions of those programs. Provider must be contracted and
accept assignment for both CHAMPUS and Medicare as
Participating Providers in order to render services to CHAMPUS
Beneficiaries. Foundation shall provide Provider with the
Benefit Program Requirements of the CHAMPUS, CHAMPUS
Supplement and other governmental programs not set forth in
this Addendum. Such Benefit Program Requirements may include
Utilization Management Program and Quality Management Program
requirements with which Provider shall comply in rendering
Contracted Services under this Addendum. Participating
Providers shall monitor the accessibility of care to
Enrollees, and adhere to the following standards: a). office
wait times for non-emergencies shall not exceed 30 minutes;
b). wait times for appointments for well visits shall not
exceed 4 weeks, 1 week for routine visits, nor 1 day for acute
illness. Participating Providers shall comply with the
Foundation's reasonable efforts to monitor and evaluate same.
2. Performance Provisions. Provider shall provide Contracted
-----------------------
Services to Beneficiaries of CHAMPUS, CHAMPUS Supplement and
other governmental programs in accordance with the following
terms: a). Provider will cooperate with Foundation in the
assumption and conduct of review activities, b). Provider
will allocate adequate space for the conduct of on site
review, c). Provider will photocopy and deliver to Foundation
all required information within 30 days of a request for
off-site review, d). Provider will provide Beneficiaries, in
writing, their rights and responsibilities, e). Provider will
inform Foundation within three working days if they issue a
notice that the Beneficiary no longer requires inpatient care,
f). Provider will assure that each case subject to
preadmission/preprocedure review has been reviewed and
approved by Foundation, g). Provider will agree, when they
fail to obtain certification as required, that Provider will
accept full financial liability for any admission subject to
preadmission review that
38
Addendum F, Exhibit I
EXHIBIT 1 TO ADDENDUM F
--------------------------------------------------------------------------------
Addendum F
was not reviewed and is subsequently found to be medically
unnecessary or provided at an inappropriate level, h).
Foundation will reimburse Provider under the diagnosis related
group reimbursement system for the costs of photocopying and
postage as established by OCHAMPUS, i). Foundation shall
provide detailed information on the review process and
criteria used, including financial liability incurred by
failing to obtain preauthorization.
3. Specialty Providers. Foundation requires all specialty
--------------------
Providers to request a TRICARE Prime Beneficiary to sign a
release of medical information at each site visit, to include
ancillary services associated with each visit whereby the PCM
and/or the MTF Commanders are designated as the recipients of
the medical records. Specialty Providers are required to
submit the medical records to the PCM and/or MTF Commander
within 14 days for all routine referrals.
4. Eligibility. Eligibility of all CHAMPUS and other governmental
-----------
program Beneficiaries may be verified by the designated agent
of such program (e.g., Defense Enrollment Eligibility
Reporting System). However, if the designated agent initially
indicates that a patient is a Beneficiary under the applicable
CHAMPUS or other governmental program, and that patient is
later determined to be ineligible at the time of service, then
Foundation shall deny any claims for payment due to
non-eligibility, and Provider may seek compensation from the
patient or the patient's other health insurance coverage.
5. National Disaster Medical System (NDMS). When required under a
---------------------------------------
CHAMPUS prime contract, Provider shall obtain membership in
the National Disaster Medical System (NDMS) network. Provider
shall work in good faith with Foundation, or its
representative, to become a member of NDMS as soon as possible
after notification of award of such prime contract.
6. Access Requirements. When required by a particular CHAMPUS
--------------------
program, Provider understands that the Military Treatment
Facility (MTF) is the first resource for health care for
CHAMPUS Beneficiaries, and that Beneficiaries gain access to
the civilian CHAMPUS provider network only through referral of
the Health Care Finder Program, or a Beneficiary's Primary
Care Manager ("PCM"), in coordination with the Health Care
Finder (HCF) Program. Provider agrees to provide services to
CHAMPUS Beneficiaries for non-emergency services only after
obtaining appropriate non-availability statements as required
from the MTF, Referral by Beneficiary's PCM, and prior
authorization through the HCF Program.
7. Benefit Program Phase-Out. Provider agrees to use its best
-------------------------
efforts to submit all CHAMPUS claims within 30 days from date
of service or discharge during the Phase-out period of a DoD
prime contract.
8. Active Duty Personnel. When required under a DoD prime
----------------------
Contract, Provider shall render Contracted Services to United
States military active duty personnel and seek compensation
from the appropriate service organization at the same rates as
provided in Exhibit 1 to this Addendum.
9. CHAMPUS Quality and Utilization Review Programs. Provider
-----------------------------------------------
agrees to comply with all provisions of the CHAMPUS Quality
and Utilization Review programs, including the provision of
medical records and other documentation for cases being
reviewed by Foundation or another CHAMPUS contractor in
compliance with these programs. Provider further authorizes
such CHAMPUS National Quality Monitoring Contractors to
release all review data obtained through medical record and
other document audit to Foundation.
39
Addendum F, Exhibit 1
EXHIBIT 1 TO ADDENDUM F
FEE-FOR-SERVICE COMPENSATION SCHEDULE
CHAMPUS BENEFIT PROGRAMS
Compensation to Provider for the delivery of Medically Necessary Covered
Contracted Services will be the lesser of 85% of the CHAMPUS Maximum Allowable
Charges, 85% of area prevailing rates, or 60% of billed charges for those
services which have a defined Allowable. Services for which a procedure code has
not been assigned, or are unvalued by CHAMPUS, compensation will be the lesser
of Average Wholesale Price minus ten percent (AWP-10%) or 60% of billed charges.
40
Addendum G
ADDENDUM G
TO FACILITY PROVIDER AGREEMENT
PREFERRED PROVIDER ORGANIZATION
(INCLUDING POINT OF SERVICE BENEFIT PROGRAMS)
Provider understands and agrees that the obligations of Foundation set forth in
this Addendum shall be the obligations of:
[X] Foundation Health National Life Insurance Company ("FHNL"), or
[_] Other: __________________________________
as applicable, all of which are Affiliates of Foundation Health Corporation
("FHC"), and not the obligations of FHC or any other Affiliate of FHC. FHNL
provides preferred provider organization ("PPO") and the indemnity and optional
PPO components of Point of Service Benefit Programs.
Provider understands that Foundation shall seek out Payors with whom Benefit
Program, third party administrator (TPA) and other contracts may be negotiated.
Foundation shall provide Provider with a listing of all such Payors, as updated
from time to time by Foundation including those Payors for whom Foundation
serves only in an administrative capacity. The listing shall include the Payors'
utilization management administrator and claims administrator when such is not
Foundation.
A. PPO BENEFIT PROGRAMS
1. Compensation Method. Provider shall render Contracted
--------------------
Services to Beneficiaries of the PPO Benefit Programs
covered under this Addendum. As compensation for rendering
Contracted Services to Beneficiaries of a PPO Benefit Program,
Provider shall be paid in accordance with the rates set forth
on Exhibit 1 of this Addendum. Such compensation shall be paid
within the time and subject to the billing requirements set
forth in Section 3.2 of the Agreement. The above
notwithstanding, for self-insured an other such Payors,
Foundation shall not be obligated to pay all or any portion of
any Provider claim unless and until Foundation has received
sufficient funds from the applicable Payor to cover such
claim.
B. POINT OF SERVICE BENEFIT PROGRAMS
---------------------------------
1. Benefit Program Design. Under a Point of Service Benefit
----------------------
Program, Beneficiaries may elect, at the time of obtaining
each Covered Medical Service, to utilize either: (1) HMO
coverage through their selected or assigned PCP; (2) other
indemnity coverage through either nonparticipating providers,
or Participating Providers where other Benefit Program
Requirements are not met; or (3) optional PPO coverage by
self-referring to PPO Participating Providers.
2. Compensation Method. Provider shall render Contracted Services
--------------------
on a fee-for-service or per diem basis to Beneficiaries of
Foundation's Point of Service Benefit Programs covered under
the PPO option of this Addendum. As compensation for rendering
such Contracted Services, Provider shall be paid the HMO
fee-for-service or per diem rates set forth in Exhibit 1 to
Addendum B. Such compensation shall be paid within the time
and subject to the billing requirements set forth in Section
3.2 of the Agreement.
41
Addendum G, Exhibit 1
EXHIBIT 1 TO ADDENDUM G
PPO COMPENSATION SCHEDULE
Compensation to Provider for the delivery of Medically Necessary Covered
Contracted Services will be the lesser of 60% of billed charges, or the rate
schedule in Attachment A.
42
Addendum H
ADDENDUM H
TO FACILITY PROVIDER AGREEMENT
OCCUPATIONALLY ILL/INJURED OR WORKERS' COMPENSATION BENEFIT
PROGRAMS
Provider understands and agrees that the obligations of Foundation set forth in
this Addendum shall be the obligations of:
[X] Foundation Health, a California Health Plan
[X] Foundation Health National Life Insurance Company
[X] California Compensation Insurance Company
|_| Other: __________________________________
as applicable, all of which are Affiliates of Foundation Health Corporation
("FHC"), and not the obligations of FHC or any other Affiliate of FHC.
Foundation shall contract with Payors, which may include Affiliates of FHC, to
provide Occupationally Ill/Injured or Workers' Compensation Benefit Programs for
Beneficiaries for work related injuries and diseases compensable under State
Occupationally Ill/Injured or Workers' Compensation law. Provider shall render
Contracted Services to Beneficiaries for occupational illnesses and injuries
covered under Foundation's and Payors' Occupationally Ill/Injured or Workers'
Compensation Benefit Programs. Foundation shall provide Provider with a listing
of all such Payors, as updated from time to time by Foundation, including those
Payors for whom Foundation serves only in an administrative capacity. The
listing shall include the Payors' utilization management administrator and
claims administrator when such is not Foundation.
A. OCCUPATIONALLY ILL/INJURED OR WORKERS' COMPENSATION BENEFIT PROGRAMS.
----------------------------------------------------------------------
1. Compensation Method. As compensation for the delivery of
-------------------
Contracted Services, limited as described above, Provider
shall be paid in accordance with the rates set forth on
Exhibit 1 of this Addendum. Such compensation shall be paid
within the time and subject to the billing requirements set
forth in Section 3.2 of the Agreement. The above
notwithstanding, for self-insured and other such Payors,
Foundation shall not be obligated to pay any or all portion of
any Provider claim, as allowed by applicable law, unless and
until Foundation has received sufficient funds from the
applicable Payor to cover such claim.
2. Requirements for Eligibility Verification and Service
--------------------------------------------------------------
Authorization.
--------------
Foundation and Payor Occupationally Ill/Injured or Workers'
Compensation Utilization Management Programs may require
Provider to: (a) verify Beneficiary eligibility to receive
Contracted Services; (b) verify that the Beneficiary's
injury or disease has been determined to "arise out of and in
the course of employment"; (c) determine the requested
treatment is Medically Necessary to cure and relieve the
work-related condition; and Contracted Services prior to
rendering such services. Provider agrees to comply with
such eligibility verification and/or Referral and/or Prior
Authorization requirements and other verification
requirements. Foundation shall advise Provider of all
applicable Utilization Management Program requirements.
43
Addendum H
3. Reports. Provider agrees to furnish, upon request, all
--------
information reasonably required by Foundation or a Payor
to verify and provide written substantiation of the
provision of Contracted Services, and the charges for such
services.
4. Return to Work. In addition to Contracted Services, and
--------------
without further compensation from Foundation or an Payor,
Provider shall work with Foundation and each Payor to develop
a return-to-work program for each Beneficiary.
44
Addendum H, Exhibit 1
EXHIBIT 1 TO ADDENDUM H
OCCUPATIONALLY ILL/INJURED OR WORKERS' COMPENSATION RATE SCHEDULE
Compensation to Provider for the delivery of Medically Necessary Covered
Contracted Services will be the lesser of 90% of the Workers' compensation fee
schedule, 60% of billed charges, or the rate schedule in Attachment A.
45
Addendum I
ADDENDUM I
TO FACILITY PROVIDER AGREEMENT
Contracted Services
OptionCare, Bakersfield
0000 Xxxxxxx Xx.
Xxxxxxxxxxx, XX 00000
805/399-8866 FAX 805/000-0000
TIN: 36-3957843
Medicare Provider # 0309760002 Medi-Cal Provider # PHA-359430
OptionCare, Ceres
0000 Xxxxxxxx Xx.
Xxxxx, XX 00000
209/531-1858 FAX 209/000-0000
TIN: 36-3957843
Medicare Provider # 0492020001 Medi-Cal Provider # PHY-370930
OptionCare, Chico
00 Xxxxxxxxxxx Xx.
Xxxxx, XX 00000
916/893-1337 FAX 916/000-0000
TIN: 36-3957843
Medicare Provider # 0388540001 Medi-Cal Provider # YP-20023
OptionCare, Compton
000 X. Xxxxxxx Xxxx.
Xxxxxxx, XX 00000-0000
310/638-7212 FAX 310/000-0000
TIN: 36-3957843
Medicare Provider # 0308890001 Medi-Cal Provider # PHA-193310
OptionCare, Eureka
0000 Xxxxxxxx Xxx., Xxxxx X
Xxxxxx, XX 00000
707/441-8520 FAX 707/000-0000
TIN: 36-3957843
Medicare Provider # 0256530002 Medi-Cal Provider # PHA-376520
46
Addendum I
OptionCare, Fairfield
0000 Xxxx Xxxx Xx., #00
Xxxxxxxxx, XX 00000
707/426-5600 FAX 707/000-0000
TIN: 36-3957843
Medicare Provider # 0315800001 Medi-Cal Provider # PHY-371400
OptionCare, Fresno
0000 X. Xxxxx Xx.
Xxxxxx, XX 00000
209/439-8877 FAX 209/000-0000
TIN: 36-3957843
Medicare Provider # 0194480002 Medi-Cal Provider # PHA-350380
OptionCare, Hemet
0000 X. Xxxxxxx Xxx.
Xxxxx, XX 00000
909/766-6560 FAX 909/000-0000
TIN: 36-3957843
Medicare Provider # 0201000001 Medi-Cal Provider # PHA-339440
OptionCare, Redding
0000 Xxxxx Xx.
Xxxxxxx, XX 00000
916/241-2273 FAX 916/000-0000
TIN: 36-3957843
Medicare Provider # 0256530002 Medi-Cal Provider # PHA-376520
OptionCare, Sacramento
0000 Xxxxxxxx Xx.
Xxxxxxxxxx, XX 00000
916/454-0444 FAX 916/000-0000
TIN: 36-3957843
Medicare Provider # 0276170001 Medi-Cal Provider # PHA-374590
OptionCare, San Diego
0000 Xxxxxxx Xxxxxx Xx.
Xxx Xxxxx, XX 00000
619/295-7595 FAX 619/000-0000
TIN: 36-3957843
Medicare Provider # 1065830001 Medi-Cal Provider # PHA-40992
47
Addendum I
OptionCare, San Xxxxxx
0000-X X. Xxxxxxxxx Xxxx.
Xxx Xxxxxx, XX 00000
415/721-2273 FAX 404/000-0000
TIN: 36-3957843
Medicare Provider # 0316750001 Medi-Cal Provider # XXX-000000
XxxxxxXxxx, Xxxxxxxx
0000 X. Xxxxxxx Xx.
Xxxxxxxx, XX 00000
209/472-0184 FAX 209/000-0000
TIN: 36-3957843
Medicare Provider # D421180002 Medi-Cal Provider # PHA-405440
OptionCare, Victorville
00000-X Xxxxxxxx Xx.
Xxxxxxxxxxx, XX 00000
619/241-0424 FAX619/241-3083
TIN: 00-0000000
Medicare Provider # 0217890001 Medi-Cal Provider # PHA-350690
OptionCare, Visalia
0000 X. Xxxxxx Xxxx.
Xxxxxxx, XX 00000
209/732-7753 FAX 209/000-0000
TIN: 36-3957843
Medicare Provider # 0194480001 Xxxx-Xxx Xxxxxxxx # XXX-000000
XxxxxxXxxx, Xxxxx
0000 X. Xxxxxxx Xx.
Xxxxx, XX 00000
619/630-5350 FAX 619/000-0000
TIN: 36-3957843
Medicare Provider # 0487820001 Medi-Cal Provider # PHA-37096
48
Attachment A
ATTACHMENT A
Fee-For-Service Reimbursement Schedule
I. HOME INFUSION THERAPY SERVICES
Reimbursement to Participating Provider for all medically necessary covered
benefits billed under the Participating Provider's Federal Tax Identification
number(s) will be as follows:
All aspects of Participating Provider's comprehensive services are covered under
one of several therapy specific prices. The therapy services listed within are
inclusive of:
1. Participating Provider's Clinical Services, and Nursing, including 24
hour/day, 7 days a week on call availability for pharmacy, nursing, and
delivery.
2. Initial nurse assessment, two nursing visits a week, and pharmacy and
clinical monitoring;
3. All therapy related IV solutions/sets, needleless system, solutions,
diluent, minibags, dressings, nursing/medical supplies and equipment;
4. Support services related to delivery and transportation, equipment rental
of infusion pumps and IV poles and other related equipment, line
maintenance, obtaining of laboratory specimens (exception: lab draws
ordered for purposes unrelated to authorized therapies), pharmacy
compounding and dispensing, and hazardous/infectious waste management,
waste disposal, and equipment cleaning;
5. Support services facilitating patient access and care, including
Managed Care Representatives, Precertification and Preauthorization
Services, education and training, and other Customer Services;
6. Information services that monitor, track and report utilization by a
variety of both clinical and financial criteria, including prescription
tracking and record keeping, utilization reporting, administration and
overhead.
7. All medication must be billed with 90780 and the NDC number and will be
allowed at AWP minus 10 percent.
A. ANTIBIOTIC, ANTIVIRAL, AND ANTIFUNGAL THERAPY
The antibiotic, antiviral, and antifungal therapy rate is composed of the daily
per diem rate, determined by the dosing schedule, plus the Average Wholesale
Price (AWP) of the antibiotic minus 10 percent. This rate is applicable for
central or peripheral lines.
Dosing Schedule Rate/Code
------------------- -----------
Every 24 hours, q24 $ 70.00/AB241
Every 12 hours, q12 $ 70.00/AB121
Every 8 hours, q8 $ 70.00/AB081
Every 6 hours, q6 $ 70.00/AB061
Every 4 hours, q4 $ 70.00/AB041
Every 3 hours, q3 $ 70.00/AB031
49
Attachment A
B. MULTIPLE ANTIBIOTIC REGIMENS (BOTH PERIPHERAL AND CENTRAL LINES):
For multiple antibiotic, antiviral, and antifungal drug regimens, the standard
daily single drug therapy per diem rate will be paid for the first drug therapy,
plus, for each additional drug therapy, an additional 50% of the per diem (or
$35) will be paid on each additional drug therapy dosing schedule. The AWP minus
10 % of ALL antibiotic, antiviral, and antifungal drugs will be paid.
C. TOTAL PARENTERAL NUTRITION (TPN) THERAPY
TPN therapy consists of amino acid/dextrose; including electrolytes, vitamins
(excluding Vitamin K), trace elements, insulin and heparin. The TPN therapy
service is composed of the daily per diem rate, determined by the daily volume
of TPN solution. The per diem rate for TPN therapy INCLUDES the TPN solutions.
There is NOT a separate rate for the AWP of the solutions. Lipids will be paid
at a separate rate, as detailed below. Any additionally authorized additives
(except renal & hepatic) will be paid at AWP minus 10 %. The pump is included in
the per diem rates.
Standard TPN Solution Rate/Code
--------------------- ------------
Solution 1.0 liters or less per day $ 135.00/TP101
Solution 1.1 to 2.0 liters per day $ 155.00/TP201
Solution 2.1 to 3.0 liters per day $ 175.00/TP301
Solution 3.1 liters or greater per day $ 185.00/TP401
Lipids will be paid at:
10% up to 500 ml $ 35.00/TP050
20% up to 500 ml $ 45.00/TP060
D. CHEMOTHERAPY
The per diem service is composed of the daily per diem rate plus the Average
Wholesale Price (AWP) minus 10 % of the chemotherapeutic agent.
Rate /Code
----------
Chemotherapy, one drug: $ 70.00/CH001 plus the AWP
minus 10% of the drug
Additional Drug Therapy:
Chemotherapy, additional drug: $ 35.00/CH002 plus the AWP
minus 10% of the drug
50
Attachment A
E. HYDRATION THERAPY
Hydration therapy consists of fluids with electrolytes. The hydration therapy
service is composed of the daily per diem rate. The per diem rate for Hydration
therapy INCLUDES the charge for the fluids and electrolytes. There is NOT a
separate rate for the AWP of the solutions. Any additives not included in the
basic hydration therapy will be reimbursed at AWP minus 10% only if authorized
by Foundation.
Standard Hydration Solution Rate/Code
--------------------------- -----------
Solution 1.0 liters or less per day $ 50.00/HD101
Solution 1.1 to 2.0 liters per day $ 50.00/HD201
Solution 2.1 to 3.0 liters per day $ 50.00/HD301
Solution 3.1 liters or more per day $ 50.00/HD401
F. PAIN MANAGEMENT THERAPY
The Pain Management therapy service rate is composed of the daily per diem rate
plus the Average Wholesale Price (AWP) minus 10% of the analgesic drug.
Rate/Code
-------------
Continuous or Intermittent pain $ 50.00/PA101 plus the AWP
management, one drug or multiple drugs minus 10% of the drug
G. ENTERAL THERAPY
The Enteral therapy service is composed of the daily per diem rate plus the
Average Wholesale Price (AWP) minus 10% of the enteral solution.
Enteral Product Rate /Code
-------------- ----------
Liquid or Powder $ 20.00/EN100 plus the AWP
minus 10% of the enteral
product.
H. PENTAMIDINE THERAPY
The Pentamidine therapy service is composed of the daily per diem rate plus the
Average Wholesale Price (AWP) minus 10% of the drug.
Rate /Code
----------
Pentamidine $ 65.00/AP100 plus the AWP
minus 10% of the drug
Specific equipment allowances:
------------------------------
Compressor will be paid separately
51
Attachment A
I. GROWTH HORMONE THERAPY
The Growth Hormone therapy rate is composed of the per vial rate plus the
Average Wholesale Price (AWP) minus 10% of the growth hormone.
Rate /Code
------------
Growth Hormone $ 20.00/GH100 plus the AWP m
inus 10% of the drug
K. NEUPOGEN, EPOGEN, & PROCRIT SUBCUTANEOUS THERAPIES
The Neupogen, Epogen & Procrit therapy service is composed of the per vial rate
plus the Average Wholesale Price (AWP) minus 10% of the drug.
Rate/Code
---------
Neupogen $ 40.00/NE100 plus the AWP minus 10% of the drug
Epogen $ 40.00/EP100 plus the AWP minus 10% of the drug
Procrit $ 40.00/PR100 plus the AWP minus 10% of the drug
L. CARDIAC (DOBUTAMINE) THERAPY
The Dobutamine therapy service is composed of the daily per diem rate plus the
Average Wholesale Price (AWP) minus 10% of the drug.
Rate/Code
---------
Dobutamine Therapy $ 80.00/CA101 plus the AWP
minus 10% of the drug
M. GAMMIMUNE THERAPY
The Gammimune therapy service is composed of the daily per diem rate plus the
Average Wholesale Price (AWP) minus 10% of the drug.
Rate/Code
---------
Gammimune Therapy $ 60.00/IM101 plus the AWP
minus 10% of the drug
52
Attachment A
N. STEROID THERAPY
The Steroid Therapy service is composed of the daily per diem rate plus the
Average Wholesale Price (AWP) minus 10% of the drug.
Rate /Code
----------
Steroid therapy $ 60.00/ST101 plus the AWP
minus 10% of the drug
O. MULTIPLE THERAPIES
Multiple therapies are defined as TWO or more therapies as defined in sections A
- N and S which occur on the same day. Multiple therapies will be paid as
follows:
The highest daily per diem rate will be paid at 100%.
The second highest per diem rate will be paid at 70%.
All following per diem rates will be paid at 50%.
All pharmaceuticals will be paid at the AWP minus 10% rate as indicated in
this per diem schedule.
Multiple therapies must be billed together on one xxxx for the same period. The
highest payment therapies will be considered first.
PER DIEM MAXIMUM
Services for any one day of Multiple Therapies may not exceed the Maximum
Per Diem Rate of $ 255.00
P. SKILLED NURSING SERVICES
See home health nursing rates.
Q. PICC LINE INSERTION SERVICE
The PICC Line Insertion Service consists of a charge for each PICC Line
Insertion visit.
Rate/Code
---------
PICC LINE INSERTION SERVICE $ 180.00/PC000
Excluded from the PICC Line Insertion Service in the per diem rate: Verification
of PICC placement via X-Ray is not included.
53
Attachment A
R. CATHETER CARE - NON THERAPY RELATED
All Catheters $6.00 per diem
S. OTHER THERAPIES AND/OR SERVICES
Any therapies not included in the agreement will be paid at 60% of the
Participating Provider's Usual and Customary rates in effect at the time the
product or service was provided. All medication must be billed with 90780 and
the NDC number and will be allowed at AWP minus 10 percent.
Code for other therapies AD100
T. RETURNED GOODS
All patient specific solutions premixed and delivered by Participating Provider
(subject to applicable state pharmacy laws) pursuant to prescription(s) written
by a patient's prescribing physician shall be billed at the time of delivery and
no credit shall be allowed for return of such goods. In no case shall this
charge be for in excess of three days supply.
Nonreturnable supplies which have been delivered in connection with any unused
solutions (referenced in the preceding paragraph) will be paid at a daily per
diem rate equal to 30% of the normal daily rate. The number of "nonreturnable
supplies" per diems charged will be equal to the number of days of drug which
are nonreturnable. In no case will this charge be in excess of three days.
Code for Returned Supplies Use specific per diem code for
the applicable therapy with
the-22 modifier.
54
Attachment A
--------------------------------------------------------------------------------
II. HOME HEALTH NURSING
A. Home Health Nursing - Intermittent Nursing Services*
Registered Nurse:
1. Assessment: $ 65/HH000
2. Visit: $ 65/HH001 3. Hourly: $ 30/HH002
Licensed Vocation Nurse:
2. Visit: $ 50/HH010 3. Hourly: $ 25/HH011
Home Health Aide:
2. Visit: $ 24/HH020
Social Work - MSW:
2. Visit: $ 65/HH030
Physical Therapy:
2. Visit: $ 65/HH040
Speech Therapy:
2. Visit: $ 65/HH050
Occupational Therapy:
2. Visit: $ 65/HH060
1. A skilled nursing (RN) assessment visit is defined as up to and
including two hours.
2. Home visits after an initial assesment are calculated at a two hour
interval.
3. To be paid for each subsequent hour on an extended visit, up to six
(6) hours per day.
* All rates include cost of medical supplies, travel, time and mileage.
Specific Medical Supplies excluded from these rates are included as Exhibit 1
to Attachment A. No additional payment will be made for holidays. These rates
apply to services provided within a 60 mile radius of the office location.
55
Attachment A
--------------------------------------------------------------------------------
III. OXYGEN and RESPIRATORY THERAPY
/HOME MEDICAL EQUIPMENT/MEDICAL SUPPLIES
30% Discount off 1997 Medicare Allowable Rates for California for
DME & Medical Supplies (Medicare Allowable Rates shall remain
fixed for the duration of the initial 3 year term of the contract,
and shall not be updated).
DME and medical supplies without a 1997 Medicare Allowable Rate
will be paid at a 40% Discount off Provider's usual & customary
rates (Billed Charges). The 40% discount applies only if billed
charges per item are at or below $2500; items above $2500 require
prior authorization and rate negotiation.
After at least one month's rental, subsequent rentals which are
less than one month in length will be pro-rated at 50% of the
monthly rental rates.
60% of each continuous use monthly rental payment shall apply
towards purchase of an item.
56
A4402 LUBRICANT, PER OZ
------------------------------------------------------------------
A4404 OSTOMY RINGS, EA
------------------------------------------------------------------
A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADH),
PER OZ
------------------------------------------------------------------
A5051 POUCH, CLOSED; W/BARRIER ATTACHED (1 PIECE)
------------------------------------------------------------------
A5052 POUCH, CLOSED; W/O BARRIER ATTACHED (1 PIECE)
------------------------------------------------------------------
A5053 POUCH, CLOSED; FOR USE OF FACEPLACE
------------------------------------------------------------------
A5054 POUCH, CLOSED; FOR UE ON BARRIER W/FLANGE (2 PIECES)
------------------------------------------------------------------
57
Attachment A, Exhibit 1
A5055 STOMA CAP
-------------------------------------------------------------------------------
A5061 POUCH, DRAINABLE; W/ BARRIER ATTACHED (1 PIECE)
-------------------------------------------------------------------------------
A5063 POUCH, DRAINABLE; FOR USE ON BARRIER W/ FLANGE (2 PIECES)
-------------------------------------------------------------------------------
A5064 POUCH, DRAINABLE; W/ FACEPLATE ATTACHED, PLASTIC OR RUBBER
-------------------------------------------------------------------------------
A5065 POUCH, DRAINABLE; FOR USE ON FACEPLATE; PLASTIC OR RUBBER
-------------------------------------------------------------------------------
A5071 POUCH, URINARY; W/ BARRIER ATTACHED (1 PIECE)
-------------------------------------------------------------------------------
A5072 POUCH, URINARY; W/O BARRIER ATTACHED (1 PIECE)
-------------------------------------------------------------------------------
A5073 POUCH, URINARY; FOR USE ON BARRIER W/ FLANGE (2 PIECES)
-------------------------------------------------------------------------------
A5074 POUCH, URINARY; W/ FACEPLATE ATTACHED, PLASTIC OR RUBBER
-------------------------------------------------------------------------------
A5075 POUCH, URINARY; FOR USE ON FACEPLATE ATTACHED, PLASTIC OR
RUBBER
-------------------------------------------------------------------------------
A5081 CONTINENT DEVICE; PLUG FOR CONTINENT STOMA
-------------------------------------------------------------------------------
A5082 CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA
-------------------------------------------------------------------------------
A5093 OSTOMY ACCESSORY; CONVEX INSERT
-------------------------------------------------------------------------------
A5102 BEDSIDE DRAINAGE BOTTLE, RIGID OR EXPANDABLE
-------------------------------------------------------------------------------
A5105 URINARY SUSPENSORY; W/ LEG BAG, W/ W/O TUBE
-------------------------------------------------------------------------------
A5112 URINARY LEG BAG; LATEX
-------------------------------------------------------------------------------
A5113 LEG STRAP; LATEX, PER SET
-------------------------------------------------------------------------------
A5114 LEG STRAP; FOAM OR FABRIC, PER SET
-------------------------------------------------------------------------------
A5123 SKIN BARRIER; W/ FLANGE (SOLID, FLEXIBLE OR ACCORDIAN),
ANY SIZE, EA
-------------------------------------------------------------------------------
A5131 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES,
PER 16 OZ
-------------------------------------------------------------------------------
58
