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EXHIBIT 10.17
CCPN and HMO MEDICAID AGREEMENT
By and Between
Americaid Texas Inc., d/b/a Americaid Community Care
and
Xxxx Children's Physician Network
A Texas 5.01(a) Non-profit Corporation
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CCPN AND HMO MEDICAID AGREEMENT
(STAR Program in the Tarrant County Service Area)
This Agreement ("Agreement") is entered into this_______day of ______________,
1996, (the "Execution Date") to become effective October 1, 1996 (the "Effective
Date"), by and between Americaid Texas, Inc. d/b/a Americaid Community Care, a
health maintenance organization certified under Article 20A of the Insurance
Code of the State of Texas (hereinafter referred to as "HMO"), and Xxxx
Children's Physician Network, a Texas non-profit corporation certified under
Section 5.01(a) of the Texas Medical Practice Act (hereinafter referred to as
"CCPN").
RECITALS
WHEREAS, HMO has been selected by the Texas Department of Health ("TDH") as one
of the health-care plans that will participate in the TDH XxxxXxxx Health
Initiative ("STAR") in the Tarrant County Service Area ("Service Area"); and
WHEREAS, HMO desires that CCPN be the exclusive provider of all pediatric health
care services listed in Attachment A, Exhibit 2 (the "Covered Health Services")
to Medicaid STAR Program beneficiaries in the age group of birth through fifteen
(15) years of age enrolled with HMO ("Members") and CCPN desires to be the
exclusive provider of Covered Health Services to HMO's Members; and
WHEREAS, the parties desire to set forth in this Agreement the terms and
conditions under which CCPN will supply and arrange for the Covered Health
Services to Members and to specify the responsibilities of the parties in
connection with this Agreement.
NOW THEREFORE, in consideration of the premises and the mutual promises,
covenants, and agreements set forth herein, the parties agree to the following
terms:
DEFINITIONS
For purposes of this Agreement, the following terms shall have the meaning set
out beside such term. In the event any of the following definitions conflict
with any of the definitions in the Exhibits, the definitions herein delineated
shall govern the
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interpretation of the term. The additional definitions delineated in the
Exhibits shall be given broad construction in the event they conflict or limit
that term as it may be defined in any other Exhibits.
1. Agreement. Means this contract including all attachments appended hereto
and any written amendments subsequently executed by the parties.
2. Capitation. Means a payment system which allocates a fixed actuarially
determined amount per month for each Member based on the appropriate STAR
Program aid category for the provision of Covered Health Services.
3. Clean Claim. Means a record of or a claim for Covered Health Services
provided to Members which is accurate, complete (ie: includes all
information necessary for a payor to determine liability), not a claim on
appeal, and not contested (ie: not reasonably believed to be fraudulent,
and not subject to a necessary release, consent, or assignment).
4. CCPN Physician. Means a duly licensed Primary Care Physician or
Specialist Physician who is employed by or has contracted with CCPN,
either directly or indirectly, and who has agreed to treat Members.
5. CCPN Participating Provider. Means a health care facility, or Health Care
Professional, other than a physician, who is employed by or has
contracted with CCPN, either directly or indirectly, and who has agreed
to treat Members.
6. Contract Anniversary Date. Means September 1st of each year of this
Agreement.
7. Contract Term. Means the term of this Agreement as specified in Section 8
hereof.
8. Covered Health Services. Means the professional, institutional, and
ancillary services listed in the State Contract, Appendix C, as the
services which are included under the HMO capitation payment for Members
15 years of age and under.
9. Emergency Care. Means bona fide emergency services provided after the
sudden onset of a medical condition (including emergency labor and deliv-
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ery) manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that the absence of immediate medical
attention could reasonably be expected to result in (1) placing the
patient's health in serious jeopardy; or (2) serious impairment to bodily
function; or (3) serious dysfunction of any bodily organ or part.
10. Exclusive Provider. Means that CCPN shall be the sole provider, either
directly or through contracted Health Care Professionals or institutions
for Institutional Services, of all pediatric health services for HMO in
the STAR Program in the Service Area.
11. Health Care Professional. Means any physician, nurse, audiologist,
physician assistant, clinical psychologist, occupational therapist,
physical therapist, speech and language pathologist, or other
professional engaged in the delivery of health services who are licensed,
practice under an institutional license, certified, or practice under
authority of a physician, legally constituted professional association or
other authority consistent with state law to provide services to such
patients.
12. Institutional Services. Means those non-professional Covered Health
Services provided by or through a state licensed facility. Such services
include, but are not limited to, inpatient or outpatient hospital
services, skilled nursing facility services and emergency room services.
13. Medical Director. Means a physician designated by HMO who is responsible
for monitoring the provision of Covered Health Services to Members.
14. Medically Necessary. Means those services or supplies necessary for the
diagnosis, prevention, care and/or treatment of a Member's illness,
disease, injury or bodily malfunction which are provided in accordance
with and are consistent with generally accepted standards of medical
practice within the Service Area.
15. Member. Means any individual age 0 through 15 years residing in the
service enrollment area who is (1) in a Medicaid eligibility category
included in the STAR Program, and (2) enrolled in the STAR Program as a
Member of Americaid Texas, Inc. d/b/a Americaid Community Care.
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16. Participating Physician. Means a duly licensed primary care physician or
specialist physician who has entered into a contract with HMO to provide
or arrange for Covered Health Services to Members.
17. Participating Provider. Means any health care facility, or Health Care
Professional, other than a physician, that provides medical services to
HMO Members pursuant to an agreement with HMO for purposes of the STAR
Program in the Service Area.
18. Primary Care Physician or Provider (PCP). Means a CCPN Physician or other
Health Care Professional who has an agreement with CCPN, who is
responsible for providing primary care services and who agrees to
coordinate and manage delivery of Covered Health Services to Members
assigned to such Primary Care Physician or Provider. CCPN's network of
Primary Care Physicians or Providers (PCPs) may include General
Practitioners; Family Practitioners; Internists; Pediatricians;
Obstetricians/Gynecologists ("Ob/Gyn"); Pediatric and Family Advanced
Nurse Practitioners ("ANPs"); Certified Nurse Midwives ("CNMs");
Physician Assistants ("PAs") specializing in Family Medicine, Internal
Medicine, Pediatric and Obstetric/Gynecology; Federally Qualified Health
Centers ("FQHCs"); Rural Health Clinics ("RHCs") and similar community
clinics. The Primary Care Physician or Provider for a Member with
disabilities or chronic or complex conditions may be a specialist who
also provides PCP services.
19. Service Area. Means the Texas counties of Tarrant, Hood, Johnson, Denton,
Parker, and Wise.
20. Specialist Physician. Means a CCPN Physician who provides specialist care
or consultative services to Members upon referral by Primary Care
Physicians or Providers.
21. State Contract. Means the agreement between HMO and TDH specifying the
terms and conditions under which Covered Health Services are to be
provided to Members.
22. State of Texas Access Reform ("STAR") Program. Means the name of the
State of Texas Medicaid Managed Care Program.
23. TDH. Means the Texas Department of Health.
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24. TDI. Means the Texas Department of Insurance.
GENERAL PROVISIONS:
1. Obligations Of HMO.
1.1 As of the Effective Date of this Agreement, HMO has entered into
certain provider contracts with pediatric Medicaid providers,
which contacts are described on Attachment D, attached hereto and
made apart hereof (the "HMO Contracts"). As more particularly
described below, CCPN will be the Exclusive Provider of Covered
Health Services to Members, either providing services directly or
arranging for the provided services. HMO will use its best efforts
to assist CCPN in establishing CCPN's network of providers to
allow CCPN to effectively and efficiently manage the care provided
to HMO's Members.
Within ninety (90) days of the Effective Date of this Agreement,
HMO (with the assistance and input from CCPN) will use its best
efforts to (1) assign all HMO Contracts to CCPN or (2) assist CCPN
in contracting directly with all Participating Physicians and
Participating Providers who are parties to the HMO Contracts.
At the end of the above referenced ninety (90) day period for
assignment or direct contracting, any HMO Contracts that have not
been assigned to CCPN or replaced with a direct CCPN contract will
be managed by HMO until September 1, 1997, when CCPN shall become
the Exclusive Provider of Covered Health Services to Members. HMO
shall inform CCPN of any action taken or decisions made regarding
the HMO Contracts. HMO agrees that it will not amend, revise, or
change any term, provision or agreement (unless required by state
or federal law or regulation) in the HMO Contracts without the
prior written approval of CCPN insofar as any amendment, revision
or change would impact the provision of or payment of any Covered
Health Services to Members under this Agreement. Furthermore,
except as otherwise mutually agreed in writing, HMO agrees to take
reasonable action necessary with respect to the HMO Contracts to
transition them to CCPN. HMO understands and agrees that on
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September 1, 1997, CCPN will be HMO's Exclusive Provider of
Covered Health Services to Members.
1.2 HMO shall be responsible for certain administrative activities
necessary or required for the operation of a health maintenance
organization unless otherwise agreed to by the parties. Such
activities shall include, but are not limited to, utilization
management, capital financing, marketing, advertising, customer
service, issuance of identification cards, accounting, maintenance
of a suitable medical management information system, claims
processing and provider relations. HMO acknowledges and agrees
that CCPN is currently developing an infrastructure to handle
administrative activities. HMO, its successors, designees or
assigns, expressly covenant and agree to transfer to CCPN all
administrative activities mutually agreed to by CCPN and HMO.
Additionally, HMO agrees to amend this Agreement to provide that
CCPN shall be paid directly from the Monthly TDH Payment the
percentage mutually agreed to be allocated for the administrative
activities transferred to CCPN.
1.3 HMO will provide to CCPN a provider manual, to be periodically up
dated, which includes, but is not limited to HMO policies and
procedures developed for the STAR Program in the Service Area.
1.4 CCPN shall be entitled to representation on selected HMO Medicaid
committees which oversee the HMO State Contract including
administrative and/or operational committees involved in the STAR
Program in the Service Area.
1.5 Subject to applicable confidentiality laws and regulations, HMO
and CCPN will allow each other access to any and all information
and documents necessary to conduct audits deemed necessary by
such party to evaluate the other party's performance under this
Agreement.
1.6 HMO will develop, distribute, and periodically update a Member
hand book which will detail a Member's rights and
responsibilities, how to access the HMO delivery system, how to
obtain emergency services and how to file grievances. HMO will
provide CCPN with a copy of the original and any updates to the
Member Handbook con-
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currently with distribution to Members, but in no event later than
seven (7) days after distribution.
1.7 HMO will establish and maintain a Member complaint and grievance
process as required by the STAR Program. Accordingly, HMO shall
implement and maintain a member complaint system which provides
for the resolution of Member complaints and implement and maintain
a Members grievance process which provides for the resolution of
Member grievances. Once this Member complaint and grievance
process is established, HMO will provide a copy of the original
prior to the Effective Date and provide CCPN reasonable prior
written notice of any modifications and/or amendments. HMO agrees
to provide to CCPN information related to Member complaints
involving CCPN.
1.8 HMO agrees to delegate credentialing to CCPN for CCPN Physicians
and CCPN Participating Providers pursuant to the Delegation of
Credentialing Agreement in Attachment A, Exhibit 5.
1.9 HMO agrees to develop utilization review, peer review and quality
assurance programs and policies with the support of CCPN. Once
these programs and policies are established, HMO will provide to
CCPN a copy of the original prior to the Effective Date and
provide CCPN reason able prior written notice of any modifications
and/or amendments.
1.10 HMO will provide monthly Enrollment Reports to CCPN and to all
Primary Care Physicians or Providers within five (5) business days
after receipt of Enrollment Reports from TDH each month covered by
this Agreement. Upon request of CCPN, its Physicians and/or
Participating Providers, HMO or TDH shall confirm the enrollment
status of any individual at any time during normal business
hours. If CCPN, its Physician and/or Participating Providers,
obtains Member verification, HMO shall not retroactively deny
payment from the Pediatric Risk Fund to such provider if HMO later
determines that a Member verified as eligible was not in fact a
Member or that the service authorized and provided was not a
Covered Health Service. Financial responsibility for the provision
of such services is subject to Section II.A.3 of Attachment A to
this Agreement.
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1.11 HMO shall provide utilization management services including
pre-certification, referral management, concurrent review,
discharge planning and case management for all Members, except for
those Members admitted to Xxxx Children's Medical Center ("CMC").
For those Members admitted to CMC, CMC shall perform concurrent
review, discharge planning and case management while HMO will
continue to provide pre-certification and referral management
services.
1.12 HMO shall provide claims processing services as may be necessary
for the appropriate adjudication and payment of all claims
submitted to HMO by CCPN Physicians and CCPN Participating
Providers.
1.13 HMO shall provide reports to CCPN, which include but are not
limited to (1) membership and eligibility, (2) cost of referrals,
(3) financial status of program, (4) utilization of benefits, (5)
members satisfaction with delivery of program benefits, (6) member
and provider utilization, and (7) daily and weekly inpatient
admissions. The reports will be prepared in a format mutually
agreed upon by CCPN and HMO and are subject to modification
during the duration of this Agreement. Reporting frequency will be
mutually determined by CCPN and HMO. Proforma reports are included
in Attachment A, Exhibit 4 of this Agreement and are provided for
illustrative purposes only. The proforma reports are not to be
construed as the final agreement between CCPN and HMO regarding
report format and distribution frequency. CCPN and HMO agree to
finalize the format, data elements, and frequency of the reports
needed within ninety (90) days after the Effective Date.
Additionally, HMO will provide CCPN access to reports required
under the State Contract and by TDH, and copies of those requested
by CCPN.
2. Obligations of CCPN.
2.1 CCPN agrees to provide, arrange for, and manage the delivery of
all Medically Necessary Covered Health Services to HMO Members who
have selected or been assigned to a CCPN Physician or a CCPN
Participating Provider.
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2.2 CCPN agrees to provide Covered Health Services to Members in the
same manner, in accordance with the same standards, and within the
same time availability as offered to their other patients of CCPN
Physicians and CCPN Participating Providers.
2.3 Subject to the terms of the State Contract, a CCPN Physician
and/or CCPN Participating Provider may refuse to continue to treat
a Member if there has been a failure to establish or maintain a
satisfactory physician- patient and/or provider-patient
relationship. In such instances CCPN Physician and/or CCPN
Participating Provider shall be obligated to abide by the
standards of medical ethics with respect to the transfer of
responsibility for patient care. CCPN and HMO Medical Director
shall determine an alternate CCPN Physician and/or CCPN
Participating Provider to assume care for the affected Member.
2.4 CCPN, in its provider contracts, will require CCPN Physicians and
CCPN Participating Providers to comply with HMO service
authorization and eligibility verification procedures as jointly
reviewed and/or approved by HMO and CCPN. These procedures will be
set forth in the provider manual.
2.5 CCPN shall make necessary and appropriate arrangements in
accordance with TDH requirements to ensure the availability and
accessibility of Covered Health Services to Members on a
twenty-four (24) hour per day, seven (7) day per week basis.
2.6 CCPN agrees that in the event of HMO's insolvency or other
cessation of operations, CCPN will continue providing Covered
Health Services to Members through the period for which payment
has been made or, for Members in an inpatient facility, until the
date of discharge from the inpatient facility.
2.7 CCPN agrees to abide by utilization review, peer review and
quality assurance programs and policies developed by HMO with the
support of CCPN. HMO and CCPN will meet jointly to review and
approve such policies and programs prior to the Effective Date.
2.8 CCPN agrees to comply with the member complaint procedure estab-
lished by HMO in accordance with State Contract and to cooperate
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with HMO in resolving any Member complaints related to providing
Covered Health Services. HMO and CCPN shall use their best efforts
to notify each other of all Member complaints involving CCPN
within a reasonable time. CCPN shall investigate such complaints
and use its best efforts to resolve them in a fair and equitable
manner. CCPN agrees to notify HMO promptly of any action taken or
proposed with respect to such complaints.
2.9 This Agreement will not be construed to limit HMO's authority or
responsibility to comply with TDI and TDH requirements. CCPN
acknowledges that HMO is responsible for complying with all
regulatory requirements, that the role of CCPN is subject to
monitoring by HMO, and that HMO may take necessary action assure
that any functions delegated to CCPN are in compliance with state
regulatory requirements.
2.10 CCPN agrees to make available its contracts with physicians and
providers to HMO to ensure compliance with Section 11.1604 of the
Texas Administrative Code.
2.11 CCPN agrees to provide HMO with evidence of financial solvency and
financial performance, such as a financial audit.
2.12 CCPN agrees to provide to HMO, on at least a monthly basis, with
the data necessary for HMO to comply with the TDI and TDH
reporting requirements with respect to any Covered Health Services
provided pursuant to this Agreement, including, but not limited
to, the following data: (i) utilization data; (ii) amounts paid by
CCPN for administrative services relating to HMO; (iii) amounts
paid by CCPN to physicians and participating providers; (iv)
methods by which physicians and participating providers were paid
by CCPN (capitation, fee-for-service, or other risk sharing
arrangements); (v) time period that claims and debts related to
claims owed by CCPN have been pending; (vi) information required
for HMO to be able to file claims for reinsurance, coordination of
benefits and subrogation; (vii) provider-enrollee satisfaction
data; (viii) inquiries and investigations of CCPN made by
regulatory agencies; and (ix) any other data necessary to assure
proper monitoring and control of HMO delivery network by HMO.
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2.13 CCPN agrees to have in place, to the extent required by federal
and state law, an affirmative action program. CCPN further agrees
to comply with:
1. Title VI of the Civil Rights Act of 1964 (Public Law 88-352),
2. Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112),
3. The Americans with Disabilities Act of 1990 (Public Law 101-336),
4. Title 40, Chapter 73, of the Texas Administrative Code, providing
in part that no persons in the United States shall, on the grounds
of race, color, national origin, sex, age, disability, political
beliefs or religion be excluded from participation in, or denied,
any aid, care, service or other benefits provided by federal
and/or state funding, or otherwise be subjected to discrimination.
5. Texas Health and Safety Code Section 85.113 (relating to workplace
and confidentiality guidelines regarding AIDS and HIV).
6. 42 CFR 493 1809 regarding the Clinical Laboratory Improvement
Amendment.
and all amendments to each, and all requirements imposed by the regulations
issued pursuant to these acts, and all other applicable federal, state and local
laws, rules and regulations.
3. CCPN Compensation
3.1 Payment for Healthcare Services. During the term of this
Agreement, HMO shall pay CCPN, CCPN Physicians and CCPN
Participating Providers monthly capitation and fee-for-service
payments in accordance with the provisions set forth in Attachment
A for all Covered Health Services arranged for or provided to
Members.
3.2 In the event that a claim for a Covered Health Service is validly
denied, CCPN will not attempt to collect payment for such claim
from the affected Member or Member's family.
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3.3 Payment for Administrative Activities. HMO shall pay CCPN within
five (5) business days of receipt of the TDH Payment (described in
Attachment A) $0.25 per Member per month for each Member enrolled
with HMO. This monthly payment is made to CCPN as compensation for
the administrative services performed by CMC in accordance with
Article 1, Section 1.11. Additionally, HMO will pay to CCPN
$10.00 for each specialist physician credentialed and $20.00 for
each primary care physician credentialed and $8.00 for each
specialist physician re-credentialed and $15.00 for each primary
care physician re-credentialed. CCPN shall invoice HMO monthly for
the number and type of physicians credentialed. HMO will not pay
CCPN to credential physicians previously credentialed by HMO until
such physicians are due to be re-credentialed.
4. Third Party Provider Agreements. In the event HMO utilizes a third party
provider to provide the carved-out services, HMO shall use its best
efforts to structure its agreement with the third party provider to allow
the inclusion of CCPN as a participating provider through such
arrangements.
5. Hold-Harmless.
5.1 CCPN hereby agrees that in no event, including, but not limited to
nonpayment by HMO, HMO insolvency or breach of this Agreement,
shall CCPN xxxx, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any
recourse against Member or persons other than HMO acting on their
behalf for Covered Health Services provided. This provision shall
not prohibit collection of charges for services provided by CCPN
but which are not covered under the STAR Program.
5.2 CCPN agrees to hold harmless the State of Texas, all state
officers and employees, and all Members in the event of nonpayment
by HMO to CCPN. CCPN further agrees to indemnify and hold harmless
the State of Texas and its agents, officers and employees against
all injuries, death, losses, damages, claims, lawsuits,
liabilities, judgments, costs and expenses which may in any manner
accrue against the State or its agents, officers or employees,
through the intentional conduct, negligence or omission of CCPN,
any shareholder, partner or
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any other individual or entity holding an equitable interest in
CCPN, his agents, officers, employees.
5.3 CCPN further agrees that (1) 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 the
Member, and that (2) this provision supersedes any oral or written
contrary agreement now existing or hereafter entered into between
CCPN and Member or persons acting on their behalf insofar as such
contrary agreement relates to liability for payment for
continuation of Covered Health Services provided under the terms
and conditions of this continuation of benefits provision.
6. Insurance
6.1 CCPN agrees to maintain policies of general and professional
liability insurance as are necessary to reasonably insure itself
and its employees against any claim or claims for damages arising
by reason of personal injuries or death occasioned directly or
indirectly in connection with the performance of any Covered
Health Services. The amounts and extent of such insurance coverage
shall be acceptable to HMO, but in no event shall professional
liability insurance be less than $100,000.00 per claim,
$300,000.00 annual aggregate, for CCPN Physicians, unless a lesser
amount is determined by HMO, in writing, to be acceptable for a
particular class or group of CCPN Physicians.
6.2 Certificates of insurance or other evidence indicating the term
and extent of professional liability insurance shall be provided
by CCPN to HMO upon request by HMO and upon execution of the final
agreement. CCPN shall require of its professional liability
carrier that HMO be named as a party entitled to a thirty (30) day
prior written notice of an intent to cancel or terminate.
6.3 HMO shall maintain, in the minimum amount of One Million Dollars
($1,000,000) per occurrence and Five Million Dollars ($5,000,000)
in the aggregate, policies of general liability, professional
liability, and directors and officers liability insurance to
insure itself and its employees against any claim or claims for
damages arising out of this Agreement. Documentary evidence of
such insurance policy or
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policies shall be provided to CCPN upon request. HMO agrees to
keep and maintain said insurance coverage in full force and effect
during the Initial Term of this Agreement and any renewal term
this Agreement. HMO or its insurance carriers will provide CCPN
with thirty (30) days advance written notice of a material
modification or cancellation of said policies. All liability
coverage shall be "occurrence based", provided, however, that in
any instance where the coverage required can openly be acquired by
means of a "claims made" policy, that policy shall provide for a
"buy-out at the tail" provision, which HMO agrees to exercise or
cause to be exercised in the event of change, cancellation or
termination of said policy.
7. Records
7.1 CCPN and HMO shall keep all administrative and financial records
and CCPN Physicians and CCPN Participating Providers shall keep
all medical records pertaining to this Agreement and furnish such
records to the appropriate party at a time and in a manner and
mode as may be required. CCPN and HMO shall make all records
available for inspection during normal business hours; provided,
however, that CCPN shall have no obligation to disclose
confidential information without proper authorization from
patients, patient representative, and/or providers. CCPN and HMO
agree that a Member's records will be treated as confidential, and
in the same manner, as any other patient records. HMO and CCPN
agree to comply with all state and federal laws and regulations
regarding the confidentiality of patient records. CCPN shall
maintain such records and provide such information to HMO as may
be necessary for HMO's quality and utilization programs to remain
in compliance with state and federal law and to meet the TDH
requirements for the STAR Program. Such maintenance of records and
information shall survive the expiration or earlier termination of
this Agreement for a period of not to exceed six (6) years or such
other period as may be required by record retention policies of
the State of Texas or HCFA.
8. Term and Termination
8.1 This Agreement shall be effective as of October 1, 1996, (the
"Effective Date"), and shall remain in effect through the end of
STAR
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Program in the Service Area, unless otherwise terminated in
accordance with this Agreement.
8.2 This Agreement shall terminate immediately upon:
(1) revocation or suspension of HMO's certificate of authority
to operate a health maintenance organization; or
(2) revocation or suspension of HMO's participation in the STAR
Program in Service Area; or
(3) any petition of bankruptcy or any insolvency process that
is filed by or against HMO or CCPN; or
(4) revocation of CCPN's 5.01(a) status pursuant to the Texas
Medical Practice Act.
(5) revocation of Xxxx Children's Medical Center's hospital
license as issued by the Texas Department of Health.
(6) failure of Xxxx Children's Health Care Network and
Americaid, Inc. to execute a mutually satisfactory
agreement detailing the terms of sharing pre-operational
costs and other business arrangements by November 1, 1996.
8.3 CCPN shall immediately suspend a CCPN Physician or a CCPN
Participating Provider from participation in the STAR Program in
Service Area if, in CCPN's or HMO's opinion, failure to take
immediate action has the potential to result in danger to the
health of any Member receiving Covered Health Services from such
provider under this Agreement. CCPN shall immediately confer in
good faith with HMO regarding such suspension. If CCPN PCP, CCPN
Specialist Physician or a CCPN Participating Provider has not, in
CCPN's or HMO's opinion, remedied the concerns which caused
suspension within thirty (30) days of such suspension notice, such
provider shall be terminated as a CCPN PCP, CCPN Specialist
Physician or a CCPN Participating Provider from participation in
the STAR Program in Service Area in accordance with such
provider's agreement with CCPN.
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8.4 In the event of termination of this Agreement, or a CCPN agreement
with an individual CCPN Physician or CCPN Participating Provider,
CCPN and its providers shall continue to arrange for the provision
of Covered Health Services to affected Members in accordance with
this Agreement, and HMO shall continue to compensate such
providers under the reimbursement provisions set forth in this
Agreement as of the date of termination until HMO or CCPN
notifies the other party that alternative coverage arrangements
have been made with respect to the affected Members. Upon
termination of this Agreement, or a CCPN agreement with an
individual CCPN Physician or CCPN Participating Provider, HMO
shall notify Members of such termination and use its best efforts
to assign Members to, or require Members to select, another
provider with sixty (60) days (or other such time as may be
required under state or federal law.) If HMO fails to transfer
Member within applicable time frame, the treating provider shall
thereafter be reimbursed at his or her usual and customary rates,
but the Pediatric Risk Fund will be charged at the lesser of the
then current Medicaid allowable rate or the lowest reimbursement
rate agreed to between provider and CCPN or HMO. HMO and CCPN
agree that nothing in this provision and/or Agreement authorizes
any provider to abandon any patient.
8.5 Dispute Resolution.
1. The parties to this Agreement agree to meet and confer in
good faith to resolve any controversy, dispute or claim
arising out of or relating to this Agreement through
informal discussions between the parties. If the parties
are unable to resolve the dispute through such discussions,
either party may initiate mediation.
2. Mediation Procedure.
a. Initiation Procedure. The initiating party shall
give written notice to the other party, describing
the nature of the dispute, its claim for relief and
identifying one or more individuals with authority
to resolve the dispute on such party's behalf. The
other party shall have five (5) business days
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within which to designate in writing one or more
individuals with authority to resolve the dispute on
such party's behalf.
b. Selection of Mediator. Within ten (10) business days
from the date of designation, the parties shall make
a good faith effort to select a person to mediate
the Dispute. If no mediator has been selected under
this procedure, the parties shall jointly request a
state district judge in Tarrant County, Texas to
supply within ten (10) business days a list of
potential qualified mediators. Within five (5)
business days of receipt of the list, the parties
shall rank the proposed mediators in numerical order
of preference, simultaneously exchange such list,
and select as the mediator the individual receiving
the highest combined ranking. If such a mediator is
not available to serve, they shall proceed to
contact the mediator who was next highest in ranking
until they select a mediator.
c. Time and Place for Mediation: Parties Represented.
In consultation with the mediator selected, the
parties shall promptly designate a mutually
convenient time and place for the mediation, such
time to be no later than thirty (30) days after
selection of the mediator. In the mediation, each
party shall be represented by a person with
authority and discretion to negotiate a resolution
of the dispute and may be represented by counsel.
d Conduct of Mediation. The mediator shall determine
the format for the meetings, and the mediation
session shall be private. The mediator will keep
confidential all information learned in private
caucus with any party unless specifically authorized
by such part to make disclosure of the information
to the other party. The parties agree that the
mediation shall be governed by the provisions of
Chapter 154 of the Texas Remedies and Practice Code
and such other rules as the mediator shall
prescribe.
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e. Fees of Mediator: Disqualification. The fees and
expenses of the mediator shall be shared equally by
the parties. The mediator shall be disqualified as
a witness, consultant, expert or counsel for nay
party with respect to the dispute and any related
matters.
f. Confidentiality. Mediation is a compromise
negotiation for purposes of Federal and State Rules
of Evidence and constitutes privileged
communication under Texas law. The entire mediation
process is confidential, and such conduct,
statements, promises, offers, views and opinions
shall not be discoverable or admissible in any legal
proceeding for any purpose.
9. Relationship of Parties
9.1 This Agreement is not intended to create, nor should it be
construed to create, any relationship between the parties other
than that of independent contractors contracting with each other
solely for the purpose of effecting the provisions of this
Agreement. Neither of the parties hereto, nor any of their
respective employees, shall be construed to be the agent,
employee, partner or representative of the other.
9.2 Each party will be responsible for its own acts or omissions that
result in injury or damage to individuals or property that arise
as a consequence of the party's performance of this Agreement
whether or not as a result of negligence. This provision shall
survive the termination of this Agreement.
9.3 HMO agrees not to restrict or interfere in any manner with the
provision of Covered Health Services by CCPN, CCPN Primary Care
Physicians, CCPN Specialist Physicians and CCPN Participating
Providers. Accordingly, HMO agrees CCPN, CCPN Physicians and CCPN
Participating Providers shall have the sole responsibility in
connection with the provision of Covered Health Services and that
nothing in this Agreement shall interfere with the professional
relationship between a Member and CCPN, CCPN Physician and CCPN
Participating Provider. HMO and CCPN further agree that this
clause
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does not purport to indemnify HMO for any tort liability resulting
from HMO's acts or omissions.
10. Miscellaneous
10.1 The waiver by either party of a breach or violation of any
provisions of this Agreement shall not operate as or be construed
to be a waiver of any subsequent breach thereof.
10.2 This Agreement shall comply and observe with all federal and state
laws in effect at Effective Date or which may come into effect
during the term of this Agreement, except where waiver of said
laws are granted by the applicable federal or state authority.
10.3 This Agreement shall be governed by and construed in accordance
with laws of the State of Texas.
10.4 The invalidity or unenforceability of any terms or conditions
hereof shall in no way effect the validity or enforceability of
any other terms or provisions hereof.
10.5 Neither party to the Agreement shall encumber, assign or otherwise
transfer the Agreement or any interest in this Agreement to any
other party; provided, however, CCPN may contract for the
provision of management and administrative services.
10.6 CCPN agrees that HMO may use CCPN Physicians' or CCPN
Participating Providers' name, address, phone number, and types of
services offered in HMO's roster of Participating Physicians and
in other HMO materials upon prior written notice to CCPN and with
prior approval by CCPN.
10.7 CCPN agrees to cooperate with HMO in programs relating to
coordination of benefits and third party liability coverage and to
execute any further documents that ' reasonably may be required or
appropriate for this purpose.
10.8 As used herein, the masculine gender includes the feminine, and
the singular includes the plural.
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10.9 Any notice, approval, waiver, objection or other communication
(for convenience, "notice") required or permitted to be given
hereunder or given in regard to this Agreement by one party to the
other shall be in writing and the same shall be given and be
deemed to have been served and given (a) if hand delivered, when
delivered in person to the address set forth hereinafter of the
party to whom notice is given, or (b) if mailed, when placed in
the United States mail, postage prepaid, by Certified Mail, Return
Receipt Requested, addressed to the party at the address
hereinafter specified. Any party may change its address for
notices by notice theretofore given in accordance with this
Section 10.9 and shall be deemed effective only when actually
received by the other party.
If to CCPN: Xxxx X. Xxxxxxxx, M.D.
President, C.E.O.
Xxxx Children's Physician
Network
000 Xxxxxxx Xxxxxx
Xxxx Xxxxx, Xxxxx 00000
Xxxxxxx X. Xxxxxx
President
Xxxx Children's Medical Center
000 Xxxxxxx Xxxxxx
Xxxx Xxxxx, Xxxxx 00000
Xxxx Xxxxxxx
Chief Financial Officer
Xxxx Children's Medical Center
000 Xxxxxxx Xxxxxx
Xxxx Xxxxx, Xxxxx 00000
with copy to counsel for CCPN: General Counsel
Xxxx Children's Medical Center
000 Xxxxxxx Xxxxxx
Xxxx Xxxxx, Xxxxx 00000
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If to HMO: Xxxxx X. Xxxxxxx, Xx.
President & CEO
AMERICAID - Texas, Inc.
000 Xxxxxxx Xxxxxx, 0xx Xxxxx
Xxxx Xxxxx, Xxxxx 00000
with copy to counsel for HMO: General Counsel
AMERICAID Community Care
0000 Xxxxxxxxxxx Xxxx
Xxxxx 000
Xxxxxxxx Xxxxx, Xxxxxxxx 00000
10.10 CCPN and HMO shall maintain in confidence all pricing and
financial information related to this Agreement and shall use
their best efforts to protect such information from being used by
any of their employees or agents in any way that is detrimental to
CCPN or HMO.
10.11 CCPN and HMO agree not to use the name, symbol, trademark or
service xxxx of the other party in any advertising or promotional
material or literature without the express prior and written
consent of either party and will cease any and all use previously
consented to upon termination of this Agreement. This excludes the
names and demographic information of providers for use in the
provider directories.
10.12 CCPN shall not be precluded from participation in other local,
state or national managed care networks.
10.13 At least ninety (90) days prior to each Contract Anniversary Date,
either CCPN or HMO may request that the reimbursement
methodologies and/or mechanisms set forth in Attachments B and C
be adjusted. Each party shall negotiate in good faith to amend
Attachments B and C to preserve the economic expectations of the
parties to the greatest extent possible in a manner consistent
with such changes. If the parties cannot reach agreement, this
Agreement shall continue in force without change for the following
year until either party can again request a change ninety (90)
days before a Contract Anniversary Date. Notwithstanding the
foregoing, if TDH changes the amount of premium paid by aid
category for the STAR Program, CCPN and
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HMO shall mutually agree to amend Attachments B and C. In the
event the parties cannot reach agreement, the payments
contemplated in Attachment B and C shall be amended by the
percentage increase or decrease in the premium of each affected
aid category. In the event that payment for a particular aid
category is modified by TDH, the revised reimbursement schedule
shall be actuarially determined by a mutually acceptable actuary.
10.14 This Agreement may be modified at any time by written mutual
consent of HMO and CCPN or when modifications are mandated by
changes in Federal or State laws.
10.15 Except for the agreement between Xxxx Children's Health Care
Network and Americaid, Inc. described in Section 8.2 hereof, this
Agreement constitutes the sole and only agreement of the parties
hereto and supersedes any prior understandings or written or oral
agreements between the parties respecting the within subject
matter.
10.16 The remedies provided to the parties by this Agreement are not
exclusive or exhaustive, but are cumulative of each other and in
addition to any other remedies the parties may have.
HISTORICALLY UNDERUTILIZED BUSINESSES
Americaid Texas, Inc. d/b/a Americaid Community Care is strongly committed to
ensuring that Historically Underutilized Businesses (HUBS) are afforded the same
opportunities as other businesses when competing as potential subcontractors
under State government contracts and that their products and services are
examined and judged objectively on their competitive merit. This corporate
commitment applies particularly to the products and services procured through
the Texas Department of Health (TDH) XxxxXXXX Health Initiative. The TDH has
established goals for procuring XxxxXXXX Health Initiative contract value
through HUBS, including health care providers and suppliers. Americaid Community
Care intends to exceed these goals. Accordingly, Americaid Community Care
expressly encourages the party to the Agreement to support and expand use of
HUBs and to document and report HUB procurement dollars to the TDH so that they
may be appropriately credited towards the XxxxXXXX Health Initiatives goals.
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IN WITNESS WHEREWOF, the undersigned have executed this Agreement to be
effective on October 1, 1996.
CCPN: HMO:
By: /s/ Xxxx Xxxx Xxxxxxxx, MD By: /s/ Xxxxx X. Xxxxxxx, Xx.
----------------------------------- ----------------------------------
Xxxx Xxxx Xxxxxxxx Xxxxx X. Xxxxxxx, Xx.
President & Chief Executive Officer President & Ceo
Xxxx Children's Physician Network AMERICAID Texas, Inc.
Date: 10/1/96 Date: 10/1/96
----------------------------------- ----------------------------------
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ATTACHMENT A
FINANCIAL ARRANGEMENTS
I. Additional Definitions. The following additional definitions shall apply
to this Attachment A.
A. Adult Enrollees means any individual 16 years of age and above
residing in the Service Area who is (1) in a Medicaid eligibility
category included in the STAR Program, and (2) enrolled in the
STAR Program as a member of Americaid Texas, Inc.
B. Adult Pool means a Risk Fund established by HMO and used for the
payment of all professional, hospital, ancillary and other medical
claim expenses attributable to Adult Enrollees. Expenses charged
to the Adult Pool shall include, but not be limited to, inpatient
facility fees, fees for alternative inpatient care (e.g., skilled
nursing, extended care and home care), outpatient surgery fees,
professional fees for primary and specialty care, and ancillary
service fees.
C. Pediatric Pool means a Risk Fund established by HMO and used for
payment of all monthly capitation payments and valid
fee-for-service claims for Covered Health Services attributable to
Members.
D. Profit Product Pool means a Risk Fund established by HMO to track
the payment of (1) all medical claim expenses, (2) administration
and marketing costs, (3) licensing fees and (4) profit sharing
payment made to TDH pursuant to the State Contract out of the
Total TDH Payment.
E. Risk Fund is a defined report to which revenues and expenses are
posted for the purpose of sharing actual and expected claim
liabilities and funding required to support the claim liability.
F. Total TDH Payment means all revenues and payments received by HMO
from TDH for each aid category of the STAR Program.
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II. Pediatric Capitation Allocation
A. HMO will receive a monthly TDH Payment (as defined below) paid
directly to HMO by TDH for Members enrolled or assigned to HMO.
"Monthly TDH Payment" means all revenue and payments received by
HMO each month of this Agreement from TDH for Members. The Monthly
TDH Payment shall be based on the eligibility category, as
determined by TDH, of Members. From this Monthly TDH Payment, HMO
shall make a monthly CCPN Capitation Payment. This CCPN Capitation
Payment shall be seventy-five percent (75%) of the total Monthly
TDH Payment received by HMO from TDH for Members, which amount
will be posted to the Pediatric Pool.
1. The monthly TDH Payment will be paid to HMO by the tenth
(10th) State working day of each month pursuant to the
contract between HMO and TDH. HMO shall post the CCPN
Capitation Payment to the Pediatric Pool within five (5)
business days of receipt of the payment from TDH, but in no
event later than the twelfth (12th) State working day.
2. Each month's CCPN Capitation Payment will be computed on
the basis of the current monthly Enrollment Report, which
is generated by TDH and sent to HMO. This current
Enrollment Report will be sent to CCPN by HMO
simultaneously with the posting of the CCPN Capitation
Payment to the Pediatric Pool. It shall include the names
and aid categories of Members included in the CCPN
Capitation Payment and shall be subject to CCPN review and
audit.
3. HMO will handle retroactive recoupment of capitated
payments from CCPN and CCPN Physicians as follows:
a. If the retroactive recoupment is a result of action
taken by TDH, then the retroactive recoupment will
follow the procedure applied to the HMO by TDH.
Under this procedure, TDH will not recoup, through
HMO, the Capitation Payment for a Member when CCPN
Physicians or CCPN Participating Providers have
actually provided a service or due to a subsequent
ineligibility determination unless 1) a
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Member cannot use CCPN facilities (e.g., move to a
different county, correction of computer or human
error, including, but not limited to, instances
where more than one plan was paid a premium for the
same Member, the Member dies prior to the first day
for the month covered by the payment, etc.) in which
case, TDH, through HMO, will recoup the Capitation
Payment for such Member; or 2) if a Member's type of
program designation needs to be retroactively
corrected in which case, TDH will recoup, through
HMO, the Capitation Payment for such Member under
the previous type program and retroactively make a
Capitation Payment to CCPN or CCPN Physicians,
through HMO, under the revised type program
designation, if appropriate; or 3) TDH notifies HMO
in writing of a valid determination by TDH of the
need to retroactively recoup the capitation payment
made for a Member.
b. Additionally, if CCPN, CCPN Physicians or CCPN
Participating Providers comply with the verification
of eligibility and benefits procedures provided to
CCPN by the Effective Date, HMO shall be financially
responsible to CCPN and CCPN Physicians for the CCPN
Capitation Payment for all care provided by CCPN
Physicians and/or CCPN Participating Providers to an
ineligible person or retroactively canceled Member
due to erroneous, incomplete or delayed HMO
eligibility listings.
4. If HMO is notified that it will be assessed a penalty by
TDH for failure to perform administrative functions, as
described in the State Contract, HMO and CCPN shall
immediately meet to discuss the cause of the TDH penalty.
If the failure to perform administrative functions is the
result of HMO's action, HMO shall be responsible for making
the monthly TDH Payment whole. If CCPN caused the failure
of HMO to provide an administrative function, then CCPN
shall be responsible for making the monthly TDH Payment
whole.
B. The Pediatric Pool shall be used by HMO for the payment and
adjudication of monthly capitation payments and valid claims
submitted by
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CCPN Physicians and CCPN Participating Providers for the Covered
Health Services.
III. Deductions
A. HMO will deduct and retain sixteen percent (16%) of the Monthly
TDH Payment for its administration and marketing activities and
any payments to Value Behavioral Health for administrative
services.
B. HMO will deduct and retain two percent (2%) of the Monthly TDH
Payment to maintain a Texas HMO license.
IV. Reimbursement of CCPN Physicians and Providers. CCPN Physicians and
Providers shall be compensated by HMO out of Pediatric Risk Fund for
Covered Health Services provided to Members as set forth below:
A. Payment to Primary Care Physicians or Providers. As compensation
for services provided or arranged for by PCP to Members under the
STAR Program in the Service Area, HMO shall make a monthly
Capitation payment from the Pediatric Risk Fund based on the
age/sex adjusted Capitation rates referenced in Attachment B of
this Agreement. This monthly PCP Capitation payment shall include
all retroactive additions and deletions as referenced in II.B.3.a
and II.B.3.b above. Monthly PCP Capitation payment is due to PCP
five (5) business days after receipt of Monthly TDH Payment by
HMO. PCP will be reimbursed for non-capitated services provided to
Members from the Pediatric Risk Fund on a fee-for-service basis at
the reimbursement rate agreed to between such provider and CCPN.
If PCP and CCPN have not agreed to a reimbursement rate, then PCP
will be reimbursed at the then current Medicaid allowable rate for
non-capitated services. Primary Care Physicians or Providers shall
submit itemized statements on current HCFA 1500 claim forms with
current HCPCS coding, current ICD9 coding and current CPT4 coding
for all capitated services and non-capitated Covered Health
Services provided by Primary Care Physicians or Providers to HMO
at the address set forth below within sixty (60) days of the date
the Covered Health Service was provided. PCP shall be paid by HMO
no later than forty-five (45) days after receipt by HMO of a
completed Clean Claim for non-capitated Covered Health Services.
If Clean Claims are not paid
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within forty-five (45) days of submission, HMO shall be subject to
Section IV.D. below.
B. Payments to Specialist Physicians. Specialist Physicians will be
reimbursed from the Pediatric Risk Fund for Covered Health
Services provided to Members on a fee-for-service basis at the
reimbursement rate agreed to between such physician and CCPN. If
Specialist Physicians and CCPN have not agreed to a reimbursement
rate, then Specialist Physician will be reimbursed at the then
current Medicaid allowable rate. Itemized statements on current
HCFA 1500 claim forms with current HCPC coding, current ICD9
coding and current CPT4 coding for all Covered Health Services
provided by Specialist Physicians must be submitted by Specialist
Physician to HMO at the address set forth below within sixty (60)
days of the date the Covered Health Service was provided. If the
claim form is not timely filed with HMO within sixty (60) days
from the date the Covered Health Service was provided, the right
to payment will be deemed waived by the Specialist Physician
unless Specialist Physician establishes to the reasonable
satisfaction of CCPN that there was reason able justification for
a delay in billing or that delay was caused by circumstances
beyond Specialist Physician's control. Specialist Physician shall
be paid by HMO no later than forty-five (45) days after receipt by
HMO of a completed Clean Claim for Covered Health Services. If
Clean Claims are not paid within forty-five (45) days of
submission, HMO shall be subject to Section IV:D. below. HMO will
notify Specialist Physician within thirty (30) days of HMO's
receipt of any claim(s) that is not a Clean Claim(s).
C. Payments to CCPN Participating Provider. CCPN Participating
Providers will be reimbursed for Covered Health Services provided
to Members on a fee-for-service basis as listed in Attachment C of
this Agreement. These fee-for-service rates will be the
reimbursement rate agreed to between such Participating Provider
and CCPN. If Participating Provider and CCPN have not agreed to a
reimbursement rate, then Participating Provider will be reimbursed
at the then current Medicaid allowable rate. Itemized statements
on current HCFA 1500 claim forms with current HCPC coding, current
ICD9 coding and current CPT4 coding for all Covered Health
Services provided by CCPN Participating Providers must be
submitted by CCPN Participat-
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ing Provider to HMO at the address set forth below within sixty
(60) days of the date the Covered Health Service was provided. If
the claim form is not filed with HMO within sixty (60) days from
the date the Covered Health Service was provided, the right to
payment will be deemed waived by the CCPN Participating Provider
unless CCPN Participating Provider establishes to the reasonable
satisfaction of CCPN that there was reasonable justification for a
delay in billing or that delay was caused by circumstances beyond
CCPN Participating Provider' s control. CCPN Participating
Provider shall be paid by HMO within forty-five (45) days after
receipt by HMO of a completed Clean Claim for Covered Health
Services. If Clean Claims are not paid within forty-five (45) days
of submission, HMO shall be subject to Section IV.D. below. HMO
will notify CCPN Participating Provider within thirty (30) days of
HMO's receipt of any claim(s) that is not a Clean Claim(s).
D. Claims Reimbursement. All Clean Claims submitted to HMO for
payment will be paid within forty-five (45) days of the date of
HMO's receipt of such Clean Claim. Claims paid after this
forty-five (45) day period will bear interest at the current prime
rate published by the Wall Street Journal ("WSJ") until paid.
Claims paid incorrectly or not paid in full will be reprocessed
and paid within thirty (30) days of the date HMO is notified in
writing of incorrect or underpayment. Claims not corrected and
paid in full within this thirty (30) day period will bear interest
at the current prime rate published by WSJ until paid.
E. Overpayment. CCPN, CCPN Physicians and/or CCPN Participating
Providers shall promptly report overpayments to HMO. HMO shall,
upon notice to HMO or upon its discovery, deduct such overpayment
from future payments with an explanation of the action taken.
F. In-house Pediatric Service. CCPN and HMO jointly will develop a
program for PCPs to elect to use the CMC In-house Pediatric
Service for Members admitted to CMC.
G. Reinsurance. Each party will purchase or obtain its own
reinsurance policy or program and each will retain any recoveries
from their program.
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V. Risk Funds.
A. General Provisions. HMO and CCPN shall establish an Adult Pool, a
Pediatric Pool, and a Profit Product Pool to serve as risk sharing
incentive arrangements to monitor utilization goals while
maintaining quality of care. The budget for each pool is set forth
below. Each pool shall be age/sex/benefit adjusted for Members or
Adult Enrollees covered by the applicable pool.
1. Pediatric Pool. HMO will allocate seventy-five percent
(75%) of the Total TDH Payment attributable to Members (the
"Pediatric Target Amount") to the Pediatric Pool.
a. If less than the Pediatric Target Amount is spent
for payment of Covered Health Services, then all (or
100%) of such surplus below the Pediatric Target
Amount (the "CCPN Surplus") shall be paid directly
to CCPN by HMO in accordance with the Settlements
described in Section VI below.
b. If more than the Pediatric Target Amount but not
more than eighty percent (80%) of the Total TDH
Payment attributable to Members is spent for the
payment of Covered Health Services, then the excess
over the Target Amount, up to, and including, eighty
percent (80%) (the "CCPN Deficit"), shall be the
financial responsibility of CCPN in accordance with
the Settlements described in Section VI below. CCPN
shall be given credit for any funds paid by CCPN to
cover deficits in the Pediatric Pool during each
year of this Agreement ("Net CCPN Deficit").
c. If more than eighty percent (80%) of the Total TDH
Payment attributable to Members is spent for the
payment of Covered Health Services, then the excess
costs over eighty percent (80%) (the "Pediatric
Deficit") shall be allocated twenty-five percent
(25%) to CCPN and seventy-five percent (75%) to HMO
in accordance with the Settlements described in
Section VI below. CCPN shall be given credit for any
funds paid by CCPN to cover deficits in the
Pediat-
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ric Pool during each year of this Agreement ("Net
CCPN Deficit").
2. Adult Pool. HMO will allocate seventy-five percent (75%) of
the Total TDH Payment attributable to Adult Enrollees (the
"Adult Target Amount") to the Adult Pool. Twenty-five
percent (25%) of any surpluses or deficits in the Adult
Pool under or over the Adult Target Amount will be
allocated to CCPN and seventy-five percent (75%) of any
surpluses and deficits in the Adult Pool under or over the
Adult Target Amount will be allocated to HMO in accordance
with the Settlements described in Section VI below.
3. Profit Product Pool. CCPN and HMO agree to share profits as
detailed in the agreement between Xxxx Children's Health
Care Network and Americaid, Inc.
VI. Reviews and Settlement. The Pediatric Pool and Adult Pool shall be
subject to quarterly year-to-date reviews and each Risk Fund shall have
an annual final settlement at the Contract Anniversary Date.
A. Reviews. At the end of the first three (3) months of this
Agreement, a quarterly year-to-date review of the Pediatric Pool
and the Adult Pool will be performed. This review will be
completed by the last day of the next quarter with subsequent
quarterly year-to-date reviews to take place every three (3)
months thereafter, except for the first year of this Agreement
where the fourth quarter will be two (2) months (July and August).
For each quarterly review, HMO will calculate the cumulative
monthly TDH Payment made to the Pediatric Pool and the Adult Pool.
HMO shall also calculate the cumulative monthly claims and
Capitation Amounts paid for the provision of Covered Health
Services to Members and the cumulative monthly claims and
capitation amounts paid for medical claims expenses of Adult
Enrollees. HMO will also report total incurred but not reported
(IBNR) claims. HMO shall provide copies of lag schedules and other
data used to determine IBNR.
B. Settlements. Reconciliation for surpluses and deficits in each
Risk Fund shall occur at the end of each year of this Agreement.
At each
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Contract Anniversary Date, final settlements of the Pediatric
Pool, the Adult Pool, and the Profit Product Pool will be
performed within ninety (90) days of the Contract Anniversary
Date. CCPN must approve the final settlement report for each Risk
Fund or HMO shall be in default of this Agreement. The CCPN
Surplus in the Pediatric Pool, if any, shall be paid by HMO to
CCPN within thirty (30) days after receipt by CCPN of the
approved, final settlement report for the Pediatric Pool.
Additionally, CCPN's percentage share of the Net CCPN Deficit and
the Net Pediatric Deficit in the Pediatric Pool, CCPN's percentage
share of the surpluses or deficits in the Adult Pool and CCPN's
percentage share of the surplus in the Profit Product Pool
calculated in accordance with Section V above, will then be
aggregated together. If a net surplus exists, CCPN will be paid
its surplus within thirty (30) days after receipt of a final
settlement report approved by CCPN. If a net deficit exists, CCPN
will pay HMO the net deficit within thirty (30) days after receipt
of a final settlement report approved by CCPN.
C. Settlement in the Event of Termination. After termination of this
Agreement, HMO and CCPN agree to reconcile payments to and
amounts owed from all Risk Funds in accordance with this Section
VI.
VII. Provider Quality Incentive Pool and Preventive Health Performance
Incentive.
A. HMO has developed a Provider Quality Incentive Pool ("PQIP") to
provide incentives to physicians in reaching preventive health
performance objectives. HMO and CCPN will jointly determine how to
administer the PQIP and pay physicians who qualify for the PQIP.
B. Additionally TDH has retained a performance objective Capitation
Amount of two dollars ($2.00) per Member per month that is
available to be paid to the HMO after the end of the each contract
year and after appropriate encounter data is reviewed and
confirmed by the Texas Department of Health. TDH will determine
the performance of HMO against the objectives described in the
State Contract. To the extent that the HMO receives incentive
payments from the TDH for meeting the preventive health
performance objectives, HMO will
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distribute to CCPN seventy-five percent (75%) of those funds
attributable to CCPN Members within five (5) days of receipt of
such payment from TDH.
VIII. Adult Enrollees Needing Pediatric Services. CCPN agrees that CCPN
Physicians and CCPN Participating Providers will provide pediatric
services to Adult Enrollees provided that; (1) HMO will pay CCPN
Physician and CCPN Participat ing Provider directly for such services at
the reimbursement rate agreed to by such CCPN Physician and CCPN
Participating Provider and (2) the Pediatric Pool will not be used for
payment of any health care services provided to Adult Enrollees.
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ATTACHMENT A
EXHIBIT 1
INTENTIONALLY LEFT BLANK
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ATTACHMENT A
EXHIBIT 2
INTENTIONALLY LEFT BLANK
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ATTACHMENT A
EXHIBIT 3
INTENTIONALLY LEFT BLANK
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ATTACHMENT A
EXHIBIT 4
Managed Care Reporting Requirements
Xxxx Children's Medical Center
As referenced in Section 1.13 of this Agreement, these reports are for
illustrative purposes only.
[_] Report: Financial Summary
Data Elements
- PMPM Age/Gender Capitation Payments
- Participating Provider
- Member
- Member Months
- Participating Provider - Detail
- CCMC - Summary
- Participating Provider Billed Charges
- Participating Provider Allowed Charges
- Participating Provider Withholds
- Charges Not Covered
- Recoveries/Refunds
Frequency: Monthly
Distribution: Network (finance)
[_] Report: Analysis Of Stop Loss/Reinsurance
Data Elements
- PMPM Age/Gender Capitation Payments
- Participating Provider
- Member
- Member Months
- Participating Provider - Detail
- CCMC - Summary
- Participating Provider Billed Charges
- Participating Provider Allowed Charges
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- Participating Provider Withholds
- Charges Not Covered
- Recoveries/Refunds
Frequency: Monthly
Distribution: Network (finance)
[_] Report: Retroactive Reporting/Calculation
Data Elements
- capitation
- enrollment
Frequency: Monthly
Distribution: Network (finance)
[_] Report: Pre-Authorization/Authorization
Data Elements
- Member/Subscriber Name
- Subscriber/Number/Medicaid Number (both)
- Expected date of service
- Diagnosis
- Service/Procedure
- PCP
- Service Participating Provider
- Authorization Number
- Authorizer Name/Phone
- Out-Of-Area Flag
- Referring Participating Provider
- Override decision flag
- Number of visits authorized
- Expected cost of service
Frequency: Weekly
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Distribution: Network (finance)
[_] Report: Incurred But Not Reported Charges by major category,
i.e., SCP, Hospital, other medical
Data Elements
- Month of Service
- Month Paid
- Lag Schedules
- Reconciliation of IBNR adjustments
Frequency: Monthly
Distribution: Network (finance)
[_] Report: Status of Encounter/Claims Processing
Data Elements
- Medicaid Number/Member Number
- Participating Provider Number
- Claim Number
- Service Code
- Date(s) of Service
- Diagnosis/CPT Code
- PCP
- Total Charge
- Date of Service
- Date of Receipt
- Amount Charged
- Amount Paid
Frequency: Daily Summary
Weekly Detail
Distribution: Network (finance)
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[_] Report: Pended Claims
Data Elements
- Member Name
- Member Number
- Claim Number
- Service Code
- Date(s) of Service
- Diagnosis/CPT Code
- Reason for Pended
- PCP
- Total Charge
- Expected Review Date
Frequency: Weekly
Distribution: Network
[_] Report: Daily Inpatient Census Report
Data Elements
- Member Name
- Member Number
- Authorization Number
- Referring Physician
- Admitting Physician
- Diagnosis Code, Procedure Code
- Admission Date
- Days Authorized
- Discharge Date
- Hospital Name
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[_] Report: Member Service
Data Elements
- Participating Provider, claim, referral information from
Customer Services module
- predefined codes to track problems and complaints
- complaint tracking
- tracking of formal grievances
- tracking of inquiries from Participating Providers and
prospects as well as members
Frequency: Monthly
Distribution: Network (finance)
[_] Report: Terminated Members Outstanding Claims
- Member Name/Address
- Member Number
- Eligibility Date
- Medicaid ID Number/Subscriber Number
- Guarantor/Guardian Name
- Date of Birth
- PCP
- Sex
- Group Name
Frequency: Ad Hoc
Distribution: CCMC
[_] Report: Utilization Management Tracking
Data Elements
- Medicaid Number/Member Number
- Participating Provider
- PCP, specialist
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- Claim Number
- Service Code
- Date(s) of Service
- Diagnosis/CPT Code
- Total Charge
- Date of Service
- Date of Receipt
- Amount Charged
- Amount Paid
Frequency: Monthly
Distribution: Network (finance)
[_] Report: Participating Provider Reports
Data Elements
- Member Name
- Subscriber Name
- Service Type (Inpatient/Outpatient, Etc.)
Detail
Summary
- Primary Care Physician or Provider
- Dates of Service (To/From)
- Service/Procedure
- Authorization Code
- Charge
Frequency: Ad Hoc
Distribution: CCMC
[_] Report: Primary Care Physician or Provider Analysis Report
Data Elements
- Member Name
- Subscriber Name
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- Service Type (Inpatient/Outpatient, Etc.)
Detail
Summary
- Referrals
- Dates of Service (To/From)
- Service/Procedure
- Authorization Code
- Charge/Cost
- Summary:
Total PMPM
Total Members Treated
Total Charges by Service Type
Capitation
Denied Encounter
Frequency: Ad Hoc
Distribution: CCMC
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ATTACHMENT A
EXHIBIT 5
DELEGATION OF CREDENTIALING AGREEMENT
THIS EXHIBIT 5 to that certain CCPN and HMO Medicaid Agreement (the "Agreement")
by and between HMO and CCPN sets forth certain additional terms governing the
relationship between the parties.
RECITALS
1. HMO maintains credentialing programs designed to periodically review and
monitor the credentials of physicians and providers who render Covered
Services to Members. HMO has established policies and procedures for
delegating certain of its administrative functions to CCPN where CCPN's
credentialing and re- credentialing standards are consistent with HMO's
standards and the standards of the NCQA, the Federal Medicaid Quality
Assurance Reform Initiative (QARI), and JCAHO.
2. CCPN desires to facilitate the credentialing review of all CCPN
Physicians and CCPN Participating Providers by performing certain
delegated functions on behalf of HMO, and HMO is willing to delegate such
functions, on the terms and conditions set forth below:
NOW THEREFORE, in consideration of the premises and of the mutual covenants
contained herein, the parties do hereby agree as follows:
1. A. Capitalized terms used herein and not defined herein shall have
the mean ing ascribed to those terms in the CCPN and HMO
Agreement.
B. Except as modified below, the provisions of the CCPN and HMO
Agreement shall remain in full force and effect.
2. CCPN will provide a copy of its credentialing policies and procedures
before or with the execution of the Agreement which shall be based on
current NCQA, QARI and JCAHO standards. CCPN has the power and authority
under applicable state law to accept the delegation of credentialing
functions.
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3. HMO hereby delegates to CCPN, and CCPN hereby agrees to provide, the
following credentialing and re-credentialing functions for all CCPN
Physicians and CCPN Participating Providers in accordance with CCPN's
credentialing policies and procedures, as these policies have been
approved by HMO, provided that in any circumstance where CCPN's
credentialing policies and procedures are less stringent than HMO's
credentialing policies and procedures, HMO's policies and procedures
shall apply:
[_] verification of Board certification for any and all specialties in
which each provider represents he/she/it is certified;
[_] verification of completion of residency and reported performance;
[_] review of CV/work history and confirmation that during the last
five (5) years there are no unexplained gaps of more than six
months;
[_] verification of hospital privileges and good standing;
[_] verification of license from a primary source;
[_] verification of valid and current DEA Certificate;
[_] verification of current malpractice insurance satisfying HMO
standards and collection of documentation in support thereof;
[_] research regarding any malpractice claims;
[_] confirmation that provider's record is clear of any
Medicare/Medicaid sanctions;
[_] confirmation that all credentialing questions on the application
have been answered and that no answer raises an issue;
[_] Confirmation that NPDB search is clean;
[_] confirmation that search of Federation files is clear;
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[_] obtain affidavit from provider that, pursuant to NCQA CR6. 1 and
CR6.2, he or she is fit to practice and has reviewed his or her
application and verifies its correctness/completeness;
[_] (PCP's/OB/GYNs only) performance of a site visit evaluation and
confirmation that evaluation is favorable;
[_] PCP's/OB/GYNs only) performance of medical record review and
confirmation that evaluation is favorable;
[_] (for Texas only) verification of DPS certification;
[_] obtain all necessary attestations and relations with respect to
information needed to perform credentialing;
[_] Re-credential each provider within two years.
4. HMO shall make available to CCPN its credentialing policies and
procedures and shall notify CCPN in writing of all substantive changes to
such credentialing policies and criteria.
5. CCPN shall at all times (a) be accountable to HMO for the credentialing
functions delegated herein (b) obtain HMO's prior written approval of any
revision to CCPN's credentialing policies and procedures used in
connection with the performance of the functions delegated hereunder, (c)
comply with the credentialing and re-credentialing standards of HMO, the
NCQA, QARA and the JCAHO, (d) abide by, and cause its Physicians and
Participating Providers to abide by, the results of any decision of HMO's
credentialing committee, and (e) take appropriate steps to implement
corrective action if HMO notifies CCPN that it has failed to perform or
comply with the terms of this Addendum.
6. HMO reserves the right, in its sole discretion, to disapprove any CCPN
Physician and/or CCPN Participating Provider, regardless of the initial
credentialing or re- credentialing decision, and CCPN's Physicians and
Participating Providers who are disapproved by HMO shall not provide
services to Members pursuant to the CCPN Agreement.
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7. CCPN shall, on a quarterly basis or more frequently if necessary for HMO
to comply with the reporting requirements of its state Medicaid contract,
provide HMO with a written report in a format reasonably acceptable to
HMO which addresses summary results of its credentialing activities. This
report should summarize process indicators, improvement activities, and
status of credentialing and re- credentialing activities.
8. HMO may review periodically CCPN's credentialing policies and criteria
and shall, from time to time, be granted access to CCPN's files, on an
unscheduled basis, to ensure compliance by CCPN with HMO's credentialing
standards. HMO may review the greater of five percent (5%) or fifty (50)
of CCPN's credentialing files in connection with each such audit.
9. HMO shall have the option to revoke its delegation of some or all of the
functions delegated hereunder if: (a) HMO, in its sole discretion, after
giving CCPN a reasonable chance to cure, is dissatisfied with the
arrangement, (b) the delegation is jeopardizing HMO's eligibility for
NCQA accreditation or its compliance with the terms of its state Medicaid
contract, or (c) HMO determines through an audit proves that CCPN has not
complied with HMO's credentialing policies and procedures and, if within
a period of time required by HMO as set forth in a notice of
noncompliance, CCPN fails to respond with a corrective action plan and
effect such plan. Any revocation made pursuant to Sections (a) or (b)
herein shall be effective immediately upon HMO notifying CCPN. If HMO
revokes the delegation of any function, HMO will resume performing that
function.
10. In the event that any of CCPN's Physicians and/or CCPN Participating
Providers ceases to meet HMO's credentialing criteria, or is disapproved
by CCPN or HMO in accordance with Section 9 above, CCPN shall promptly
notify HMO, and if such CCPN Physician and/or CCPN Participating Provider
is a Primary Care Physician and/or providing an active course of
treatment to a Member, make alternate arrangements for the provision of
Covered Services.
11. CCPN shall immediately notify HMO if any information comes to its
attention regarding any adverse action taken with respect to the
licensure of any CCPN Physician and/or CCPN Participating Provider,
suspension or termination (in whole or in part) of a CCPN Physician's
hospital staff privileges or clinical privileges, suspension or
termination of CCPN, or a CCPN Physi-
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ian's, Medicare or Medicaid privileges, a lawsuit is filed against a CCPN
Physician alleging professional negligence, or any other information
that adversely reflects on the ability or capacity of a CCPN Physician to
provide medically appropriate care consistent with appropriate standards
of professional competence and conduct.
12. CCPN agrees to require its Physicians and Participating Providers to
cooperate with and abide by the results of HMO's credentialing policies
and procedures whether implemented through CCPN or directly by HMO.
13. CCPN shall permit HMO to conduct an initial due diligence audit to
confirm that CCPN is in compliance with each of the provisions of this
Addendum. Information disclosed shall be protected by any and all
applicable peer review legal protection.
14. CCPN's credentialing activities shall be coordinated with HMO's quality
improvement program and utilize information derived from HMO's programs,
whether delegated or not, related to member services, utilization
management and quality assurance.
15. CCPN shall comply with all state requirements (including applicable
licensure, State Medicaid and Star Healthplan) and requirements of other
applicable regulatory authorities in the performance of the
administrative functions delegated hereunder. CCPN shall, upon written
request, provide HMO with documentation of the satisfaction of these
requirements.
16. CCPN shall obtain errors and omissions insurance related to its
credentialing activities, or self-insure at its own expense, in the
minimum coverage amount of $1,000,000.
17. Upon the revocation of the functions delegated hereunder or the
termination of the Agreement, CCPN shall assist HMO in the transfer of
records related to the information requested as part of the Credentialing
Program.
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Attachment B
CCPN Physician Reimbursement
Physician reimbursement effective October 1, 1996, shall be governed by the
following reimbursement terms:
I. Primary Care Capitation Payments. HMO shall compensate Primary Care
Physicians or Providers from the Pediatric Risk Pool through
age/sex/benefit adjusted capitation rates for Primary Care Services. A
listing of Primary Care Services included in the capitation rate is
attached.
A. Capitation Payments - Primary Care Physicians or Providers
PMPM capitation rate cells by age/sex factor:
====================================================================================================================================
<500 Member Average 500-750 Member Average >750 Member Average
------------------------------------------------------------------------------------------------------------------------------------
Age
Category Female Male Female Male Female Male
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
Age <2 $39.59 $39.59 $41.67 $41.67 $43.75 $43.75
------------------------------------------------------------------------------------------------------------------------------------
Age 2-4 $13.31 $13.31 $14.01 $14.01 $14.71 $14.71
------------------------------------------------------------------------------------------------------------------------------------
Age 5-14 $8.08 $8.08 $8.51 $8.51 $8.94 $8.94
------------------------------------------------------------------------------------------------------------------------------------
Age 15-19 $7.70 $5.81 $8.10 $6.12 $8.51 $6.43
------------------------------------------------------------------------------------------------------------------------------------
Age 20-24 $8.66 $6.05 $9.12 $6.37 $9.58 $6.69
====================================================================================================================================
For PCP's with <250 members, there will be an annual true-up of 100% of the
Medicaid fee-for-service equivalent in the event capitation payments are less
than this amount.
Rates are adjusted quarterly on a prospective basis, once a membership level has
been maintained during the prior quarter.
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B. Primary Care Fee-For-Service Payments - Primary Care Physicians or
Providers. HMO shall compensate Primary Care Physicians or
Providers for CPT codes not listed on the attached listing of
Primary Care Services on a fee-for-service basis for non-capitated
services provided to Members at the reimbursement rate agreed to
between such provider and CCPN. If PCP and CCPN have not agreed to
a reimbursement rate, then PCP will be reimbursed at the then
current Medicaid allowable rate for non-capitated services with
the exception of the following: 1) Immunizations will be
reimbursed at 90% of the prevailing Medicaid maximum allowable fee
schedule. 2) Injectable drugs will be reimbursed based upon the
cost of the injectable drugs at the average wholesale price (AWP).
III Specialist Reimbursement. HMO shall compensate Specialist Physicians from
the Pediatric Risk Fund for Covered Health Services on a fee for service
basis at the reimbursement rate agreed to between such physician and
CCPN. If Specialist Physicians and CCPN have not agreed to a
reimbursement rate, then Specialist Physician will be reimbursed at the
then current Medicaid allowable rate.
IV Risk Sharing/Incentive Program. Each CCPN Physician will be eligible to
participate in a risk sharing/incentive program to be developed by CCPN.
HMO and CCPN will jointly determine how to integrate the Hospital and
Referral Pool ("HARP") developed by HMO and the Risk Sharing Incentive
Program developed by CCPN.
V Other Reimbursement Schedules. To be completed within fifteen (15) days
of the Effective Date.
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ATTACHMENT C
CCPN Participating Provider Reimbursement Rates
To be completed within fifteen (15) days of Effective Date.
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ATTACHMENT C
Reimbursement Rates for Services Provided at Xxxx Children's Medical Center
Inpatient Services:
All inpatient services will be reimbursed at 60% of billed charges.
Emergency Services - excluding physician charges:
Level 1 (highest intensity) 60% of total charges
Level 2 $500 per case
Level 3 $250 per case
Xxxxx 0 X/X
Xxxxx 0 X/X
Xxxxxxxxxx Surgery:
The Ambulatory Surgery Categories (ASCs) are the Medicare groupings. The
following are all inclusive global fees covering all pre-op admission and lab
services, medications, equipment usage, operating and recovery rooms, and all
other normal supplies and services required for the procedure. Implants and
prosthetics are excluded from these fees and will be reimbursed at current
Medicaid maximum allowable fee schedule. Physician fees are excluded from these
fees.
Group 1 $361
Group 2 $510
Group 3 $585
Group 4 $750
Group 5 $900
Group 6 $1,125
Group 7 $1,300
Group 8 $1,350
Others 60% of charges
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When multiple procedures are performed during the same operative session, the
following hierarchy applies:
First procedure @ 100% of highest ASC rate.
Second procedure @ 50% of next highest ASC rate.
Third procedure @ 35% of next highest ASC rate.
Fourth or more procedure @ 15% of applicable ASC rate.
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ATTACHMENT D
Americaid Contracts
To be completed within fifteen (15) days of the Effective Date.
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Home Health
Private Duty Nursing (RN/LVN) @ $33/hr
Skilled Nursing Visit @ $110/hr
Rehab @ $150/visit
Speech @ $120/visit
Occupational @ $120 per visit
Other Home Health services @ Current medicaid allowables
Other:
Any service not listed will be reimbursed at 60% of billed charges.
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AMERICAID Texas, Inc.
PARTICIPATING GROUP PHYSICIANS AGREEMENT
THIS PARTICIPATING GROUP PHYSICIAN AGREEMENT ("Agreement") effective
9/1, 1995 (the "Effective Date"), is made and entered into by and between
AMERICAID Texas, Inc. ("AMERICAID") and Group for which the authorized
signature appears below.
WITNESSETH
WHEREAS, AMERICAID is a health maintenance organization which will
arrange for the provision of certain health care services to Covered Persons
through a cost-effective, coordinated health care delivery system (sometimes
referred to as the "Provider Network" or "Network");
WHEREAS, Group is comprised of Providers duly licensed to practice
medicine in the state(s) identified in the AMERICAID Physician Application and
meets AMERICAID's physician credentialing criteria;
WHEREAS, AMERICAID desires that Group provide and Group agree to
provide services to Covered Persons under the terms and conditions of this
Agreement; and
WHEREAS, AMERICAID and Group, in order to comply with all applicable
regulatory requirements, agree to be bound by the provisions of this Agreement.
NOW, THEREFORE, in consideration of the mutual covenants and condi
tions contained herein and for other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, AMERICAID and Group
agree as follows:
ARTICLE I. AMERICAID'S OBLIGATIONS
1.1 General. AMERICAID shall be solely responsible for all payment and
administrative activities necessary or required for the operation of a
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health maintenance organization. Such activities shall include, but
are not limited to, making Covered Persons available to the Network,
capital financ ing, marketing, advertising, customer service, claims
processing, collection, maintenance of Network directory and records,
accounting, management, and development of contracts with Providers of
Covered Services.
1.2 Provider Manuals. AMERICAID shall provide Group with a Provider
Manual, to be periodically updated, which details policies and
procedures of AMERICAID, and the terms of which are incorporated
herein by reference.
1.3 Procedures. AMERICAID shall develop and implement grievance, utiliza
tion review, drug utilization, quality assurance and other procedures
required by law or regulation.
1.4 Professional Relationship: Responsibility and Non Exclusivity.
Participating Physicians in the Group shall be solely responsible for
all medical advice and services Participating Physicians in the Group
perform or prescribe with regard to Covered Persons. This Agreement
will not be deemed in any way to limit or restrict the Group from
entering into other arrangements or pro grams of a similar nature with
other managed care entities.
1.5 Provider Listing. Payor(s) shall have the right to use Group's name
and the names of the Group's Participating Providers, business
addresses, phone numbers, hospital affiliations, educational
background, certifications, and specialties for purposes of marketing,
informing Covered Persons of the identity of the Group and the names
of the Group's Participating Providers, and otherwise to carry out the
terms of this Agreement and the payor(s) Agreement.
1.6 Volume. AMERICAID does not, by this Agreement or otherwise, promise,
warrant or guarantee Group any minimum number of Covered persons on
Participating Physicians' panel or as referrals to Group's Providers.
ARTICLE II. GROUP'S OBLIGATIONS
2.1 Coordinated and Managed Care. Group shall participate in the systems
established by AMERICAID and Payor(s) designed to facilitate the
coordina tion of health care services received by Covered Persons.
Subject to medical
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judgment, patient care interests, and the patient's express
instructions, and recognizing that a level of a Covered Person's
Covered Services may be affected by the Group Participating Physicians
rendering services, Group and its Participating Providers shall abide
by the rules and regulations of Payor(s) and AMERICAID governing
referrals of Covered Persons and reporting of clinical encounter data.
If Group Participating Physicians determine that a Covered Person
requires hospitalization, Group Participating Physicians shall abide
by the applicable utilization review process established or adopted by
AMERICAID and Payors.
2.2 Covered Person Verification. Pursuant to the procedures established by
Payor(s), Group Participating Providers shall establish Covered
Person's eligibility for the services requested prior to the rendering
of such services.
2.3 Compliance with Utilization Management, Quality Assurance, Rules and
Regulations, and Policies and Procedures. Group Participating
Providers shall comply and cooperate with all requirements of
AMERICAID and payor(s) set forth in this Agreement and in the
AMERICAID Provider Manual, and all amendments thereto, governing
credentialing, utilization management, quality assurance program,
grievances, rules and regulations and policies and procedures of
AMERICAID or governing state and federal laws and regulations,
including without limitation policies and procedures concerning
coordination of benefits and third party liability.
2.4 Availability of Services. Group Participating Providers shall provide
all Covered Services in the same manner, in accordance with the same
accepted medical standards, and within the same time availability,
offered to all of Group Participating Providers' patients. Group
Participating Providers or Group's delegates shall be available to
provide Covered Services to Covered Persons seven (7) days per week,
twenty-four (24) hours per day.
2.5 Non-Discrimination. Group Providers shall not discriminate in the
rendering of services under this Agreement on the basis of a Covered
Person's race, color, national origin, sex, sexual orientation, age,
religion, place of resi dence, health status, handicap, or source of
payment.
2.6 Provision of Non-Covered Services. In the event that Group
Participating Providers provide any services other than Covered
Services to any Covered Person, prior to the provision of such
services, Group Participating Providers
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will advise the Covered Person, in writing, (a) of the nature of the
service; (b) that the service is not a Covered Service for which
payor(s) will pay; and (c) that the Covered Person will be responsible
for paying for the service.
2.7 Primary Care Physician Services. For each Group Provider credentialed
by AMERICAID as a Participating Primary Care Physician, Group
Participating Physician agrees to accept as patients all Covered
Persons who are eligible to select Group Physician and who have
selected him or her as their Participating Primary Care Physician,
and to provide or arrange for the provision of appropriate Covered
Services within the scope of each Group Physician's practice, to such
Covered Persons. Participating Physician will refer Covered Persons to
Specialist Physicians only in accordance with procedures estab lished
by AMERICAID, which procedures may include, without limitation, use of
a prescribed referral form.
2.8 Specialist Physician Services. For each Group Provider credentialed by
AMERICAID as a Specialist Physician. Group Participating Provider
agrees to accept as patients all Covered Persons who are referred by
Primary Care Physicians participating in the AMERICAID Network, and to
provide or arrange for the provision of appropriate Covered Services
within the scope of each Group Provider's practice, to such Covered
Persons. Participating Provider will refer Covered Persons to other
Specialist Physicians only in accordance with procedures established
by AMERICAID, which procedures may include, without limitation, use of
a prescribed referral form.
2.9 Hospital Affiliation and Privileges. Each Group Participating
Physician shall maintain in effect privileges to practice at one or
more Participating Hospitals and shall immediately notify AMERICAID in
the event Participating Physicians' privileges are revoked, limited,
surrendered, or suspended at any hospital or health care facility
including any Participating Hospital.
2.10 Insurance Coverage. Each Group Participating Provider shall purchase
and maintain professional liability insurance, general comprehensive
liability insurance, and workers' compensation insurance in amounts as
may be required by AMERICAID, but in no event, less than the amount
required by law. Professional liability insurance limits shall be, at
a minimum, $1,000,000 per occurrence/$3,000,000 aggregate.
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61
Group shall provide AMERICAID with whatever documentation may be
requested by AMERICAID to evidence compliance with all the foregoing
insurance requirements. Group shall provide AMERICAID with at least
thirty (30) days notification prior to: any reduction in the amount of
coverage, any adverse changes in policy terms, or cancellation or
non-renewal of any required coverage. Group warrants that any
associated health professional Group employ or with whom Group contract
shall purchase and maintain whatever type and amount of professional
liability insurance as may be required by AMERICAID for that class of
provider.
2.11 Indemnification. Group hereby agrees that in no event, including, but
not limited to nonpayment by the HMO, HMO insolvency, or breach of
this agreement, shall Group xxxx, charge, collect a deposit from, seek
compensation, remuneration, or reimbursement from, or have any
recourse against subscriber, enrollee, or persons other than HMO
acting on their behalf for services provided pursuant to this
agreement. This provision shall not prohibit collection of
supplemental charges or copayments on HMO's behalf made in accordance
with the terms between HMO and subscriber enrollee. Group further
agrees that (1) 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 the HMO subscriber/enrollee, and
that (2) this provision supersedes any oral or written contrary
agreement not existing or hereafter entered into between the Group and
subscriber, enrollee, or persons acting on their behalf. Any
modifications, addition, or deletion to the provisions of this clause
shall become effective on a date no earlier than 15 days after the
commissioner of insurance has received written notice of such proposed
changes.
2.12 Obligation to Continue Care. In the event that AMERICAID becomes
insolvent, AMERICAID's obligations to pay compensation for Covered
Services under this Agreement may be assumed by Payor(s). Such
assumption by payor(s) notwithstanding, if Payor(s) becomes insolvent
or fails for any reason to pay compensation for Covered Services as
required by this Agreement, or if Payor(s) Agreement is terminated,
but Payor(s) so requests, Group Participating Providers nevertheless
agree that, at Payor'(s) request, Group Physicians shall continue to
treat Covered Persons then under a course of active treatment, under
the terms of this Agreement, until provision has been made for their
assignment to another physician or until such treatment has been
completed, whichever occurs first, or for such longer period as may
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62
be required by law. Such period shall not exceed the period for which
a Covered Person's premiums have been paid, except that treatment of
any Covered Person confined to an inpatient facility shall continue
until such Covered Person is discharged or another physician has
assumed care of such Covered Person. Group Providers shall not xxxx
Covered Persons or persons acting on their behalf for Covered Services
rendered during such period.
2.13 Billing.
a. Group Participating Provider shall submit claims on the
appropriate claim form for all Covered Services within sixty (60) days
of the date those services are rendered. Claims received after this
sixty (60) day period may be denied for payment. Group Participating
Provider shall submit claims to the location described in the
applicable Program Requirements.
b. Any amount owing under this Agreement, (i) if owed by
AMERICAID, shall be paid within thirty (30) days unless, (ii) if owed
by a Payor, shall be paid within sixty (60) days after receipt of a
Clean Claim, or the claim involves coordination of benefits, except as
otherwise provided in the applicable Payor(s) Agreements.
2.14 In the event that AMERICAID contracts with any state Medicaid program,
and Physicians are Participating Providers for that product, the
following shall apply:
a. Laboratory Compliance. Group shall comply with all
requirements of the Clinical Laboratory Improvement Act ("CLIA"), and
implementing regulations. Upon execution of this Agreement, Group
agrees to furnish written verification to AMERICAID that its own
laboratory(ies), if any, and those with which it conducts business
related to Covered Persons, has (have) a CLIA certificate of
registration or a waiver, and a CLIA identification number. Group also
shall furnish annually to AMERICAID a written list of diagnostic tests
performed in its laboratory(ies), if any, and those with which it
conducts business related to Covered Persons. Group shall notify
AMERICAID of changes in the CLIA status of its laboratory(ies), and
those with which it conducts business related to Covered Persons, in
writing within five (5) days of such changes.
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b. Americans with Disabilities Act Compliance. Group shall
comply with all requirements of the Americans with Disabilities Act
("ADA"), and implementing regulations. Group shall not discriminate
against any qualified disabled individual covered by the ADA. Group
Participating Providers shall provide physical access for Covered
Persons, including, at a minimum, street level access or accessibility
ramp into office; wheelchair access to lavatory; and an elevator, if
Group Participating Provider's office is more than one story. Group's
provision of services, notices and other materials shall be
appropriate for all Covered Persons, including the blind, hearing
impaired and individuals who do not speak English.
c. Exhaustion of Benefits. For Medicaid services furnished to a
Covered Person in excess of the New Jersey Medicaid benefit
limitations, Group Provider shall xxxx Medicaid directly and not
AMERICAID, upon receipt from AMERICAID of an Exhaustion of Benefits
letter.
d. Financial Disclosure. Group shall provide necessary
financial disclosure required by 42 C.F.R. 434,42 U.S.C. Sections
1903(m), and applicable state laws.
e. Compliance with Other Laws. Group agrees to comply with
applicable requirements of Title XIX of the Social Security Act. 42
U.S.C. 1396b(m) and Title XIII of the Federal Public Health Services
Act, regulations promul gated thereunder, and all other applicable
state and Federal legal and xxxxxx xxxx requirements.
2.15 Representations and Warranties. Group hereby represents that all of
the information and documentation provided by Group to AMERICAID prior
to and during the term of this Agreement, including but not limited to
that set forth in an application to become Participating Group and in
credentialing materials, is true and correct and Group hereby agrees
to update any such information and documentation within three (3)
business days if any change should occur regarding any such
information or documentation previously provided to AMERICAID.
2.16 Participation of Group Providers. Participating Group Providers must
comply with criteria and the terms of this agreement. However,
AMERICAID is not obligated to accept all members of the Group as
Participating Providers.
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2.17 Agreement Governs. To the extent of any conflict between the terms of
this Agreement and any ancillary obligation created, or documentation
including the Provider Manual provided to the Group, the terms of this
Agreement shall govern.
ARTICLE III. PAYMENT FOR SERVICES
3.1 Payment for Group Services. Group's compensation is described in
Attachment A.
3.2 Coverage Verification. Except in an Emergency, prior to providing
services to any patient who presents himself or herself as a Covered
Person, Group shall verify such patient's coverage with the patient's
Payor(s) as required by AMERICAID or the applicable Payor(s) Health
Plan. Payor(s) will also notify Group of the appropriate method by
which to verify a Covered Person's coverage.
3.3 No Recourse Against Covered Persons. Except as otherwise provided in
this Agreement, Group shall not xxxx, charge or attempt to collect
from any Covered Person for any services provided under this
Agreement, including the difference between the amount of
reimbursement payable under this Agreement and the Group's Normal
Charges for the services rendered. For all Covered Services delivered
pursuant to this Agreement to Covered Persons, Group shall not, under
any circumstances, including insolvency of AMERICAID: (1) xxxx, charge
or attempt to collect any money from any Covered Person; (2) maintain
any action at law against any Covered Person to collect money owed to
Group by AMERICAID; or (3) hold any Covered Person liable in any other
way for Covered Services provided to such Covered Person. Whenever
AMERICAID fails to meet its obligation to pay fees under this
Agreement for Covered Services already rendered to a Covered Person,
AMERICAID, rather than the Covered Person, shall be liable for such
fees. Solely for purposes of this Section 3.3, "Covered Person" shall
include a Covered Person and any person acting on behalf of such
Covered Person, except AMERICAID. However, Group may xxxx Covered
Person for non-Covered Services. This provision shall survive the
termination of this Agreement.
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3.4 Insolvency of AMERICAID. In the event that AMERICAID becomes insolvent
or unable to pay Group, Group will not seek compensation for services
rendered from any Payor(s), its officers, agents, or employees, or the
Covered Persons or their eligible dependents.
ARTICLE IV. RECORDS
4.1 Records. Group Participating Providers shall maintain the medical,
financial and administrative records concerning services provided to
Covered Persons that Group Providers would maintain in the normal
course of business. Such records shall be retained by Group Providers
for the period of time required by all applicable laws or regulations
but in no event less than five (5) years from the date the service was
rendered or termination of this Agreement, whichever first occurs.
Group agrees that AMERICAID and the applicable Payor(s), as well as
state and Federal agencies, have the right to review records directly
related to services rendered to Covered Persons, upon reason able
notice, during regular business hours. Group further agrees to obtain
any necessary releases from Covered Persons with respect to their
records and the information contained therein to permit Payor(s), or
state and Federal agencies, access to such records. AMERICAID and
Group Participating Providers agree that each Covered Person's medical
records shall be treated as confidential so as to comply with all
state and federal laws and regulations regarding the confidentiality
of patient records. Subject to the foregoing, Group shall supply
AMERICAID and state and Federal agencies, at no charge, with copies of
Covered Persons' medical records upon request Group Participating
Providers shall participate in any system established by AMERICAID to
facilitate the sharing of records, subject to applicable
confidentiality require ments. Notwithstanding termination of this
Agreement or termination of Group participation in any Payor(s) Health
Plan for any reason, the access to records granted hereunder shall
survive the termination of both this Agreement and any Payor(s)
Health Plan.
4.2 Transfer and Confidentiality. Group Participating Providers agree to
cooperate in the transfer of Covered Persons' medical records to
other Participating Providers, to assume any cost associated
therewith, and to transfer any medical records in Group's Providers
custody within ten (10) days of a Covered Person's request. Group
further agrees to cooperate with AMERICAID and any state or federal
agency in making available, and in arranging or allowing inspection
of, such records as may be required under
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state or federal law or regulation or as may be appropriate to
disclose to such authorities in connection with their assessment of
quality of care or investiga tion of Covered Person's grievances or
complaints. AMERICAID and Group Providers agree that Covered Persons'
medical records shall be treated as confidential so as to comply with
all state and federal laws and regulations regarding the
confidentiality of patient records
4.3 Other Records. During the term of this Agreement, Group Provider
shall, upon request of Payor(s), furnish any other record related to
services fur nished pursuant to this Agreement, or a copy thereof.
Upon termination or expiration of this Agreement, Group Provider shall
provide copies of all such records to AMERICAID prior to final
settlement of all claims and outstand ing contract issues.
4.4 Production of Records Notwithstanding Termination. Notwithstanding
termination of this Agreement, the access to records granted hereunder
in this Article IV shall survive the termination of this Agreement.
ARTICLE V. TERM, TERMINATION AND MODIFICATION
5.1 Initial Term and Renewal: Termination. This Agreement shall have an
initial term of one (1) year, commencing as of the Effective Date, and
shall renew automatically for successive terms of one (1) year unless
either party gives the other at least one hundred twenty (120) days'
prior written notice that the Agreement shall not renew. In addition
to the other termination provisions, AMERICAID and Group shall each
have the right to terminate this Agreement, without cause, upon one
hundred twenty (120) days' prior written notice to the other party.
5.2 Termination; Cause. Either party may terminate this Agreement for
cause (defined as a material default or breath by such other party)
upon sixty (60) days prior written notice, which notice shall set
forth the grounds for termination, if the grounds for termination
continue for the sixty (60) day period after written notice, the
nonbreaching party shall have the right to immediately terminate this
Agreement Notwithstanding any provision in this Agreement to the
contrary, Group Providers shall continue to provide Covered Services
to Covered Persons during the sixty (60) day period.
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5.3 Termination; Automatic. This Agreement shall automatically and
immediately terminate upon the expiration, surrender, revocation,
restriction or suspension of Group's participation in Medicare or
Medicaid.
5.4 Amendment by Notification. Notwithstanding any other provision to the
contrary, this Agreement may be amended in any respect by AMERICAID at
any time by giving thirty (30) days written notice to Group
accompanied by a description of the amendment. With the sole exception
of amendments to Attachment C, hereto, the amendment is not acceptable
to Group. Group may object to the amendment, in writing, within thirty
(30) days of receiving said notice. If no objection is received by
AMERICAID within thirty (30) days, Group shall be deemed to have
accepted the amendment as of its effective date (which shall be no
earlier than the expiration of said thirty (30) day period). If such
an objection is received by AMERICAID within such thirty (30) day
period, then the amendment shall not take effect, and the Agreement
shall otherwise remain in full force and effect
ARTICLE VI. MISCELLANEOUS
6.1 Acceptance and Regulatory Approval. The obligations of AMERICAID and
Participating provider to perform any of the duties or obligations
contained in this Agreement are made specifically and expressly
contingent upon the issuance of a Certificate of Authority to
AMERICAID by the appropriate state agency(ies). Upon execution of this
Agreement, and providing that issuance of a Certificate of Authority
has been accomplished, Provider agrees to become a Participating
Provider with respect to AMERICAID. Until such time as a certificate
of Authority has been issued to AMERICAID, this Agreement shall be
deemed to be a binding letter of intent.
6.2 Amendment. Except as stated in Article V, this Agreement may be
amended or modified only by a written agreement executed by both
parties.
6.3 Waivers. The waiver by either party of a breach or violation of any
provision of this Agreement shall not operate as or be continued to be
a waiver of any subsequent breath of this Agreement.
6.4 Severability. The invalidity or unenforceability of any terms or
conditions shall in no way affect the validity or enforceability of
any other term or provision.
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6.5 Assignment. Except as otherwise provided, neither this Agreement nor
any of the rights or obligations under this Agreement may be assigned
or transferred without the prior written consent of the non-assigning
party, and in the case of an assign ment by Group, this Agreement may
not be assigned without the prior written consent of Payor. AMERICAID
shall have the right to assign this Agreement to a wholly-owned or
controlled entity or to Payor(s) (upon AMERICAID's becoming insolvent)
and Payor(s) may assign its interests herein to successors-in-interest,
without the consent of, but upon written notice to, Group.
6.6 Conformance with Law. Each party shall carry out all activities
undertaken by it pursuant to this Agreement in conformance with all
applicable federal, state and local laws, rules and regulations. The
relationships and transactions contemplated by this Agreement may be
subject to regulation by state or federal governmental authorities. In
the event that any action of a governmental authority impairs, limits,
or delays AMERICAID's performance of any obligation hereunder,
AMERICAID shall be excused from such performance, and AMERICAID's
failure to perform such obligation for such reason shall not
constitute a breach of this Agreement.
6.7 Notice. Any notice required to be given pursuant to the terms and
provisions of this Agreement shall be sent by certified mail, return
receipt requested, postage prepaid, hand delivery; overnight prepaid
delivery; or confirmed facsimile, to the parties at the addresses set
forth in the Participating Provider Application.
6.8 Independent Contractor Status. This Agreement is not intended to
create nor shall it be deemed or construed to create any relationship
between the parties other than that of independent contractors.
Neither of the parties to this Agreement, nor any of their respective
employees, shall be construed to be the agent, employer or
representative of the other.
6.9 Entire Agreement. This Agreement, including the AMERICA1D Provider
Manual and any amendments, riders, attachments, or appendices,
constitutes the entire understanding between the parties and
supersedes any prior understandings and agreements between the parties
or between Group and any Covered Person or other person on behalf of
any Covered Person, whether written or oral, respecting the subject
matter of this Agreement.
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6.10 Coordination of Defense of Claims. The parties shall make all
reasonable efforts, consistent with advice of counsel and the
requirements of the respective insurance policies and carriers to
coordinate the defense of all claims in which the other party is
either a named defendant or has a substantial possibility of being
named.
6.11 Governing Law. This Agreement has been executed and delivered and
shall be construed and enforced in accordance with the laws of the
state of identified in the AMERICAID Participating Provider
Application, excluding and without application of any choice of law
principles.
ARTICLE VII. DEFINITIONS
For purposes of this Agreement, the following terms have the ascribed
meaning:
7.1 Associated Health Professional. A nurse practitioner, midwife, or
physician's assistant who is an employee of, or independent contractor
to, a Participating Physician or Group.
7.2 Clean Claim. Means a request for payment for Covered Services
submitted by Group which is accurate, complete, in the format required
by the applicable Payor(s) and as to which there is no issue (such as
coordination of benefits) regarding a Payor's responsibility for
payment.
7.3 Covered Person. Any person who has entered into, or on whose behalf
there has been entered into, an agreement with a Payor(s) for the
provision of Covered Services to such person.
7.4 Covered Services. Those health care services Covered Persons are
entitled to receive pursuant to a Payor(s) Agreement.
7.5 Emergency Services. Those health care services within or outside of
AMERICAID's enrollment area, required to be provided to an enrollee as
a result of an injury or the sudden onset of an illness having the
potential of causing immediate disability or death, or requiring the
immediate alleviation of severe pain, or the time required to reach
facilities of a provider with
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which AMERICAID has arrangements, would have meant risk of permanent
damage to the recipient's health.
7.6 Normal Charge. Physician's usual and customary charge per individual
unit of service.
7.7 Participating Hospital. A facility licensed under applicable state law
as a general acute care hospital and which has contracted as an
independent contractor with AMERICAID to provide certain Covered
Services to Covered Persons.
7.8 Participating Physician. A physician who has contracted, directly or
indirectly, as an independent contractor with AMERICAID to provide
certain Covered Services to Covered Persons and who is duly licensed
under applicable state law.
7.9 Participating Provider. A Participating Physician, Participating
Hospital and any other licensed health care facility or professional,
who or which has entered into a written agreement to provide services
to Covered Persons is duly licensed under applicable state law, and
who or which is currently so credentialed and designated as such by
AMERICAID.
7.10 Payor. Either AMERICAID or any third-party payor(s) including, but not
limited to, an employer, multiple employer trust or union trust, or
state agency or entity that contracts on behalf of a state's Medicaid
beneficiaries, or other similar managed care plan that has entered
into an agreement with AMERICAID for the provision of Covered Services
to Covered Persons through Participating Providers.
7.11 Payor Agreement. The agreement by and between Payor's and AMERICAID
under which AMERICAID either provides directly or arranges for the
provision of certain Covered Services to Covered Persons.
7.12 Primary Care Physician. A Participating Physician who has been
credentialed by AMERICAID as a Primary Care Physician, and who engages
in the practice of medicine, supervises, coordinates and provides
initial and basic care to patients, initiates patient referrals for
Specialist Care Services, and maintains continuity of patient care;
and who practices in the fields of general practice, internal
medicine, pediatrics, or family medicine.
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7.13 Specialist Physician. A Participating Physician who is Board-certified
or who has completed an approved residency program in a medical
specialty and is credentialed by AMERICAID as a specialist; who
provides Covered Services to Covered Persons within the range of that
specialty; and who meets the requirements established by AMERICAID
for Specialist Physicians.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be
executed personally or by their duly authorized officers or agents.
GROUP PHYSICIAN AMERICAID Texas, Inc.
/s/ Xxxx X. Xxxxxxx /s/ Xxxxxx Xxxxxxxx
--------------------------------- -------------------------------
Signature Signature
Xxxx X. Xxxxxxx Xxxxxx Xxxxxxxx AVP
--------------------------------- -------------------------------
Print Name Print Name and Title
9/7/1995 1/4/1996
--------------------------------- -------------------------------
Date Date
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SETTLEMENT AGREEMENT
This settlement agreement is entered into by AMERICAID Texas, Inc., d/b/a
AMERICAID Community Care ("AMERICAID") and Xxxx Children's Physician Network
("Network").
WHEREAS, AMERICAID and Network entered into an Agreement, effective
October 1, 1996 ("the 1996 Agreement"), whereby Network agreed to provide or
arrange to provide Covered Health Services to Members in the Medicaid STAR
Program (the "Program");
WHEREAS, AMERICAID and Network subsequently entered into a Second
Amendment to the 1996 Agreement, dated to be effective March 1, 1998, whereby
AMERICAID and Network attempted to clarify and define the claims processing
procedures for certain emergency room and outpatient surgery services under the
Program;
WHEREAS, the 1996 Agreement and the Second Amendment contain provisions
describing reimbursement amounts and claims processing procedures for emergency
room services, emergency room physician services, inpatient services, pediatric
inpatient physician services, outpatient services, outpatient clinic and
recurring visits and outpatient surgeries ("Services") under the Program;
WHEREAS, a dispute has arisen regarding the amount owed by AMERICAID for
certain Services provided by or at Xxxx Children's Medical Center with discharge
dates between October 1, 1996, through August 31, 1997 ("CCMC Claims") pursuant
to the reimbursement and claims processing provisions of the 1996 Agreement and
the Second Amendment;
WHEREAS, AMERICAID and Network agree that CCMC Claims that have
previously been processed pursuant to the reimbursement and claims processing
provisions of the 1996 Agreement and the Second Amendment totalled $603,179.78;
WHEREAS, AMERICAID and Network agree that AMERICAID re-processed a
portion of the CCMC Claims described in the previous paragraph and paid Network
the amount of $271,308.78 for such re-processed claims;
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WHEREAS, AMERICAID and Network agree to a contractual adjustment of
$51,871.00 relating to CCMC Claims;
WHEREAS, AMERICAID and Network agree that the CCMC Claims totalling
$603,179.78 have been reduced by the payment of $271,308.78 for the re-processed
claims and by the contractual adjustment of $51,871.00 leaving the outstanding
balance of $280,000.00 for such CCMC Claims;
WHEREAS, AMERICAID and Network wish to settle this outstanding balance
related to the CCMC Claims in lieu of attempting to continue to re-process the
CCMC Claims;
NOW, THEREFORE, AMERICAID and Network agree to compromise and settle this
outstanding balance of the CCMC Claims as follows:
1. AMERICAID will pay Network the amount of Two Hundred Eighty
Thousand Dollars ($280,000.00) upon execution of this settlement
agreement by the parties hereto;
2. Network agrees to accept this $280,000.00 amount as full and final
payment for the balance of the CCMC Claims for discharge dates
between October 1, 1996 through August 31, 1997;
3. One Hundred Percent (100%) of this $280,000.00 amount shall be
paid from the Pediatric Pool (as defined in the 1996 Agreement)
for the contract year ending August 31, 1997;
4. AMERICAID and Network agree that this $280,000.00 amount will be
calculated as part of any overall risk settlement entered into
between the parties for the contract year ending August 31, 1997;
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5. AMERICAID and Network agree that any payments received by Network
for CCMC Claims in excess of this $280,000.00 amount shall be
refunded by Network to AMERICAID within sixty (60) days of receipt
by Network.
AMERICAID TEXAS, INC. XXXX CHILDREN'S PHYSICIAN NETWORK
By: /s/ Xxx Xxxxxxx By: /s/ Xxxx X. Xxxxxxx
------------------------------- ---------------------------------
Xxx Xxxxxxx, President Xxxx X. Xxxxxxx
Senior Vice President/CFO
Date: 5/21/98 Date: 5/21/98
----------------------------- -------------------------------
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MEDICAID MANAGED CARE
CCPN ANCILLARY PROVIDER AGREEMENT
THIS CCPN ANCILLARY AGREEMENT ("Agreement") is entered into this 11th day of
November, 1998, but to be effective the 1st day of March, 1998 (the "Effective
Date"), by and between Xxxx Children's Physician Network, a Texas non-profit
corporation certified under Section 5.01(a) of the Texas Medical Practice Act
("CCPN") and Pecan Valley Mental Health Mental Retardation Region ("Ancillary
Provide").
WITNESSETH
WHEREAS, CCPN is a non-profit health care corporation licensed as a 5.01(a)
which has entered into exclusive agreements with Rio Grande HMO, Inc. d/b/a HMO
Blue(R), DFW Metroplex, Xxxxxx Methodist Texas Health Plan, Inc. and Americaid
Texas, Inc., d/b/a Americaid Community Care (collectively "Payor") to provide
and arrange to provide a pediatric provider network to deliver Covered Health
Services to Covered Persons in the Service Area who enroll in or who are
assigned to the STAR Program.
WHEREAS, Ancillary Provider provides Early Childhood Intervention Services to
all eligible children under the age of three (3) in Hoodd Xxxxxx County Texas,
who qualify ("EQ Children"), such services being more particularly described
below;
WHEREAS, CCPN desires that Ancillary Provider provide and Ancillary Provider
agrees to provide Covered Health Services to Covered Persons residing in the
Service Area who enroll in or who are assigned to the STAR Program under the
terms and conditions of this Agreement;
WHEREAS, Ancillary Provider agrees to accept the applicable reimbursement and
applicable terms and conditions set forth in this Agreement and the applicable
HMO Agreement.
WHEREAS, CCPN and Ancillary Provider, in order to comply with all applicable
regulatory requirements, including but not limited to IDEA, Part H, agree to be
bound by the provisions of this Agreement and the provisions of the applicable
HMO Agreement.
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NOW, THEREFORE, in consideration of the mutual covenants and conditions
contained herein and for other good and valuable consideration, the receipt and
sufficiency of which are hereby acknowledged, CCPN and Ancillary Provider agree
as follows:
1. DEFINITIONS
For purposes of this Agreement, the following terms have the ascribed meaning:
1.1 Agreement. Means this contract, including all attachments appended hereto
and any written amendments subsequently executed by the parties.
1.2 Annual Reviews. Full review of the IFSP (defined below) conducted
annually by the interdisciplinary team to establish continued eligibility
and to revise the contents of the IFSP if necessary.
1.3 Clean Claim. Means a record of or a claim for Covered Health Services
provided to Members which is accurate, complete (i.e. includes all
information necessary to determine liability), not a claim on appeal, and
not contested (i.e. not reasonably believed to be fraudulent, and not
subject to a necessary release, consent, or assignment).
1.4 Covered Health Services. Means those ancillary services covered under the
Medicaid Star Program.
1.5 Covered Person. For Early Childhood Intervention Services, means any
individual age 0 through 2 years of age residing in the Service Area who
is (1) entitled to benefits under Title XIX of the Social Security Act
and the Texas Medical Assistance Plan, (2) in a Medicaid eligibility
category included in the STAR Program, and (3) enrolled in the STAR
Program as a member of Payor, and (4) is documented as developmentally
delayed, has a diagnosed physical or mental condition that has a high
probability of resulting in a developmental delay or who exhibits
atypical development as determined by the ECI interdisciplinary team.
1.6 Early Childhood Intervention. A federally mandated program which serves
children from birth through age two with developmental delays, or the
likelihood of developmental delays, and their families through programs
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authorized under part H of the Individuals With Disabilities Education
Act (20 United States Code 1471, et seq.).
1.7 Early Childhood Intervention Services. Means the following rehabilitation
services:
1.7.1 administer physical therapy, occupational therapy, speech and
audiology services, nutrition services and psychological services
as related to each ECI Child, except for PACT eligible services;
1.7.2 develop Individual Family Service Plans ("IFSP") for each ECI
Child relating to ECI assessments;
1.7.3 provide written reports to HMO which will include: IFSP, Six Month
Review, Annual Reviews, and regular progress notes every three
months for each ECI Child.
1.8 Emergency Care. Means bona fide emergency services provided after the
sudden onset of a medical condition (including emergency labor and
delivery) manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that the absence of immediate medical
attention could reasonably be expected to result in (1) placing the
patient's health in serious jeopardy; or (2) serious impairment to bodily
function; or (3) serious dysfunction of any bodily organ or part.
1.9 Evaluation and Assessment. The ongoing procedures used by appropriate
qualified personnel throughout the period of a child's eligibility to
identify:
1.9.1 The child's unique needs and strengths;
1.9.2 The resources, priorities, and concerns of the family and
identification of supports and services necessary to enhance
developmental needs of the children; and
1.9.3 The nature and extent of intervention services needed by the child
and the family.
1.10 Health Care Professional. Means any physician, nurse, audiologist,
physician assistant, clinical psychologist, occupational therapist,
physical therapist,
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speech and language pathologist, or other professional engaged in the
delivery of health services who are licensed, practice under an
institutional license, certified, or practice under authority of a
physician, legally constituted professional association or other
authority consistent with state law to provide services to such patients.
1.11 HMO Agreement. The agreements by and between Rio Grande HMO d/b/a HMO
Blue(R), DFW Metroplex, Xxxxxx Methodist Texas Health Plans, Inc.,
Americaid Texas, Inc., d/b/a Americaid Community Care and CCPN through
which CCPN is the exclusive provider of all Covered Health Services to
Covered Persons in the STAR Program in the Service Area.
1.12 IFSP Review. Review of the IFSP conducted at least every six months.
1.13 Individualized Family Service Plan (IFSP). A written plan developed by
the interdisciplinary team in accordance with criteria established in at
25 TAC* 621 .21 et seq. based on all assessment and evaluation
information, including the family's description of their strengths and
needs, which outlines the early intervention services for the child and
the child's family.
1.14 Interdisciplinary Team. The child's parent(s) and a minimum of two
professionals from different disciplines who meet to share evaluation
information, determine eligibility, assess needs, and develop the IFSP.
1.15 Medically Necessary. Means the physical medicine/health services other
than behavioral health services which are identified by the IFSP
interdisciplinary team and approved, recommended, or prescribed by the
child's physician and are:
1.15.1 reasonable and necessary to prevent illnesses or medical
conditions, or provide early screening, interventions and/or
treatments for conditions that cause suffering or pain, cause
suffering or pain, cause physical deformity or limitations in
function, threaten to cause or worsen a handicap, cause illness or
infirmity of a Covered Person, or endanger life;
1.15.2 provided in the child's natural environment, unless the early
intervention can not be achieved satisfactorily in the natural
environment and
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at appropriate levels of care or the treatment of a Covered
Persons medical conditions;
1.15.3 consistent in type, frequency and duration of care/treatment with
health/medical practice guidelines that are references to
professionally recognized health care organizations or
governmental agencies, including the Texas Interagency Council on
Early Childhood Intervention;
1.15.4 consistent with the diagnoses of the conditions; and
1.15.5 no more intrusive or restrictive than necessary to provide a
proper balance of safety, effectiveness, and efficiency.
1.15.6 not modified or altered by CCPN or applicable HMO in the amount,
duration and scope of services established for the Covered Person
by the IFSP team and approved by the PCP.
1.16 Medically Necessary Behavioral Health Services means those behavioral
health services which:
1.16.1 are reasonable and necessary for the diagnosis or treatment of a
mental health or chemical dependency disorder or to improve or
maintain or to prevent deterioration of functioning resulting from
such a disorder;
1.16.2 are in accordance with professionally accepted clinical guidelines
and standards of practice in behavioral health care;
1.16.3 are furnished in the child's natural environment, unless the early
intervention can not be achieved satisfactorily in the natural
environment
1.16.4 are the most appropriate level or supply of service which can
safely be provided;
1.16.5 could not have been omitted without adversely affecting the
Member's mental and/or physical health or the quality of care
rendered; and
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1.16.6 not modified or altered by the Payor in the amount, duration and
scope of services established for the Member by the IFSP team and
approved by the PCP.
1.17 Natural Environments. Settings that individual families identify as
natural or normal for their family, including the home, neighborhood and
community settings in which children without disabilities participate. To
the maximum extent appropriate to meet the needs of the child, early
intervention services must be provided in natural environments, including
the home and community settings in which children without disabilities
participate.
1.18 Program for Application for Children of Texas (PACT).
1.19 Participating Physician. Means a duly licensed Primary Care Physician or
Specialist Physician who is employed by or has contracted with CCPN, and
who has agreed to provide professional services to Covered Persons.
1.20 Participating Hospital. Means any health care facility who has contracted
directly or by assignment with CCPN to provide pediatric institutional
and/or ancillary services to Covered Persons.
1.21 Participating Provider. Means any health care facility, or Health Care
Professional, other than a physician, that provides medical services to a
Covered Person pursuant to an agreement with a Payor for purposes of the
STAR Program in the Service Area.
1.22 Payor Plan. Means the Medicaid STAR Program.
1.23 Payor. Means Americaid Texas, Inc., d/b/a Americaid Community Care,
Xxxxxx Methodist Texas Health Plan, Inc. and Rio Grande HMO d/b/a HMO
Blue(R), DFW Metroplex.
1.24 Primary Care Physician. Means a physician in the field of general
practice, family practice, internal medicine, pediatrics, or
obstetrics/gynecology who is responsible for providing primary care
services and who agrees to coordinate and manage delivery of Covered
Health Services to Covered Persons assigned to such Primary Care
Physician.
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1.25 Procedural Safeguards. The rights provided children and families in the
Individuals with Disabilities Education Act (IDEA) and the Federal
Educational Rights and Privacy Act (FERPA) (20 USC 1232 et seq.) that
protect the family from intrusion and coercion, including at least four
considerations: privacy, confidentiality, full disclosure of information,
and the family's right to decide about all aspects of the IFSP.
1.26 Service Area. Means the Texas counties of Tarrant, Hood, Johnson, Denton,
Parker, and Wise.
1.27 Specialist Physician. Means a physician who provides specialist care or
consultative services to Covered Persons upon referral by Primary Care
Physicians.
2. DUTIES AND OBLIGATIONS OF CCPN
2.1 Payment for Services.
2.1.1 Ancillary Provider shall be compensated in accordance with the
provisions set forth in Exhibit "C."
2.1.2 The Payor payments shall be payment-in-full for rendering Covered
Health Services to Covered Persons on a fee for service basis at a
rate equal to the then current Medicaid allowable rate. If the
Medicaid allowable rate is not available, reimbursement will be at
the then current Medicare rate: If a Medicare rate is not
available, reimbursement will be at 65% of Ancillary Provider's
usual and customary billed charge.
2.1.3 CCPN agrees to compensate or arrange with payor to compensate
Ancillary Provider either directly or through Payors at the rate
described in Exhibit "C,' within thirty (30) days of receipt by
HMO.
2.2 Utilization Management and Quality Improvement Plan. CCPN shall provide,
upon request, to Ancillary Provider a copy of any utilization management
and quality improvement plan adopted or administered by CCPN and/or
Payor, and any modifications thereto, applicable to Provider.
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2.3 Medical Records. CCPN shall maintain any medical records to which it has
access under this Agreement in confidence and in accordance with
applicable law.
2.4 Eligibility Verification. CCPN will provide Ancillary Provider with
access to all eligibility information available from Payor regarding
current Covered Persons.
3. ANCILLARY PROVIDER OBLIGATIONS
3.1 Services. Ancillary Provider shall make available and provide Medically
Necessary Covered Health Services to Covered Persons on a twenty-four
(24) hour per day seven (7) days per week basis pursuant to the terms of
the Payor Plan in the same manner, in accordance with the same standards,
and within the same time availability as offered to Ancillary Provider's
other patients.
3.2 Pre-Certification/Pre-Authorization. CCPN will provide Ancillary Provider
with access to all eligibility information available from Payor regarding
current Covered Persons. Unless a Medical Emergency exists, Ancillary
Provider shall verify coverage of a patient and obtain the required
Pre-certification/Pre-Authorization prior to commencement of treatment in
accordance with procedures developed by CCPN and/or Payor and set forth
in the Payor provider manuals, which shall be delivered to Ancillary
Provider upon the full execution of this Agreement. Any changes or
amendments to a provider manual will be provided to Ancillary Provider in
writing at least thirty (30) days prior to the effective date of such
change or amendment, unless a shorter time for implementation is required
by the State of Texas/Texas Department of Health.
3.3 Compliance with Utilization Management, Quality Assurance Rules and
Regulations and Policies and Procedures. Ancillary Provider shall follow
and adhere to all CCPN and/or Payor standards, policies, procedures,
programs, rules and regulations (including but not limited to any CCPN
and/or Payor utilization management and quality assurance programs), any
or all of which CCPN and/or Payor may amend in its own discretion from
time-to-time. CCPN and/or Payor will provide to Ancillary Provider
amendments and/or modifications to such standards, policies, procedures,
programs, rules and regulations at least thirty (30) days prior to the
effective date of such amendments and/or modifications, unless a shorter
time for implementation is
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required by the State of Texas/Texas Department of Health. Further,
Ancillary Provider agrees to be bound by all of the standards, policies,
rules, and regulations adopted or utilized by CCPN and/or Payor from
time-to-time in connection with applicable Payor Agreement. Copies of
such standards, policies, procedures, programs, rules and regulations
shall be made available for examination by Ancillary Provider upon
request.
3.4 Compliance with CCPN Participation Criteria. Ancillary Provider warrants
and represents that it currently complies with all and shall continue to
meet and remain in compliance with the CCPN Participation Criteria set
forth on Exhibit "B" which is attached and hereby incorporated by
reference and made part of this Agreement.
3.5 No Guarantee of Selection or Utilization. Ancillary Provider acknowledges
that CCPN does not warrant, promise, or guarantee (1) that Ancillary
Provider will be selected by CCPN and/or Payor to participate as a
Participating Physician in accordance with the HMO Agreements or (2)
that, if selected, Ancillary Provider will either be utilized by any
minimum number of Covered Persons or remain a member of the provider
panel.
3.6 Insolvency. In the event of CCPN or Payor's insolvency or other cessation
of operation, Ancillary Provider will continue providing Medically
Necessary Covered Health Services to Covered Persons through the period
for which payment has been made or, for Covered Persons in an inpatient
setting, until the date of discharge.
3.7 Referrals. Consistent with sound medical practice and in accordance with
accepted community professional standards for rendering quality medical
care, Ancillary Provider covenants that it will use its best effort to
make referrals of Covered Persons to other Participating Physicians,
Participating Providers and/or Participating Hospitals.
3.8 Nondisclosure. Unless required by law or unless consulting with Ancillary
Provider's attorney, Ancillary Provider shall not disclose the terms of
this Agreement or any HMO Agreement, including but not limited to any fee
schedule, without the prior written consent of CCPN. This paragraph shall
survive the termination of this Agreement.
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3.9 Marketing. Ancillary Provider shall permit CCPN to designate and make
public reference to Ancillary Provider as a Participating Provider.
Ancillary Provider shall not use the name or trademark of CCPN or Payor
without the prior approval in writing by CCPN. Ancillary Provider agrees
that CCPN and Payor may use its name, address, telephone number and a
description of specialty in any roster of Participating Providers
published by CCPN or Payor. The roster may be inspected by, and is
intended for the use of, prospective and existing Covered Persons as well
as for advertising purposes.
3.10 Reporting Duty. Ancillary Provider agrees to report to CCPN within
fourteen (14) calendar days whenever it becomes aware of any of the
following as permitted by law:
3.10.1 Any cancellation or material modification of Ancillary Provider's
liability coverage; or
3.10.2 Any malpractice claim against Ancillary Provider; or
3.10.3 Any criminal action filed or brought against Ancillary Provider.
CCPN shall only use the information described in this section for its
described purpose and shall keep such information confidential unless
required by law or the applicable HMO Agreement.
3.11 Reporting Requirements. Ancillary Provider covenants and agrees that it
will provide to CCPN or Payor, as appropriate, the data necessary for
CCPN or Payor to comply with the TDI and TDH reporting requirements with
respect to any Covered Health Services provided pursuant to this
Agreement.
3.12 Reporting Changes Ancillary Provider Information. Ancillary Provider
shall notify CCPN in writing at least thirty (30) calendar days prior to
any change in Ancillary Provider's business address, business telephone
number, office hours, tax identification number, malpractice insurance
carrier or coverage, State of Texas license number, or Drug Enforcement
Agency registration number.
3.13 Non-Discrimination. To the extent required by State or federal law,
Ancillary Provider agrees to have in place an affirmative action program.
Provider further covenants and agrees that they will comply with (a)
Title VI of the
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Civil Rights Act of 1964 (P.L. 88-352); (b) Section 504 of the
Rehabilitation Act of 1973 (P.L. 93-112); (c) The Americans with
Disabilities Act of 1990 (P.L. 101-336); (d) Title 40, Chapter 73, of the
Texas Administrative Code, providing in pertinent part that no persons in
the United States shall on the basis of race, color, national origin,
sex, age, disability, political beliefs or religion be excluded from
participation in, or denied, any aid, care, service or other benefits
provided by federal and/or state funding, or otherwise subject to
discrimination; and (e) Texas Health and Safety Code Section 85.113
(relating to workplace and confidentiality guidelines regarding AIDS and
HIV), and all amendments to each, and all requirements imposed by the
regulations issued pursuant to these acts.
4. ANCILLARY PROVIDER CHARGES, REIMBURSEMENT PROCEDURE AND XXXXXXXX
4.1 Provider Charges and Confidentiality. This Agreement shall cover only
those individual HMO Agreements and their respective individual Payor as
specified by Ancillary Provider on Exhibit "A," which is attached hereto
and made a part hereof. Ancillary Provider agrees to accept payment in
accordance with the applicable schedules contained in Exhibit "C" for
Covered Health Services furnished to Covered Persons enrolled with Payors
which are specified in Exhibit "A." Ancillary Provider shall maintain the
confidentiality of such reimbursement schedule and shall not disclose
such reimbursement schedule to any third party unless required by law or
authorized in writing by CCPN.
4.2 Payment in Full. Ancillary Provider shall accept as payment in full, for
Covered Health Services provided, the compensation specified in Exhibit
"C." Ancillary Provider agrees that in no event, including but not
limited to nonpayment by the Payor and/or CCPN, or Payor and/or CCPN
insolvency, or breach of this Agreement, shall Ancillary Provider xxxx,
charge, collect a deposit from, seek compensation, remuneration, or
reimbursement from, or have any recourse against any Covered Person or
any person other than Payor and/or CCPN pursuant to this Agreement,
except insofar as what is permitted by Section 4.3 below; further, that
(1) 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 the Covered Person and (2) this provision
supersedes any oral or written contrary agreement now existing or
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hereafter entered into between Ancillary Provider and Covered Persons or
other persons acting on their behalf.
4.3 Copayments and Deductibles. Ancillary Provider understands and agrees
that the Payor (or, if applicable, CCPN) has no responsibility to pay any
amount except as described in Paragraph 4.2 above and Ancillary Provider
shall, unless prohibited by state or federal law, xxxx and attempt to
collect copayments, deductibles and any other fees which are the Covered
Person's responsibility under the Covered Person's Payor Plan. For
medical services not covered by this Agreement and for so long as not
prohibited by CCPN and/or Payor or by state or federal law, Ancillary
Provider may xxxx a Covered Person or other responsible party.
4.4 Reimbursement and Billing Procedures. Unless otherwise specified in
writing by CCPN and/or Payor, Ancillary Provider shall submit all claims
directly to Payor. Ancillary Provider shall comply with the reimbursement
and billing procedures required by CCPN and/or Payor. Ancillary Provider
will use the standard HCFA 1500 or such other claim form furnished by
Payor or CCPN to xxxx for services rendered. CCPN reserves the right to
review all bills submitted by Ancillary Provider to the Payor.
4.5 Timeliness of Claim Submission. Ancillary Provider shall submit claims
for Covered Services within sixty (60) days from the date such Covered
Services were provided, unless an exception has been issued by HMO in
writing, and then xxxx shall be submitted within one hundred eighty (180)
days.
4.6 Payor's Responsibility. Unless otherwise specified in writing by CCPN,
Ancillary Provider specifically acknowledges and agrees that (1) the
Payor shall have the full and final responsibility for payment of claims,
and (2) CCPN is not responsible for, does not guarantee, and does not
assume responsibility for payment of any claim. Unless otherwise provided
for in this Agreement or specified in writing by CCPN, all final claims
decisions will be the responsibility of the Payor. Ancillary Provider
acknowledges and agrees that if CCPN specifies in writing to Ancillary
Provider that CCPN and not Payor has full and final responsibility for
payment of claims or Ancillary Provider's reimbursement, then under no
circumstances will Ancillary Provider seek or claim payment from such
Payor.
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4.7 Coordination of Benefits. Ancillary Provider will (a) cooperate with CCPN
and Payor in coordination of benefits, (b) provide CCPN and Payor
relevant information relating to any other coverage held by a Covered
Person, and (c) abide by the coordination of benefits, subrogation and
duplicate coverage policies and procedures of CCPN and/or Payor as set
forth in the Payor provider manuals. Ancillary Provider shall consent to
the release of medical information by CCPN or Payor to other group health
plans necessary and lawful to accomplish coordination of benefits. If the
Payor (or, if applicable, CCPN) is the primary carrier, then Ancillary
Provider compensation will be on the basis specified in this Agreement
and the applicable HMO Agreement. If the Payor (or, if applicable, CCPN)
is other than the primary carrier and Ancillary Provider's xxxx to the
primary carrier(s) was not computed on the basis specified in this
Agreement, then, unless the Payor Agreement specifies otherwise, any
further reimbursement to Physician from the Payor (or, if applicable,
CCPN) may not exceed an amount which, when added to amounts shown on the
explanation of benefits from the primary carrier(s), equals the amount
specified in this Agreement.
5. MEDICAL RECORDS AND CONFIDENTIALITY
5.1 Maintenance of Medical Records. Ancillary Provider shall maintain for at
least a three year period of time or if the Covered Person was younger
than 18 years of age when treated, seventy-five days after the date of
the Covered Person's 20th birthday or seventy-five days after the 10th
anniversary of the date on which the Covered Person was last treated,
whichever date is later, or for any longer period of time specified by
state law or the Payor Plan, and make readily available to CCPN, Payor,
and governmental agencies with regulatory authority, all medical and
related administrative records of Covered Persons that receive Covered
Services, as required by CCPN in accordance with this Agreement or
pursuant to applicable law.
5.2 Maintenance of Financial Records. Ancillary Provider shall maintain for
at least a three year period of time from the date a Covered Person was
last treated, or for any longer period of time specified by state law,
all financial records relating to the payment for medical services
provided to a Covered Person.
5.3 Transferability. Ancillary Provider, upon request of the Covered Person
or other Participating Physician, and subject to applicable disclosure
and
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confidentiality laws, will transfer the medical records of the
Covered Person to such other Participating Physician, Provider and/or
Hospital. This obligation shall survive any subsequent termination or
expiration of this Agreement.
5.4 Access to Medical Records. Subject to applicable disclosure and
confidentiality laws, Ancillary Provider shall provide CCPN, Payor, or
any duly designated third party with reasonable access to medical
records, books, and other records of such Provider relating to Covered
Health Services (including the cost thereof) provided to Covered Persons
during the term of this Agreement and thereafter for a period in
conformance with Section 10.5 and state and federal law. CCPN and Payor
shall be entitled to obtain copies of Covered Person's medical records.
In addition, Ancillary Provider, at its expense, will provide CCPN with
all records reasonably necessary to carry out CCPN's and Payor's
utilization management and quality improvement programs. The provisions
of this paragraph shall not operate to waive or limit any restriction on
release or disclosure of patient records established in any other
provisions of this Agreement or as otherwise required by law.
5.5 Confidentiality of Medical Records. Ancillary Provider covenants that
information concerning Covered Persons shall be kept confidential and
shall not be disclosed to any person except as authorized by state and
federal law. This confidentiality provision shall remain in effect
notwithstanding any subsequent termination or expiration of this
Agreement.
5.6 Proprietary CCPN Information. Ancillary Provider may, from time to time,
receive proprietary information from CCPN. Provider agrees that such
information shall be kept confidential and, unless otherwise required by
law, shall not be disclosed to any person except as authorized in writing
by CCPN.
6. INDEPENDENT RELATIONSHIP
None of the provisions of this Agreement are intended to create nor shall
be deemed or construed to create any relationship between CCPN and
Ancillary Provider other than that of independent parties contracting
with each other. Neither of the parties hereto, nor any of their
respective officers, directors or employees, or agents shall be construed
to be the agent, employee or representative of the other. Neither party
is authorized to represent the other for any purpose whatsoever without
the prior consent of the other. CCPN shall
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not have nor shall it exercise any control or direction over the
Ancillary Provider.
7. INSURANCE
Ancillary Provider shall maintain at least the minimum amount of One
Million Dollars ($1,000,000) per occurrence and Three Million Dollars
($3,000,000) in the aggregate, policies of general liability,
professional liability, and directors and officers liability insurance to
insure itself and its employees against any claim or claims for damages
arising pursuant to this Agreement. Documentary evidence of such
insurance policy or policies shall be provided to CCPN upon request.
Ancillary Provider agrees to keep and maintain said insurance coverage in
full force and effect during this Agreement. Ancillary Provider or its
insurance carriers will provide CCPN with thirty (30) days advance
written notice of a material modification or cancellation of said
policies. All liability coverage shall be "occurrence based", provided,
however, that in any instance where the coverage required can openly be
acquired by means of a "claims made" policy, that policy shall provide
for a "buy-out at the tail" provision, which Ancillary Provider agrees to
exercise or cause to be exercised in the event of change, cancellation or
termination of said policy.
Certificates of insurance or other evidence indicating the term and
extent of professional liability insurance shall be provided by Ancillary
Provider to CCPN upon execution of this Agreement. Ancillary Provider
shall require its professional liability carrier to name CCPN as a party
entitled to a thirty (30) day prior written notice of an intent to cancel
or terminate Ancillary Provider's coverage.
8. NON-EXCLUSIVITY
Nothing contained in this Agreement shall preclude Ancillary Provider
from participating in or contracting with any other health care provider
organization, managed care plan, health maintenance organization,
insurer, employer, or any other third party payor.
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9. CONDITION PRECEDENT
This Agreement shall not be effective unless and until Ancillary Provider
has been successfully credentialed by CCPN. The failure of Ancillary
Provider to become successfully credentialed by CCPN will result in this
Agreement being null, void and of no force or effect.
10. TERM AND TERMINATION
10.1 This Agreement shall have an initial term which shall expire on September
1, 1998. Unless earlier terminated hereunder, the Agreement shall
automatically renew for successive terms of one (1) year each.
10.2 This Agreement may be terminated by CCPN upon the occurrence of any of
the following:
10.2.1 CCPN may terminate this Agreement, with or without cause, by
giving the Ancillary Provider ninety (90) days written notice.
10.2.2 Suspension, restriction, revocation or surrender of Ancillary
Provider's license to render services in any state.
10.2.3 CCPN shall have the right, but not the obligation, to terminate
this Agreement immediately if that certain agreement between CCPN
and Payor dated effective October 1, 1996 is terminated.
10.2.4 Conduct which is detrimental to patient welfare and care.
10.2.5 Extreme misconduct on the part of Ancillary Provider or its
employees detrimental to the interests to CCPN.
10.2.6 Failure to maintain the insurance coverage required by this
Agreement.
10.2.7 Failure to comply with CCPN and/or Payor guidelines, credentialing
criteria, policies and procedures.
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10.3 This Agreement may be terminated by Ancillary Provider by giving written
notice to CCPN, with cause upon sixty (60) days and without cause upon
one hundred twenty (120) days written notice.
10.4 Either party may terminate this Agreement upon thirty (30) days prior
notice if the other party fails to perform any material covenant,
undertaking, obligation or condition as set forth in this Agreement.
10.5 No Limitation of Rights. Nothing contained herein shall be construed to
limit either party's lawful remedies in the event of a material breach of
this Agreement.
10.6 Access to Records. Notwithstanding termination of this Agreement,
Ancillary Provider, CCPN and Payor shall continue to have access to the
records maintained by Ancillary Provider in accordance with Section 5.1,
5.2 and 5.4 for a period of three (3) years from the date of the
provision of the Covered Services to Covered Persons to which the records
refer for purposes consistent with the rights, duties and obligations
under this Agreement and Payor Agreements.
10.7 Post Termination. Following termination of this Agreement, Ancillary
Provider shall continue to provide Covered Services to any Covered Person
who is under active treatment either until such treatment is completed or
responsibility is assumed by another Participating Provider. Ancillary
Provider shall be compensated for such Covered Services in accordance
with the terms of the applicable Payor Agreement.
11. GENERAL PROVISIONS
11.1 Amendments. This Agreement may be amended in writing as mutually agreed
upon by the parties.
11.2 Assignment. This Agreement, being intended to be personal to these
parties shall not be assigned, sublet, delegated or transferred by CCPN
or Provider to any other party without the prior written consent of the
other party which shall not be unreasonably withheld.
11.3 Notice. Any notice required to be given pursuant to the terms and
provisions hereof shall be in writing and sent by hand delivery or by
certified mail,
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return receipt requested, postage prepaid, to CCPN or to the Provider at
the respective addresses indicated herein. Notice shall be deemed to be
effective when mailed or hand delivered, but notice of change of address
shall be effective upon receipt.
11.4 Governing Law and Venue. This Agreement shall be governed in all respects
by the laws of the State of Texas. The venue of any legal action arising
from the Agreement shall be in Tarrant County, Texas, and CCPN and
Provider specifically waive any right of venue that either might
otherwise have.
11.5 Severance of Invalid Provisions. If any provision of this Agreement is
held to be illegal, invalid or unenforceable under present or future laws
effective during the term hereof, such provision shall be fully
severable. This Agreement shall be construed and enforced as if such
illegal, invalid or unenforceable provision had never comprised a part
hereof, and the remaining provisions shall remain in full force and
effect unaffected by such severance, provided that the invalid provision
is not material to the overall purpose and operation of this Agreement
11.6 Waiver. The waiver by either party of any breach of any provision of this
Agreement or warranty representation herein set forth shall not be
construed as a waiver of any subsequent breach of the same or any other
provision. The failure to exercise any right hereunder shall not operate
as a waiver of such right. All rights and remedies provided herein are
cumulative.
11.7 Entire Agreement. This Agreement contains all the terms and conditions
agreed upon by the parties hereto regarding the subject matter of this
Agreement. Any prior agreements, promises, negotiations or
representations, either oral or written, relating to the subject matter
of this Agreement not expressly set forth in this Agreement are of no
force or effect.
11.8 Force Majeure. If either party fails to perform its obligations hereunder
because of strikes, accidents, acts of God, or action or inaction of any
government body or other proper authority or other causes beyond its
control then such failure to perform shall not be deemed a default
hereunder and shall be excused without penalty until such time as said
part is capable of performing.
11.9 Mediation. Except as otherwise specifically provided for herein, in the
event of any dispute, controversy or claim between the parties arising
out of or
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relating to this Agreement either during or after the term hereof, the
parties hereby agree that, unless waived by the parties, they shall first
submit such dispute, controversy or claim to non-binding mediation in
Tarrant County, Texas. The parties shall use reasonable efforts to reach
a mutually agreed to resolution of the dispute, controversy or claim
through such mediation process and shall reasonably cooperate with each
other and the mediator in attempting to resolve such dispute,
controversy, or claim. In the event such dispute, controversy or claim is
not resolved through the use of the mediation process, the parties shall
be free to pursue any rights or remedies they may have in another forum.
Each party shall bear its own costs and expenses in pursuing any rights
or remedies associated with this Agreement, unless otherwise agreed to by
the parties or unless otherwise ordered by a court of competent
jurisdiction. The cost of employing a mediator shall be equally shared by
the parties.
12. SPECIAL PROVISIONS
12.1 With regard to Early Childhood Intervention services outlined under Part
H of the Individual With Disabilities Education Act, (20 USC 1471 , et
seq.) CCPN shall provide or arrange for the provision of all federally
mandated services contained at 34 CFR 303.1 et seq., and 25 TAC 621.21 et
seq. relating to identification, evaluation, assessment and referral and
delivery of health care services contained in a Covered Person's IFSP.
12.2 CCPN shall ensure that network providers are educated regarding the
identification of Members under age 3 who have or are at risk for having
disabilities and/or developmental delays. CCPN shall ensure that all
providers refer identified Members in the service area to Ancillary
Provider within two working days from the day the Member is identified.
12.3 An interdisciplinary team convened by Ancillary Provider that includes
the parent must meet to determine a child's eligibility for ECI services.
The team, under the authority of the Ancillary Provider, shall determine
eligibility for ECI services in accordance with criteria contained at 25
TAC * 621.21 et seq. The IFSP is to be developed by the interdisciplinary
team under the authority of Ancillary Provider in accordance with
criteria contained at 25 TAC * 621.21 et seq.
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12.4 CCPN shall reimburse Ancillary Provider for all health related
assessments performed by Ancillary Provider for a child who has gone
through an initial ECI intake and screening process regardless of the
origin of the initial referral. CCPN shall not require any prior
authorization for assessments or evaluations. All assessment and
evaluation data including but not limited to test protocols and/or
assessment reports must be maintained as part of the child's main records
at the Ancillary Provider. Psychological services will be coordinated
through a behavioral health provider designated by HMO.
12.5 CCPN shall coordinate and cooperate with Ancillary Provider to ensure
that all medical diagnostic procedures are conducted and medical records
are provided to perform developmental assessments and develop the IFSP
within the timeliness established at 34 CFR 303.1 et seq.
12.6 CCPN shall reimburse Ancillary Provider for all health related
assessments performed by Ancillary Provider for a child to go through an
annual review. CCPN shall not require any prior authorization for
assessment or evaluations required for annual reviews. All assessment and
evaluation data including but not limited to test protocols and/or
assessment reports must be maintained as part of the child's main records
at Ancillary Provider.
12.7 Health and behavior health-related services that are determined necessary
by the interdisciplinary team, identified in the IFSP and, approved,
recommended or prescribed by the child's PCP will be provided by
qualified providers employed by or contracted with Ancillary Provider and
provided in natural settings to the maximum extent appropriate and are to
be reimbursed by CCPN. CCPN shall approve all health and behavioral
health related services identified in the IFSP that are approved,
recommended or prescribed by the child's PCP and shall not modify the
IFSP or alter the amount, duration and scope of services established by
the Member's IFSP. Behavioral health services make up only a small
fraction of all rendered ECI services and are rarely required. TDH
acknowledges the STAR Health Plan contract with the provider of
behavioral health services. TDH supports collaboration between ECI and
the behavioral health services provider to more effectively serve the ECI
eligible STAR Members. TDH supports the STAR Health Plan's position to
require pre-authorization for behavioral health services called for by
the IFSP and that all claims for behavioral health services be billed to
behavioral health services provider.
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12.8 CCPN will assure that no unnecessary barriers are created for Member to
obtain IFSP services, including requiring prior authorizations for the
ECI assessment and insufficient authorization periods for prior
authorized services. CCPN will approve therapy and other necessary health
related services for time frames called for the IFSP, not to exceed 6
months. If ECI subcontracts health related services to another entity,
then subcontractor must obtain recertification every thirty (30) days.
ECI must notify CCPN/HMO of subcontractor's arrangements within
seventy-two (72) hours of referral. ECI must refer only to participants
of Medicaid Program.
12.9 All post-assessment Ancillary Services must be prior authorized.
Ancillary Provider understands and agrees that Ancillary Provider is
responsible for obtaining confirmation of eligibility at the first of
every month, for each ECI Child. Ancillary Provider understands and
agrees that CCPN nor Payor will not be liable for services rendered to an
ineligible member and will to another payor source. Children receiving
therapy services who have chronic conditions require on-going medical
supervision. To establish medical necessity the PCP's prescription and
revised IFSP are needed at least every six months.
12.10 The initial therapy treatment plan must include the PCP's prescription, a
current IFSP, a copy of the current evaluation, documentation indicting
treatment goals, and anticipated measurable progress. To request an
extension of services after the six (6) month review, the treatment plan
should include the current PCP's prescription, a summary of measurable
progress made during the treatment period and documentation indicating
new treatment goals and anticipated measurable progress for the next
treatment period.
12.11 Ancillary Provider understands and agrees to coordinate all
therapy/nutrition services with Payor. Ancillary Provider will provide a
summary of assessment results to the client's Primary Care Physician and
the Payor Medical Case manager upon completion as soon as possible. A
Payor Case Manager will be invited to the IFSP meeting to be included on
the interdisciplinary team responsible for the development of the IFSP.
Ancillary Provider will provide advance notice of the IFSP meeting to the
client's Primary Care Physician and Payor's Case Manager to facilitate
their attendance at the IFSP meeting. A copy of the IFSP must be provided
to Payor's Case Management prior to the issuance of and authorization for
services set forth in the IFSP. If Ancillary Provider finds that a
Payor's Case Manager has not been made aware of the requested ECI
services, Ancillary Provider will take steps to
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include the Payor's Case Manager in the development and/or continued
maintenance of the IFSP.
12.12 Ancillary Provider understands and agrees that upon checking eligibility
at the first of the month it is found that an in-process IFSP or
authorization of an IFSP exists from traditional Medicaid or another HMO
for a newly eligible Payor member, Ancillary Provider will contact
Payor's Case Manager. Ancillary Provider will provide to Payor a copy of
the IFSP and any benchmark report information which has been completed.
If the PCP has changed from the PCP of record on the existing IFSP due to
plan change, Ancillary Provider and Payor Case Management will coordinate
with the new PCP the status of the existing IFSP. After review of the
IFSP, Payor's Case Management will provide to Ancillary Provider a new
authorization applicable to the member's eligibility with Payor. The
current PCP and Payor's Case Manager will become members of the
interdisciplinary team for the IFSP.
12.13 Clean claims will be paid within thirty (30) days. CCPN shall ensure that
payments to providers for services rendered are made within thirty (30)
days of receipt of a clean claim, that records are retained for a period
of five (5) years and the confidentiality of the records is maintained.
12.14 CCPN shall ensure that the rights provided to children and families in
Part H of IDEA (20 USC 1480 et seq.) and FERPA, which protect the family
from intrusion and coercion, and incorporates rights of privacy,
complaint resolution, confidentiality, full disclosure of information and
the family's right to decide about all aspects of the IFSP are preserved.
12.15 In those instances where CCPN utilizes provider of health or behavior
health services for early intervention services other than currently
approved and funded ECI providers, CCPN shall ensure that such providers
meet all the requirements imposed upon current ECI providers as contained
in 20 USC 1471 et seq., 34 CFR 303.1 et seq., Chapter 73, Human Resources
Code, Vernon's Texas Codes Annotated, and 25 TAC 621.21 et seq. CCPN
shall be approved by the Texas Interagency Council on Early Childhood
Intervention to provide early intervention services through network
providers outside existing ECI program and its subcontractors. Approval
by the Interagency Council will be contingent upon an acceptable
agreement between CCPN and Ancillary Provider regarding coordination and
cooperation regarding all aspects of the delivery of early intervention
services to ECI eligible children.
22
97
12.16 Ancillary Provider will notify CCPN or HMO case manager immediately upon
learning of a Covered Person who has been referred to ECI or that is
being served by ECI.
12.17 Ancillary Provider will provide a summary of the assessment results to
the medical case manager and PCP within ten (10) working days. Ancillary
Provider will provide as much advance notice as possible, but at least
forty-eight (48) hours notice prior to the IFSP meeting to the medical
case manager and PCP.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
on the 11 day of November, 1998.
XXXX CHILDREN'S PECAN VALLEY MENTAL
PHYSICIAN NETWORK HEALTH AND MENTAL
RETARDATION REGION
By:/s/ Xxxx Xxxx Xxxxxxxx, M.D.
------------------------------------
Xxxx Xxxx Xxxxxxxx, M.D. By:/s/ Xxxxxxx Xxxxxx, Ed.D.
President and CEO ------------------------------
Title: Executive Director
---------------------------
Printed Name: Xxxxxxx Xxxxxx
-------------------
Address for Notice: Address for Notice:
Xxxx Children's Physician Network X.X. Xxx 000
801 Seventh Avenue ------------------------
Xxxx Xxxxx, Xxxxx 00000
Atm: President 000 X. Xxxxx Xxxxxx
------------------------
Xxxxxxxxxxxx, XX 00000
------------------------
23
98
EXHIBIT "A"
PROVIDER SELECTION PAGE
Indicate the Payor(s) with which you choose to participate:
X Rio Grande HMO, Inc., d/b/a HMO Blue(R), DFW Metroplex
-----
X Americaid Texas, Inc., d/b/a Americaid Community Care
-----
X Xxxxxx Methodist Texas Health Plan, Inc.
-----
24
99
EXHIBIT "B"
CCPN PARTICIPATION CRITERIA
PARTICIPATION CRITERIA FOR ANCILLARY PROVIDER
1. Attested and completed application.
2. Current and unrestricted Texas Licensure, appropriate for the Ancillary
Provider.
3. Accreditation by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), American Osteopathic Association (AOA), or other
appropriate nationally recognized accrediting agency and/or certification
by Medicare appropriate for the Ancillary Provider.
4. No disciplinary actions by Medicare, Medicaid or State Licensing agency.
5. Evidence of adequate malpractice and casualty coverage.
6. Governance, management, administration, and organizational structure
appropriate for the size and type of Ancillary Provider.
7. Ability and willingness to provide access to appropriate patient/member
financial information.
Utilize an appropriate financial planning process.
Engage in responsible accounting practices.
Present accurate fiscal information.
Evidence of financial stability.
8. Demonstrated willingness to accept reimbursement methods established by
CCPN and/or Payor.
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100
9. Demonstrated ability and willingness to xxxx according to Plan
requirements established by CCPN and/or Payor.
10. In conformance with all state and local safety requirements and OSHA
regulations.
11. Information management processes are planned and designed to meet
internal and external information needs.
12. Appropriate risk management program is established and implemented.
13. Reports documenting findings and intervention are maintained.
14. Staffing is adequate and appropriate for the type and size of the
Ancillary Provider. Physician/Medical supervision is available as
appropriate.
15. Staff appropriately licensed/certified based on job description.
16. Educational and training programs which keep staff current in general
information and specialty-specific information are provided.
17. Protocol for credentialing and/or privileging independently practicing
professionals which provides for primary source verification of
credentials and procedures for appointment/reappointment and appeals.
18. Requirement of continuing education appropriate for each specialty.
19. Organization of professional staff which provides for adequate monitoring
of quality of care.
20. Protocol for contracting of professional and/or ancillary services
ensures contracted professionals meet CCPN Participation Criteria.
21. Medical records are maintained in a manner that is current, legible,
detailed, organized and permits effective patient care and quality
review.
22. Storage of records allows prompt retrieval of clinical information,
including statistics.
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101
23. Medical records are systematically reviewed for conformance to documented
standards with corrective action when standards are not met.
24. Records identify the patient, diagnosis and treating provider and other
professionals, support the assessment, justify treatment and document the
course and results.
25. Confidentiality and security are maintained.
26. If there is an organized pharmacy, it is supervised by a Registered
Pharmacist.
27. If medications are stored or dispensed, written policies and procedures
providing safe, secure storage of medications as well as appropriate
dispensing and monitoring procedures.
28. Therapeutic services adequate for quality patient care are available.
29. Services are provided and supervised by appropriately qualified,
certified staff.
30. Equipment is adequate, current and well-maintained.
31. 24 hour provider coverage is available as needed.
32. Equipment and supplies for emergency patient care is adequate, current
and well-maintained.
33. Personnel is trained and adequate for patient emergencies.
34. Emergency policies and procedures are well documented.
35. Documented transfer arrangement with a network acute care facility as
appropriate.
36. Availability of patient referrals to multiple levels of care and other
appropriate providers in order to provide a continuum of care.
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102
37. Demonstrated need for the services provided.
38. Willingness to participate in managed care.
39. Meets the needs of the network related to geographic location and
services provided as defined by the Strategic Planning Committee.
40. A QM/QI program approved by the governing body is implemented.
41. The program is comprehensive and includes quality of clinical care and
quality of service.
42. Individual provider performance is considered in
recredentialing/reappointment professional providers and outside
contractors.
43. Satisfactory utilization statistics.
44. There is a documented UM plan which meets the needs of the Ancillary
Provider and the Network.
28
103
OCCUPATIONAL THERAPY
PROCEDURE
CODE DESCRIPTION RATES
5381X* Assessment/Reassessment $40.00
584lX Therapy, Initial 30 minutes $20.00
5850X Therapy, Ea. additional 15 minutes $10.00
5853X Therapy, more than one hour $40.00
5842X Group treatment $10.00 per client per session
5384X Assistive technology - equipment training $40.00 per session
5387X Seating Assessment $40.00 per session
NUTRITIONAL ASSESSMENT, COUNSELING, FOLLOW-UP
PROCEDURE
CODE DESCRIPTION RATES
5294X** Nutritional services $30.00 per session
* Assessment/Reassessment services do not require prior authorization by
Payor. However, payment for Assessment/Reassessment services is
contingent upon member's eligibility with Payor at the time services are
rendered.
** Assessment/Reassessment devices for Dietary Counseling are allowed once
every six months without prior authorization. All post assessment Dietary
Counseling services require prior authorization for reimbursement
purposes.
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104
AMENDMENT
to
CCPN and HMO MEDICAID AGREEMENT
by and between
AMERICAID Texas Inc., d/b/a AMERICAID Community Care
and
Xxxx Children's Physician Network A Texas 5.01(a) Non-Profit Corporation
Dated October 9, 1997
Pursuant to the Texas Department of Insurance (TDI) requirements, the
above referenced Agreement shall be modified, effective immediately, as stated
below to comply with the Texas Insurance Code (TIC). The original Agreement
remains in full force and effect. To the extent that any provisions herein
contained conflict with a provision of the Agreement, this Addendum prevails.
Pursuant to Article 20A.02 (g) of the TIC, "Emergency Care" means health
care services provided in a hospital emergency facility or comparable facility
to evaluate and stabilize medical conditions of a recent onset and severity,
including but not limited to severe pain, that would lead a prudent layperson,
possessing an average knowledge of medicine and health, to believe that his or
her condition, sickness or injury is of such a nature that failure to get
immediate medical care could result in: (a) placing the patient's health in
serious jeopardy; (b) serious impairment to bodily functions; or (c) serious
dysfunction of any bodily organ or part; (d) serious disfigurement; or (e) in
the case of a pregnant woman, serious jeopardy to the health of the fetus.
Pursuant to Article 20A.18A(c) of the TIC, the termination of the
AMERICAID/provider contract, except for reason of medical competence or
professional behavior, does not release AMERICAID from the obligation to
reimburse the provider who is treating an enrollee of special circumstances,
such as a person who has a disability, acute condition, or life threatening
illness, or is past the twenty-fourth week of a pregnancy at no less than the
contract rate for that enrollee's care in exchange for continuity of ongoing
treatment of an enrollee then receiving medically necessary treatment in
accordance with the dictates of medical prudence.
Pursuant to Article 20A.18A(e), AMERICAID shall begin payment of
capitated amounts to the enrollee's primary care provider (PCP) no later than
the 60th (sixtieth) day following the date an enrollee has selected or has been
assigned a PCP.
105
Pursuant to Article 20A.18A(i), Provider shall post, in Provider's
office, a notice to enrollees on the process for resolving complaints with
AMERICAID. Notice must include the Texas Department of Insurance toll free
telephone number for filing complaints.
Pursuant to Article 20A.14(g) No type of provider licensed or otherwise
authorized to practice in this state may be denied participation to provide
health care services which are delivered by AMERICAID and which are within the
scope of licensure or authorization of the type of provider on the sole basis of
type of license or authorization. However, if a hospital, facility, agency, or
supplier is certified by the Medicare program, Title XVIII of the Social
Security Act (42 U.S.C. Section 1395 et seq.), or accredited by the Joint
Commission on Accreditation of Healthcare Organizations or another national
accrediting body, AMERICAID shall be required to accept such certification or
accreditation. This section may not be construed to (1) require AMERICAID to
utilize a particular type of provider in its operation; (2) require, except as
provided in Article 21.52B of this code, that AMERICAID accept each provider of
a category or type; or (3) require that health maintenance organizations
contract directly with such providers. Notwithstanding any other provision,
nothing herein shall be construed to limit AMERICAID's authority to set the
terms and conditions under which health care services will be rendered by
providers. All providers must comply with the terms and conditions established
by AMERICAID for the provision or health services and for designation as a
provider.
Pursuant to Article 20A.14(h) AMERICAID shall provide a twenty (20)
calendar day period each calendar year during which any provider or physician in
the geographic service area may apply to participate in providing health care
services or medical care under the terms and conditions established by Americaid
for the provision of such services and the designation of such providers and
physicians. Americaid will notify, in writing, such provider or physician of the
reason for nonacceptance to participate in providing health care services or
medical care. This section may in no way be construed to (1) require that
AMERICAID utilize a particular type of provider or physician in its operation;
(2) require that AMERICAID accept a provider or physician of a category or type
that does not meet the practice standards and qualifications established by
AMERICAID; or (3) require that AMERICAID contract directly with such providers
or physicians.
Pursuant to Article 20A.14(i)(1), AMERICAID may not prohibit, attempt to
prohibit, or discourage a physician or provider from:
2
106
a. discussing with or communicating to a current, prospective or
former patient, or a party designated by a patient, information or
opinions regarding the patient's health care, including but not
limited to the patient's medical condition or treatment options;
b. discussing with or communicating in good faith to a current,
prospective or former patient, information or opinions regarding
the provisions, terms, requirements or services of the health care
plan as they relate to the health care needs of the patient.
Pursuant to Article 20A.14(i)(2), AMERICAID shall not in any way
penalize, terminate, or refuse to compensate, for covered services, a physician
or provider for discussing or communicating with a current, prospective, or
former patient, or a party designated by a patient pursuant to this section.
Pursuant to Article 20A.14(k), AMERICAID shall not engage in any
retaliatory action, including termination of, or refusal to renew a contract,
against a physician or provider because the physician or provider has, on behalf
of an enrollee, reasonably filed a complaint against AMERICAID or has appealed a
decision of AMERICAID.
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107
Pursuant to Article 20A.14(l), AMERICAID may not use any financial
incentive or make any payment to a physician or provider that acts directly or
indirectly as an inducement to limit medically necessary services.
AMERICAID Texas, Inc. Xxxx Children's Physician Network
/s/ Xxxxxx X. Xxxxxxxx /s/ Xxxx Xxxx Xxxxxxxx, MD
------------------------------- ---------------------------------
Signature Signature
Xxxxxx X. Xxxxxxxx Xxxx Xxxx Xxxxxxxx, MD
Associate Vice President President and CEO
------------------------------- ---------------------------------
Print Name and Title Print Name and Title
August 26, 1999 August 12, 1999
------------------------------- ---------------------------------
Date Date
000 Xxxxxxx Xxxxxx
Xx. Xxxxx, XX 00000
--------------------------------
Address
(817) 885 -1416
--------------------------------
Telephone
4
108
AMENDMENT TO
CCPN AND HMO MEDICAID AGREEMENT
THIS AMENDMENT TO CCPN AND HMO MEDICAID AGREEMENT (the "Amendment") is
entered into as of the 1st day of January, 2000 (the "Effective Date"), by and
between AMERICAID Texas, Inc., a Texas corporation ("HMO") and Xxxx Children's
Physician Network, a Texas non-profit corporation ("CCPN").
RECITALS:
WHEREAS, HMO and CCPN have entered into a CCPN and HMO Medicaid Agreement
on October 1, 1996 (the "Initial Agreement"), as amended pursuant to the
Modification Agreement (defined below) and the amendments identified on Schedule
1 attached hereto (as amended, the "Medicaid Services Agreement"); and
WHEREAS, HMO and CCPN desire to amend the Medicaid Services Agreement on
the terms set forth below; and
WHEREAS, Xxxx Children's Health Care System (f/k/a Xxxx Children's Heath
Care Network) and AMERIGROUP Corporation (f/k/a AMERICAID, Inc.) as parties to
that certain Agreement executed October 9, 1997 to be effective as of September
1, 1995 (the "Modification Agreement") are executing this Amendment solely to
acknowledge that certain of its terms modify the terms of the Modification
Agreement.
NOW, THEREFORE, in consideration of the premises and the mutual promises,
covenants and agreements set forth herein, and for other good and valuable
consideration, the receipt and sufficiency of which is hereby acknowledged, the
parties agree as follows:
1. Definitions. Capitalized terms not otherwise defined herein shall have
the meaning given such terms under the Medicaid Services Agreement.
2. Modifications to Compensation Terms.
a) The "Financial Arrangements" set forth in Attachment A of the
Initial Agreement, as amended, are amended and restated in their
entirety as set forth in Attachment A attached hereto; such
attachment shall
109
supersede Sections 5, 6 and 7 of the Modification Agreement. The
new terms therein with respect to the administration and
settlement of the pools shall be effective retroactively to
September 1, 1998 (not withstanding the Effective Date herein for
the other terms of this Amendment) so that they shall apply for
purposes of the 98/99 Year-End Settlement. The Exhibits to
Attachment A of the Initial Agreement (e.g., Exhibits 4 and 5)
shall continue to apply.
b) Attachments B and C to the Initial Agreement are hereby amended
and restated by the rates set forth in revised Attachments B and C
attached hereto, and Schedule A-IV.H (which had been implemented
pursuant to the Second Amendment dated March 1, 1998) is hereby
amended and restated by the rates set forth in Attachment D
hereto.
3. Delegation of Additional Administrative Functions.
a) CCPN shall have the option to receive delegation of medical
management, provider services and/or claims processing,
adjudication and payment (the "Administrative Functions"), if each
of the conditions in this Section 3 are satisfied. CCPN shall
provide HMO with not less than ninety (90) days (the "Notice
Period") prior written notice of exercise (the "Exercise No xxxx")
and shall, with such Notice, provide HMO with such documentation
and information as HMO may deem reasonably necessary to
demonstrate that the conditions have been or will be satisfied.
HMO shall promptly review whether all conditions are satisfied, it
being the intent of the parties to implement the delegation not
earlier than ninety (90) days nor later than one hundred fifty
(150) days after the Exercise Notice is received (assum ing all
conditions are satisfied). The conditions are as follows:
i) CCPN has received delegation of the same Administrative
Func tions from all other contracted health maintenance or
managed care organizations in connection with CCPN's
provision of Medicaid services to such organizations'
members under the STAR Program (or its successor program)
and at least one of such delegated arrangements for a
Medicaid product will be operational by the end of the
Notice Period;
2
110
ii) CCPN meets all of HMO's standards for performing such ser
vices, including, without limitation, HCFA, TDI and TDH
require ments, and the standards and requirements of HEDIS
and NCQA. Upon request by CCPN, HMO agrees to provide any
such xxxx dards related to the aforementioned
administrative functions to CCPN. CCPN acknowledges that
HMO shall have the ability to perform a site visit and
audit prior to the delegation of such admin istrative
functions to ensure compliance with HMO's standards;
iii) CCPN and HMO agree to negotiate and enter into a mutually
acceptable delegation agreement to ensure CCPN
appropriately assists HMO in meeting all then applicable
legal requirements (including, without limitation, any
applicable requirements of HCFA, TDH, TDI or Texas Senate
Xxxx 890 or its successor) and the standards and
requirements of HEDIS and the NCQA, and continues to
satisfy the conditions set forth herein. The agreement
shall, among other things, (A) ensure appropriate
accountabilities for performance, service delivery, and
data reporting (CCPN shall, among other things, be required
to timely report all data elements presently used by HMO in
its claims processing and precertification functions so
that there will be no disruption in HMO's ability to
accurately project medical claims), (B) ensure CCPN's
participation in and compliance with federal, state and
NCQA reviews, (C) establish performance standards and penal
ties, (D) include reciprocal indemnification provisions by
which each party agrees to defend and hold the other
harmless from claims, damages, penalties, sanctions, etc.
(whether governmental, private party or otherwise) related
to, among other things, the functions for which the
indemnifying party is responsible under the agreement,
whether performed by such party or sub-delegated, (B)
prohibit sub-delegation without HMO's prior written
consent, and (F) establish the circumstances under which
delegation may be revoked;
iv) The parties shall have mutually agreed on (A) the amount
HMO shall pay CCPN for CCPN's performance of the
Administrative Functions, which amount will consider, among
other
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111
things, HMO's costs to provide oversight of the delegation
and HMO's actual average total direct costs for such
services as a percentage of total premium and applied to
the premium payable with respect to pediatric Members (as
defined in Attachment A), and (B) adjustments required to
the Pool allocation and settlement method ologies set forth
on Attachment A in light of such modified pay ment terms;
and
v) If claims processing and precertification is to be
delegated,
(A) CCPN must successfully complete a thorough review by
HMO and/or its designee (such as external auditors)
re xxxxxxx appropriate internal controls over the
performance of such services (based on HMO's then
applicable review tool) prior to implementation;
(B) The delegation agreement shall further provide that
on a periodic basis, but not less than quarterly for
internal re view and annually for external review,
CCPN (and its designees, if any) will be audited to
ensure that the controls and procedures reviewed
prior to implementation are in place and are being
used appropriately and that any defi ciencies will
be promptly cured through a corrective action plan;
and
(C) The delegation agreement shall further require CCPN
to meet on an ongoing basis HMO's then applicable
financial adequacy and reporting requirements for
delegated claims relationships.
4. Use of HMO-to-HMO Contract. To the extent permitted by law, at CCPN's
option, the obligations of CCPN under the Medicaid Services Agreement
shall be effected through Xxxx Children's Health Plan (through an
HMO-to-HMO contract), which plan shall maintain sufficient risk reserves
to satisfy all of CCPN's obligations hereunder.
5. Modifications to Administrative Processes. Within thirty (30) days of
execution of this Amendment, CCPN and HMO agree to work collaboratively
to reform in writing the current processes regarding claims submis-
4
112
sions, claims adjudication, claims resubmissions, and accounts
receivable. CCPN and HMO shall each assign a high level person to guide
the reformation process with HMO's person also available on a bi-weekly
basis to resolve all pending claims problems.
6. Effect of Increases to Xxxx'x Charge Master and Adjustments to
Cost-to-Charge Ratio. The rates/charges upon which HMO is reimbursing
CCMC are not subject to increase in connection with any increase in
CCMC's charge master until October 1 each year, beginning October 1,
2000. CCPN shall (or shall cause CCMC to) provide HMO with written notice
of the change. CCMC's current cost-to-charge ratio (percentage discount)
used by the State shall be the basis for reimbursement prospectively and
shall not change (notwithstanding the State's May, 2000 adjustments, if
any) until October 1, 2000, at which time the cost-to-charge ratio shall
be adjusted prospectively to the cost-to-charge ratio then in use by the
State (i.e., the ratio adopted in May 2000). Then, on June 1, 2001, and
annually on June 1 thereafter, the cost-to-charge ratio shall be adjusted
(again to apply on a prospective basis only) to the cost-to-charge ratio
that the State is then using. Because of system configuration
requirements, any change required by the foregoing may be delayed by HMO
for up to, but not more than, sixty (60) days.
7. Clarifications with Respect to the Modification Agreement.
a) The text in the first sentence of Section 10 of the Modification
Agreement beginning with "as well as" and ending with "AMERICAID"
is hereby replaced with the following: "as well as any additional
counties into which TDH permits AMERICAID to expand such Service
Area."
b) It is understood and agreed that the automatic one year renewals
following the initial term, as described in Section 13 of the
Modification Agreement, shall not apply if either party gives 180
days notice of termination prior to the end of the term then in
effect.
8. Services Outside of Service Area. If CCPN desires to be a provider in
HMO's Dallas STAR network, HMO shall include CCPN in its network on such
terms as the parties agree; provided, such participation shall be on
Dallas contract terms and not part of the incentive arrangement
implemented through the Risk Funds.
5
113
9. Additional Regulatory Amendments. The Medicaid Services Agreement is
hereby further amended by the terms set forth on Attachment E hereto
which are incorpo rated for purposes of regulatory compliance.
10. Miscellaneous. Each party represents and warrants that it has full
corporate power and has taken all required corporate and other action
necessary to permit it to execute and deliver this Amendment. Except as
modified by the provisions of this Amendment, all of the terms of the
Medicaid Services Agreement shall remain in full force and effect (the
parties hereby acknowledge that Schedule 1 accurately identifies the
applicability of the terms of the prior amendments from and after the
date hereof). This Amendment may be executed in any number of
counterparts, by each party on a separate counterpart, each of which,
when so executed and delivered, shall be deemed to be an original and all
of which taken together shall constitute one and the same instrument.
6
114
IN WITNESS WHEREOF, the parties hereto have executed this Amendment as of
the day and year first above written.
AMERICAID TEXAS, INC.
By: /s/ Xxxxx X. Xxxxxxx, Xx.
----------------------------
Name: Xxxxx X. Xxxxxxx, Xx.
----------------------
Title: CEO
-----------------------
XXXX CHILDREN'S PHYSICIAN NETWORK
By: /s/ Xxxx Xxxx Xxxxxxxx, MD
-----------------------------
Name: Xxxx Xxxx Xxxxxxxx, MD
----------------------
Title: President & CEO
----------------------
SEEN AND ACKNOWLEDGED:
XXXX CHILDREN'S HEALTH CARE SYSTEM
By: /s/ Xxxx X. Xxxxxxx
----------------------------
Name:Xxxx X. Xxxxxxx
-----------------------
Title: E.V.P./ CEO
---------------------
AMERIGROUP CORPORATION
By: /s/ Xxxxx X. Xxxxxxx
-----------------------------
Name: Xxxxx X. Xxxxxxx
---------------------
Title:
---------------------
7
115
SCHEDULE 1
LIST OF AMENDMENTS TO MEDICAID SERVICES AGREEMENT
Terms that have been
Superseded, Terminated or
Document are No Longer Applicable
-------- ------------------------
1. Modification Agreement (as defined above) Sections 2, 3, 4, 5, 6, 7
and 14(a)(i) (10 and 13,
only partially)
2. First Amendment effective 1/1/98 (Footer All sections superseded
12/4/97)
3. First Amendment entered into 10/31/96 All sections terminated
4. Second Amendment entered into 11/26/96 All sections terminated
5. Third Amendment effective 1/31/97 None (document is effective)
6. Second Amendment effective 3/1/98 (Footer Section 5 superseded as of 1/1/00
TXACCNO2.268)
7. Amendment by Mutual Consent effective 7/1/99 All terms superseded as of
(Footer FWPCPAMD) 1/1/00
8. Amendment signed 8/12/99 (Footer None (document is effective)
TICAMEND)
116
ATTACHMENT A
FINANCIAL ARRANGEMENTS
117
ATTACHMENT A
FINANCIAL ARRANGEMENTS
I. Additional Definitions. The following additional definitions shall apply
to this Attachment A.
A. Adult Enrollees means any individual 16 years of age and above
residing in the Service Area who is (1) in a Medicaid eligibility
category included in the STAR Program, and (2) enrolled in the
STAR Program as a member of Americaid Texas, Inc.
B. Adult Pool means a Risk Fund established by HMO and used for the
payment of all professional, hospital, ancillary and other medical
claim expenses attributable to Adult Enrollees. Expenses charged
to the Adult Pool shall include, but not be limited to, inpatient
facility fees, fees for alternative inpatient care (e.g., skilled
nursing, extended care and home care), outpatient surgery fees,
professional fees for primary and specialty care, and ancillary
service fees.
C. Adult Pool Deficit means the amount by which the medical claim
expenses charged to the Adult Pool for an applicable year exceed
the Adult Target Amount (defined below) for such year.
D. Adult Pool Surplus means the amount by which the Adult Target
Amount for the applicable year exceeds the medical claim expenses
charged to the Adult Pool for such year.
E. Adult Target Amount has the meaning given in Section V.C. below.
F. CCPN Physician and CCPN Participating Provider each shall have the
meaning set forth for such terms in the Agreement.
G. Members has the meaning set forth in the Agreement.
H. Pediatric Pool means a Risk Fund established by HMO and used for
payment of all monthly capitation payments and valid
fee-for-service claims for Covered Health Services attributable to
Members.
Attachment A Page 1
118
I. Pediatric Pool Deficit means the amount by which the medical claim
expenses charged to the Pediatric Pool for an applicable year
exceed the Pediatric Target Amount (defined below) for such year.
J. Pediatric Pool Surplus means the amount by which the Pediatric
Target Amount for the applicable year exceeds the medical claim
expenses charged to the Adult Pool for such year.
K. Pediatric Target Amount means for each applicable year the sum of
the monthly allocations to the Pediatric Pool for such year.
L. Profit Product Pool means a Risk Fund established by HMO as a
reserve to cover deficits in the Adult and Pediatric Pools and
which is funded by HMO with seven percent (7%) of the Total TDH
Payments received by HMO for all STAR Members and Adult Enrollees
in the Tanant Service Area (excluding SSI).
M. Profit Product Pool Total means for each applicable year the sum
of the monthly allocations to the Profit Product Pool for such
year.
N. Risk Fund is a defined report to which revenues and expenses are
recorded for the purpose of tracking actual and expected claim
liabilities and funding required to support the claim liability.
O. Total TDH Payment means all revenues and payments received by HMO
from TDH for all STAR Members and Adult Enrollees in the Tarrant
Service Area (excluding SSI).
II. Allocations to Pediatric Pool.
A. HMO will receive a Monthly TDH Payment (as defined below) paid
directly to HMO by TDH for Members enrolled or assigned to HMO.
"Monthly TDH Payment" means all revenue and payments received by
HMO each month of this Agreement from TDH for Members. The Monthly
TDH Payment shall be based on the eligibility category, as
determined by TDH, of Members. From this Monthly TDH Payment, HMO
shall post to the Pediatric Pool seventy-five percent (75%) of the
total Monthly TDH Payment received by HMO from TDH for Members.
Attachment A Page 2
119
1. HMO shall post the requisite amount to the Pediatric Pool after
receipt of payment from TDH.
2. The amount recorded each month will be computed on the basis of
the current monthly Enrollment Report, which is generated by TDH
and sent to HMO. This current Enrollment Report will be sent to
CCPN by HMO simultaneously with the posting of the requisite
amount to the Pediatric Pool. It shall include the names and aid
categories of Members that correspond to the recorded amount and
shall be subject to CCPN review and audit.
3. HMO will handle retroactive recoupment of capitated payments from
CCPN and CCPN Physicians as follows:
a. If the retroactive recoupment is a result of action taken
by TDH, then the retroactive recoupment will follow the
procedure applied to the HMO by TDH. Under this procedure
as presently implemented, TDH will not recoup, through HMO,
a capitation payment for a Member when CCPN Physicians or
CCPN Participating Providers have actually provided a
service or due to a subsequent ineligibility determination
unless 1) a Member cannot use CCPN facilities (e.g., move
to a different county, correction of computer or human
error, including, but not limited to, instances where more
than one plan was paid a premium for the same Member, the
Member dies prior to the first day for the month covered by
the payment, etc.) in which case, TDH, through HMO, will
recoup the capitation payment for such Member; or 2) if a
Member's type of program designation needs to be
retroactively corrected in which case, TDH will recoup,
through HMO, the capitation payment for such Member under
the previous type program and retroactively make a
capitation payment to CCPN or CCPN Physicians, through HMO,
under the revised type program designation, if appropriate;
or 3) TDH notifies HMO in writing of a
Attachment A Page 3
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valid determination by TDH of the need to retroactively
recoup the capitation payment made for a Member.
b. Additionally, if CCPN, CCPN Physicians or CCPN
Participating Providers comply with the verification of
eligibility and benefits procedures provided to CCPN by the
Effective Date, HMO shall be financially responsible to
CCPN and CCPN Physicians for the capitation payment
described below for all care provided by CCPN Physicians
and/or CCPN Participating Providers to an ineligible person
or retroactively canceled Member due to erroneous,
incomplete or delayed HMO eligibility listings.
4. If HMO is notified that it will be assessed a penalty by TDH for
failure to perform administrative functions, as described in the
State Contract, HMO and CCPN shall immediately meet to discuss the
cause of the TDH penalty. Each party shall indemnify and hold
harmless the other party from any such penalties incurred or
arising from any breach or other violation of the terms of the
Agreement (including the terms of this Attachment A) by the
indemnifying party. The preceding sentence shall not apply to the
handling of any "Allocated Penalty Amount," as defined and
described below.
B. HMO also shall adjust the Pediatric Pool as may be required pursuant to
Section III.A below in connection with Administrative Cost Reductions.
C. The Pediatric Pool shall be used by HMO for the payment and adjudication
of monthly medical capitation payments and other valid medical claims
submitted by CCPN Physicians and CCPN Participating Providers or any
other applicable provider for the Covered Health Services.
Attachment A Page 4
121
III. Exclusions from Allocations to Pediatric Pool.
A. (i) Subject to subsections (ii), (iii) and (iv) below, HMO will
exclude sixteen percent (16%) of the Monthly TDH Payment from the
allocations to the Pediatric Pool for its administration and
marketing activities related to Members and any payments to Value
Options Behavioral Health or its successor for administrative
services (collectively, the "Pediatric Administrative Expenses").
(ii) In connection with each Year-End Settlement, HMO shall
evaluate whether the Pediatric Administrative Expenses for such
Year are less than 16% of the aggregate Monthly TDH Payments
attributable to Members for such Year (the amount of such
difference, the "Pediatric Expense Savings").
(iii) If the Pediatric Expense Savings that accrue in connection
with such Year-End Settlement(s) exceed the amount required to be
realized by HMO to recoup its net implementation costs and costs
related to Experience Rebates for Contract Years ending 1997, 1998
and 1999 of $2,327,607.31 in the aggregate (as may be adjusted to
recognize any subsequent change in the State policies or financial
information used to calculate such figure) (such difference, the
"Excess"), then for the Year-End Settlement in which such Excess
first results, the amount of the Pediatric Pool for such Year
shall be increased by an amount equal to the Excess; provided,
however, the increase in the amount of the Pediatric Pool, and the
corresponding decrease in the aggregate amount excluded on account
of Pediatric Administrative Expenses, shall in no event result in
the aggregate amount excluded on account of the Pediatric
Administrative Expenses for such Year being less than thirteen
percent (13%) of the aggregate Monthly TDH Payments attributable
to Members for such Year (the "Minimum Administrative Expense
Allocation").
(iv) In connection with the Year-End Settlement immediately
following the Year in which the Excess is applied and in
connection with each Year-End Settlement thereafter, (A) the
amount of the Pediatric Pool each year shall be increased by the
amount of the Pediatric Expense Savings for such Year, and (B) the
exclusions, made on account of Pediatric Administrative Expenses
shall be correspond-
Attachment A Page 5
122
ingly decreased, subject in each case to the Minimum
Administrative Expense Allocation for such Year.
(v) Each quarter, HMO shall provide CCPN with a quarterly report
with respect to estimated Pediatric Administrative Expenses for
the prior quarter.
B. HMO will exclude two percent (2%) of the Monthly TDH Payment from
the allocations to the Pediatric Pool to maintain a Texas HMO
license.
C. HMO will exclude seven percent (7%) of the Monthly TDH Payment
from the allocations to the Pediatric Pool and post such amount to
the Profit Product Pool.
IV. Reimbursement of CCPN Physicians and Providers for Pediatric Services.
CCPN Physicians and Providers shall be compensated by HMO out of the
Pediatric Pool funds for Covered Health Services provided to Members
pursuant to the contractual terms then in effect, which are subject to
the following:
A. Payment to Primary Care Physicians or Providers. As compensation
for services provided or arranged for by a PCP to Members under
the STAR Program in the Service Area, HMO shall make a monthly
capitation payment from the Pediatric Pool funds based on the
age/sex adjusted capitation rates referenced in Attachment B of
this Agreement or shall reimburse such PCP in accordance with such
HMO fee schedule as such PCP may have elected. Monthly PCP
capitation payments, as applicable, shall include all retroactive
additions and deletions as referenced in II.A.3.a and II.A.3.b
above. Monthly PCP capitation payments are due to the applicable
PCPs five (5) business days after receipt of the Monthly TDH
Payment by HMO. Capitated PCPs will be reimbursed for
non-capitated services provided to Members from the Pediatric Pool
funds on a fee-for-service basis at the reimbursement rate agreed
to between such provider and CCPN, which is presently HMO's fee
schedule (any changes to such reimbursement rates, if higher than
the HMO fee schedule then in effect, shall be subject to Section
IV.C below); if PCP and CCPN have not agreed to a reimbursement
rate, then PCP will be reimbursed at the
Attachment A Page 6
123
then current Medicaid allowable rate for noncapitated services or
the HMO's usual and customary rates, whichever is less. Primary
Care Physicians or Providers shall submit itemized statements on
current HCFA 1500 claim forms with current HCPCS coding, current
ICD9 coding and current CPT4 coding for all capitated services and
non-capitated Covered Health Services provided by Primary Care
Physicians or Providers to HMO at the address set forth below
within sixty (60) days of the date the Covered Health Service was
provided. PCPs shall be paid by HMO no later than thirty (30) days
after receipt by HMO of a completed Clean Claim for non-capitated
Covered Health Services (or within such period as may otherwise be
prescribed by law). If Clean Claims submitted by CCPN
Participating Providers are not paid within such period, HMO shall
be subject to Section IV.E below. HMO will notify applicable CCPN
Participating Providers of any claims that are not Clean Claims
within thirty (30) days of HMO's receipt of such claims.
B. Payments to Specialist Physicians. Specialist Physicians will be
reimbursed from the Pediatric Pool funds for Covered Health
Services provided to Members on a fee-for-service basis at the
reimbursement rate agreed to between such physician and CCPN,
which is presently HMO's fee schedule (any changes to such
reimbursement rates, if higher than the HMO fee schedule then in
effect, shall be subject to Section IV.C below). If Specialist
Physicians and CCPN have not agreed to a reimbursement rate, then
Specialist Physician will be reimbursed at the then current
Medicaid allowable rate. Itemized statements on current HCFA 1500
claim forms with current HCPC coding, current ICD9 coding and
current CPT4 coding for all Covered Health Services provided by
Specialist Physicians must be submitted by Specialist Physician to
HMO at the address set forth below within sixty (60) days of the
date the Covered Health Service was provided. If the claim form is
not timely filed with HMO within sixty (60) days from the date the
Covered Health Service was provided, the right to payment will be
deemed waived by the Specialist Physician unless Specialist
Physician establishes to the reasonable satisfaction of CCPN that
there was reasonable justification for a delay in billing or that
delay was caused by circumstances beyond Specialist Physician's
control. Specialist Physician shall be paid by HMO no later than
thirty (30) days after receipt by HMO of a completed Clean Claim
for
Attachment A Page 7
124
Covered Health Services (or within such period as may otherwise be
prescribed by law). If submitted Clean Claims are not paid within
such period, HMO shall be subject to Section IV.E below. HMO will
notify applicable Specialist Physicians of any claims that are not
Clean Claims within thirty (30) days of HMO's receipt of such
claims.
C. Increases in Reimbursement Rates for PCPs and Specialists. The
parties acknowledge and agree that the reimbursement rates
presently in effect are based on AMERICAID's fee schedule (HMO
agrees to provide CCPN with a complete copy of the fee schedule in
effect within thirty (30) days of CCPN's request). To ensure that
such reimbursement rates continue to reasonably reflect the then
current Medicaid reimbursement/payment methodologies and that
subsequent increases agreed to between CCPN and its providers will
not inequitably increase the medical expense ratio under the
Pediatric Pool and can be administered by HMO under its claims
payment system, CCPN agrees that the fee schedule shall not be
increased more than once a year and that CCPN shall provide HMO
with prior written notice of any proposed increase. The notice
shall include in reasonable detail the reasons therefor and
contain pro forma calculations that have been prepared using
CCPN's usual and customary accounting practices and, where
applicable, reasonable actuarial assumptions. HMO's consent to
such increase shall be required unless (i) the increase to the fee
schedule represents an increase in the rates of five percent (5%)
or less (as calculated on a weighted average basis; i.e., taking
into account whether the impact of all rate adjustments causes an
increase in the aggregate pro forma physician reimbursement of
five percent (5%) or less) or (ii) CCPN provides pro forma
calculations which reflect the expected adverse effect, if any, of
the greater than five percent (5%) increase in the fee schedule
and, in connection with the settlements described in Section VI
below, CCPN holds HMO harmless from any actual adverse effect
resulting from a greater than five percent (5%) increase in the
physician reimbursement. The foregoing notwithstanding, no
increase may be effected in any year unless (a) a Pediatric Pool
Surplus existed for the immediately preceding Contract Year and
(b) the pro forma calculations for the Contract Year in which the
increase is proposed to be effective indicate an expected
Pediatric Pool Surplus for such year as well. Because of system
configuration requirements, any change required by the fore-
Attachment A Page 8
125
going may be delayed by HMO for up to, but not more than, sixty
(60) days.
D. Payments to CCPN Participating Provider. CCPN Participating
Providers will be reimbursed for Covered Health Services provided
to Members on a fee-for-service basis as listed in Attachment B of
this Agreement. These fee-for-service rates will be the
reimbursement rate agreed to between such Participating Provider
and CCPN. If Participating Provider and CCPN have not agreed to a
reimbursement rate, then Participating Provider will be reimbursed
at the then current Medicaid allowable rate. Itemized statements
on current HCFA 1500 claim forms with current HCPC coding, current
ICD9 coding and current CPT4 coding for all Covered Health
Services provided by CCPN Participating Providers must be
submitted by CCPN Participating Provider to HMO at the address set
forth below within sixty (60) days of the date the Covered Health
Service was provided. If the claim form is not filed with HMO
within sixty (60) days from the date the Covered Health Service
was provided, the right to payment will be deemed waived by the
CCPN Participating Provider unless CCPN Participating Provider
establishes to the reasonable satisfaction of CCPN that there was
reasonable justification for a delay in billing or that delay was
caused by circumstances beyond CCPN Participating Provider's
control. CCPN Participating Provider shall be paid by HMO within
thirty (30) days after receipt by HMO of a completed Clean Claim
for Covered Health Services (or within such period as may
otherwise be prescribed by law). If submitted Clean Claims are not
paid within such period, HMO shall be subject to Section IV.E
below. HMO will notify applicable CCPN Participating Providers of
any claims that are not Clean Claims within thirty (30) days of
HMO's receipt of such claims.
E. Claims Reimbursement. All Clean Claims submitted to HMO by CCPN,
CCPN Physicians or CCPN Participating Providers for payment will
be paid within thirty (30) days of the date of HMO's receipt of
such Clean Claim (or within such period as may otherwise be
prescribed by law). Upon CCPN's request each quarter (and
automatically in connection with each Year-End Settlement if not
earlier requested), HMO will reimburse CCPN (or the applicable
CCPN Physician CCPN Participating Provider) for any incurred late
payment
Attachment A Page 9
126
penalties related to such Clean Claims that were not timely paid
during such period. This amount shall be equal to the interest on
the claims paid amount during the preceding quarter or year, as
applicable, that exceeded the applicable time limit for payment.
The interest rate is 1.5% per month (18% annual for each month any
such Clean Claim remains unadjudicated) or such rate as may be
prescribed by law. Subject to Section VI.D below, such late
payment penalties, at HMO's discretion, may be charged to the
Pediatric Pool (as charged, the "Allocated Penalty Amount").
F. Overpayment. CCPN, CCPN Physicians and/or CCPN Participating
Providers shall promptly report overpayments to HMO. HMO shall,
upon notice to HMO or upon its discovery, deduct such overpayment
from future payments with an explanation of the action taken.
G. In-house Pediatric Service. CCPN and HMO jointly will develop a
program for PCPs to elect to use the CMC In-house Pediatric
Service for Members admitted to CMC.
H. Reinsurance. Notwithstanding anything to the contrary set forth
herein, (i) CCPN agrees to purchase and maintain reinsurance in
amounts required by law (including where substantial financial
risk exists), regulation, and the STAR program, and (ii) HMO will
reimburse CCPN out of the Pediatric Pool for such reinsurance,
provided, CCPN shall promptly notify HMO of all recoveries so that
such recoveries may be recorded as additional allocations to the
Pediatric Pool revenues. CCPN shall provide HMO with prior written
notice of any changes in the reinsurance in effect (including,
without limitation, any changes in the rates, premiums and/or
underwriter/insurer) so that HMO may verify that CCPN is providing
adequate coverage for, among other things, HMO's continued
compliance with TDH/TDI requirements. HMO agrees to provide CCPN,
on a monthly basis on or before the twenty-fifth (25th) day of
such month, the reinsurance report required under Exhibit 4 to
this Attachment A.
I. Claims Procedures for Emergency Room and Outpatient Services. [See
Section 2 of the Amendment to which this document is attached.]
Attachment A Page 10
127
V. Risk Funds.
A. General Provisions. HMO and CCPN shall establish an Adult Pool, a
Pediatric Pool, and a Profit Product Pool to serve as risk sharing
incentive arrangements to monitor utilization goals while
maintaining quality of care. The budget for each pool is described
below. Each pool shall be adjusted for actual Members or Adult
Enrollees covered by the applicable pool.
B. Pediatric Pool. Revenues and expenses shall be recorded and
charged to the Pediatric Pool as described above and balances
reconciled and settled as described below.
C. Adult Pool. HMO will allocate (post) seventy-five percent (75%) of
the Total TDH Payment attributable to Adult Enrollees (the "Adult
Target Amount") to the Adult Pool and charge all medical claim
expenses attributable to Adult Enrollees to such Pool. Balances
shall be reconciled and settled as described below.
D. Profit Product Pool. CCPN and HMO agree that the Profit Product
Pool shall be used as described below.
VI. Reviews and Settlement. The Pediatric Pool and Adult Pool shall be
subject to quarterly year-to-date reviews and each Risk Fund shall have
an annual final settlement, described below, as of each Contract
Anniversary Date (a "Year-End Settlement") for the then ending year of
this Agreement (the "Contract Year"), at which time the surpluses and
deficits in each Risk Fund shall be reconciled and each party's rights
and obligations with respect to such surpluses and deficits, as
determined pursuant to Section VII below, shall be satisfied.
A. Reviews. Within twenty-five (25) days of the end of each month of
this Agreement, an unaudited monthly report of the Pediatric Pool
and the Adult Pool results will be produced. HMO will also report
and record total incurred but not reported (IBNR) claims.
B. Settlements. The Year-End Settlement of the Pediatric Pool, the
Adult Pool, and the Profit Product Pool for each Contract Year
will be performed in two phases, consisting of an interim
reconciliation after
Attachment A Page 11
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the first ninety (90) days following each Contract Anniversary
Date and a final settlement immediately prior to HMO's submission
of its Managed Care Financial and Statistical Report (or its
successor) to TDH (the "Annual Report") for such preceding Year;
provided, however, if the TDH Annual Report is not submitted
within two hundred seventy (270) days of the Contract Anniversary
Date, a second reconciliation will be performed until the final
settlement can be performed contemporaneously with the submission
of the Annual Report. In connection with each reconciliation and
the final settlement, HMO shall calculate pursuant to Section VII
the net amount payable to or due from CCPN and the net amount to
be retained or absorbed by HMO and deliver written notice thereof
to CCPN. Such calculations shall be based on the information then
available and, if applicable, shall take into account payments
made pursuant to this Section VI in connection with prior
reconciliation(s) for such Year. At the time of each
reconciliation for such Year and the final settlement, HMO shall
pay CCPN the net amount agreed as due CCPN, or conversely, CCPN
shall pay HMO the net amount agreed as due from CCPN; it being
understood and agreed that the parties shall agree upon each
reconciliation and the final settlement within thirty (30) days of
HMO's delivery of the written calculations with respect to the
reconciliations and settlement, as applicable.
C. Settlement in the Event of Termination. After termination of this
Agreement, HMO and CCPN agree to reconcile payments to and amounts
owed from all Risk Funds in accordance with this Section VI.
D. Adjustment for Allocated Penalty Amount. In connection with each
Year-End Settlement, any Allocated Penalty Amount charged to the
Pediatric Pool shall be reversed (i.e., excluded from the medical
expenses charged to the Pediatric Pool for purposes of the
Year-End Settlement).
VII. Rights and Obligations with Respect to Pool Surpluses and Deficits. The
following describes each party's rights and obligations in connection
with the Year-End Settlements in each identified scenario. To the extent
TDH requires that positive balances in any one or more of the Pools/Risk
Funds be subject to any Experience Rebate paid to TDH under the State
Contract, such
Attachment A Page 12
129
Experience Rebate will proportionately impact CCPN and HMO with respect
to such affected pools in accordance with the percentage allocations
specified herein.
A. Surplus in Both the Pediatric Pool and the Adult Pool. If there is
a Pediatric Pool Surplus and an Adult Pool Surplus, then (i) HMO
shall pay CCPN an amount equal to the sum of 100% of the Pediatric
Pool Surplus, 25% of the Adult Pool Surplus, and 25% of the Profit
Product Pool Total, and (ii) HMO shall be entitled to retain the
remaining 75% of the Adult Pool Surplus and 75% of the Profit
Product Pool Total.
B. Deficit in Both the Pediatric Pool and the Adult Pool. If there is
a Pediatric Pool Deficit and an Adult Pool Deficit, then (i) CCPN
shall pay HMO an amount equal to the sum of 75% of the Pediatric
Pool Deficit and 25% of the Adult Pool Deficit, (ii) HMO shall pay
CCPN an amount equal to 25% of the Profit Product Pool Total,
(iii) HMO shall absorb 25% of the Pediatric Pool Deficit and 75%
of the Adult Pool Deficit, and (iv) HMO shall be entitled to
retain an amount equal to the remaining 75% of the Profit Product
Pool Total.
C. Deficit in Adult Pool and Surplus in Pediatric Pool.
1. If there is an Adult Pool Deficit and a Pediatric Pool
Surplus, then the aggregate net surplus allocable to each
party shall be compared. For purposes of such comparison,
it shall be assumed that (a) CCPN would (i) receive 100% of
the Pediatric Pool Surplus, (ii) reimburse HMO for 25% of
the Adult Pool Deficit, and (iii) receive 25% of the Profit
Product Pool Total (the net result, the "Assumed Net CCPN
Share (Scenario C)"), and (b) HMO would (i) absorb 75% of
the Adult Pool Deficit, and (ii) retain 75% of the Profit
Product Pool Total (the net result, the "Assumed Net HMO
Share (Scenario C)").
2. If the Assumed Net CCPN Share (Scenario C) is less than or
equal to 50% of the aggregate of the Assumed Net CCPN Share
(Scenario C) and the Assumed Net HMO Share (Scenario C),
then the rights and obligations of CCPN and HMO shall be
determined in accordance with the method of deter-
Attachment A Page 13
130
mining the Assumed Net CCPN Share (Scenario C) and Assumed
Net HMO Share (Scenario C), as applicable, described in
Section VII.C.1 above.
3. If the Assumed Net CCPN Share (Scenario C) is more than 50%
of the aggregate of the Assumed Net CCPN Share (Scenario C)
and the Assumed Net HMO Share (Scenario C), then
a. CCPN shall
(i) receive the difference of 100% of the
Pediatric Pool Surplus less the Pediatric
Surplus Reduction Amount (defined below),
(ii) reimburse HMO for 25% of the Adult Pool
Deficit, and
(iii) receive the difference of 25% of the Profit
Product Pool Total less the CCPN Profit Share
Reduction Amount (defined below), if any, and
b. HMO shall
(i) absorb 75% of the Adult Pool Deficit, and
(ii) retain the Pediatric Surplus Reduction
Amount, the CCPN Profit Share Reduction
Amount (if applicable), and 75% of the Profit
Product Pool Total.
4. As used in this Section C,
a. The "Pediatric Surplus Reduction Amount" means the
amount which if subtracted from the Pediatric Pool
Surplus included in the calculation of the Assumed
Net CCPN Share (Scenario C) and then added to the
Assumed Net HMO Share (Scenario C) would make such
shares for CCPN and HMO equal; provided, the amount
so subtracted shall in no event exceed 25% of
Attachment A Page 14
131
the Pediatric Pool Surplus (if such maximum is
reached before the desired true-up is effected, then
the CCPN Profit Share Reduction Amount described
below shall apply).
b. The "CCPN Profit Share Reduction Amount" means the
amount which if subtracted from CCPN's share of the
Profit Product Pool Total included in the
calculation of the Assumed Net CCPN Share (Scenario
C) and then added to the Assumed Net HMO Share
(Scenario C) (as increased by the Pediatric Surplus
Reduction Amount) would make such shares for CCPN
and HMO equal (it being understood that the CCPN
Profit Share Reduction Amount can equal up to, but
not exceed, CCPN's full 25% share of the Profit
Product Pool Total).
5. Notwithstanding anything to the contrary set forth in
subsections (3) and (4) of this Section VII.C, the amounts
subtracted in connection with the Pediatric Surplus
Reduction Amount and, if applicable, the CCPN Profit Share
Reduction Amount shall be limited to such amounts which
when added to HMO's Assumed Net HMO Share (Scenario C)
would cause the net pool distributions to HMO to equal
5.25% of the Total TDH Payment.
D. Deficit in Pediatric Pool and Surplus in Adult Pool.
1. If there is a Pediatric Pool Deficit and an Adult Pool
Surplus, then the aggregate net surplus allocable to each
party shall be compared. For purposes of such comparison it
shall be assumed that (a) CCPN would (1) reimburse HMO for
75% of the Pediatric Pool Deficit, (2) receive 25% of the
Adult Pool Surplus, and (3) receive 25% of the Profit
Product Pool Total (the net result, the "Assumed Net CCPN
Share (Scenario D)"), and (b) HMO would (1) absorb 25% of
the Pediatric Pool Deficit, (2) retain 75% of the Adult
Pool Surplus, and (3) retain 75% of the Profit Product Pool
Total (the net result, the "Assumed Net HMO Share (Scenario
D)").
Attachment A Page 15
132
2. If the Assumed Net HMO Share (Scenario D) is less than or
equal to 75% of the aggregate of the Assumed Net CCPN Share
(Scenario D) and the Assumed Net HMO Share (Scenario D),
then the rights and obligations of CCPN and HMO shall be
determined in accordance with the method of determining the
Assumed Net CCPN Share (Scenario D) and Assumed Net HMO
Share (Scenario D), as applicable, described in Section
VII.D.1 above.
3. If the Assumed Net HMO Share (Scenario D) is more than 75%
of the aggregate of the Assumed Net CCPN Share (Scenario D)
and the Assumed Net HMO Share (Scenario D), then
a. CCPN shall
(i) reimburse HMO for 75% of the Pediatric Pool
Deficit,
(ii) receive (or have applied as a credit) 25% of
the Adult Pool Surplus, and
(iii) receive (or have applied as a credit) the HMO
Profit Share Reduction Amount (defined
below), and
(iv) receive (or have applied as a credit) up to
an additional 25% of the Profit Product Pool
Total, and
b. HMO would
(i) absorb 25% of the Pediatric Pool Deficit,
(ii) retain 75% of the Adult Pool Surplus, and
(iii) retain the difference of 75% of the Profit
Product Pool Total less the HMO Profit Share
Reduction Amount.
Attachment A Page 16
133
4. As used in this Section D, the "HMO Profit Share Reduction
Amount" means that amount which if subtracted from HMO's
share of the Profit Product Pool included in the
calculation of the Assumed Net HMO Share (Scenario D) and
then added to the Assumed Net CCPN Share (Scenario D) would
make the respective shares for HMO and CCPN equal 75% and
25%; provided, the amount so subtracted shall in no event
exceed up to an additional 25% of the Profit Product Pool
Total (i.e. CCPN's share of the Profit Product Pool Total
would not exceed 50% of the aggregate Profit Product Pool
Total when the HMO Profit Share Reduction Amount is added
to the 25% share under Section VII.D.3.a.(iv) above).
E. Examples. Mathematical examples of Scenarios C and D above are set
forth in Exhibit 1 attached.
VIII. Preventive Health Performance Incentive.
A. TDH has retained a performance objective capitation amount of two
dollars ($2.00) per Member per month that is available to be paid
to the HMO after the end of each Contract Year and after
appropriate encounter data is reviewed and confirmed by the Texas
Department of Health. TDH will determine the performance of HMO
against the objectives described in the State Contract. To the
extent that the HMO receives incentive payments from the TDH for
meeting the preventive health performance objectives, HMO will
distribute to CCPN seventy-five percent (75%) of those funds
attributable to CCPN Members within five (5) days of receipt of
such payment from TDH. The foregoing notwithstanding, the parties
acknowledge that such practice will end with the 1999 Contract
Year as TDH will completely curtail payment of such amount.
IX. Adult Enrollees Needing Pediatric Services. CCPN agrees that CCPN
Physicians and CCPN Participating Providers will provide pediatric
services to Adult Enrollees provided that: (1) HMO will pay CCPN
Physician and CCPN Participating Provider directly for such services at
the reimbursement rate agreed to by such CCPN Physician and CCPN
Participating Provider and (2) the Pediatric Pool will not be used for
payment of any health care services provided to Adult Enrollees.
Attachment A Page 17
134
AMERICAID - FORT WORTH
COOKCHILDRENS FY00 RISK ARRANGEMENT
EXAMPLE SCENARIOS
-------------------------------------------------------------------------------------
ILLUSTRATION DYNAMICS: SCENARIO C
-------------------------------------------------------------------------------------
Pedi Pool To 75% Target FAVORABLE
Adult Pool To 75% Target UNFAVORABLE
Cap(s) Triggered NO
XXXX ACC
PEDI POOL ADULT POOL TOTAL NOTES
------------------------------------------------------------------------------------------------------------------------------
Member Months 226,200 49,500 272,700 sample member months
Premium Revenue $28,200,000 $13,900,000 $42,100,000 sample revenue
PMPM $124.67 $280.81 $152.70
Medical Expense $18,200,000 $13,500,000 $31,700,000 sample medical
PMPM $80.46 $272.73 $114.98
MLR 64.5% 97.1% 75.3% PEDI FAV, ADULT UNFAV
Admin Expense 14% $3,948,000 $1,946,000 $5,894,000
HMO License Allowance 2% $564,000 $278,000 $842,000
Recoupment Withhold 2% $564,000 $278,000 $842,000
------------------------------------------------------------------------------------------------------------------------------
GROSS MARGIN $4,924,000 ($2,102,000) $2,822,000 RISK ARRANGEMENT BALANCE
------------------------------------------------------------------------------------------------------------------------------
Pedi Pool Variance to Target $2,950,000
Pedi Pool Variance Split $2,212,500 $737,500 Pedi favorability split 75/25
75% 25%
Adult Pool Variance To Target ($3,075,000)
Adult Pool Variance Split ($768,750) ($2,306,250) Adult unfavorability split 25/75
25% 75%
Product Profit Pool 7% $2,947,000
Product Profit Pool Split $0 $2,947,000 Product Profit split 0/100
0% 100%
Pre-State Subtotal $1,443,750 $1,378,250 $2,822,000
ACC Pre-State Return 3.27% return below 5.25% cap
Distribution Split 51.2% 48.8% distribution below 50/50 cap
------------------------------------------------------------------------------------------------------------------------------
Adjusted Product Profit Pool Split $0 $2,947,000 $2,947,000
0.0% 100.0% NO PPP SPLIT ADJUSTMENT
Adjusted Pre-State Subtotal $1,443,750 $1,378,250 $2,822,000
Adjusted ACC Pre-State Return 3.27% return below 5.25% cap
Adjusted Distribution Split 51.2% 48.8% distribution below 50/50 cap
$0 Profit Share Threshold 3% $1,263,000
Amount Subject To Profit Share $115,250
State Profit Share 25% ($28,813)
State Profit Share Split ($7,203) ($21,609) ($28,813) State Profit Share split 25/75
25% 75%
------------------------------------------------------------------------------------------------------------------------------
BOTTOM LINE $1,436,547 $1,356,641 $2,793,188 FINAL RESULTS
ACC RETURN 3.41% 3.22%
DISTRIBUTION SPLIT 51.4% 48.6%
FIGURES SHOWN WOULD BE APPLIED TO CIRCULAR FORMULA SETTLEMENT MODEL FOR SETTLEMENT DISBURSEMENT
135
AMERICAID - FORT WORTH
COOKCHILDRENS FY00 RISK ARRANGEMENT
EXAMPLE SCENARIOS
-------------------------------------------------------------------------------------
ILLUSTRATION DYNAMICS: SCENARIO D
-------------------------------------------------------------------------------------
Pedi Pool To 75% Target UNFAVORABLE
Adult Pool To 75% Target FAVORABLE
Cap(s) Triggered YES
XXXX ACC
PEDI POOL ADULT POOL TOTAL NOTES
----------------------------------------------------------------------------------------------------------------------------------
Member Months 226,200 49,500 272,700 sample member months
Premium Revenue $28,200,000 $13,900,000 $42,100,000 sample revenue
PMPM $124.67 $280.81 $152.70
Medical Expense $22,100,000 $9,900,000 $32,000,000 sample medical
PMPM $97.70 $200.00 $116.07
MLR 78.4% 71.2% 76.0% PEDI UNFAV, ADULT FAV
Admin Expense 14% $3,948,000 $1,946,000 $5,894,000
HMO License Allowance 2% $564,000 $278,000 $842,000
Recoupment Withhold 2% $564,000 $278,000 $842,000
----------------------------------------------------------------------------------------------------------------------------------
GROSS MARGIN $1,024,000 $1,498,000 $2,522,000 RISK ARRANGEMENT BALANCE
----------------------------------------------------------------------------------------------------------------------------------
Pedi Pool Variance to Target ($950,000)
Pedi Pool Variance Split ($712,500) ($237,500) Pedi unfavorability split 75/25
75% 25%
Adult Pool Variance To Target $525,000
Adult Pool Variance Split $131,250 $393,750 Adult unfavorability split 25/75
25% 75%
Product Profit Pool 7% $2,947,000
Product Profit Pool Split $736,750 $2,210,250 Product Profit split 25/75
25% 75%
Pre-State Subtotal $155,750 $2,366,500 $2,522,000
ACC Pre-State Return 5.62%
Distribution Split 6.2% 93.8% ACC SHARE > 75%
----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
Adjusted Product Profit Pool Split $1,211,750 $1,735,250 $2,947,000
41.1% 58.9% PPP SPLIT DUE TO CAP
Adjusted Pre-State Subtotal $630,500 $1,891,500 $2,522,000
Adjusted ACC Pre-State Return 4.49%
Adjusted Distribution Split 25.0% 75.0% SPLIT CAPPED AT 25/75
$0 Profit Share Threshold 3% $1,263,000
Amount Subject To Profit Share $628,500
State Profit Share 25% ($157,125)
State Profit Share Split ($39,281) ($117,844) ($157,125) State Profit Share split 25/75
25% 75%
----------------------------------------------------------------------------------------------------------------------------------
BOTTOM LINE $591,219 $1,773,656 $2,364,875 FINAL RESULTS
ACC RETURN 1.40% 4.21%
DISTRIBUTION SPLIT 25.0% 75.0%
FIGURES SHOWN WOULD BE APPLIED TO CIRCULAR FORMULA SETTLEMENT MODEL FOR SETTLEMENT DISBURSEMENT
136
ATTACHMENT B
REVISED PHYSICIAN REIMBURSEMENT RATES
I. PRIMARY CARE CAPITATION PAYMENTS. - HMO shall compensate Primary Care
Physicians or Providers from the Pediatric Risk Pool through
age/sex/benefit adjusted capitation rates for Primary Care Services.
A. Capitation Payments - Primary Care Physicians or Providers
Per Member Per Month = weighted average based upon the actual
distribution of the provider panel of members. See below for specific
capitation rates by cell.
<500 Member Avg. 500-750 Member Avg. >750 Member Avg.
================================================== ================================ ===============================
CATEGORY
AGE FEMALE MALE FEMALE MALE FEMALE MALE
================================================== ================================ ===============================
61 days to
<2 years $39.59 $39.59 $41.67 $41.67 $43.75 $43.75
-------------------------------------------------- -------------------------------- -------------------------------
2-4 years $13.31 $13.31 $14.01 $14.01 $14.71 $14.71
-------------------------------------------------- -------------------------------- -------------------------------
5-14 years $8.08 $8.08 $8.51 $8.51 $8.94 $8.94
-------------------------------------------------- -------------------------------- -------------------------------
15 years $7.70 $5.81 $8.10 $6.12 $8.51 $6.43
================================================== ================================ ===============================
16 + years FFS FFS FFS FFS FFS FFS
================================================== ================================ ===============================
For PCPs with less than 250 members, there will be an annual true-up to 100% of
the fee-for-service equivalent in the event capitation payments are less than
the fee-for-service total.
Average membership is calculated based upon the total members per Group
(contract) divided by the number of PCPs in the Group serving AMERICAID Members.
Rates are adjusted quarterly on a prospective basis, once a membership level has
been maintained during the prior quarter.
Notwithstanding the foregoing PMPM capitation rate cells by age/sex factors, HMO
shall compensate Participating Primary Care Physicians or Providers on a
fee-for-service basis for Covered Health Services provided to Members age sixty
(60) days
B-1
137
or less. Payment for such services will be deducted from the Pediatric Risk Fund
and shall be reimbursed at the lesser of billed charges or the AMERICAID
Medicaid Fee Schedule. A sample of fees from the AMERICAID Medicaid Fee Schedule
is attached as Schedule "1", and made a part hereof. Capitation payments will
not be applicable to such Members until they are sixty-one (61) days old.
B. Primary Care Fee-For-Service Payment - Primary Care Physicians or
Providers
HMO shall compensate Primary Care Physicians or Providers for CPT codes
not listed on the attached listing of Primary Care Services on a fee-for-service
basis for non-capitated services provided to Members at the reimbursement rate
agreed to between such provider and CCPN. If PCP and CCPN have not agreed to a
reimbursement rate, then PCP will be reimbursed at the then current Medicaid
allowable rate for non-capitated services with the exception of the following:
1) Immunizations will be reimbursed at 90% of the prevailing Medicaid maximum
allowable fee schedule, and 2) Injectable drugs will be reimbursed at the
average wholesale price (AWP). The rate agreed to between such provider and CCPN
shall not exceed HMO's fee schedule, except as otherwise provided in the
agreement to which this schedule is attached.
II.
============================================================================================================================
Primary
Diagnosis Code DESCRIPTION MEDICAID
----------------------------------------------------------------------------------------------------------------------------
V72.3 Well Woman Annual GYN Visit $47.00
Includes: Office Visit, Pap Smear
and Breast, Pelvic and Rectal Exams.
============================================================================================================================
B-2
138
===========================================================================================================================
DESCRIPTION MEDICAID
---------------------------------------------------------------------------------------------------------------------------
Care for Newborns in the first 60 days of life BILLED CHARGES
UP TO THE
AMERICAID FEE
SCHEDULE
---------------------------------------------------------------------------------------------------------------------------
Primary Care for Members 16 years and older BILLED CHARGES
UP TO THE
AMERICAID FEE
SCHEDULE
===========================================================================================================================
===========================================================================================================================
Reporting of Texas Health Steps screenings on a HCFA-l500 based on the Texas Health Steps codes $21.00 per visit
and periodicity schedule in the TDH/NHIC Medicaid Manual.
---------------------------------------------------------------------------------------------------------------------------
Reporting of the Administration of Immunizations on a HCFA-1500 based on the Texas Health Steps $3.00 per
codes and periodicity schedule in the TDH/NI-IIC Medicaid Manual. administration
===========================================================================================================================
III. Specialist Reimbursement. HMO shall compensate Specialist physicians for
Covered Health Services on a fee for service basis at the reimbursement rate
agreed to between such physicians and CCPN, which payments shall be charged to
the Pediatric Pool. If Specialist Physicians and CCPN have not agreed to
reimbursement rate, then Specialist Physicians will be reimbursed at the then
current Medicaid allowable rate. The rate agreed to between such provider and
CCPN shall not exceed HMO's fee schedule, except as otherwise provided in the
agreement to which this schedule is attached.
IV. Primary Care Fee-For-Service Option. AMERICAID and CCPN acknowledge and
agree that CCPN has the option to offer contracted Primary Care Physicians or
Providers Fee-For-Service reimbursement methodology as an option to the
capitation described above. The rate agreed to between such provider and CCPN
shall not exceed HMO's fee schedule, except as otherwise provided in the
agreement to which this schedule is attached.
V. Risk Sharing/Incentive Program. Each CCPN Physician will be eligible to
participate in a risk sharing/incentive program to be developed by CCPN.
B-3
139
SCHEDULE 1 TO ATTACHMENT B
SAMPLE AMERICAID FEE SCHEDULE
140
ATTACHMENT C
REVISED HOSPITAL REIMBURSEMENT RATES
Inpatient, Outpatient and Ambulatory Surgery Services Provided by CCMC All
medically necessary inpatient, outpatient and ambulatory surgery services will
be reimbursed in accordance with CCMC's applicable charge master and the
applicable cost-to-charge ratio (percentage discount), as each is determined
pursuant to the Amendment dated as of January 1, 2000 to which this is attached.
AMERICAID is not obligated to pay clinic facility charges until such time as
clinic physician accepts a lesser payment for physician services.
- Hospital claims for dental surgeries will be paid without prior
authorization requirements.
- Care Team (sexual and physical abuse) charges (facility and physician
charges) will be paid without prior authorization requirements.
C-1
141
ATTACHMENT D
CLAIMS PROCEDURES FOR EMERGENCY ROOM AND
OUTPATIENT SERVICES
1) ER Services
Reimbursement for ER Services will be based upon discharge level;
determination of whether to pay ER claims will be based on admission
triage level. Admission triage levels 1, 2 and 3 will be paid based upon
the discharge level (professional claims submitted by physicians will be
reimbursed according to the applicable professional fee schedule). ER
visits with an admission triage level of 4 or 5 will be paid a triage fee
unless the visit meets certain criteria outlined below.
Claims will be paid based on the level of care documented on the claim.
There are 5 discharge triage levels:
------------------------------------------------------------------------------------------------------------------------------
Discharge Level Line Item Charge on the UB-92 Reimbursement
for Revenue Code 450,
"Emergency Room"
------------------------------------------------------------------------------------------------------------------------------
Level I $447.00 or $400.00 ___% of charges*
------------------------------------------------------------------------------------------------------------------------------
Level II $263.00 or $200.00 $500 per case
------------------------------------------------------------------------------------------------------------------------------
Level III $153.00 or $100.00 $250 per case
------------------------------------------------------------------------------------------------------------------------------
Level IV $90.00 or $50.00 $98 per case
------------------------------------------------------------------------------------------------------------------------------
Level V $53.00 or $25.00 $37 per case
------------------------------------------------------------------------------------------------------------------------------
CCPN will continue to notify AMERICAID, within one (1) business day, of
any inpatient admissions or observation stays that result from an
Emergency Room visit.
OTHER TYPES OF SERVICES PERFORMED IN THE ER ? In cases when minor
procedures are performed in the ER or a physician meets a patient at the
ER for service/treatment, CCMC's claims will be submitted as "Outpatient
Hospital Services" with no triage level assigned. CCMC's claims will be
reimbursed in accordance with CCMC's applicable charge master and the
applicable cost-to-charge ratio (percentage discount), as each is
determined pursuant to the Amendment dated as of January 1, 2000 to which
this is
D-1
142
attached. CCMC will provide AMERICAID a list of ER "clinic" codes used so
that AMERICAID can pursue an automated method of identifying these
claims.
2) OUTPATIENT SURGERY - Dental surgeries (CPT Code 41899) have been grouped
as "Group 9" and paid an all inclusive global fee of $553.00. The
following list of procedures which are ungroupable are included in the
group listed in the right hand column of the table below. Any future
ungroupable procedure will be paid at an inclusive global fee of $510.00,
subject to multiple procedure protocol currently specified in the
contract.
-----------------------------------------------------------------------------------------------------------------------------------
PROCEDURE CPT RATE GROUP
-----------------------------------------------------------------------------------------------------------------------------------
Incision and drainage of abscess 10060 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, benign lesion, except skin tag 11401 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Injection procedure during cardiac cath. 93542 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, benign lesion, except skin tag 11421 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Control nasal hemorrhage, anterior 30901 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, benign lesion, except skin tag 11420 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, benign lesion, except skin tag 11400 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Injection procedure during cardiac cath. 93541 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Nasal endoscopy, diagnostic, uni/bilateral 31231 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, other benign lesion 11440 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, other benign lesion 11441 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Injection procedure during cardiac cath. 93544 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Injection procedure during cardiac cath. 93543 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Removal of sutures under anesthesia 15850 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Repair umbilical hernia, under age 5 49580 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Repair initial inguinal hernia < 6 mos. 49495 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Application of hip spica cast 29305 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Fracture nasal turbinate(s), t 30930 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Plastic repair of cleft lip/na 40761 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Repair initial inguinal hernia (6 mos. to 5 yrs.) 49500 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Adenoidectomy, primary 42830 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Intubation, endotracheal, emergency 31500 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Tonsillectomy and adenoidectomy 42820 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Tonsillectomy, primary and secondary 42825 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, benign lesion except skin tag 11422 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Probing of nasoclarimal duct 68810 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
D-2
143
-----------------------------------------------------------------------------------------------------------------------------------
Incision and removal of foreign body 10120 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Removal of skin tags, multiple 11200 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Cathexerization of umbilical vein 36510 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Cathexerization, umbilical artery 36660 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Layer closure of wounds of scalp 12031 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Scraping of cornea, diagnostic 65430 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Removal of corneal epithelium; 65435 $361 I
-----------------------------------------------------------------------------------------------------------------------------------
Unlisted procedure external ear 69399 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Unlisted procedure, skin, mucous mbrane 17999 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Layer closure of wounds of neck 12041 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Closed treatment of radial & ulnar 25560 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Excision, other benign lesion 11442 $361 1
-----------------------------------------------------------------------------------------------------------------------------------
Unlisted procedure lacrimal system 68899 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Probe Nasolacrimal duct 68811 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Repair of retinal detachment 67101 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Unlisted procedure, male genital syst. 55899 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Total abdominal hysterectomy 58150 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Angiography, renal, unilateral 75722 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Cystoscopy and treatment 52301 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Angiography, renal, bilateral 75724 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Unlisted procedure, accessory sinuses 31299 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Probe Nasolacrimal duct w/insertion 68815 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Percutaneous balloon valvuloplasty 92990 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Treatment of slipped femoral epiphysis 27176 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Cutaneous vesicostomy 51980 $510 2
-----------------------------------------------------------------------------------------------------------------------------------
Xxx xxxxx xxxxxx xxxxxxxxxxx xxxxxx 00000 $750 4
-----------------------------------------------------------------------------------------------------------------------------------
Repair of hypospadias repair 54324 $750 4
-----------------------------------------------------------------------------------------------------------------------------------
Combined right heart catheterization 93526 $750 4
-----------------------------------------------------------------------------------------------------------------------------------
Unlisted procedure, dentoalveolar 41899 $553 9
-----------------------------------------------------------------------------------------------------------------------------------
3) Interim billing ? CCMC submits claims every 30 days even if patient is
not discharged. Interim bills will be processed and paid under the
contract terms.
D-3
144
4) ER to Inpatient or ER to 24-hour Observation will be reimbursed at the
inpatient reimbursement level when an ER visit results in an admission or
a 24-hour observation.
----------------------
*Determined in accordance with CCMC's applicable charge master and the
applicable cost-to-charge ratio (percentage discount), as each is determined
pursuant to the Amendment dated as of January 1, 2000 to which this is attached.
X-0
000
XXXXXXXXXX E
AMENDMENTS FOR PURPOSES OF REGULATORY COMPLIANCE
146
ATTACHMENT E
AMENDMENTS FOR PURPOSES OF
REGULATORY COMPLIANCE
1. No payment by HMO to CCPN or any CCPN Physician or Participating Provider
shall be a financial incentive or a direct or indirect inducement to
limit Medically Necessary Covered Services.
2. HMO will not impose restrictions upon the provider's free communication
with members about a member's medical conditions, treatment options or
their costs, HMO's referral policies, and other HMO policies, including
financial incentives or arrangements.
3. CCPN and its Physicians and Participating Providers understand that any
violation by a provider of a state or federal law relating to the
delivery of services by the provider under this Agreement, or any
violation of the State Contract could result in liability for money
damages, and/or civil or criminal penalties and sanctions under state
and/or federal law.
4. Federal and state laws provide severe penalties for any provider who
attempts to collect any payment from or xxxx a Member or Adult Enrollee
for a covered service.
5. (a) This Agreement is subject to all state and federal laws and
regulations relating to fraud and abuse in health and the Medicaid
program. CCPN and its Physicians and Participating Providers must
cooperate and assist TDH and any state or federal agency that is charged
with the duty of identifying, investigating, sanctioning or prosecuting
suspected fraud and abuse. The provider must provide originals and/or
copies of any and all information, allow access to premises and provide
records to TDH or its authorized agent(s), THHSC, HCFA, U.S. Department
of Health and Human Services, FBI, TDI, and the Texas Attorney General's
Medicaid Fraud Control Unit upon request and free of charge. The provider
must report any suspected fraud or abuse including any suspected fraud
and abuse committed by HMO or a recipient to TDH for a referral to THHSC.
(b) The Texas Medicaid Fraud Control Unit must be allowed to conduct
private interviews of providers and their employees, contractors and
patients.
E-1
147
Requests for information must be complied with in the form and language
requested. Providers and their employees and contractors must cooperate
fully in making themselves available in person for interview,
consultation, grand jury proceedings, pre-trial conference, hearings,
trial and any other process, including investigations. Compliance with
this requirement is at the HMO's and provider's own expense.
6. CCPN shall (or shall cause its Physicians and Participating Providers) to
submit proxy claims forms to HMO for services provided to all STAR
Members that are capitated by HMO in accordance with the encounter data
submission requirements established by the HMO and the State.
7. No provider may interfere with or place liens upon the State's right or
the HMO's right, acting as the State's agent, to recover from third party
resources.
8. Subtitle H of the Medicaid Balanced Budget Act of 1997, Section
1852(d)(2) requires Providers to comply with guidelines respecting
coordination of post-stabilization care in the same manner as such
guidelines apply to Medicare + Choice plans offered under part C of Title
XVIII.
9. Pursuant to Section 12.2.4 of the Texas Department of Health Medicaid
contract, CCPN shall, and shall cause its Physicians and Participating
Providers to, submit claims no later than ninety-five (95) days after the
date services are provided.
10. 28 Texas Administrative Code, Section 11.1102 requires that any
modifications, addition, or deletion to the provisions of the Hold
Harmless clause shall be effective no earlier than fifteen (15) days
after the Commissioner of Insurance has received written notice of such
proposed changes.
11. Pursuant to Section 7.2.8.1 of the Texas Department of Health Medicaid
contract, CCPN acknowledges that services provided under this Agreement
are funded by state and federal funds under the Texas Medical Assistance
Program (Medicaid) and that CCPN, its Physicians and Participating
Providers are subject to all state and federal laws, rules and
regulations, penalties, and sanctions that apply to persons or entities
receiving state and federal funding.
X-0
000
00. 28 Texas Administrative Code, Section 11.901 requires that a Physician or
Provider receive written notice of termination at least ninety (90) days
prior to the effective date of the termination of the Physician or
Provider, except in the case of imminent harm to patient health, action
against license to practice, or fraud pursuant to Insurance Code Article
20A.l8A(b), in which case termination may be immediate. Upon written
notification of termination, a Physician or Provider may seek review of
the termination within a period not to exceed sixty (60) days, pursuant
to the procedure set forth in the Insurance Code Article 20A.18A(b). HMO
must provide notification of the termination of a Physician or Provider
to its enrollees receiving care from the provider being terminated at
least thirty (30) days before the effective date of the termination.
Notification of termination of a Physician or Provider to enrollees for
reasons related to imminent harm may be given to enrollees immediately.
HMO and CCPN shall coordinate the delivery of the foregoing notices, with
CCPN being required to provide notice whenever it terminates a Physician
or Provider.
13. Subtitle H of the Medicaid Balanced Budget Act of 1997 requires, in
accordance with 42 C.F.R. Section 434.28, HMO to maintain written
policies and procedures in compliance with Advance Directives. CCPN
shall, and shall cause its Physicians and Participating Providers to,
fulfill their obligations in regard to Advance Directives as outlined in
the AMERICAID Provider Manual.
Advance Directives as defined in 42 C.F.R. Section 489.100 means a
written instruction, such as a living will or durable power of attorney
for health care, recognized under State law (whether statutory or as
recognized by the courts of the State), relating to the provision or
withholding of health care when the individual is incapacitated.
14. The Texas Department of Health has modified the definition of Emergency
Medical Condition (and references in the Agreement to "Emergency
Condition" shall be deemed) to read as follows:
Emergency Medical Condition means a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain), such
that a prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate medical
care could result in:
E-3
149
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or party;
(d) serious disfigurement; or
(e) in the case of a pregnant woman, serious jeopardy to the health of
the fetus.
15. THE FOLLOWING LANGUAGE MODIFICATIONS APPLY TO INDEPENDENT PRACTICE
ASSOCIATIONS (IPAS) IN GROUP AGREEMENTS ONLY:
IPA. Independent Practice Association - "A professional association
organized under the Texas Professional Association Act (Article 1528f,
Vernon's Texas Civil Statutes), a nonprofit health corporation certified
under Section 501, Medical Practice Act (Article 4495b, Vernon's Texas
Civil Statutes), another person or entity wholly owned by physicians, an
approved nonprofit health corporation, a person who is wholly owned or
controlled by a provider or by a group of providers who are licensed to
provide the same health care service, or a person who is wholly owned or
controlled by one or more hospitals and physicians, including a
physician-hospital organization..."
The Texas Department of Health Medicaid contract, Section 7.18.2.1
requires the UM protocol used by a delegated network to produce
substantially similar outcomes, as approved by Texas Department of
Health, as the UM protocol employed by HMO. The responsibilities of HMO
in delegating UM functions to a delegated network will be governed by
Article 16.3.11 of such contract.
Section 7.18.2.3 requires the delegated network to comply with the same
records retention and production requirements, including Open Records
requirements, as HMO under such contract.
Section 7.18.2.4 requires the delegated network to be subject to the same
marketing restrictions and requirements, as HMO under such contract.
16. THIS SECTION APPLIES TO HOME HEALTH AGENCIES AND DURABLE MEDICAL
EQUIPMENT SUPPLIERS ONLY: At HMO's request, Provider shall provide HMO
evidence of surety bond in compliance with Section 4724(b) of the
Balanced Budget Act of 1997.
X-0
000
XXXXXXXXXX A
EXHIBIT 5
DELEGATION OF CREDENTIALING AGREEMENT
THIS EXHIBIT 5 to that certain CCPN and HMO Medicaid Agreement (the "Agreement")
by and between HMO and CCPN sets forth certain additional terms governing the
relationship between the parties.
RECITALS
1. HMO maintains credentialing programs designed to periodically review and
monitor the credentials of physicians and providers who render Covered
Services to Members. HMO has established policies and procedures for
delegating certain, of its administrative functions to CCPN where CCPN's
credentialing and re-credentialing standards are consistent with HMO's
standards and the standards of the NCQA, the Federal Medicaid Quality
Assurance Reform Initiative (QAR1), and JCAHO.
2. CCPN desires to facilitate the credentialing review of all CCPN
Physicians and CCPN Participating Providers by performing certain
delegated functions on behalf of HMO, and HMO is willing to delegate such
functions, on the terms and conditions set forth below:
NOW THEREFORE, in consideration of the premises and of the mutual covenants
contained herein, the parties do hereby agree as follows:
1. A. Capitalized terms used herein and not defined herein shall have the
meaning ascribed to those terms in the CCPN and HMO Agreement.
B. Except as modified below, the provisions of the CCPN and HMO Agreement
shall remain in full force and effect.
2. CCPN will provide a copy of its credentialing policies and procedures
before or with the execution of the Agreement which shall be based on
current NCQA, QARI and JCAHO standards. CCPN has the power and authority
under applicable state law to accept the delegation of credentialing
functions.
3. HMO hereby delegates to CCPN, and CCPN hereby agrees to provide, the
following credentialing and re-credentialing functions for all CCPN
Physicians and CCPN Participating Providers in accordance with CCPN's
credentialing policies and procedures, as these policies have been
approved by HMO, provided that in any circumstance where CCPN's
credentialing policies and procedures are less stringent than HMO's
credentialing policies and procedures, HMO's policies and procedures
shall apply:
Attachment A - Page 1
151
- verification of Board certification for any and all specialties in
which each provider represents he/she/it is certified;
- verification of completion of residency and reported performance;
- review of CV/work history and confirmation that during the last five
(5) years there are no unexplained gaps of more than six months;
- verification of hospital privileges and good standing;
- verification of license from a primary source;
- verification of valid and current DEA Certificate;
- verification of current malpractice insurance satisfying HMO standards
and collection of documentation in support thereof;
- research regarding any malpractice claims;
- confirmation that provider's record is clear of any Medicare/Medicaid
sanctions;
- confirmation that all credentialing questions on the application have
been answered and that no answer raises an issue;
- confirmation that NPDB search is clean;
- confirmation that search of Federation files is clear;
- obtain affidavit from provider that, pursuant to NCQA CR6.1 and
CR6.2, he or she is fit to practice and has reviewed his or her
application and verifies its correctness/completeness;
- (PCP's/OB/GYNs only) performance of a site visit evaluation and
confirmation that evaluation is favorable;
- (PCP's/OB/GYNs only) performance of medical record review and
confirmation that evaluation is favorable;
- (for Texas only) verification of DPS certification;
- obtain all necessary attestations and relations with respect to
information needed to perform credentialing;
Attachment A - Page 2
152
- Re-credential each provider within two years.
4. HMO shall make available to CCPN its credentialing policies and
procedures and shall notify CCPN in writing of all substantive changes to
such credentialing policies and criteria.
5. CCPN shall at all times (a) be accountable to HMO for the credentialing
functions delegated herein (b) obtain HMO's prior written approval of any
revision to CCPN's credentialing policies and procedures used in
connection with the performance of the functions delegated hereunder, (c)
comply with the credentialing and re-credentialing standards of HMO, the
NCQA, QARA and the JCAHO, (d) abide by, and cause its Physicians and
Participating Providers to abide by, the results of any decision of HMO's
credentialing committee, and (e) take appropriate steps to implement
corrective action if HMO notifies CCPN that it has failed to perform or
comply with the terms of this Addendum.
6. HMO reserves the right, in its sole discretion, to disapprove any CCPN
Physician and/or CCPN Participating Provider, regardless of the initial
credentialing or re-credentialing decision, and CCPN's Physicians and
Participating Providers who are disapproved by HMO shall not provide
services to Members pursuant to the CCPN Agreement.
7. CCPN shall, on a quarterly basis or more frequently if necessary for HMO
to comply with the reporting requirements of its state Medicaid contract,
provide HMO with a written report in a format reasonably acceptable to
HMO which addresses summary results of its credentialing activities. This
report should summarize process indicators, improvement activities, and
status of credentialing and re-credentialing activities.
8. HMO may review periodically CCPN's credentialing policies and criteria
and shall, from time to time, be granted access to CCPN's files, on an
unscheduled basis, to ensure compliance by CCPN with HMO's credentialing
standards. HMO may review the greater of five percent (5%) or fifty (50)
of CCPN's credentialing files in connection with each such audit.
9. HMO shall have the option to revoke its delegation of some or all of the
functions delegated hereunder if: (a) HMO, in its sole discretion, after
giving CCPN a reasonable chance to cure, is dissatisfied with the
arrangement, (b) the delegation is jeopardizing HMO's eligibility for
NCQA accreditation or its compliance with the terms of its state Medicaid
contract, or (c) HMO determines through an audit proves that CCPN has not
complied with HMO's credentialing policies and procedures and, if within
a period of time required by HMO as set forth in a notice of
noncompliance, CCPN fails to respond with a corrective action plan and
effect such plan. Any revocation made pursuant to Sections (a) or (b)
herein shall be effective immediately upon HMO notifying CCPN. If HMO
revokes the delegation of any function, HMO will resume performing that
function.
Attachment A - Page 3
153
10. In the event that any of CCPN's Physicians and/or CCPN Participating
Providers ceases to meet HMO's credentialing criteria, or is disapproved
by CCPN or HMO in accordance with Section 9 above, CCPN shall promptly
notify HMO, and if such CCPN Physician and/or CCPN Participating Provider
is a Primary Care Physician and/or providing an active course of
treatment to a Member, make alternate arrangements for the provision of
Covered Services.
11. CCPN shall immediately notify HMO if any information comes to its
attention regarding any adverse action taken with respect to the
licensure of any CCPN Physician and/or CCPN Participating Provider,
suspension or termination (in whole or in part) of a CCPN Physician's
hospital staff privileges or clinical privileges, suspension or
termination of CCPN, or a CCPN Physician's, Medicare or Medicaid
privileges, a lawsuit is filed against a CCPN Physician alleging
professional negligence, or any other information that adversely reflects
on the ability or capacity of a CCPN Physician to provide medically
appropriate care consistent with appropriate standards of professional
competence and conduct.
12. CCPN agrees to require its Physicians and Participating Providers to
cooperate with and abide by the results of HMO's credentialing policies
and procedures whether implemented through CCPN or directly by HMO.
13. CCPN shall permit HMO to conduct an initial due diligence audit to
confirm that CCPN is in compliance with each of the provisions of this
Addendum. Information disclosed shall be protected by any and all
applicable peer review legal protection.
14. CCPN's credentialing activities shall be coordinated with HMO's quality
improvement program and utilize information derived from HMO's programs,
whether delegated or not, related to member services, utilization
management and quality assurance.
15. CCPN shall comply with all state requirements (including applicable
licensure, State Medicaid and Star Healthplan) and requirements of other
applicable regulatory authorities in the performance of the
administrative functions delegated hereunder. CCPN shall, upon written
request, provide HMO with documentation of the satisfaction of these
requirements.
16. CCPN shall obtain errors and omissions insurance related to its
credentialing activities, or self-insure at its own expense, in the
minimum coverage amount of $1,000,000.
17. Upon the revocation of the functions delegated hereunder or the
termination of the Agreement, CCPN shall assist HMO in the transfer of
records related to the information requested as part of the Credentialing
Program.
Attachment A - Page 4
154
FIRST AMENDMENT OF
CCPN AND HMO MEDICAID AGREEMENT
BY AND BETWEEN
AMERICAID TEXAS, INC., D/B/A AMERICAID COMMUNITY CARE,
AND
XXXX CHILDREN'S PHYSICIAN NETWORK
This First Amendment of CCPN and HMO Medicaid Agreement (the
"Agreement") is made and entered into by and between Americaid Texas, Inc.
("HMO") and Xxxx Children's Physician Network ("CCPN") on October 31, 1996.
WHEREAS, HMO and CCPN entered into the Agreement effective as of
October 1, 1996; and
WHEREAS, the Agreement required HMO and CCPN to enter into a
mutually satisfactory agreement detailing the terms of sharing pre-operational
costs and other business arrangements by November 1, 1996;
WHEREAS, the parties desire to negotiate for an additional thirty
(30) days, thereby extending the date to enter into a mutually safisfactory
agreement to December 2, 1996; and
WHEREAS, the parties desire to amend the Agreement to reflect the
date of December 2, 1996 as the deadline for negotiations.
NOW, THEREFORE, for the mutual benefit of both HMO and CCPN, HMO and
CCPN agree to amend the Agreement as follows:
155
1. Section 8, "Term and Termination," Paragraph 8.2(6) is amended by
deleting the reference to November 1, 1996 and substituting
therefor the date of December 2, 1996.
2. Except for the amendment specified above, all provisions of the
Agreement remain in full force and effect and are hereby ratified
and affirmed.
3. All defined terms as contained herein shall have the same
definitions as are contained in the Agreement.
This First Amendment has been executed as of the date and year first
written above.
Xxxx Children's Physician Network
By:/s/ Xxxx Xxxx Xxxxxxxx, M.D.
----------------------------------
Xxxx Xxxx Xxxxxxxx, M.D.
President and
Chief Executive Officer
Americaid Texas, Inc.
By: /s/ Xxxxx X. Xxxxxxx, Xx.
----------------------------------
Xxxxx X. Xxxxxxx, Xx.
President and
Chief Executive Officer
156
SECOND AMENDMENT OF
CCPN AND HMO MEDICAID AGREEMENT
BY AND BETWEEN
AMERICAID TEXAS, INC., D/B/A AMERICAID COMMUNITY CARE,
AND
XXXX CHILDREN'S PHYSICIAN NETWORK
This Second Amendment of CCPN and HMO Medicaid Agreement (the
"Agreement") is made and entered into by and between Americaid Texas, Inc.
("HMO") and Xxxx Children's Physician Network ("CCPN") on November 26, 1996.
WHEREAS, HMO and CCPN entered into the Agreement effective as of
October 1, 1996; and
WHEREAS, the Agreement required HMO and CCPN to enter into a
mutually satisfactory agreement detailing the terms of sharing pre-operational
costs and other business arrangements by November 1, 1996;
WHEREAS, the parties entered into a First Amendment of CCPN and HMO
Medicaid Agreement dated October 31, 1996 extending the date to enter into a
mutually satisfactory agreement to December 2, 1996; and
WHEREAS, the parties desire to again amend the Agreement to reflect
the date of January 31, 1997 as the deadline for negotiations.
157
NOW, THEREFORE, for the mutual benefit of both HMO and CCPN, HMO and
CCPN agree to amend the Agreement as follows:
1. Section 8, "Term and Termination," Paragraph 8.2(6) is
amended by deleting the reference to December 2, 1996 and
substituting therefor the date of January 31, 1997.
2. Except for the amendment specified above, all provisions of
the Agreement remain in full force and effect and are hereby
ratified and affirmed.
3. All defined terms as contained herein shall have the same
definitions as are contained in the Agreement.
This Second Amendment has been executed as of the date and year
first written above.
Xxxx Children's Physician Network
By:
----------------------------------------
Xxxx Xxxx Xxxxxxxx, M/D.
President and Chief Executive Officer
Americaid Texas, Inc.
By:
----------------------------------------
Xxxxx X. Xxxxxxx, Xx.
President and Chief Executive Officer
2
158
SECOND AMENDMENT TO
CCPN AND HMO MEDICAID AGREEMENT
THIS SECOND AMENDMENT TO CCPN AND HMO MEDICAID AGREEMENT ("Second
Amendment") is entered into effective this 1st day of March, 1998 (the
"Effective Date"), by and between AMERICAID Texas, Inc. d.b.a. AMERICAID
Community Care ("HMO" or "AMERICAID") and Xxxx Children's Physician Network
("CCPN").
WHEREAS, HMO and CCPN entered into that certain CCPN and HMO
Medicaid Agreement dated to be effective October 1, 1996 (the "Agreement");
WHEREAS, HMO and CCPN entered into that certain First Amendment to
CCPN and HMO Medicaid Agreement effective January 1, 1998 (the "First
Amendment"); and
WHEREAS, HMO and CCPN desire to further amend the Agreement by
transferring certain data entry functions from CCPN to HMO, by reducing the
administrative fee paid by HMO to CCPN to reflect CCPN's reduced administrative
duties, and clarify and define certain claims processing procedures for
emergency room and outpatient procedures, and are entering into this Second
Amendment for such purpose.
NOW, THEREFORE, for and in consideration of the mutual promises,
covenants and conditions contained herein, and other good and valuable
consideration, the receipt and sufficiency of which are hereby acknowledged and
confessed, HMO and CCPN hereby agree as follows:
1. All defined terms used in this Second Amendment shall have the
same meanings as ascribed to such terms in the Agreement and the
First Amendment.
2. The terms, conditions and provisions of this Second Amendment
shall control over any inconsistent terms, conditions and
provisions contained in the Agreement and First Amendment,
3. Section 1.11. The last sentence of Section 1.11 of the Agreement
shall be deleted in its entirety and replaced with the
following:
159
"For those Members admitted to CMC, CMC shall perform concurrent
review, discharge planning and case management while HMO will
provide pre-certification and referral management services and data
entry services for all inpatient review information generated for
Members admitted to CMC."
4. Section 3.3. The first sentence of Section 3.3 of the Agreement
shall be deleted in its entirety and replaced with the following:
"HMO shall pay CCPN according to HMO's best information within five
(5) business days of receipt of the TDH Payment (described in
Attachment A) $0.20 per Member per month for each Member enrolled
with HMO. HMO will conduct a true-up in the month following each
payment.
5. Attachment A, Financial Arrangements. A new section IV.H. shall
be added to Attachment A, Financial Arrangements, of the Agreement,
and shall read as follows:
"Claims Procedures for Emergency Room and Outpatient Services.
Attached hereto and incorporated herein as Schedule "A - IV.H" is a
description of emergency room and outpatient claims processing
procedures to be implemented by the parties hereto as of the
effective date of this Second Amendment."
6. Except as amended hereby, the Agreement, as amended by the First
Amendment, is unchanged and is ratified and affirmed by HMO and
CCPN as valid and subsisting.
AMERICAID Texas, Inc. d.b.a, Xxxx Children's Physician Network
AMERICAID Community Care
By: /s/ Xxxxx X. Xxxxxxx, Xx. By: /s/ Xxxx Xxxx Xxxxxxxx, MD
----------------------------------- ------------------------------------
Printed Name: Xxxxx X. Xxxxxxx , Xx. Xxxx Xxxx Xxxxxxxx, M.D.
-------------------------
Title: President & CEO President & CEO
--------------------------------
2
160
SCHEDULE "A-IV-H"
CLAIMS PROCEDURES FOR
EMERGENCY ROOM AND OUTPATIENT SERVICES
1) ER Services
Reimbursement for ER Services will be based upon discharge level;
determination of whether to pay ER claims will be based on admission
triage level. Admission triage levels 1,2, and 3 will be paid based
upon the discharge level (professional claims submitted by
physicians will be reimbursed according to the applicable
professional fee schedule). ER visits with an admission triage level
of 4 or 5 will be paid a triage fee unless the visit meets certain
criteria outlined below.
AMERICAID Service Center Medical Management will authorize ER visits
with Admission Triage Levels 1,2 and 3 for certain Admission Triage
Levels 4 and 5 based on the Admission Triage Level listed in a
column on the daily ER Report submitted by CCMC to the AMERICAID
Service Center Medical Management Department. The Admission Triage
Levels 4 and 5 that will be authorized are those that are referred
by the PCP; those whose PCPs cannot be reached; those which Nurse on
Call has recommended be seen; and, those newborns with no PCP
identified. AMERICAID Service Center Medical Management will not
authorize any other Admission Triage Levels 4 or 5. Claims with
authorizations will be paid at the Discharge Level identified by
pricing on the claim. There are 5 discharge triage levels:
-------------------------------- ----------------------------------------------------------- -------------------------------
Line Item Charge on the UB-92
for Revenue Code 450,
Discharge Level "Emergency Room" Reimbursement
-------------------------------- ----------------------------------------------------------- -------------------------------
Level I $447.00 or $400.00 60% of charges
-------------------------------- ----------------------------------------------------------- -------------------------------
Level II $263 .00 or $200.00 $500 per case
-------------------------------- ----------------------------------------------------------- -------------------------------
Level III $153.00 or $100.00 $250 per case
-------------------------------- ----------------------------------------------------------- -------------------------------
Level IV $90.00 or $50.00 $98 per case
-------------------------------- ----------------------------------------------------------- -------------------------------
Level V $53.00 or $25.00 $37 per case
-------------------------------- ----------------------------------------------------------- -------------------------------
3
161
Claims with no authorization in the system will default to pay a triage
fee of $25.
OTHER TYPES OF SERVICES PERFORMED IN THE ER - In cases when minor
procedures are performed in the ER or a physician meets a patient at the
ER for service/treatment, CCMC's claims will be submitted as "Outpatient
Hospital Services" with no triage level assigned. CCMC's claim will be
paid at 60% of billed charges. CCMC will provide AMERICAID a list of ER
"clinic" codes used so that AMERICAID can pursue an automated method of
identifying these claims.
2) OUTPATIENT SURGERY - Dental surgeries (CPT Code 41899) have been grouped
as "Group 9" and paid an all inclusive global fee of $553.00. The
following list of procedures which are ungroupable are included n the
group listed in the right hand column of the table below. Any future
ungroupable procedure will be paid at an inclusive global fee of $510.00,
subject to multiple procedure protocol currently specified in the
contract.
------------------------------------------------------------------------ ---------------- ----------------- -----------------
PROCEDURE CPT RATE GROUP
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Incision and drainage of abscess 10060 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision, benign lesion, except skin tag 11040 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Injection procedure during cardiac cath. 93542 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision, benign lesion, except skin tag 11421 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Control nasal hemorrhage, anterior 30901 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision benign lesion, except skin tag 11420 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision benign lesion, except skin tag 11400 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Injection procedure during cardiac cath. 93541 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Nasal endoscopy, diagnostic, uni/bilateral 31231 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision, other benign lesion 11440 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision, other benign lesion 11441 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Injection procedure during cardiac cath. 93544 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Injection procedure during cardiac cath. 93543 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Removal of sutures under anesthesia 15850 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Repair umbilical hernia, under age 5 49580 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Repair initial inguinal hernia < 6 mos. 49495 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Application of hip spica cast 29305 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Fracture nasal turbinate(s), t 30930 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Plastic repair of cleft lip/na 40761 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
4
162
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Repair initial inguinal hernia (6 mos to 5 yrs) 49500 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Adenoidectomy, primary 42830 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Intubation, endotracheal, emergency 31500 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Tonsillectomy and adenoidectomy 42820 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Tonsillectomy, primary or secondary 42825 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision, benign lesion except skin tag 11422 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Probing of nasoclacrimal duct 68810 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Incision and removal of foreign body 10120 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Removal of skin tags, multiple 11200 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Catherization of umbilical vein 36510 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Catherization, umbilical artery 36660 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Layer closure of wounds of scalp 12031 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Scraping of cornea, diagnostic 65430 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Removal of corneal epithelium; 65435 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Unlisted procedures external ear 69399 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Unlisted procedures, skin, mucous mbrane 17999 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Layer closure of wounds of neck 12041 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Closed treatment of radial & ulnar 25560 $361 1
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Excision, other benign lesion 11442 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Unlisted procedure lacrimal system 68899 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Probe Nasolacrimal duct 68811 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Repair of retinal detachment 67101 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Unlisted procedure, male genital syst. 55899 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Total abdominal hysterectomy 58150 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Angiography, renal, unilateral 75722 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Cystoscopy and treatment 52301 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Angiography, renal bilateral 75724 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Unlisted procedure, accessory sinuses 31299 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Probe Nasolacrimal duct w/insertion 68815 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Percutaneous balloon valvuloplasty 92990 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Treatment of slipped femoral epiphysis 27176 $510 2
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Cutaneous vesicostomy 51980 $750 4
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Xxx xxxxx xxxxxx xxxxxxxxxxx xxxxxx 00000 $750 4
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Repair of hypospadias repair 54324 $750 4
------------------------------------------------------------------------ ---------------- ----------------- -----------------
Combined right heart catheterization 93526 $553 9
------------------------------------------------------------------------ ---------------- ----------------- -----------------
5
163
3) Interim billing CCMC submits claims every 30 days even if
patient is not discharged. Interim bills will be processed and
paid under the contract terms.
4) ER to Inpatient or ER to 24-hour Observation will be
reimbursed at the inpatient reimbursement level when an ER
visit results in an admission or a 24-hour observation.
6
164
THIRD AMENDMENT OF
CCPN AND HMO MEDICAID AGREEMENT
BY AND BETWEEN
AMERICAID, TEXAS, INC., D/B/A/ AMERICAID COMMUNITY CARE,
AND
XXXX CHILDREN'S PHYSICIAN NETWORK
This Third Amendment of CCPN and HMO Medicaid Agreement (the
"Agreement") is made and entered into by and between Americaid Texas,
Inc. ("HMO") and Xxxx Children's Physician Network ("CCPN") to be
effective January 31, 1997.
WHEREAS, HMO and CCPN entered into the Agreement effective as of
October 1, 1996; and
WHEREAS, the Agreement required HMO and CCPN to enter into a
mutually satisfactory agreement detailing the terms of sharing
pre-operational costs and other business arrangements by November 1,
1996;
WHEREAS, the parties entered into a First Amendment of CCPN and HMO
Medicaid Agreement dated October 31, 1996 extending the date to enter
into a mutually satisfactory agreement to December 2, 1996; and
WHEREAS, the parties entered into a Second Amendment extending the
negotiation date to January 31, 1997; and
WHEREAS, the parties desire to again amend the Agreement to delete
any date as a deadline for negotiations.
165
NOW, THEREFORE, for the mutual benefit of both HMO and CCPN, HMO and
CCPN agree to amend the Agreement as follows:
1. Section 8, "Term and Termination", Paragraph 8.2(6) is
deleted in its entirety.
2. Except for the amendment specified above, all provisions of
the Agreement remain in full force and effect and are hereby
ratified and affirmed.
3. All defined terms as contained herein shall have the same
definitions as are contained in the Agreement.
This Third Amendment has been executed as of the date and year first
written above.
Xxxx Children's Physician Network
By: /s/ Xxxx Xxxx Xxxxxxxx, M.D.
----------------------------------
Xxxx Xxxx Xxxxxxxx, M.D.
President and
Chief Executive Officer
Americaid Texas, Inc.
By: /s/ Xxxxx X. Xxxxxxx, Xx.
----------------------------------
Xxxxx X. Xxxxxxx, Xx.
President and
Chief Executive Officer
166
AMENDMENT BY MUTUAL CONSENT
TO
PARTICIPATING GROUP PHYSICIAN AGREEMENT BETWEEN
AMERICAID TEXAS, INC. AND XXXX CHILDREN'S PHYSICIAN NETWORK
Effective July 1, 1999, pursuant to Section 10.14, (Amendment by Written Mutual
Consent), of the November 10, 1996 CCPN & Medicaid Agreement ("Agreement")
between AMERICAID Texas, Inc., d/b/a Americaid Community Care ("AMERICAID") and
Cooks Children's Physician Network, ("CCPN"), AMERICAID and CCPN mutually
consent to amend the Agreement as follows:
Attachment B is revoked in its entirety and amended to include revised
ATTACHMENT B which shall read as follows:
ATTACHMENT B
AMERICAID COMMUNITY CARE
CCPN PHYSICIAN REIMBURSEMENT
TEXAS HEALTH STEPS REIMBURSEMENT
TARRANT SERVICE DELIVERY AREA
Physician reimbursement effective July 1, 1999, shall be governed by the
following reimbursement terms:
I. PRIMARY CARE CAPITATION PAYMENTS. -- HMO shall compensate Primary
Care Physicians or Providers from the Pediatric Risk Pool through
age/sex/benefit adjusted capitation rates for Primary Care Services.
A. Capitation Payments -- Primary Care Physicians or Providers
Per Member Per Month = weighted average based upon the actual
distribution of the provider panel of members. See below for
specific capitation rates by cell.
167
<500 Member Avg. 500-750 Member Avg. >750 Member Avg.
CATEGORY AGE FEMALE MALE FEMALE MALE FEMALE MALE
========================== ============================ ================================= ==============================
61 days to $39.59 $39.59 $41.67 $41.67 $43.75 $43.75
<2 years
-------------------------- ---------------------------- --------------------------------- ------------------------------
2-4 years $13.31 $13.31 $14.01 $14.01 $14.71 $14.71
-------------------------- ---------------------------- --------------------------------- ------------------------------
5-14 years $8.08 $8.08 $8.51 $8.51 $8.94 $8.94
-------------------------- ---------------------------- --------------------------------- ------------------------------
15 years $7.70 $5.81 $8.10 $6.12 $8.51 $6.43
========================== ============================ ================================= ==============================
16+ years FFS FFS FFS FFS FFS FFS
========================== ============================ ================================= ==============================
For PCPs with less than 250 members, there will be an annual true-up to 100% of
the fee-for-service equivalent in the event capitation payments are less than
the fee-for-service total.
Average membership is calculated based upon the total members per Group
(contract) divided by the number of PCPs in the Group serving AMERICAID Members.
Rates are adjusted quarterly on a prospective basis, once a membership level has
been maintained during the prior quarter.
B. Primary Care Fee-For-Service Payment -- Primary Care Physicians or
Providers.
1. HMO shall compensate Primary Care Physicians or Providers
for CPT codes not listed on the attached listing of Primary
Care Services on a fee-for-service basis for non-capitated
services provided to Members at the reimbursement rate
agreed to between such provider and CCPN. If PCP and CCPN
have not agreed to a reimbursement rate, then PCP will be
reimbursed at the then current Medicaid allowable rate for
non-capitated services with the exception of the following:
1) Immunizations will be reimbursed at 90% of the
prevailing Medicaid maximum allowable fee schedule. 2)
Injectable drugs at the average wholesale price (AWP).
2
168
2.
=========================== ================================================================= ======================================
PRIMARY
DIAGNOSIS CODE DESCRIPTION MEDICAID
=========================== ================================================================= ======================================
Well Woman Annual GYN Visit Includes: Office Visit, Pap Smear,
V72.3 and Breast, Pelvic and Rectal Exams. $47.00
=========================== ================================================================= ======================================
=========================== ================================================================= ======================================
DESCRIPTION MEDICAID
============================================================================================= ======================================
BILLED CHARGES UP TO THE AMERICAID FEE
Care for Newborns in the first 60 days of life. SCHEDULE
============================================================================================= ======================================
BILLED CHARGES UP TO THE AMERICAID FEE
Primary Care of Members 16 years and older. SCHEDULE
============================================================================================= ======================================
Reporting of Texas Health Steps screenings on a HCFA-1500 based on the Texas Health Steps
codes and periodicity schedule in the TDH/NHIC Medicaid Manual. $20.00 per visit
============================================================================================= ======================================
Reporting of the Administration of Immunizations on a HCFA-1500 based on the Texas Health
Steps codes and periodicity schedule in the TDH/NHIC Medicaid Manual. $3.00 per administration
============================================================================================= ======================================
III. Specialist Reimbursement. HMO shall compensate Specialist physicians
from the Pediatric Risk Fund for Covered Health Services on a fee
for service basis at the reimbursement rate agreed to between such
physicians and CCPN. If Specialist Physicians and CCPN have not
agreed to reimbursement rate, then Specialist Physicians will be
reimbursed at the then current Medicaid allowable rate.
IV. Risk Sharing/Incentive Program. Each CCPN Physician will be eligible
to participate in a risk sharing/incentive program to be developed
by CCPN. HMO and CCPN will jointly determine how to integrate the
Hospital and Referral Pool ("HARP") developed by HMO and the Risk
Sharing Incentive Program developed by CCPN.
3
169
IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be executed
personally or by their duly authorized officers or agents.
AMERICAID Texas, Inc. Xxxx Children's Physician Network
/s/ Xxxxxx Xxxxxxxx /s/ Xxxx Xxxx Xxxxxxxx, MD
---------------------------- -----------------------------------------
Signature Signature
XXXXXX X. XXXXXXXX
ASSOCIATE VICE PRESIDENT Xxxx Xxxx Xxxxxxxx, M.D., President & CEO
---------------------------- -----------------------------------------
Print Name and Title Print Name and Title
SEP 13 1999 09-03-99
---------------------------- -----------------------------------------
Date Date
000 0xx Xxxxxx
-----------------------------------------
Address
Ft. Xxxxx XX 00000
-----------------------------------------
(000) 000-0000
-----------------------------------------
Telephone Number
4
170
AMENDMENT BY NOTIFICATION
Pursuant to the Amendment by Notification Section of the AMERICAID Participating
Physician/Provider Group Agreement, effective December 1, 1999, ATTACHMENT A is
revoked in its entirety and amended to include revised ATTACHMENT A, which shall
read as follows:
AMERICAID COMMUNITY CARE
PRIMARY CARE PHYSICIAN REIMBURSEMENT
TEXAS HEALTH STEPS REIMBURSEMENT
Providers are reimbursed subject to the terms of Article III.,
Payment for Services
PRIMARY CARE PHYSICIAN REIMBURSEMENT
I. Primary Care Physician (PCP) Capitation
Per Member Per Month = weighted average based upon the actual
distribution of the provider panel of members. See below for
specific capitation notes by cell.
<500 Member Avg. 500-750 Member Avg. >750 Member Avg.
=========================== ============================ ================================= =========================================
CATEGORY AGE FEMALE MALE FEMALE MALE FEMALE MALE
=========================== ============================ ================================= =========================================
61 days to $39.59 $39.59 $41.67 $41.67 $43.75 $43.75
<2 years
--------------------------- --------------------------------- -----------------------------------------
2-4 years $13.31 $13.31 $14.01 $14.01 $14.71 $14.71
--------------------------- --------------------------------- -----------------------------------------
5-14 years $ 8.08 $ 8.08 $ 8.51 $ 8.51 $ 8.94 $ 8.94
--------------------------- --------------------------------- -----------------------------------------
15 years $ 7.70 $ 5.81 $ 8.10 $ 6.12 $ 8.51 $ 6.43
=========================== ============================ ================================= =========================================
For PCPs with less than 250 members, there will be an annual true-up to 100% of
the fee-for-service equivalent in the event capitation payments are less than
the fee-for-service total.
Average membership is calculated based upon the total members per Group
(contract) divided by the number of PCPs in the Group serving AMERICAID Members.
171
Rates are adjusted quarterly on a prospective basis, once a membership level has
been maintained during the prior quarter.
[PAGE 2 IS MISSING]
III. PRIMARY CARE PHYSICIAN QUALITY IMPROVEMENT PROGRAM (PQIP)
Provider Quality Incentive Program is established to reward
providers for producing high quality results in the following
categories:
- Patient access and satisfaction
- Membership retention
- Prevention and Education
- Clinical outcomes
- Compliance with AMERICAID policies and procedures
A. For Members 16 years of age and over, this fund is
available based on the following conditions:
- A minimum of 50 members 16 years of age and older per
provider
- HARP must have a positive balance, but the plan reserves
the right to pay out, even if negative
- PQIP payout to occur on an annual basis after HARP
resolution
- Provider panel must remain open to new AMERICAID members
- Participation as PCP at time of PQIP payment
B. For Members under 16 years of age, this fund will pay
out as follows on an ongoing basis based on reporting
Texas Health Steps Services within 60 days of completing
the service:
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DESCRIPTION REIMBURSEMENT
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Reporting of Texas Health Steps screenings on a HCFA-1500 based on the Texas $21 per visit
Health Steps codes and periodicity schedule in the TDH/NHIC Medicaid Manual
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Reporting of the Administration of Immunizations on a HCFA-1500 based on the Texas Health $3 per administration
Steps codes and periodicity schedule in the TDH/NHIC Medicaid Manual
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AMERICAID reserves the right to change the PCP's method of reimbursement if the
PCP's compliance rates for their members is below 60% and is in the lowest 25%
of PCPs over a calendar quarter. In that case, the cost of Texas Health Step
Services will be excluded from the PCP Capitation reimbursement, the reporting
reimbursement for Members under 16 years of age under PQIP will be eliminated,
and Texas Health Steps Services will be reimbursed on a fee-for-service basis to
allow other providers to xxxx for these services.
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SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
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- Complete items 1, 2, and 3. Also complete item 4 A. Received by (Please Print Clearly) B. Date of Delivery
if Restricted Delivery is desired. Xxxxxx X. Xxxxx NOV 08 1999
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- Print your name and address on the reverse so that -----------------------------------------------------------------------
we can return the card to you. C. Signature
- Attach this card to the back of the mailpiece, or [ ] Agent
on the front if space permits. X /s/ Xxxxxx X. Xxxxx [ ] Addressee
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D. Is delivery address different from item 1? [ ] Yes
If YES, enter delivery address below: [ ] No
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1. Article Addressed to:
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Xxxx Xxxxx RN -----------------------------------------------------------------------
Vice President, Managed Care 3. Service Type
Xxxx Children's Physician Network [X] Certified Mail [ ] Express Mail
000 0xx Xxx [ ] Registered [X] Return Receipt for Merchandise
Xxxx Xxxxx, XX 00000 [ ] Insured Mail [ ] C.O.D.
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4. Restricted Delivery? (Extra Fee) [ ] Yes
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2. Article Number (Copy from service label)
Z 265 886 276
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