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EXHIBIT 10.16
Portions of this Exhibit have been omitted pursuant to a request for
confidential treatment. The omitted portions, marked by an * and [ ], have been
separately filed with the Commission.
GROUP PRACTICE
MANAGED CARE AGREEMENT
PARTIES
THIS AGREEMENT is by and between CIGNA HealthCare of Georgia, Inc. ("CIGNA"),
and The ENT Center of Atlanta, Inc. and is entered into as of the Effective
Date.
PURPOSE
CIGNA contracts directly or indirectly with Payors, employers, individuals,
insurers, sponsors and others, to provide, insure, arrange for or administer the
provision of health care services;
CIGNA contracts with physicians, hospitals and other health care practitioners
and entities, to provide, arrange for or administer, at predetermined rates, the
delivery of such health care services;
CIGNA and The ENT Center of Atlanta, Inc. desire to enter into this Agreement
relating to certain health care services for individuals;
In consideration of the mutual promises herein, the parties agree as follows:
I. DEFINITIONS
Defined terms are set forth herein and in the Program Attachments.
CIGNA AFFILIATE means any direct or indirect subsidiary of CIGNA Corporation.
COINSURANCE means a payment that a Participant is required to make to a
Participating Provider for Covered Services under a Service Agreement, which is
calculated as a percentage of the contracted reimbursement rate of such
services.
COPAYMENT OR DEDUCTIBLE means a payment that a Participant is required to make
to a Participating Provider under a Service Agreement, which is calculated as a
fixed dollar payment.
COVERED SERVICES means those health care services provided to a Participant in
accordance with a Service Agreement.
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EMERGENCY means an illness or accident in which the onset of symptoms is both
sudden and so severe as to require immediate medical or surgical treatment. This
includes accidental injuries or medical emergencies of a life-threatening nature
or when serious impairment of bodily functions would result if treatment were
not rendered immediately.
PARTICIPANT means any individual, or eligible dependent of such individual,
whether referred to as "Insured," "Subscriber," "Member," "Participant,"
"Enrollee," "Dependent" or otherwise, who is eligible for Covered Services
pursuant to a Service Agreement.
PARTICIPATING HOSPITAL means a hospital that has a direct or indirect
contractual agreement with CIGNA and to which a Participating Provider may admit
Participants for care and treatment in accordance with Program Requirements.
PARTICIPATING PROVIDER means a hospital, a physician or any other health care
practitioner or entity that has a direct or indirect contractual arrangement
with CIGNA to provide Covered Services.
PAYOR means CIGNA or such other entity which, pursuant to a Service Agreement,
funds, administers, offers or insures Covered Services and which has agreed to
act as Payor in accordance with this Agreement.
PROGRAM means the Health Maintenance Organization (HMO) or other types of health
care or administrative services which are provided by or arranged by CIGNA or
CIGNA Affiliates and which are specifically described in applicable Program
Attachments and Program Requirements.
PROGRAM REQUIREMENTS means the rules and procedures that establish conditions to
be followed by Participating Providers with respect to Programs. Reference to
Program Requirements includes the Summary of Program Requirements distributed by
CIGNA.
QUALITY MANAGEMENT means the processes established and operated by CIGNA or its
designee relating to the quality of Covered Services.
REPRESENTED PHYSICIAN means a physician: (a) who is employed by, associated with
or otherwise represented by The ENT Center of Atlanta, Inc.; (b) who is
authorized by The ENT Center of Atlanta, Inc. to provide services pursuant to
this Agreement; (c) who has completed a CIGNA Physician Application; and (d) who
has agreed with The ENT Center of Atlanta, Inc. to be subject to the
requirements of this Agreement to the extent applicable to Represented
Physician.
SERVICE AGREEMENT means those agreements among CIGNA or a CIGNA Affiliate, and
an employer, insurer, labor union, trust or other organization or entity, or an
individual, that specifies services to be provided to or for the benefit of, or
arranged for or reimbursed to or
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for the benefit of Participants, the terms and conditions under which those
services are to be provided or reimbursed, and is consistent with applicable
Program Requirements.
UTILIZATION MANAGEMENT means the processes to review and determine whether
certain health care services provided or to be provided to Participants are in
accordance with Program Requirements.
II. PARTIES' OBLIGATIONS
A. SERVICES
1. The ENT Center of Atlanta, Inc., its Represented Physicians
and CIGNA shall act in accordance with the terms of this
Agreement and applicable Program Attachments and Program
Requirements. The ENT Center of Atlanta, Inc. shall accept the
rates set forth in this Agreement as payment in full for all
services provided to Participants pursuant to this Agreement.
2. The ENT Center of Atlanta, Inc. through its Represented
Physicians shall provide Covered Services with the same
standard of care, skill and diligence customarily used by
similar physicians in the community in which such services are
rendered. The ENT Center of Atlanta, Inc. and its Represented
Physicians shall render Covered Services in the same manner,
in accordance with the same standards, and with the same
availability, as offered to other patients. The ENT Center of
Atlanta, Inc. and its Represented Physicians shall not
differentiate or discriminate in the treatment of any
Participant because of race, color, national origin, ancestry,
religion, sex, marital status, sexual orientation, age, health
status or source of payment.
3. The ENT Center of Atlanta, Inc. and its Represented Physicians
shall provide Covered Services at locations approved by CIGNA.
Locations shall not be eliminated or changed without sixty
(60) days' prior written notice to CIGNA.
4. The ENT Center of Atlanta, Inc. shall designate one or more
Participating Hospitals where Represented Physicians will
admit Participants under their care unless otherwise approved
by CIGNA or its designee. The ENT Center of Atlanta, Inc. and
its Represented Physicians shall admit Participants only to
Participating Hospitals except in the case of an Emergency or
as otherwise described in applicable Program Requirements or
as otherwise required by law.
5. For referrals, The ENT Center of Atlanta, Inc. and its
Represented Physicians shall refer Participants to
Participating Providers except in the case of an Emergency or
as otherwise described in applicable Program Requirements or
as otherwise required by law.
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6. The ENT Center of Atlanta, Inc. and its Represented Physicians
shall be bound by and comply with the provisions of applicable
state and federal laws, regulations, and Program Requirements.
The ENT Center of Atlanta, Inc. and its Represented Physicians
shall comply with the requirements of and shall participate in
Quality Management and Utilization Management.
7. CIGNA shall establish a system of Participant identification,
communicate Program Requirements to Participating Providers
and identify Participating Providers to Payors and
Participants.
8. CIGNA shall contract, directly or indirectly, with Payors who
agree to pay in accordance with this Agreement for Covered
Services rendered by The ENT Center of Atlanta, Inc. and its
Represented Physicians
9. CIGNA shall, upon specific request by The ENT Center of
Atlanta, Inc., identify the Payor responsible for payment of
Covered Services.
10. Upon written request by CIGNA, The ENT Center of Atlanta, Inc.
shall prohibit a Represented Physician from continuing to
provide services to Participants under this Agreement. The ENT
Center of Atlanta, Inc. shall take such action within thirty
(30) days of the receipt of CIGNA's request, unless CIGNA
requests immediate action by The ENT Center of Atlanta, Inc.
subject to any notice requirements in The ENT Center of
Atlanta, Inc. contract with the Represented Physicians.
B. COMPENSATION AND BILLING
1. The ENT Center of Atlanta, Inc. shall receive payments for
Covered Services as set forth in this Agreement. Compensation
arrangements and rates are set forth in applicable Program
Attachments.
2. The ENT Center of Atlanta, Inc. shall comply with the
limitations on billing Participants as set forth in applicable
Program Attachments.
3. The ENT Center of Atlanta, Inc. shall xxxx for Covered
Services according to the following:
a. The ENT Center of Atlanta, Inc. shall submit claims
on the appropriate claim form for all non-covered
capitated 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.
The ENT Center of Atlanta, Inc. shall submit claims
to the location described in the applicable Program
Requirements.
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b. Any amount owing under this Agreement shall be paid
within thirty (30) days after receipt of a complete
claim, unless additional required information is
requested within the thirty (30) day period, or the
claim involves coordination of benefits, except as
otherwise provided in the applicable Program
Attachments.
4. The following provisions apply regarding coordination of
benefits:
a. Certain claims for services rendered to Participants
are claims for which another payor may be primarily
responsible under coordination of benefit rules. The
ENT Center of Atlanta, Inc. shall xxxx such claims to
the primary payor when information regarding such
primary payor is available, or upon designated
Payor's request.
b. When designated Payor is primary under applicable
coordination of benefits rules, Payor shall pay
benefits as set forth in this Agreement without
regard to the obligations of any secondary payor.
c. When designated Payor is determined to be secondary
to any other payor including Medicare, Payor will pay
no greater amount than the difference between the
amount payable to The ENT Center of Atlanta, Inc. by
the primary payor and the amount for Covered Services
owing under this Agreement. Payor shall not be liable
for any amount unless Payor has received The ENT
Center of Atlanta, Inc.'s claim for such secondary
payment within ninety (90) days of the date when
Payor is determined to be secondary.
d. Where another payor is primary under coordination of
benefits rules, The ENT Center of Atlanta, Inc. shall
follow that payor's billing rules.
5. The ENT Center of Atlanta, Inc. may xxxx an individual
directly for any services provided following the date the
individual ceases to be a Participant. Designated Payor has no
obligation under this Agreement to pay for services rendered
to individuals who no longer are Participants.
C. RECORDS
1. CIGNA and The ENT Center of Atlanta, Inc. agree that clinical
records of Participants shall be regarded as confidential and
both shall comply with all applicable federal and state laws
and regulations regarding such records.
2. The ENT Center of Atlanta, Inc. shall maintain and furnish
such records and documents as may be required by applicable
laws, regulations and Program Requirements. The ENT Center of
Atlanta, Inc. shall cooperate with CIGNA
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to facilitate the information and record exchanges necessary
for Quality Management, Utilization Management, peer review,
or other programs required for CIGNA's operations.
3. The ENT Center of Atlanta, Inc. shall provide CIGNA or its
designee with reasonable access during regular business hours
to specified clinical and medical records of Participants
maintained by The ENT Center of Atlanta, Inc. for the period
required by applicable law and at any time thereafter that
such access is reasonably required in connection with a
Participant's health care.
4. Designated Payor shall be responsible for obtaining
Participant's consent to the release of medical record
information by The ENT Center of Atlanta, Inc. for the
purposes stated in this section, and such Payor shall
indemnify and hold harmless The ENT Center of Atlanta, Inc.
for any claim by a Participant for breach of confidentiality
resulting from The ENT Center of Atlanta, Inc.'s compliance
with this section.
D. PARTICIPANT GRIEVANCE
The ENT Center of Atlanta, Inc. shall cooperate with CIGNA in the
implementation of its Participant grievance procedure and shall assist
CIGNA in taking appropriate corrective action. The ENT Center of
Atlanta, Inc. shall comply with all final determinations made by CIGNA
pursuant to such grievance procedure.
E. INSURANCE AND LIABILITY
1. Throughout the term of this Agreement, The ENT Center of
Atlanta, Inc. will ensure Represented Physicians have general
and professional liability coverage in a form and amount
acceptable to CIGNA. The ENT Center of Atlanta, Inc. shall
require each Represented Physician to maintain such coverages
in a form and amount acceptable to CIGNA. The ENT Center of
Atlanta, Inc. shall give CIGNA certificates of insurance
evidencing the coverages described herein upon request. The
ENT Center of Atlanta, Inc. shall give CIGNA thirty (30) days'
prior written notice of cancellation, modification or
termination of any such insurances. The ENT Center of Atlanta,
Inc. shall give CIGNA prompt written notice of any claims
against The ENT Center of Atlanta, Inc.'s or any of its
Represented Physicians' liability coverage.
2. The ENT Center of Atlanta, Inc. shall notify CIGNA immediately
of the initiation of any complaint, inquiry, investigation, or
review with or by any licensing or regulatory authority, peer
review organization, hospital committee, or other committee,
organization or body which reviews quality of medical care
which complaint, inquiry, investigation, or review directly or
indirectly, evaluates or focuses on the quality of care
provided by The ENT Center of
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Atlanta, Inc. or its Represented Physicians either in any
specific instance or in general.
3. Neither party hereto shall be liable for defending or for the
expense of defending the other party, its agent, or employees,
against any claim, legal action, dispute resolution or
administrative or regulatory proceeding arising out of or
related to such other party's actions or omissions under this
Agreement. Neither party hereto shall be liable for any
liability of the other party, its agents, or employees,
whether resulting from judgement, settlement, award, fine or
otherwise, which arises out of such other party's actions or
omissions under this Agreement.
F. INDEMNIFICATION
Each party agrees to indemnify, defend and hold harmless the other, its
agents and employees from and against any and all liability or expense,
including defense costs and legal fees, incurred in connection with
claims for damages of any nature, including but not limited to bodily
injury, death, personal liability, property damage, or other damages
arising from the performance of or failure to perform, its obligations
under this Agreement, or incurred as a result of the indemnifying
party's violation of applicable law, unless it is determined that the
liability was the direct consequence of negligence or willful
misconduct on the part of the indemnified party, its agents or
employees.
G. INSPECTIONS
Upon reasonable notice and at reasonable hours, CIGNA or its agents may
inspect The ENT Center of Atlanta, Inc.'s premises and operations to
ensure that they are adequate to meet Participants' needs.
H. REPRESENTATIONS
1. Each Represented Physician represents and warrants that the
information set forth in the CIGNA Physician Application is
true and correct. The ENT Center of Atlanta, Inc. shall
promptly notify CIGNA of any changes in the information
contained in any Represented Physician's Application within
thirty (30) days of such change.
2. The ENT Center of Atlanta, Inc. represents and warrants that
only Represented Physicians will be allowed to provide Covered
Services.
3. The ENT Center of Atlanta, Inc. represents and warrants that
it is authorized to act on behalf of its Represented
Physicians and will provide evidence of authority upon
request.
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4. The ENT Center of Atlanta, Inc. will provide evidence of
Represented Physicians' agreement to abide by the terms of
this Agreement upon request.
5. CIGNA makes no representations or guarantees concerning the
number of Participants it can or will refer to The ENT Center
of Atlanta, Inc. under this Agreement.
I. CONFIDENTIALITY
The following information is confidential and or proprietary: 1) the
terms and conditions of this Agreement, including financial rates; 2)
all information provided by CIGNA to The ENT Center of Atlanta, Inc.
regarding CIGNA's or its Affiliates' Service Agreements, marketing
strategies, or plans for development of new products, services or
programs; and 3) all other information designated by CIGNA as
confidential or proprietary. Neither The ENT Center of Atlanta, Inc.
nor any of its agents or representatives, including Represented
Physicians whether during the term of this Agreement or subsequent
thereto, shall disclose any of such information
III. MISCELLANEOUS OBLIGATIONS
A. INDEPENDENT CONTRACTOR RELATIONSHIP
1. This Agreement is not intended to create nor shall be
construed to create any relationship between CIGNA and The ENT
Center of Atlanta, Inc. other than that of independent
entities contracting for the purpose of effecting provisions
of this Agreement. Neither party nor any of their
representatives shall be construed to be the agent, employer,
employee or representative of the other.
2. Nothing in this Agreement, including The ENT Center of
Atlanta, Inc. and its Represented Physicians' participation in
the Quality Management and Utilization Management process,
shall be construed to interfere with or in any way affect
Represented Physicians' obligation to exercise independent
medical judgement in rendering health care services to
Participants.
B. TERM OF AGREEMENT
This Agreement shall begin on the Effective Date and shall continue for
a three (3) year term and year to year thereafter, unless terminated as
set forth below.
C. TERMINATION
1. For Cause. The ENT Center of Atlanta, Inc. or CIGNA may
terminate this Agreement at any time for cause. Cause for
termination includes, but is not limited to, the following:
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a. Material failure of CIGNA, when acting as Payor, to
make required compensation payments to The ENT Center
of Atlanta, Inc.
b. Failure of CIGNA to maintain licenses or
certifications required to operate in conformity with
this Agreement.
c. Any material change or alteration by CIGNA of Program
Requirements if such action is unacceptable to The
ENT Center of Atlanta, Inc., providing that The ENT
Center of Atlanta, Inc. gives CIGNA notice of
rejection of such action within thirty (30) days of
receipt by The ENT Center of Atlanta, Inc. of CIGNA's
notice concerning the change or alteration.
d. Habitual neglect or continued failure by either party
to perform its duties under this Agreement.
e. Initiation of bankruptcy proceedings by or against
either party.
f. Material breach of this Agreement by either party.
g. Failure by The ENT Center of Atlanta, Inc. or its
Represented Physicians to maintain licenses required
to perform The ENT Center of Atlanta, Inc.'s duties
under this Agreement, or to comply with applicable
laws, regulations or Program Requirements.
h. Any material misrepresentation or falsification of
any information submitted by The ENT Center of
Atlanta, Inc. to CIGNA.
i. Commission or omission of any act or any conduct or
allegation of conduct for which The ENT Center of
Atlanta, Inc.'s license or certification may be
subject to revocation or suspension, whether or not
actually revoked or suspended, or if The ENT Center
of Atlanta, Inc. is otherwise disciplined by any
licensing, regulatory, professional entity or any
professional organization with jurisdiction over The
ENT Center of Atlanta, Inc.
j. Failure of The ENT Center of Atlanta, Inc. to
maintain required liability coverage protection.
k. Commission or omission of any act or conduct by The
ENT Center of Atlanta, Inc. which is detrimental to
Participants' health or safety. CIGNA may terminate
this agreement if The ENT Center of Atlanta, Inc.
does not make appropriate arrangements with the
Represented Physician.
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Any occurrence under paragraphs (g) through (k) above shall be grounds
for immediate termination. Termination for any other reason set forth
above shall be upon thirty (30) days prior written notice by the
terminating party.
2. Without Cause. This Agreement may be terminated at any time
without cause or prejudice upon ninety (90) days' prior
written notice by either party.
3. Termination of Individual Program Attachments. Program
Attachments may be terminated individually by amendment as
provided in Section III.H. of this Agreement. Termination of
any individual Program Attachment will not have the effect of
terminating the entire Agreement and all remaining Sections
and Program Attachments of the Agreement will remain in full
force.
D. RIGHTS AND OBLIGATIONS UPON TERMINATION
Upon termination of this Agreement for any reason, the rights of each
party hereunder shall terminate, except as provided in any Program
Attachment to this Agreement. Any such termination, however, shall not
release The ENT Center of Atlanta, Inc. or CIGNA from obligations under
this Agreement prior to the effective date of termination.
E. ASSIGNMENT AND DELEGATION OF DUTIES
Neither CIGNA nor The ENT Center of Atlanta, Inc. may assign duties,
rights or interests under this Agreement unless the other party shall
so approve by written consent, provided, however, that any reference to
CIGNA herein shall include any successor in interest and that CIGNA may
assign its duties, rights and interests under this Agreement in whole
or in part to a CIGNA Affiliate or may delegate any and all of its
duties in the ordinary course of business.
F. USE OF NAME
The ENT Center of Atlanta, Inc. agrees that The ENT Center of Atlanta,
Inc. and its Represented Physicians' names, office telephone numbers,
addresses, specialties, board certifications, hospital affiliations and
other relevant data may be included in literature distributed to
existing or potential Participants, Participating Providers and Payors.
The ENT Center of Atlanta, Inc.'s use of CIGNA's name or CIGNA
Affiliate's name, or any other use of The ENT Center of Atlanta, Inc.'s
or its Represented Physicians' names by CIGNA shall be upon prior
written approval or as the parties may agree.
G. INTERPRETATION
The validity, enforceability and interpretation of this Agreement shall
be governed by any applicable federal law and by the applicable laws of
the state in which The ENT
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Center of Atlanta, Inc. and its Represented Physicians are licensed and
have rendered Covered Services.
H. AMENDMENT
1. CIGNA may amend this Agreement and Program Attachments by
providing prior written notice to The ENT Center of Atlanta,
Inc. Failure of The ENT Center of Atlanta, Inc. to object in
writing to any such proposed amendment within thirty (30) days
following receipt of notice shall constitute The ENT Center of
Atlanta, Inc.'s acceptance thereof. Notification to CIGNA of
rejection of any proposed amendment means that this Agreement
shall remain in force without the proposed amendment.
2. In the event that state or federal law or regulation should
change, alter or modify the present services, levels of
payments to CIGNA, standards of eligibility of Participants,
or any operations of CIGNA, such that the terms, benefits and
conditions of this Agreement must be changed accordingly, then
upon notice from CIGNA, The ENT Center of Atlanta, Inc. shall
continue to perform services under this Agreement as modified.
3. Except as provided above, amendments to this Agreement shall
be agreed to in advance in writing by CIGNA and The ENT Center
of Atlanta, Inc.
I. PROGRAM ATTACHMENTS
The Program Attachments hereto are a part of this Agreement and their
terms shall supersede those of other parts of this Agreement in the
event of a conflict.
J. ENTIRE CONTRACT
This Agreement together with all Program Attachments contains all the
terms and conditions agreed upon by the parties, and supersedes all
other agreements, express or implied, regarding the subject matter.
K. NOTICE
Any notice required hereunder shall be in writing and shall be sent by
United States mail, postage prepaid, to CIGNA and The ENT Center of
Atlanta, Inc. at the addresses set forth below.
L. ENFORCEABILITY AND WAIVER
The invalidity and nonenforceability of any term or provision of this
Agreement shall in no way affect the validity or enforceability of any
other term or provision. The
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waiver by either party of a breach of any provision of this Agreement
shall not operate as or be construed as a waiver of any subsequent
breach thereof.
M. REGULATORY APPROVAL
In the event that CIGNA has not been licensed or has not received any
applicable regulatory approval for use of this Agreement prior to the
execution of this Agreement, this Agreement shall be deemed to be a
binding letter of intent. In such event, the Agreement shall become
effective on the date that such regulatory approval is obtained. If
CIGNA is unable to obtain such licensure or approval after due
diligence, CIGNA shall notify The ENT Center of Atlanta, Inc. and both
parties shall be released from any liability under this Agreement,
provided however, that if such licensure or approval is obtained upon
the condition of CIGNA's amendment of this Agreement, then this
Agreement shall continue and CIGNA shall amend pursuant to Section
III.H.
N. DISPUTE RESOLUTION
1. The parties agree to meet and confer in good faith to resolve
any problems or disputes that may arise under this Agreement.
2. If the dispute is not resolved through the aforementioned
process and to the extent permitted by law, the matter in
controversy shall be submitted either to dispute resolution
entity, or to a single arbitrator selected by the American
Arbitration Association, as the parties shall agree within 60
days of the last attempted resolution. If the matter is
submitted to arbitration, it shall be conducted in accordance
with the commercial arbitration rules of the American
Arbitration Association and shall be held in the jurisdiction
of The ENT Center of Atlanta, Inc. domicile. Both parties
expressly covenant and agree to be bound by the decision of
the dispute resolution entity or arbitrator as final
determination of the matter in dispute. Each party shall
assume its own costs, but shall share the cost of the
resolution entity equally. Judgment upon the award rendered by
the resolution entity may be entered in any court having
jurisdiction thereof.
[REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK]
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IN WITNESS WHEREOF, the parties hereto have executed and delivered this
Agreement as of the EFFECTIVE DATE.
CIGNA
EFFECTIVE DATE By:
----------------------------------------------
Name: X.X. Xxxxxxx
9-1-92 Title: General Manager
--------------------------- -------------------------------------------
0000 Xxxx Xxxxxxxxx Xxxxxx, X.X.
-------------------------------------------------
Midtown Plaza II, Suite 1300
-------------------------------------------------
Xxxxxxx, XX 00000
-------------------------------------------------
Address
THE ENT CENTER OF ATLANTA, INC.
Date August 7, 1995 Xxxxx X. Xxxxx, M.D.
----------------- -------------------------------------------------
Please Print or Type Name
By:
----------------------------------------------
Name:
Title: President
-------------------------------------------
Specialty: Otolaryngology-Head & Neck Surgery
-------------------------------------------------
0000 Xxxxxxxxx-Xxxxxxxx Xxxx, Xxxxx 000
-------------------------------------------------
Xxxxxxx, Xxxxxxx 00000
-------------------------------------------------
Address
00-0000000
-----------------------------------
Federal Tax Identification Number
PROGRAM ATTACHMENTS:
HMO Specialty Care Program Attachment
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HMO SPECIALTY CARE PROGRAM ATTACHMENT
TO GROUP MANAGED CARE AGREEMENT
(CAPITATION)
PURPOSE
The terms and provisions of this HMO Specialty Care Program Attachment and the
Agreement are applicable to Covered Services rendered in accordance with a
Service Agreement which is consistent with the HMO Program.
I. DEFINITIONS
CAPITATION PAYMENT means a predetermined periodic payment for certain Covered
Services that is made to The ENT Center of Atlanta, Inc. by CIGNA for each
Participant who is a member of The ENT Center of Atlanta, Inc.'s Patient Panel.
MEDICAL DIRECTOR means a physician designated by CIGNA to manage Quality
Management and Utilization Management responsibilities, or that physician's
designee.
PATIENT PANEL means those Participants who have designated or have otherwise
been assigned to The ENT Center of Atlanta, Inc. or its Represented Physicians
as the primary source for certain Covered Services pursuant to a Service
Agreement or HMO Program Requirements.
POINT OF SERVICE BUSINESS means a type of business pursuant to a Service
Agreement which allows the Participant to choose a Participating Provider or a
non-Participating Provider for Covered Services at the time such services are
sought.
PRIMARY CARE PHYSICIAN means a physician duly licensed to practice medicine who
is a Participating Provider with CIGNA to provide Covered Services in the field
of general medicine, internal medicine, family practice or pediatrics, and who
has agreed to provide primary care physician services to a Patient Panel or
other Participants in accordance with HMO Program Requirements.
STANDARD BUSINESS means a type of business pursuant to a Service Agreement where
Covered Services are available to Participants only from Participating
Providers, except in cases of Emergency.
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II. PARTIES' OBLIGATIONS
A. COVERED SERVICES
1. The ENT Center of Atlanta, Inc. through its Represented
Physicians shall provide or arrange for the provision of all
specialty care Covered Services within the scope of its
Represented Physicians' practice that are required by
Participants in accordance with the terms of this Agreement,
this HMO Program Attachment and HMO Program Requirements. The
ENT Center of Atlanta, Inc. and its Represented Physicians
shall accept the compensation set forth in this HMO Program
Attachment as payment in full for such services.
2. Except in an Emergency, prior authorization by a Participant's
Primary Care Physician or CIGNA as prescribed by HMO Program
Requirements is required for payment of Covered Services
rendered to Participants. All referrals shall be to
Participating Providers, except where an Emergency requires
otherwise or in other cases where Medical Director
specifically authorizes the referral. CIGNA may withhold a
portion of The ENT Center of Atlanta, Inc.'s reimbursement if
Represented Physicians fail to comply with such requirements.
3. The ENT Center of Atlanta, Inc. through its Represented
Physicians shall provide necessary Covered Services to
Participants on a 24-hour per day, 7-day per week basis or
arrange with a physician to cover The ENT Center of Atlanta,
Inc.'s Patient Panel in its Represented Physicians' absence.
The ENT Center of Atlanta, Inc. will ensure that such covering
physician (a) will not seek compensation from CIGNA for
services for which The ENT Center of Atlanta, Inc. receives
Capitation Payments from CIGNA; (b) will not xxxx Participants
for Covered Services under any circumstances except for
Copayments, Deductibles or Coinsurance; and (c) will obtain
authorization from CIGNA prior to all hospitalizations or
referrals of Participants, except in Emergencies. The ENT
Center of Atlanta, Inc. will not be liable for services to
Participants in non-participating hospitals.
Emergency and urgent otolaryngology services to Participants
provided by any physicians not participating with The ENT
Center of Atlanta, Inc. will be paid by CIGNA Healthcare and
will not be deducted from capitation payment made to The ENT
Center of Atlanta, Inc.
4. The ENT Center of Atlanta, Inc. through its Represented
Physicians shall provide Covered Services to all Participants
unless The ENT Center of Atlanta, Inc. notifies CIGNA that The
ENT Center of Atlanta, Inc. cannot accommodate additional
patients pursuant to the HMO Program Requirements.
EXD-2
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
5. The ENT Center of Atlanta, Inc. shall maintain a sufficient
number of Specialty Care Physicians as reasonably determined
by CIGNA.
6. CIGNA will pay for all otolaryngology services that are
provided to Participants that are referred to Emory Clinic
and/or Emory Clinic physicians.
Participants will be referred to Emory Clinic and/or Emory Clinic
physicians if it is deemed necessary by The ENT Center of Atlanta, Inc.
physician reviewer after approval from the Medical Director of CIGNA.
B. CAPITATION PAYMENTS
l. On or before the 15th of each month, CIGNA shall pay The ENT
Center of Atlanta, Inc. an amount equal to the applicable
monthly capitation rate adjusted for Copayments as shown below
for each Participant in The ENT Center of Atlanta, Inc.
Patient Panel. THE CAPITATION PAYMENT SHALL BE COMPENSATION
FOR ALL COVERED SERVICES PROVIDED TO PARTICIPANTS THAT ARE
DESIGNATED The ENT Center of Atlanta, Inc. The monthly
capitation rates are as follows:
ORIGINAL:
STANDARD BUSINESS [*] PMPM
POINT OF SERVICE BUSINESS: [*] PMPM
AMENDED EFF. 9-1-94
STANDARD BUSINESS: [*] PMPM
POINT OF SERVICE BUSINESS: [*] PMPM
2. If a Participant is added to The ENT Center of Atlanta, Inc.'s
Patient Panel on or before the 15th day of a month, a full
month's Capitation Payment will be due for that month. There
will be no Capitation Payment due for Participants added after
the 15th day of the month.
3. A full month's Capitation Payment will be due for the month of
termination of a Participant if the Participant terminates
after the 15th day of the month. If a Participant terminates
on or before the 15th day of a month, no Capitation Payment
will be due for the month of termination.
EXD-3
17
4. Where CIGNA, due to information delays, must make a
retroactive addition or deletion to The ENT Center of Atlanta,
Inc.'s Patient Panel, CIGNA shall make a retroactive
capitation adjustment concurrent therewith. In those instances
where a Participant has been retroactively deleted and has
received Covered Services from The ENT Center of Atlanta, Inc.
after the effective date of a
deletion but prior to CIGNA informing The ENT Center of Atlanta, Inc. of such
deletion, The ENT Center of Atlanta, Inc. may xxxx participant for such services
rendered.
5. Any amendment of Capitation Payment rates, whether on an
annual basis or upon changes in benefit designs such as
changes in Copayment levels, shall be in accordance with the
Amendment provisions of this Agreement.
6. There will be an annual review of capitation rates.
C. ENCOUNTER AND CLAIMS DATA
The ENT Center of Atlanta, Inc. or its Represented Physicians shall
provide CIGNA with encounter data on a monthly basis showing all
services provided to each Participant for whom The ENT Center of
Atlanta, Inc. receives Capitation Payments. The ENT Center of Atlanta,
Inc. or its Represented Physicians shall submit claims for all
non-capitated services rendered to Participants on standard HCFA-1500
or other acceptable billing forms and in accordance with the billing
requirements set forth in Section II.B. of this Agreement. Such
encounter and claims data shall be submitted in accordance with
applicable Program Requirements and in a format acceptable to CIGNA.
CIGNA can initiate termination of this Agreement if The ENT Center of
Atlanta, Inc. fails to provide such encounter and claims data in
accordance with this Agreement.
D. FEE-FOR-SERVICE PAYMENTS
In addition to Capitation Payments for Covered Services provided to
Participants in The ENT Center of Atlanta, Inc.'s Patient Panel, The
ENT Center of Atlanta, Inc. shall be reimbursed for the Covered
Services provided to Participants by Dr. Xxxxxx Xxxxxxxx as designated
in exhibit "C" at the lesser of Atlanta Ear, Nose and Throat
Associates, P.C.'s billed charges or CIGNA's maximum fee schedule in
effect at the time of service.
E. ASSIGNMENT AND IDENTIFICATION OF PARTICIPANTS
The ENT Center of Atlanta, Inc. shall comply with the requirements of,
and shall participate in, CIGNA's procedures with respect to assignment
and identification of Participants as outlined in the Program
Requirements.
XXX-0
00
X. COORDINATION OF BENEFITS
1. CIGNA and The ENT Center of Atlanta, Inc. agree to cooperate
to exchange information relating to coordination of benefits
with regard to any Participant for whom The ENT Center of
Atlanta, Inc. is providing or arranging services.
2. With respect to capitated Covered Services:
a. Certain claims for services rendered to Participants
are claims for which another payor may be primarily
responsible under coordination of benefits rules. The
ENT Center of Atlanta, Inc. shall pursue and process
any coordination of benefits relating to services
provided by The ENT Center of Atlanta, Inc., provided
that the amount of such recoveries are reported
monthly to CIGNA.
b. When designated Payor is primary under applicable
coordination of benefit rules, The ENT Center of
Atlanta, Inc. shall consider the Capitation Payment
as payment in full for Covered Services rendered to
Participants and shall not seek additional
reimbursement from any secondary Payors.
3. With respect to non-capitated Covered Services:
a. Certain claims for services rendered to Participants
are claims for which another payor may be primarily
responsible under coordination of benefit rules. The
ENT Center of Atlanta, Inc. shall xxxx such claims to
the primary payor when information regarding such
primary payor is available, or upon designated
Payor's request.
b. When designated Payor is primary under applicable
coordination of benefit rules, Payor will pay
benefits as set forth in this Agreement without
regard for the obligations of any secondary payor.
c. When Payor is determined to be secondary to any other
payor including Medicare, Payor will pay no greater
than that amount which, when added to amounts payable
to The ENT Center of Atlanta, Inc. from other sources
under the applicable coordination of benefit rules,
equals one hundred percent of The ENT Center of
Atlanta, Inc.'s reimbursement for Covered Services
pursuant to this Agreement. Payor shall not be liable
for any amount unless Payor has received The ENT
Center of Atlanta, Inc.'s claim for such secondary
payment within ninety (90) days of the date when
Payor is determined to be secondary.
G. FINANCIAL REPORTING
EXD-5
19
The ENT Center of Atlanta, Inc. shall provide CIGNA with copies of
financial reports, including income statements and balance sheets, upon
request by CIGNA.
H. REIMBURSEMENT OF CIGNA EXPENDITURES
CIGNA shall be entitled to recover from The ENT Center of Atlanta, Inc.
any expenditure made, or recover any cost incurred by CIGNA, in
providing for any Covered Services for which The ENT Center of Atlanta,
Inc. or its Represented Physicians were obligated hereunder but failed
to so provide. CIGNA may deduct an amount sufficient to reimburse CIGNA
for such expenditures and costs from any payments due to The ENT Center
of Atlanta, Inc. from CIGNA. CIGNA shall provide The ENT Center of
Atlanta, Inc. with written notice and full disclosure of costs incurred
prior to any such deduction.
I. OTHER PROCEDURES
1. Any procedure or service other than those set forth above and
as further defined in the HMO Program Requirements as being
covered either by Capitation Payments or by fee-for-service
payments shall be reimbursed only if CIGNA's authorization is
obtained prior to performance of the procedure or service.
2. The ENT Center of Atlanta, Inc. and its Represented Physicians
shall use reasonable efforts to prescribe or authorize the
substitution of generic pharmaceuticals when appropriate and
shall cooperate with CIGNA's formulary and HMO Program
Requirements regarding the substitution of generic
pharmaceuticals.
J. TRANSFERS
The ENT Center of Atlanta, Inc. shall assist CIGNA in facilitating the
transfer of Participants from a non-Participating Hospital to a
Participating Hospital if determined medically acceptable by
Represented Physician and the attending physician, subject to review by
CIGNA's Medical Director. The ENT Center of Atlanta, Inc. shall be
financially responsible for the professional and facility (inpatient)
expenses if The ENT Center of Atlanta, Inc. refuses to accept transfer
without reasonable cause after such transfer is determined medically
acceptable in the manner set forth above.
K. LIMITATIONS ON BILLING PARTICIPANTS
1. The ENT Center of Atlanta, Inc. for itself and on behalf of
each Represented Physician, hereby agrees that in no event,
including, but not limited to non-payment by CIGNA, CIGNA's
insolvency or breach of this Agreement, shall The ENT Center
of Atlanta, Inc. or any Represented Physician xxxx, charge,
EXD-6
20
collect a deposit from, seek compensation, remuneration or
reimbursement from, or have any recourse against Participants
or persons other than CIGNA for Covered Services. This
provision shall not prohibit collection of any applicable
Copayments, Deductibles or Coinsurance billed in accordance
with the terms of a Service Agreement.
a. Any modification, additions, or deletion to the
provisions of this hold harmless clause shall become
effective on a date no earlier than fifteen (15) days
after the applicable state regulatory agency has
received written notice of such proposed changes.
2. The ENT Center of Atlanta, Inc. further agrees that this
provision shall survive the termination of this Agreement
regardless of the cause giving rise to such termination and
shall be construed to be for the benefit of Participants, and
that this provision supersedes any oral or written agreement
to the contrary now existing or hereafter entered into between
The ENT Center of Atlanta, Inc. or its Represented Physicians
and the Participant or persons acting on the Participant's
behalf.
L. COMPENSATION FOR COVERED SERVICES PROVIDED TO NON-PATIENT PANEL
PARTICIPANTS
In the event that an HMO Program Participant who is not included in The
ENT Center of Atlanta, Inc.'s Patient Panel is referred by that
Participant's Primary Care Physician to The ENT Center of Atlanta, Inc.
CIGNA shall compensate The ENT Center of Atlanta, Inc. for Covered
Services rendered at the lesser of Represented Physician's billed
charges or CIGNA's maximum allowable fee schedule in effect at the time
Covered Services are rendered.
III. RIGHTS AND OBLIGATIONS UPON TERMINATION
A. Upon termination of this Agreement, The ENT Center of Atlanta,
Inc. through its Represented Physicians shall continue to
provide Covered Services for specific conditions for which a
Participant was under Represented Physician's care at the time
of such termination so long as Participant retains eligibility
under a Service Agreement, until the earlier of completion of
such services, CIGNA's provision for the assumption of such
treatment by another physician, or the expiration of twelve
(12) months. CIGNA shall compensate The ENT Center of Atlanta,
Inc. for Covered Services provided to any such Participant in
accordance with CIGNA'S Maximum Allowable Rate but not greater
than billed charges, until sixty (60) days following
termination and thereafter compensation for continued services
authorized by CIGNA shall be as mutually agreed, but not at a
rate greater than The ENT Center of Atlanta, Inc.'s usual
billed charges.
EXD-7
21
B. The ENT Center of Atlanta, Inc. and its Represented Physicians
have no obligation under this Agreement to provide services to
individuals who cease to be Participants.
[REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK]
EXD-8
22
EXHIBIT A
HMO PROGRAM ATTACHMENT - CAPITATION
CLAIMS PAYMENT RESPONSIBILITIES
(delegated claims payment)
The ENT Center of Atlanta, Inc. shall administer claims for Covered Services
rendered by Represented Physicians in accordance with this Exhibit and the terms
of the Agreement.
1. The ENT Center of Atlanta, Inc. agrees to reimburse
Represented Physicians for Covered Services within forty-five
(45) days of receipt of a properly completed xxxx for Covered
Services. CIGNA may withhold all or a portion of The ENT
Center of Atlanta, Inc.'s Capitation Payment if The ENT Center
of Atlanta, Inc. repeatedly fails to reimburse Represented
Physicians on a timely basis.
2. With reasonable notice, The ENT Center of Atlanta, Inc. agrees
to allow CIGNA representatives to conduct on-site reviews of
The ENT Center of Atlanta, Inc. claims administration
facilities. Such reviews shall be for the sole purpose of
evaluating The ENT Center of Atlanta, Inc. performance against
CIGNA's claims administration standards and to ascertain the
quality and timeliness of The ENT Center of Atlanta, Inc.
claims processing. The ENT Center of Atlanta, Inc. agrees to
correct any deficiencies detected during such reviews within
sixty (60) days of CIGNA's submission of a written report
detailing such deficiencies.
3. The ENT Center of Atlanta, Inc. shall be responsible for the
production of all applicable tax reporting documents (e.g.,
1099s) for Represented Physicians. Such documents shall be
produced in a format and within the time frames set forth in
applicable state and federal laws and/or regulations.
4. The ENT Center of Atlanta, Inc. shall ensure that Represented
Physicians submit claims for Covered Services rendered to
Participants in other Programs for which CIGNA has retained
claims payment responsibility directly to CIGNA in accordance
with the applicable Program Attachment and Program
Requirements.
5. The ENT Center of Atlanta, Inc. shall produce explanations of
benefits for Represented Physicians and Represented Physicians
shall produce explanations of benefits for Participants when
applicable. Such explanations of benefits shall be in a format
and contain data elements acceptable to CIGNA.
6. The ENT Center of Atlanta, Inc. shall develop and deliver
training programs for Represented Physicians which outline The
ENT Center of Atlanta, Inc.
-1-
23
billing and reimbursement processes. The ENT Center of
Atlanta, Inc. shall make reasonable efforts to ensure that
Represented Physicians avoid submitting claims to CIGNA for
those Covered Services rendered to Participants for whom The
ENT Center of Atlanta, Inc. has been delegated claims payment
responsibility.
7. The ENT Center of Atlanta, Inc. or its Represented Physicians
shall provide CIGNA with encounter data on a monthly basis
showing all services provided to each Participant for whom The
ENT Center of Atlanta, Inc. receives Capitation Payments. Such
encounter data shall be submitted in accordance with
applicable HMO Program Requirements and in a format acceptable
to CIGNA. CIGNA may elect to terminate this Agreement if The
ENT Center of Atlanta, Inc. fails to submit encounter data in
accordance with this Agreement.
-2-
24
EXHIBIT B
HMO PROGRAM ATTACHMENT - CAPITATION
UTILIZATION MANAGEMENT
(partial delegation of utilization management)
1. The ENT Center of Atlanta, Inc. will assist CIGNA in the implementation
of its Utilization Management program. Any Utilization Management
program activities performed by The ENT Center of Atlanta, Inc. shall
be in accordance with NCQA standards and acceptable to CIGNA.
2. The ENT Center of Atlanta, Inc. shall prepare such periodic reports or
other data as reasonably requested by CIGNA relating to its Utilization
Management activities in a format acceptable to CIGNA.
3. The ENT Center of Atlanta, Inc. shall not materially modify its
Utilization Management activities without CIGNA's prior approval.
4. CIGNA shall have the right to audit The ENT Center of Atlanta, Inc.'s
Utilization Management activities upon reasonable prior notice. The ENT
Center of Atlanta, Inc. shall cooperate with any such audits.
5. If CIGNA determines that The ENT Center of Atlanta, Inc. cannot meet
its Utilization Management obligations set forth herein, CIGNA may
elect to assume responsibility for such activities. If CIGNA elects to
assume responsibility for such activities, the parties agree to
renegotiate the rates set forth in this Agreement to the extent
necessary, and The ENT Center of Atlanta, Inc. shall cooperate and
provide to CIGNA any information necessary to perform such activities.
6. All referrals shall be to Represented Providers, except where an
Emergency requires otherwise or in other cases where the referral is
specifically authorized by CIGNA's Medical Director or his/her designee
or The ENT Center of Atlanta, Inc.'s Medical Director, if permitted by
CIGNA to make such authorizations. Except in an Emergency, The ENT
Center of Atlanta, Inc. shall require all Represented Providers to
obtain authorization from CIGNA or, The ENT Center of Atlanta, Inc. if
permitted by CIGNA to make such authorizations, prior to hospital
admission of any Participant or outpatient surgical procedures.
7. The ENT Center of Atlanta, Inc. agrees to include CIGNA's Medical
Director or Medical Director designee on The ENT Center of Atlanta,
Inc. committees which are responsible for the review and continued
development of The ENT Center of Atlanta, Inc.'s Utilization Management
program and other related programs.
25
EXHIBIT C
The following services for Sanjay Bhansalli, M.D. will be paid at CIGNA
Healthcare of Georgia's maximum fee schedule in effect at the time of service:
Procedure
Code Description
95920 Intraoperative neurophysiology testing, per hour
(Use code 95920 in addition to the evoked potential study
performed 92280, 92585, 95925)
95925 Somotosensory testing (eg, cerebral evoked potentials), one or
more nerves
(For visual evoked potentials, see 92585)
(For brainstem evoked response recording, see 92585)
(For auditory evoked potentials, see 92585)
95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing
95935 "H" or "F" reflex study, by electrodiagnostic testing
95937 Neuromuscular junction testing (repetitive stimulation, each
nerve, any one method)
69700 Closure postauricular fistula, mastoid (separate procedure)
69710 Implantation or replacement of electromagnetic bone conduction
hearing device in temporal bone (replacement procedure
includes removal old device)
69711 Removal of repair of electromagnetic bone conduction hearing
device in temporal bone
69720 Decompression facial nerve, intratemporal; lateral geniculate
ganglion
69725 including medial to geniculate ganglion
69740 Suture facial nerves, intratemporal, with or without graft or
decompression; lateral to geniculate ganglion
69745 including medial to geniculate ganglion (For extracranial
suture of facial nerve, see 64864)
-1-
26
69801 Labyrinthotomy, with or without cryosurgery or other
nonexcisional destructive procedures or tack procedure;
transcanal
69802 with mastoidectomy
69805 Endolymphatic sac operation; without shunt
69806 with shunt
69820 Fenestration semicircular canal
69840 Revision fenestration operation
69905 Labyrinthectomy; transcanal
69910 with mastoidectomy
69915 Vestibular nerve section, translabyrinthine approach
(For transcranial approach, see 69950)
69930 Cochlear device implantation, with or without mastoidectomy
69949 Unlisted procedure, inner ear
(For external approach, see 69535)
69950 Vestibular nerve section, transcranial approach
69955 Total facial nerve decompression and/or repair (may include
graft)
69960 Decompression internal auditory canal
69970 Removal of tumor, temporal bone
69979 Unlisted procedure, temporal bone, middle fossa approach
69530 Petrous apicectomy including radical mastoidectomy
69535 Resection temporal bone, external approach
(For middle fossa approach, see 69950-69970)
69300 Otoplasty, protruding ear, with or without size reduction
-2-
27
69310 Reconstruction of external auditory canal (meatoplasty) (eg.
for stenosis due to trauma, infection) (separate procedure)
69320 Reconstruction external auditory canal for congenital atresia,
single stage
63707 Repair of dural/CSF leak, not requiring laminectomy
62100 Cranectomecty for repair of dural/CSF leak, including surgery
for rhinorrhea/otorrhea
62120 Repair for encephalocele, skull vault, including crainoplasty
62121 Cranotomy for repair of encephalocele, skull base
62140 Cranioplasty for skull defect; up to 5 cm diameter
61595 Transtemporal approach to posterior cranial fossa, jugular
foramen or midline skull base, including mastoidectomy,
decompression of sigmoid sinus and/or facial nerve with or
without mobilization
61596 Transcochlear approach to posterior cranial fossa, jugular
foramen or midline skull base, including labyrinthectomy,
decompression, with or without mobilization of facial nerve
and/or petrous carotid artery
61597 Transcondylar (far lateral) approach to posterior cranial
fossa, jugular foramen or midline skull base, including
occipital condylectomy, mastoidectomy, resection of C l-C3
vertebral body(s), decompression of vertebral artery, with or
without mobilization
61598 Transpetrosal approach to posterior cranial fossa, clivus or
xxxxxx magnum, including ligation of superior petrosal sinus
and/or sigmoid sinus
61600 Resection of excision of neoplastic, vascular or infectious
lesion of base of anterior cranial fossa; extradural
61601 intradural, including dural repair, with or without graft
61605 Resection of excision of neoplastic, vascular or infectious
lesion of intratemporal fossa, parapharyngeal space,
petrousapex; extradural
61606 intradural including repair; with or without graft
-3-
28
61607 Resection or excision of neoplastic, vascular or infectious
lesion of parasellar area, carvernous sinus, clivus or midline
skull base; extradural
61608 intradural including dural repair, with or without graft
(Report procedures 61609-61612 as "add-on to primary
definitive procedures 61605, 61606, 61607 or 61608)
61609 Transection or ligation, carotid artery in cavernous sinus;
without repair
61610 with repair by anastomosis or graft
61611 Transection or ligation, carotid artery in petrous canal;
without repair
61612 with repair by anastomosis or graft
61613 Obliteration of carotid aneurysm, arteriovenous malformation,
or cartoid- cavernous fistula by dissection within cavernous
sinus
61615 Resection or excision of neoplastic, vascular or infectious
lesion base of posterior cranial fossa, jugular foramen,
foramen magnum, or Cl-C3 vertebral bodies; extradural
61616 intradural including dural repair; with or without graft
61618 Secondary repair of dura for CSF leak, anterior, middle or
posterier cranial fossa following surgery of the skull base;
by free tissue graft (eg, pericranium, fascia, tensor fascia
lata, adipose tissue, homologous or synthetic grafts)
61619 by local or regionalized vascularized pedicle flap or
myocutaneous flap (including galea, temporalis, frontalis or
occipitalis muscle)
61580 Craniofacial approach to anterior cranial fossa; extradural,
including lateral rhinotomy, ethmoidectomy, sphenoidectomy
without maxillectomy or orbital exenteration
61581 extradural, including lateral rhinotomy, orbital exenteration,
ethmoidectomy, sphenoidectomy and/or maxillectomy
61582 extradural, including unilateral or bitrontal craniotomy,
elevation or resection of frontal lobe(s), osteotomy of base
of anterior cranial fossa
61583 intradural, including unilateral or bifrontal craniotomy,
elevation or resection of frontal lobe, osteotomy of base of
anterior cranial fossa
-4-
29
61584 Orbitcranial approach to anterior cranial fossa, extradural,
including supreorbital ridge osteotomy and elevation of
frontal and/or temporal lobe(s); without orbital exenteration
61585 with orbital exenteration
61590 Infratemporal pre-auricular approach to middle cranial fossa
(parapharyngeal space, infratemporal and midline skull base,
nasopharynx), with or without disarticulation of the mandible,
including paroitidectomy, craniotomy, decompression and/or
mobilization of the facial nerve and/or petrous carotid artery
61591 Infratemporal post-auricular approach to middle cranial fossa
(internal auditory meatus, petrous apex, tentorium, cavernous
sinus, pasasellar area, infratemporal fossa) including
mastoidectomy, resection of sigmoid sinus, with or without
decompression and/or mobilization of contents of auditory
canal or petrous carotid artery
61592 Orbitocranial zygomatic approach to middle cranial fossa
(cavernous sinus and carotid artery, clivus, basilar artery or
petrous apex) including osteotomy of zygoma, craniotomy,
extra- or intradural elevation of temporal lobe
61526 Craniectomy, bone flap, craniotomy, transtemporal (mastoid)
for excision of cerebellopontine angle tumor;
61530 combined with midde/posterior fossa craniotomy/craniectomy
61518 Craniectomy for excision of brain tumor, infratentorial or
posterior fossa; except menningioma, cerebellopontine angle
tumor, or midline tumor at base skull
61519 menningioma
61520 xxxxxxxxxxxxxxxx xxxxx xxxxx
00000 midline tumor at base of skull
42425 total, en bloc removal with sacrifice of facial nerve
42426 total with unilaterial radical neck dissection
-5-
30
GROUP PRACTICE
MANAGED CARE AGREEMENT
CONTENTS
PARTIES..................................................................... 1
PURPOSE..................................................................... 1
I. DEFINITIONS........................................................ 1
II. PARTIES' OBLIGATIONS............................................... 3
A. Services.................................................. 3
B. Compensation and Billing.................................. 4
C. Records................................................... 5
D. Participant Grievance..................................... 6
E. Insurance and Liability................................... 6
F. Indemnification........................................... 7
G. Inspections............................................... 7
H. Representations........................................... 7
I. Confidentiality........................................... 8
III. MISCELLANEOUS OBLIGATIONS.......................................... 8
A. Independent Contractor Relationship....................... 8
B. Term of Agreement......................................... 8
C. Termination............................................... 8
D. Rights and Obligations Upon Termination...................10
E. Assignment and Delegation of Duties.......................10
F. Use of Name...............................................10
G. Interpretation............................................10
H. Amendment.................................................11
I. Program Attachments.......................................11
J. Entire Contract...........................................11
K. Notice....................................................11
L. Enforceability and Waiver.................................11
M. Regulatory Approval.......................................12
N. Dispute Resolution........................................12
