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EXHIBIT 10.86
SECOND AMENDMENT TO THE UTILIZATION REVIEW AGREEMENT DATED
JANUARY 1, 1989
BETWEEN
HEALTHCARE COMPARE CORP.
AND
NATIONAL ASSOCIATION OF LETTER CARRIERS HEALTH BENEFIT PLAN
THIS AGREEMENT is entered as of this 1st day of January, 1991, between
HealthCare COMPARE Corp. (hereinafter called "COMPARE"), and National
Association of Letter Carriers Health Benefit Plan (hereinafter called
"CARRIER").
WITNESSETH
WHEREAS, COMPARE AND CARRIER have heretofore entered into a certain UTILIZATION
REVIEW AGREEMENT, dated January 1, 1989, which provides for utilization review
services to be rendered to CARRIER,
WHEREAS, COMPARE and CARRIER desire to amend the Utilization Review Agreement in
the manner set out herein.
NOW, THEREFORE, in consideration of the mutual covenants and agreements set out
herein, one dollar and other good and valuable consideration, receipt of which
is acknowledged, the parties hereto agree as follows:
A. Effective January 1, 1991, the Mental Health Services Review
Program as described in Exhibit IIG-FI shall be added to the scope of
services to be provided under the Utilization Review Agreement.
B. The Amended Schedule of Fees attached hereto and made a part
hereof shall replace and supersede all previous Schedules of
Fees.
C. Parties hereby ratify and affirm the Utilization Review Agreement and
agree that it is in full force and effect and valid except as amended
herein. This Amendment shall prevail over any conflict with the
Utilization Review Agreement. In all respects the Utilization Review
Agreement shall be construed and interpreted to include all of the
terms of this Amendment as if the same were set out therein.
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Page 2 of 2
IN WITNESS WHEREOF the duly authorized representatives of the parties have
executed this Amendment as of the day and year first above written.
National Association of Letter HealthCare COMPARE Corp.
Carriers Health Benefit Plan
By: Xxxxx X. Xxxxxxx By: Xxxxx X. Xxxxx
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Title: Administrator Title: President
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Date: 3/25/91 Date: 3/27/91
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NATIONAL ASSOCIATION OF LETTER CARRIERS HEALTH
BENEFIT PLAN
Amended Schedule of Fees
Effective 1/1/89 through 12/31/89 *
HOSPITAL REVIEW.....................................$1.23 per enrollee per month
CASE MANAGEMENT..................................................$160 per hour**
Effective 1/1/90 through 12/31/90 *
HOSPITAL REVIEW.................................... $1.29 per enrollee per month
CASE MANAGEMENT..................................................$178 per hour**
Effective 1/1/91 through 12/31/91 *
HOSPITAL REVIEW.....................................$1.36 per enrollee per month
CASE MANAGEMENT..................................................$189 per hour**
MENTAL HEALTH SERVICES REVIEW.......................$0.23 per enrollee per month
Plus $189 per hour ***
All Years
ADMINISTRATIVE RUN-OFF FEE..........................50% of the final monthly fee
* Adjustments to fees will be made annually.
* * The hourly charge is for time and services of staff personnel who may
be physicians, registered nurses or allied personnel.
* * * The hourly charge is for all activity associated with practitioner-to-
practitioner review and independent chart review.
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EXHIBIT IIG-FI
MENTAL HEALTH SERVICES REVIEW PROGRAM
FOR
NATIONAL ASSOCIATION OF LETTER CARRIERS HEALTH BENEFIT PLAN
A. SCOPE OF PROGRAM
The Mental Health Services Review Program provides pre-admission and
continued stay review of all full-time (or round-the-clock) inpatient (MDC 19 &
20) hospital admissions in hospitals or free-standing psychiatric facilities
where the length of stay is greater than seven (7) days. It also provides
review of all fully inpatient programs that focus on specific metal health
problems. An admission is reviewed under this program if the hospitalization
occurs in the 00 Xxxxxx Xxxxxx, if the services are rendered during the term of
this Agreement as described in Section 12 of this Agreement; and beginning on
the date of admission or the notification date, whichever is later. However,
if the service is ongoing and the admission began within two weeks of the date
of notification, COMPARE will include in its telephone review those two weeks
of service. If the admission began more than two weeks prior to the date of
notification, COMPARE will not perform review for that period. If PLAN desires
review for the period earlier, COMPARE will agree to provide the review if PLAN
obtains and provides the medical record. In those situations, COMPARE will
charge for that review at its normal, customary hourly rate, and the medical
records received shall become the property of COMPARE. In the event of an
emergency admission to inpatient facilities, review will begin at the time of
admission rather than at the time of notification to COMPARE, if COMPARE is
notified of that admission within three business days of the admission.
Completion of review may require that the attending physician provide medical
information to COMPARE's Mental Health Services Review Program by telephone;
failure of the attending physician to do so on a timely basis may result in
the inability to complete review.
All conditions and terms of the Utilization Review Agreement are in full force
and effect.
Review of inpatient mental health services not in accordance with the
definition of the scope of the program contained herein will occur at the
request of PLAN and the discretion of COMPARE. PLAN may be asked to provide
medical records for treatment which occurred prior to the beginning of the term
of this Agreement or the notification to COMPARE of the treatment, whichever is
later, and the PLAN will be responsible for obtaining and paying for such
records. PLAN will be billed for such reviews at COMPARE's then customary
charges for such services.
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The decision whether or not to be admitted to or remain in the hospital is made
only by the Covered Person and his or her attending physician. Failure to
follow program procedures may affect benefit coverage.
The program offers review of inpatient services with lengths of stay greater
than seven (7) days for:
1. full-time inpatient care in hospitals or free-standing
psychiatric facilities.
2. full-time inpatient programs which focus on specific mental
health problems (e.g., drug/alcohol abuse).
B. PROCESS
A. Initiation of Review
1. Elective Inpatient Admissions
The Covered Person and his/her practitioner determine the Covered
Persons care and hospitalization. However, in order to qualify
for maximum benefits coverage, prior to the admission the attending
practitioner must call COMPARE, using the toll-free number, and
provide demographic information, the Covered Person's history and
physical findings, drug work up, comprehensive treatment plan,
treatment goals, and proposed duration of therapy, as well as
information on educational background of the primary and attending
practitioner. If the Covered Person is participating in a formal
mental health program, the practitioner must also inform the
coordinator if the program has been certified by an authorizing
organization (e.g., AHA, JCAHA). Failure of the attending physician to
provide information as outlined on a timely basis may result in
inability to complete review.
This information is then reviewed by a COMPARE coordinator. A Mental
Health Review (MHR) practitioner contacts the attending physician if the
information appears to be incomplete or if it does not appear that the
admission can be certified as medically necessary under the terms of
the Covered Persons benefit plan.
If COMPARE'S coordinator or MHR practitioner determines that the
admission can be certified as medically necessary under the terms of
the benefit plan, he or she assigns a length of stay to determine the
date for the nest review. All recommendations of non-certification and
all cases where review is incomplete are verified to the PLANS written
copies of which will also be sent to the Covered
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Person, attending physician, and hospital if appropriate. COMPARE will
provide verbal notice of its recommendations to the attending
practitioner and will assign a certification number to the
certification period.
2. Emergency Admission
If the Covered Person is admitted to an inpatient setting on an
emergency basis, COMPARE must be notified by telephone within three
business days of the admission. Once this notification is
received, review is conducted as described above.
3. Cases Excluded From Review
In the following cases, a record will be opened and identified by a
specific reason code; however, review will not be performed for:
a. admissions where the proposed length of stay is seven (7) days
for less. In all such cases, the discharge date will be
verified by COMPARE and, if the patient remains in the hospital
beyond seven days, COMPARE will place a call to the attending
practitioner to initiate review.
b. court ordered admissions
c. cases where PLAN indicates that the patient has reached PLAN's
lifetime maximum as described in its official Brochure.
B. Extensive Review
COMPARE initiates all extended stay review for inpatient care. Two
days before an assigned length of stay ends, COMPARE calls the
attending physician to confirm that the Covered Person is still
receiving care and to obtain the information needed to perform the
review. Once again, a COMPARE MHR practitioner contacts the attending
physician if there is a question on certification. If certification is
recommended, a new length-of-stay is assigned.
If the attending practitioner cooperates with the Program, this process
is repeated until the Covered Person is discharged, until the
equivalent of the lifetime maximum benefit is reached, or until a
recommendation is made for non-certification under the terms of the
benefit plan.
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COMPARE will provide verbal notice of all its extension review
recommendations to the attending practitioner and will assign a
certification number to the certification period. All recommendations
of non-certification and all cases where review is incomplete are
verified to the PLAN, written copies of which will also be sent to the
Covered Person, attending physician, and hospital is appropriate.
C. REPORTS
COMPARE will provide PLAN with written reports of its review activities under
this Agreement as follows:
Basic Reports Frequency
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(1) Mental Health Services Review Summary (Quarterly & Annually)
Report (Reviews Requested/Outcomes)
(2) Mental Health Services Review (Quarterly)
Case Report
COMPARE reserves the right to refine the style and content of the
above-referenced reports and to substitute such other reports as it deems will
provide comparable information to PLAN.
D. CHARGES FOR MENTAL HEALTH SERVICES REVIEW
All activity associated with the first level of review as described herein is
covered under the capitation fee set out in the Schedule of Fees. All
activity associated with practitioner-to-practitioner review and independent
chart review is billable at the hourly professional review fee set out in the
Schedule of Fees.
