"ALL SECTIONS MARKED WITH TWO ASTERISKS ("**") REFLECT PORTIONS WHICH HAVE
BEEN REDACTED AND FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE
COMMISSION BY PROSPECT MEDICAL HOLDINGS, INC. AS PART OF A REQUEST FOR
CONFIDENTIAL TREATMENT."
1994 AMENDMENT TO
IPA COMMERCIAL SERVICES AGREEMENT
The undersigned parties to the PacifiCare IPA Commercial Services Agreement
between PacifiCare of California ("PacifiCare") and Santa Xxx-Tustin Physicians
Group, Inc. ("IPA") do hereby amend said Agreement as follows:
1. Section 3.29, WITHDRAWAL OF A MEMBER PHYSICIAN, shall be added as follows:
"3.29 WITHDRAWAL OF A MEMBER PHYSICIAN - In the event IPA seeks to
withdraw one or more of the Member Physicians from providing or arranging Health
Care Services to Subscribers under this Agreement, IPA must notify PacifiCare of
such withdrawal in writing at least sixty (60) days prior to the effective
withdrawal date. After the effective date of withdrawal, IPA shall still be
responsible to provide or arrange for Medical Services to such Subscribers."
2. Attachment A5, HOSPITAL CONTROL PROGRAM, is amended as follows:
See Exhibit 1, attached hereto and incorporated herein by this reference.
3. Attachment C, CAPITATION PAYMENT RATES, shall be amended as follows:
The first paragraph shall be amended as follows: "The monthly Capitation
Payment which PacifiCare shall pay IPA shall equal IPA's cumulative shares of
the Percent of Premium. The Percent of Premium designated by PacifiCare for
payment for Medical Services shall equal [ ** ] of the gross premiums
billed by PacifiCare each month for coverage of Subscribers designating IPA
as their Participating Medical Group pursuant to the PacifiCare Health Plan,
not including the Supplemental Benefit Premiums less [ ** ] in
consideration of the Individual Stop Loss Program noted in Attachment A3
hereto, and also less necessary consideration as determined by PacifiCare for
supplemental benefits for which IPA assumes no financial responsibility. In
instances where billed premiums reflect an additional charge to account for
broker's fees that exceed PacifiCare's standard broker commission schedule
("Broker Fee Adjustment"), such Broker Fee Adjustment shall not be included
in the calculation of the IPA's Monthly Capitation Payment. IPA's portion of
the Percent of Premium shall equal IPA's cumulative share per employer group,
based upon the number of men, women and children Subscribers of such employer
group designating IPA as their Participating Medical Group for the month of
Capitation Payment."
1
A second paragraph shall be inserted in Attachment C as follows: "An
Experience-Rated Plan is a non-federally qualified plan in which the
employers' premium is partially deferred and/or adjusted to reflect the
actual medical costs incurred by the employers' Subscribers. For
Experience-Rated Plans, the percent of premium for Capitation Payment
purposes shall be calculated as a percent of the Actuarial Experience Rate,
rather than of gross premiums billed. The Actuarial Experience Rate is
calculated by the same method used to determine the premium for federally
qualified plans, except that trended claims/utilization data may be
considered to determine expected medical costs, and PacifiCare's
administrative retention may be adjusted to reflect actuarial risk taken by
the employer instead of PacifiCare. The Actuarial Experience will also be
higher than billed premiums where employer premiums are partially deferred."
4. Attachment E, PHARMACY CONTROL PROGRAM, is amended in full as follows:
See Exhibit 2, attached hereto and incorporated herein by this reference.
5. Attachment F, AIDS STOP LOSS PROGRAM, is amended in full as follows:
See Exhibit 3, attached hereto and incorporated herein by this reference.
6. Attachment H, DIVISION OF FINANCIAL RESPONSIBILITY, is amended in full as
follows:
See Exhibit 4, attached hereto and incorporated herein by this reference.
The effective date of this Amendment is January 1, 1994.
By signing below, both parties hereto have executed and agreed to this
Amendment.
PACIFICARE OF CALIFORNIA SANTA XXX-TUSTIN MEDICAL PHYSICIANS
GROUP, INC.
By: By: /s/ Xxxxxx X. Xxxxx
---------------------------------- -----------------------------------
Xxxxx Xxxxxxx, Vice President
Print name: Xxxxxx X. Xxxxx
---------------------------
Title: President
--------------------------------
Date: Date: 12/22/93
-------------------------------- ---------------------------------
Tax I.D.: 00-0000000
-----------------------------
2
EXHIBIT 1
ATTACHMENT A5
1994 - HOSPITAL CONTROL PROGRAM
1. INTRODUCTION
The Hospital Control Program is designed to provide a financial incentive for
the control of Hospital Services, in-area Emergency Services and selected other
outpatient services. The Hospital Control Program utilizes a Withhold Amount as
defined below. Risk limitations are included at both the individual Subscriber
claim level, through the payment of a reinsurance premium for specific stop loss
(the deductible, premium and coinsurance rates are specified in the Budget
below); and at the aggregate level, through a percentage limitation on overall
shared savings or losses. HCP calculations are based on Budgets in effect for
each month.
a. WITHHOLD AMOUNT - PacifiCare shall withhold from IPA's monthly
Capitation Payment an amount equal to [ ** ] to apply to IPA's share
of Budget Deficits, if any. PacifiCare may prospectively adjust the
Withhold Amount on a quarterly basis based upon the results of Hospital
Control Program calculations. If the Agreement is terminated or
non-renewed pursuant to Section 6 or Section 7 of the Agreement,
PacifiCare may choose to adjust the Withhold Amount at the time that
the notice of termination or non-renewal is served.
2. BUDGET DOLLARS $PMPM
-------------
Inpatient Hospital [ ** ]
Utilization Rate 207 days PTMPY
Per diems, net of discounts:
Regular Plans [**]
Co-Pay Plans [**]
[**]
Emergency Room and Ambulance Services [ ** ]
Outpatient Surgery and other Services [ ** ]
Selected OP Services from Capitation [ ** ]
(Chemotherapy, Dialysis, home health etc)
Urgent Care Center Agreement [ ** ]
Hospital Control Program Payout Pool [ ** ]
SUB-TOTAL [ ** ]
Reinsurance Program Deductible [ ** ] [ ** ]
TOTAL BUDGET PMPM [ ** ]
3
Attachment A5 Continued
The Total Budget per Subscriber per month ("PMPM") to be used for settlement
purposes shall be calculated by applying the IPA's specific composite age/sex
factor to the budgeted amounts for Inpatient Hospital, Emergency Room and
Ambulance Services, Outpatient Surgery Services, and Selected Outpatient
Services. The composite age/sex factor will be calculated by multiplying the
IPA's member months within each age/sex category listed below and dividing the
sum of these numbers by IPA's total member months. The age/sex adjusted dollar
figure will be added to the other Hospital Control Program budget components.
AGE/SEX AGE/SEX
CATEGORY FACTOR
-------- ------
Child, age 0-1 [ ** ]
Child, age 2-9 [ ** ]
Child, age 10-17 [ ** ]
Female, age 18-29 [ ** ]
Female, age 30-44 [ ** ]
Female, age 45-64 [ ** ]
Female, age 65+ [ ** ]
Male, age 18-29 [ ** ]
Male, age 30-44 [ ** ]
Male, age 45-64 [ ** ]
Male, age 65+ [ ** ]
3. ACTUAL COSTS
Actual costs are defined for purposes of the Hospital Control Program as
the sum of the following:
a. Hospital Services incurred during the period of calculation for
which PacifiCare has received a claim and paid, valued at the amount
paid by PacifiCare;
b. For quarterly interim calculations, Hospital Services incurred
during the period of calculation for which PacifiCare has received a
claim but has not paid, less an average aggregate discount factor (for
year-end calculations, only paid claims will be included);
c. Hospital Services incurred prior to the period of calculation,
and paid during the current period;
LESS:
d. Subscriber claim costs in excess of the reinsurance deductible
and coinsurance specified in the Budget;
e. Third party recoveries and coordination of benefits
recoveries received during the period of calculation that are
associated with current or prior calculation periods.
4
Attachment A5 Continued
4. CALCULATION OF SAVINGS AND LOSSES
The inpatient hospital component of the budget is stated assuming [ ** ] of
Subscribers enroll in benefit plans with hospital service copayments,
coinsurance and deductible obligations ("Co-Pay Plans"). It is also assumed
that [ ** ] of Subscribers enroll in non-Co-Pay Plans ("Regular Plans").
The Budget will be adjusted to reflect the actual number of Subscribers who
enroll in the Co-Pay Plans and Regular Plans based upon PacifiCare's Member
Month Moving Analysis Report for the period (MB0530). The MB0530 Report is a
report that reflects actual eligible Subscribers by benefit plan for the
period, as adjusted for retroactive eligibility terminations and additions
reported during the period as of the report's run date. The Budget, when
adjusted as described above, shall be referred to as the Earned Budget. The
Earned Budget may be greater or less than the Total Budget PMPM indicated in
Section 2 above.
5. BUDGET DEFICIT
If the Actual Costs exceed the Earned Budget during any Year, the amount of
this excess will be referred to as the Budget Deficit. IPA's share of the
Budget Deficit shall be [ ** ] of the Budget Deficit, [ ** ] of the
Earned Budget. In the event of a Budget Deficit, PacifiCare shall pay IPA
the Withhold Amount, less IPA's share of the Budget Deficit. If IPA's share
of the Budget Deficit is greater than the Withhold Amount for the Initial
Term, the difference between these amounts (the "Additional Payable Amount")
shall be payable by IPA to PacifiCare within thirty (30) days from receipt of
the calculation.
6. BUDGET SURPLUS
In the event that Actual Costs are less than the Earned Budget for any year,
this shall be referred to as a Budget Surplus. In the event of a Budget
Surplus, PacifiCare shall pay IPA the Withhold Amount, plus the share of savings
relative to the bed days per thousand Subscribers per year (PTMPY) indicated in
the following sliding scale schedule:
Bed Days; Outpt. Surgery IPA % SHARE OF SAVINGS
PTMPY Limited to [ ** ] of Earned Budget
------------------------ -------------------------------------
Over 269 [ ** ]
245 - 269 [ ** ]
220 - 244 [ ** ]
under 220 [ ** ]
5
Attachment A5 Continued
For the purpose of this calculation, "Bed Days; Outpt. Surgery" shall be
defined as acute inpatient days plus outpatient surgeries, minus any acute
inpatient days or outpatient surgeries which are covered under the reinsurance
program, or are paid through a third party recovery, or through coordination of
benefits.
7. PERIODIC CALCULATIONS
Cumulative calculations of the Hospital Control Program results will be based on
calendar quarters. Interim calculations and payments will be made within sixty
(60) days of the end of each calendar quarter except for the fourth quarter for
which no calculation or payment will be made in anticipation of the final year
end settlement. Calculations will be made in accordance with the contractual
terms above and the amount of PacifiCare's quarterly payments to or from IPA
will be sixty percent (60%) of the amount due in order to adjust for incurred
Hospital Service claims not yet received by PacifiCare.
A calendar year-end calculation of the Hospital Control Program shall be made by
PacifiCare and payment, if required, shall be made within one hundred twenty
(120) days of the end of the calendar year. If an additional amount is payable
by IPA to PacifiCare, such payment is due within thirty (30) days of receipt of
calculation.
8. MONTHLY REPORTING
PacifiCare will distribute a report monthly, on or before the 15th day of the
month, that lists the payments made during the previous month for services
included in the Hospital Control Program.
9. SPECIAL CONDITIONS FOR EMERGENCY SERVICES
If the IPA and/or its participating physicians direct a PacifiCare Subscriber to
use the emergency room of a hospital, and PacifiCare determines that the use of
those services were not Emergency Services as defined in this Agreement,
PacifiCare reserves the right to deduct the emergency room professional
component from the IPA's Capitation Payment as a penalty for improper referral.
When an inappropriate referral for emergency care has been determined by
PacifiCare, a written Conformance Request will be forwarded to the IPA. The
Conformance Request will serve as notice that all subsequent inappropriate
referrals will have the penalty applied.
10. Any hospital or emergency expenses that are considered third party
liability, workers compensation claims, or coordination of benefits claims,
shall be included in the Hospital Control Program calculations. If, at a later
date, these claims are collected from any third party, then an adjustment will
be made in the calculations.
6
EXHIBIT 2
ATTACHMENT E
1994 PHARMACY CONTROL PROGRAM
The purpose of the Pharmacy Control Program (PCP) is to provide incentive to the
IPA to xxxxxx the efficient utilization of prescription services. IF PHARMACY
COSTS PMPM FOR 1994 ARE AT OR BELOW THE IPA'S "AGE, SEX AND COPAYMENT ADJUSTED"
BUDGET, the IPA is given the opportunity to share in savings realized by IPA
maintaining or improving specific utilization goals as outlined below.
TOTAL BUDGET PMPM - The actual budget to be used for settlement purposes will be
calculated by applying the age/sex factor for each Subscriber to the budgeted
Copay Plan for each subscriber. The total budget will be based on the mix of
age, sex, and copayment plans of Subscribers who have designated IPA as their
Participating Medical Group:
AGE/SEX FACTORS
AGE/SEX CATEGORY AGE/SEX FACTOR
Child, Under 1 [ ** ]
Child, Age 1 [ ** ]
Child, Age 2-9 [ ** ]
Child, Age 10-17 [ ** ]
Female, Age 18-19 [ ** ]
Female, Age 20-24 [ ** ]
Female, Age 25-29 [ ** ]
Female, Age 30-34 [ ** ]
Female, Age 35-44 [ ** ]
Female, Age 45-59 [ ** ]
Female, Age 50-54 [ ** ]
Female, Age 55-59 [ ** ]
Female, Age 60-64 [ ** ]
Female, Age 65+ [ ** ]
Male, Age 18-19 [ ** ]
Male, Age 20-24 [ ** ]
Male, Age 25-29 [ ** ]
Male, Age 30-34 [ ** ]
Male, Age 35-44 [ ** ]
Male, Age 45-49 [ ** ]
Male, Age 50-54 [ ** ]
Male, Age 55-59 [ ** ]
Male, Age 60-64 [ ** ]
Male, Age 65+ [ ** ]
7
PLAN FACTORS
COPAY PLAN TYPE 1994 BUDGET
$0 Copay [ ** ]
$1 Copay [ ** ]
$2 Copay [ ** ]
$3 Copay [ ** ]
$4 Copay [ ** ]
$5 Copay [ ** ]
$6 Copay [ ** ]
$7 Copay [ ** ]
$8 Copay [ ** ]
$9 Copay [ ** ]
$10 Copay [ ** ]
$5/$10 Copay[*] [ ** ]
$5/$15 Copay[*] [ ** ]
$5/$5 + 30% Copay[*] [ ** ]
$5 MFP[**] [ ** ]
$7 MFP[**] [ ** ]
$5/$10 MFP[**] [ ** ]
* Tiered copay plans. A $5/$10 copay plan has a $5 copay for generic scripts
and a $10 copay for brand name scripts.
** Modified family planning (MFP) plans exclude [ ** ].
Debited against this budget will be the actual expenses paid by PacifiCare for
pharmacy services of those Subscribers which designated IPA as their
Participating Medical Group for the applicable month. If pharmacy costs pmpm
for 1994 are at or below budget, the IPA will be able to participate in the
incentive programs described below.
GENERIC PERCENTAGE INCENTIVE - The Pharmacy Control Program shall be indexed
to PacifiCare's [ ** ], which shall be adjusted to reflect brand name drugs
going off-patent in [ ** ]. For every percentage point IPA exceeds
PacifiCare's [ ** ] PacifiCare shall pay IPA an amount per member per month
in accordance with the following prescription utilization rate scale:
8
PRESCRIPTION UTILIZATION RATE
(RX/MEM/YR) *
GREATER THAN
PAYOUT FACTOR PMPM OR EQUAL TO LESS THAN
------------------ ----------- ---------
[ ** ] [ ** ] [ ** ] [ ** ]
[ ** ] [ ** ] [ ** ] [ ** ]
[ ** ] [ ** ] [ ** ] [ ** ]
[ ** ] [ ** ] [ ** ] [ ** ]
[ ** ] [ ** ] [ ** ] [ ** ]
[ ** ] [ ** ] [ ** ]
[ ** ]
FORMULARY BONUS - If IPA qualifies for a generic percentage rate payment as
outlined above, a bonus payment of [ ** ] shall be paid for every [ ** ]
IPA's formulary utilization percentage rate exceeds [ ** ] up to a maximum
of [ ** ].
IPA agrees to participate in a generic substitution and formulary program
established by PacifiCare's Formulary Advisory Committee.
UTILIZATION AND CALCULATION REPORTS
PacifiCare shall provide quarterly utilization reports showing IPA's generic
percentage, prescription rate, formulary percentage, and year to date
pharmacy budget along with a comparison to [ ** ]. PacifiCare shall
provide semi-annual Pharmacy Control Program calculations and incentive
payments. The first payment shall be for the six months ending June 30, 1994
and shall be paid within sixty days of this date. The final calculation and
incentive payment shall be cumulative for the twelve months ending December
31, 1994 and shall be paid within one hundred twenty days of year end.
In the event that IPA receives a semi-annual incentive payment that is greater
than the cumulative twelve month calculated amount, PacifiCare shall be due a
refund of the difference.
9
EXHIBIT 3
ATTACHMENT F
1994 AIDS STOP LOSS PROGRAM
PacifiCare agrees to provide additional financial protection to IPA for the cost
of Medical Services rendered to Subscribers who have "Acquired Immunodeficiency
Syndrome" (AIDS). Subscribers who are eligible for this program are as follows:
Subscribers who are admitted to a hospital or referred to home health care
for the treatment of an opportunistic infection and have been diagnosed
with clinical AIDS according to the current Case Definition of AIDS used by
the Center for Disease Control (CDC) for National Reporting (CDC-reportable
AIDS).
Once PacifiCare's Medical Services Department has verified that a Subscriber
meets the definition above, further expenses for Medical Services associated
with the Subscriber's AIDS care will be paid by PacifiCare as defined by Cost of
Care in Attachment A4 hereto. THE CONDITION FOR WHICH TREATMENT IS RENDERED
MUST BE DIRECTLY RELATED TO AIDS. EXPERIMENTAL TREATMENT IS NOT COVERED. To
receive reimbursement, IPA must submit a Stop Loss claim to PacifiCare
indicating the date the Subscriber became eligible for the AIDS Stop Loss
Program and the expenses incurred on behalf of the Subscriber after the
effective date. IPA may include claims under the AIDS Stop Loss Program
commencing on the date the Subscriber was admitted to the hospital, or on the
date home health care was provided the Subscriber, pursuant to the eligibility
criteria noted above. Expenses for Medical Services pertaining to AIDS care
rendered from January 1, 1994 through December 31, 1994 only will be included in
the AIDS Stop Loss Program. A final claim must be filed for such Medical
Services by March 31, 1995 to be included in this AIDS Stop Loss Program.
All claims submitted for consideration under the AIDS Stop Loss Program must be
processed and coordinated in a confidential manner. Inquiries for determining
such procedures should be directed to PacifiCare's Medical Director.
10
EXHIBIT 4
ATTACHMENT G
DIVISION OF FINANCIAL RESPONSIBILITY
The attached template outlines the division of financial responsibility
between IPA, the Hospital Control Program (HCP), and PacifiCare (PC), the intent
being to clarify Medical Service and Hospital Service categories in order to
provide for accurate administration. As it is impossible to include every
service available, the template serves as a model under which broad Medical
Service and Hospital Service categories suggest the appropriate financial
responsibility for services or items not specifically listed.
11
DIVISION OF FINANCIAL RESPONSIBILITY
CALIFORNIA
Commercial Services Agreement
(IPA Capitated, Hospital Control Program with PacifiCare)
IPA SANTA XXX-TUSTIN PHYSICIANS GROUP, INC.
Responsible Party
-------------------------------------------------------
List of Benefits IPA PacifiCare PacifiCare
---------------- HCP 100%
AIDS - Professional Component
- Facility Component
Allergy
- Testing
- Serum (is not covered by all plans;
those with coverage are noted
in back of in back of
eligibility list)
Ambulance, Air or Ground - In Area
- Out of Area
Amniocentesis
Anesthetics, Administration of
(Anesthesiology)
Apnea Monitor (DME)
Artificial Insemination [ ** ](1)
Artificial Limbs (DME)
Biofeedback
Blood & Blood Products (Including
Professional Component)
- From Blood Bank
- Autologous Blood Donation
Chemical Dependency Rehabilitation
Chemotherapy
- Drugs
- Professional Component
Chiropractic (requires P.M.G. referral)
Circumcision
Colostomy Supplies
- Outpatient
- Inpatient
Contact Lenses
- Intraocular lens (surgically
implanted)
- Incident to Cataract Surgery
Cosmetic Surgery (Medically Necessary)
- Facility Component
- Professional Component
Dental Services (for repair of
accident/injury only)
- Facility Component
- Professional Component
Detox
- Facility Component
- Professional Component
(1) All references to division of responsibility have been deleted.
12
DIVISION OF FINANCIAL RESPONSIBILITY
CALIFORNIA
Commercial Services Agreement
(IPA Capitated, Hospital Control Program with PacifiCare)
IPA SANTA XXX-TUSTIN PHYSICIANS GROUP, INC.
Responsible Party
-------------------------------------------------------
List of Benefits IPA PacifiCare PacifiCare
----------------
Durable Medical Equipment (DME)
- Surgically Implanted
- Inpatient
- Outpatient
- Hearing Aids
- Custom made
- Custom fitted
Emergency Room Facility Component
- In Area
- Out of Area
Emergency Room Physicians - In Area
- Initial Treatment [ ** ](1)
- Consults
- Out of Area
Employment Physical
Endoscopic Studies
- With Biopsy
- Without Biopsy
Experimental Procedures
Family Planning (e.g.: Abortions,
Amniocentesis, Artificial Insemination,
Contraceptive Devices, Genetic Testing,
Infertility Treatment, Tubal
Ligation, Vasectomy)
- Professional Component
- Facility Component
- Diaphragms
- Oral Contraceptives
- Invitro Fertilization
- Reversal of Sterilization
Fetal Monitoring
- Outpatient (diagnostic)
- Inpatient
Genetic Testing
Health Education
Health Evaluation (Physical)
Hearing Aids
Hearing Screening
Hemodialysis
- Inpatient
- Outpatient
(1) All references to division of responsibility have been deleted.
13
DIVISION OF FINANCIAL RESPONSIBILITY
CALIFORNIA
Commercial Services Agreement
(IPA Capitated, Hospital Control Program with PacifiCare)
IPA SANTA XXX-TUSTIN PHYSICIANS GROUP, INC.
Responsible Party
-------------------------------------------------------
List of Benefits IPA PacifiCare PacifiCare
---------------- 100%
Home Health Care
(includes IV)
Hospice Services
- Inpatient
- Professional Component
Hospital Based Physicians (Inpatient)
- Anesthesiology
- Audiology
- Cardiology
- Diagnostic Services
- Neonatology
- Neurology [ ** ](1)
- Nephrology
- Pathology
- Physical Medicine
- Pulmonary
- Radiology
- Radiation Oncology
- Surgeon
Hospitalization, Inpatient Services
Supplies and Testing
- In Area
- Out of Area
Immunization and Inoculations
- As Medically indicated
- For work/travel
Infertility (diagnosis and treatment)
- Professional Component
- Facility Component
Injections and Injected Substances
(outpatient)
Insulin & Syringes
Laboratory Services
- Outpatient
- Inpatient
Lithotripsy
- Professional Component
- Facility Component
Mammography
Marriage Counseling
(1) All references to division of responsibility have been deleted.
14
DIVISION OF FINANCIAL RESPONSIBILITY
CALIFORNIA
Commercial Services Agreement
(IPA Capitated, Hospital Control Program with PacifiCare)
IPA SANTA XXX-TUSTIN PHYSICIANS GROUP, INC.
Responsible Party
-------------------------------------------------------
List of Benefits IPA PacifiCare PacifiCare
---------------- 100%
Medication
- Intravenous (as outpatient or
home health)
- Inpatient
- O.P. covered injectables
- O.P. non-injectables
Mental Health
- Inpatient Facility Component
- Inpatient Professional Component
- Outpatient Professional Component
Nuclear Medicine Diagnostics
Nuclear Medicine Treatment/Therapy
- Facility Component (inpatient)
- Facility Component (outpatient)
- Professional Component
Nutritional/Dietetic Counseling
O.B. Complications (In Area)
- Outpatient Diagnostic Services
- Inpatient Facility Component [ ** ](1)
- Inpatient Professional Component
PMG Referred
- Emergent Diagnostics (OB Unit)
- ER Treatment
Office Visit Supplies, Splints,
Bandages, custom fitted appliances,
etc.
Organ Transplants (non-experimental)
- Facility component
- Professional component
O.P. Surgery
- Facility Component
- Professional Component
(Interpretative MD's)
- Professional Component - other
(i.e., Surgeon, Assistant Surgeon,
etc.)
- Anesthesiology
Outpatient Surgery/Facility Based
Physicians
- Anesthesiology
- Audiology
- Cardiology
- Emergency Room
- Diagnostic Services
- Neonatology
- Neurology
- Nephrology
- Pathology
- Physical Medicine
- Pulmonary
- Radiology
- Radiation Oncology
- Surgeon
(1) All references to division of responsibility have been deleted.
15
DIVISION OF FINANCIAL RESPONSIBILITY
CALIFORNIA
Commercial Services Agreement
(IPA Capitated, Hospital Control Program with PacifiCare)
IPA SANTA XXX-TUSTIN PHYSICIANS GROUP, INC.
Responsible Party
-------------------------------------------------------
List of Benefits IPA PacifiCare PacifiCare
---------------- HCP 100%
Outpatient Diagnostic Services -
Facility and Professional (including
but not limited to those listed below)
- Angiograms
- Cat Scan
- 2 D Echo
- EEG
- EKG
- EMG
- ENG
- MRI
- Treadmills
- Ultrasound
Pediatric Services (newborn)
Physical Therapy
- Inpatient [ ** ](1)
- Outpatient
Physician visits
- To Hospital
- To S.N.F.
- To Patients Home
Physician Office Visits/Consultations
Podiatry Services (requires P.M.G.
referral)
Pregnancy
- Professional Component
- Facility Component
Prosthetic Devices
- Surgically Implanted
- Outpatient
Radiation Therapy
- Professional Component
- Facility Component (inpatient)
- Facility Component (outpatient)
Radiology Services
- Outpatient
- Inpatient
- O.P. Surgery
Reconstructive Surgery
- Facility Component
- Professional Component
- Prosthetics
Refractions
(1) All references to division of responsibility have been deleted.
16
DIVISION OF FINANCIAL RESPONSIBILITY
CALIFORNIA
Commercial Services Agreement
(IPA Capitated, Hospital Control Program with PacifiCare)
IPA SANTA XXX-TUSTIN PHYSICIANS GROUP, INC.
Responsible Party
-------------------------------------------------------
List of Benefits IPA PacifiCare PacifiCare
---------------- HCP 100%
Rehabilitation (Short Term, i.e.: P.T.,
O.T., Speech, Cardiac Therapy)
- Inpatient Facility Component
- Inpatient Professional Component
- Outpatient Facility Component
- Outpatient Professional Component
Skilled Nursing Facility
Social Services - Medical
Specialist Consultations
Surgical Supplies
- Inpatient
- Outpatient Facility [ ** ](1)
- Outpatient IPA
TMJ
- Dental Treatment
- Diagnosis and Medically Necessary
Correction
- Inpatient Facility Component
Transfusions
- From Blood Bank
- Autologous Blood Donation
Tissue Plasminogen Activator (TPA)
Vision Screening
Vision Care
- Implanted lenses (cataract surgery)
- Lenses and Frames incident to
cataract surgery
- Non-cataract related lenses and
frames
- Medically necessary care
- Refractions
(1) All references to division of responsibility have been deleted.
17
