df2=pd.DataFrame(columns=['Filename','Agreement_Name (Contract Title)','PAYER NAME','Health Plan State','Affiliate (Y/N)','Credentialing Application Indicator','Term Clause','Evergreen, Fixed or Hard Term','Termination Date','Termination Upon Notice - Days','Termination With Cause - Days','Amend Contract Upon notice Flag (Y/N)','Timeframe to Object - Days','Assignments Clause (Y/N)','Contract Effective Date','IRS #','IRS_Name'
,'NPI (10-digits)','NPI_NAME','PROV_GROUP_TIN_SIGNATORY','PROV_TIN_OTHER','PROV_NPI_OTHER','Notice to Provider Name','Notice to Provider Address','Sequestration Language','Sequestration Reductions, included [Medicare only] (Y/N)','PROV_TIN_OTHER.1','PROV_NPI_OTHER.1','Parent Agreement Code','Pages','page_num',
'Attachment/Exhibit','Line of Business','Provider Type','Provider Type - Level 2','Service Type','Plan Type','Lesser of Logic Language, included (Y/N)','Lesser of Rate','Reimb. Methodology','Reimb. Methodology_short','If rate is % of Payer or MCR [STANDARD]','If rate is % of Payer or MCR [STANDARD]_Short','If rate is Flat Fee [STANDARD]','Default Term','Default Rate','Inclusion of essential RBRVS "Fee Source" Language (Y/N)','CDM Neutralization Language, included (Y/N)','Chargemaster Protection Language','Exclusions','Not to Exceed','Escalator or COLA (Y/N)','Escalator I, Eff. Date','IP/OP','IP - DSH/IME/UC, included (Y/N)','IP - Stoploss Catastrophic Threshold'])
Filename,Agreement_Name (Contract Title),PAYER NAME,Health Plan State,Affiliate (Y/N),Credentialing Application Indicator,Term Clause,"Evergreen, Fixed or Hard Term",Termination Date,Termination Upon Notice - Days,Termination With Cause - Days,Amend Contract Upon notice Flag (Y/N),Timeframe to Object - Days,Assignments Clause (Y/N),Contract Effective Date,IRS #,IRS_Name,NPI (10-digits),NPI_NAME,PROV_GROUP_TIN_SIGNATORY,PROV_TIN_OTHER,PROV_NPI_OTHER,Notice to Provider Name,Notice to Provider Address,Sequestration Language,"Sequestration Reductions, included [Medicare only] (Y/N)",PROV_TIN_OTHER.1,PROV_NPI_OTHER.1,Parent Agreement Code,Pages,page_num,Attachment/Exhibit,Line of Business,Provider Type,Provider Type - Level 2,Service Type,Plan Type,"Lesser of Logic Language, included (Y/N)",Lesser of Rate,Reimb. Methodology,Reimb. Methodology_short,If rate is % of Payer or MCR [STANDARD],If rate is % of Payer or MCR [STANDARD]_Short,If rate is Flat Fee [STANDARD],Default Term,Default Rate,"Inclusion of essential RBRVS ""Fee Source"" Language (Y/N)","CDM Neutralization Language, included (Y/N)",Chargemaster Protection Language,Exclusions,Not to Exceed,Escalator or COLA (Y/N),"Escalator I, Eff. Date",IP/OP,"IP - DSH/IME/UC, included (Y/N)",IP - Stoploss Catastrophic Threshold
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Inpatient Covered Services - Medical/Surgical,,N,,"103.5 percent of the applicable CMS Medicare Inpatient Prospective Payment (IPPS) rates of Medicare Severity Diagnosis Related Groups (MS-DRGs) published on the CMS website on the date of the Member's discharge, including associated add-on and outlier payments as determined by CMS. All costs that are excluded by CMS from the IPPS rate will not be paid by Health Plan.",103.% of MCR,103.5% of MCR,1.035,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,All costs that are excluded by CMS from the IPPS rate will not be paid by Health Plan.,,N,,IP,N,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Inpatient Covered Services - Inpatient Rehabilitation,,N,,103.5 percent of Health Plan's Medicare rate schedule based on the applicable CMS Medicare Case-Mix Group (CMG) rates for inpatient rehabilitation published on the CMS website on the date of the Member's discharge.,103.% of MCR,103.5% of MCR,1.035,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,IP,N,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Inpatient Covered Services - Inpatient psychiatric /Alcohol/Substance Abuse Covered Services rendered to Member in an inpatient psychiatric facility or unit within the Provider's hospital facility,,N,,"$1,750 per diem",Flat Fee,,,"$1,750 Per Diem","All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,Y,1-Apr-22,IP,N,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Specialty Hospital - IP Specialty Hospital for Long Term Acute Care: - IP Specialty Hospital for Long Term Acute Care Covered Services rendered to Member within Henry J. Carter Specialty Hospital,,N,,"$2,250 per diem (Non-COVID 19 Diagnosis) $2,750 per diem (COVID19 Diagnosis: ICD. 10 Code - U07.1) $350 per treatment (Dialysis Add-On: Rev Codes 0800-0809)",Flat Fee,,,"$2,250 Per Diem (Non-COVID 19 Diagnosis) / $2,750 Per Diem (COVID19 Diagnosis) / $350 Per Treatment (Dialysis Add-On)","All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,Y,1-Apr-22,IP,N,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,"Outpatient Covered Services - Emergency Room (technical only, not inclusive of physician services)",,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Urgent Care (Per Visit) (Rev Code 0516),,N,,150 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR OPPS/APC rates,150% of MCR OPPS/APC rates,1.5,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,"Outpatient Covered Services - Ambulatory Surgery (Including but not limited to Lithotripsy, PTCA, Cardiac Cath, Laparoscopy)",,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Observation,,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - PT/OT/ST (Per Visit),,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Dialysis,,N,,110 percent of the End Stage Renal Dialysis (ESRD) Prospective Payment System (PPS) rates published on the CMS website on the date the Covered Service is rendered.,% of ESRD PPS rates,110% of ESRD PPS rates,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Chemotherapy Administration (Excludes Drugs),,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,Excludes Drugs,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Behavioral Health: -Intensive Outpatient Mental Health / Substance Abuse -Partial Hospitalization -Continuing Day Treatment -ECT -Ambulatory Detox -Telehealth Services,,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Lab/Radiology/Pathology,,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Radiation Therapy Hyperbaric Therapy,,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - MRI / CAT Scan / PET Scan / Sonograms,,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.,% of MCR OPPS/APC rates,110% of MCR OPPS/APC rates,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - Trauma Activation Fees (Rev Codes 0681-0684),,N,,60% of Charges,% of BC,60% of BC,0.6,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Outpatient Covered Services - All Other Outpatient Services (including clinic and DTC services),,N,,110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered or other successor CMS methodology as applicable.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,FQHC,FQHC Services (Payment Codes G0466-G0470),,N,,110 percent of the applicable CMS Medicare FQHC Prospective Payment System rates published on the CMS website on the date the Covered Service is rendered or other successor CMS methodology as applicable.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,All other outpatient services not priced by Medicare,,N,,"115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",% of MCD,115% of MCD,1.15,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,OP,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Primary Care Services: (CPT-4 Codes 99201-99499),,N,,110 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,OBGYN Maternity Care and Deliveries: (CPT-4 Codes 59000-59622),,N,,110 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.,% of MCR,110% of MCR,1.1,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Specialty Services,,N,,103.5 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.,103.% of MCR,103.5% of MCR,1.035,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Anesthesia Conversion Factor (15 Minute Time Units) (CPT-4 Codes 00100 to 01999),,N,,$45 per unit,Flat Fee,,,$45 per unit,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Telehealth Services,,N,,103.5 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.,103.% of MCR,103.5% of MCR,1.035,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,Allied Health Professionals,,N,,85 percent of the CMS Medicare Primary Care Services fee schedule referenced above for the applicable locality published on the CMS website on the date the Covered Services are rendered.,% of MCR,85% of MCR,0.85,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,All other Specialties,,N,,103.5 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.,103.% of MCR,103.5% of MCR,1.035,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,37,ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL),MEDICARE ADVANTAGE,Facility,Hospital,All other professional services not priced by Medicare,,N,,"115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",% of MCD,115% of MCD,1.15,,"All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.",60% of Charges,N,N,,,,N,,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,Skilled Nursing Facility,Health Plan's Medicare SNF Per Diem Rate Table - Level 1,,N,,Level 1 | $575 | 191,Flat Fee,,,$575 ,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,Skilled Nursing Facility,Health Plan's Medicare SNF Per Diem Rate Table - Level 2,,N,,Level 2 | $675 | 192,Flat Fee,,,$675 ,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,Skilled Nursing Facility,Health Plan's Medicare SNF Per Diem Rate Table - Level 3,,N,,Level 3 | $725 | 193,Flat Fee,,,$725 ,,,N,N,,,,Y,1-Apr-22,IP,N,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,Skilled Nursing Facility,Health Plan's Medicare Specialty SNF Per Diem Rate Table - Traumatic Brain Injury (Seaview Only),,N,,Traumatic Brain Injury (Seaview Only) | $875 | 199,Flat Fee,,,$875 ,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,Skilled Nursing Facility,Health Plan's Medicare Specialty SNF Per Diem Rate Table - Ventilator (Harry J. Carter Only),,N,,"Ventilator (Harry J. Carter Only) | $1,325 | 199",Flat Fee,,,"$1,325 ",,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,Skilled Nursing Facility,Covered Services,,N,,"Effective April 1, 2022, services priced at a flat rate shall be increased by 3% annually up to year 3 through March 31, 2024.",% of AC,3% of AC,0.03,,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,,Home Health Care - Skilled Nursing,,N,,Skilled Nursing | 551 | $180 per visit,Flat Fee,,,$180 per visit,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,,Home Health Care - LPN,,N,,LPN | 550 | $180 per visit,Flat Fee,,,$180 per visit,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,,Home Health Care - Medical Social Services,,N,,Medical Social Services | 561 | $230 per visit,Flat Fee,,,$230 per visit,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,,Home Health Care - Physical Therapy,,N,,Physical Therapy | 421 | $195 per visit,Flat Fee,,,$195 per visit,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,,Home Health Care - Speech Therapy,,N,,Speech Therapy | 441 | $215 per visit,Flat Fee,,,$215 per visit,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,,Home Health Care - Occupational Therapy,,N,,Occupational Therapy | 431 | $200 per visit,Flat Fee,,,$200 per visit,,,N,N,,,,Y,1-Apr-22,,,
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1,PARTICIPATING PROVIDER AGREEMENT,"WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York",New York,Yes,Yes,"7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.",Evergreen,,90,90,Yes,,Yes,4/1/2021,13-2655001,New York City Health and Hospitals Corporation,,,,,,,"160 Water Street 6th Flr Rm 642 New York, NY 10038",,,,,318243,43,41,ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE),MEDICARE ADVANTAGE,Facility,,Home Health Care - Home Health Aide,,N,,Home Health Aide | 571 | $85 per visit,Flat Fee,,,$85 per visit,,,N,N,,,,Y,1-Apr-22,,,
Sequestration Reductions, included [Medicare only] (Y/N)
PROV_TIN_OTHER.1
PROV_NPI_OTHER.1
Parent Agreement Code
Pages
page_num
Attachment/Exhibit
Line of Business
Provider Type
Provider Type - Level 2
Service Type
Plan Type
Lesser of Logic Language, included (Y/N)
Lesser of Rate
Reimb. Methodology
Reimb. Methodology_short
If rate is % of Payer or MCR [STANDARD]
If rate is % of Payer or MCR [STANDARD]_Short
If rate is Flat Fee [STANDARD]
Default Term
Default Rate
Inclusion of essential RBRVS "Fee Source" Language (Y/N)
CDM Neutralization Language, included (Y/N)
Chargemaster Protection Language
Exclusions
Not to Exceed
Escalator or COLA (Y/N)
Escalator I, Eff. Date
IP/OP
IP - DSH/IME/UC, included (Y/N)
IP - Stoploss Catastrophic Threshold
2
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Inpatient Covered Services - Medical/Surgical
N
103.5 percent of the applicable CMS Medicare Inpatient Prospective Payment (IPPS) rates of Medicare Severity Diagnosis Related Groups (MS-DRGs) published on the CMS website on the date of the Member's discharge, including associated add-on and outlier payments as determined by CMS. All costs that are excluded by CMS from the IPPS rate will not be paid by Health Plan.
103.% of MCR
103.5% of MCR
1.035
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
All costs that are excluded by CMS from the IPPS rate will not be paid by Health Plan.
N
IP
N
3
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
103.5 percent of Health Plan's Medicare rate schedule based on the applicable CMS Medicare Case-Mix Group (CMG) rates for inpatient rehabilitation published on the CMS website on the date of the Member's discharge.
103.% of MCR
103.5% of MCR
1.035
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
IP
N
4
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Inpatient Covered Services - Inpatient psychiatric /Alcohol/Substance Abuse Covered Services rendered to Member in an inpatient psychiatric facility or unit within the Provider's hospital facility
N
$1,750 per diem
Flat Fee
$1,750 Per Diem
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
Y
1-Apr-22
IP
N
5
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Specialty Hospital - IP Specialty Hospital for Long Term Acute Care: - IP Specialty Hospital for Long Term Acute Care Covered Services rendered to Member within Henry J. Carter Specialty Hospital
N
$2,250 per diem (Non-COVID 19 Diagnosis) $2,750 per diem (COVID19 Diagnosis: ICD. 10 Code - U07.1) $350 per treatment (Dialysis Add-On: Rev Codes 0800-0809)
Flat Fee
$2,250 Per Diem (Non-COVID 19 Diagnosis) / $2,750 Per Diem (COVID19 Diagnosis) / $350 Per Treatment (Dialysis Add-On)
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
Y
1-Apr-22
IP
N
6
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Outpatient Covered Services - Emergency Room (technical only, not inclusive of physician services)
N
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
7
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
150 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR OPPS/APC rates
150% of MCR OPPS/APC rates
1.5
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
8
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Outpatient Covered Services - Ambulatory Surgery (Including but not limited to Lithotripsy, PTCA, Cardiac Cath, Laparoscopy)
N
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
9
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Outpatient Covered Services - Observation
N
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
10
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
11
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Outpatient Covered Services - Dialysis
N
110 percent of the End Stage Renal Dialysis (ESRD) Prospective Payment System (PPS) rates published on the CMS website on the date the Covered Service is rendered.
% of ESRD PPS rates
110% of ESRD PPS rates
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
12
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
Excludes Drugs
N
OP
13
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
14
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
15
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
16
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered.
% of MCR OPPS/APC rates
110% of MCR OPPS/APC rates
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
17
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
18
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Outpatient Covered Services - All Other Outpatient Services (including clinic and DTC services)
N
110 percent of the applicable CMS Medicare Outpatient Prospective Payment System (OPPS)/APC rates published on the CMS website on the date the Covered Service is rendered or other successor CMS methodology as applicable.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
19
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
FQHC
FQHC Services (Payment Codes G0466-G0470)
N
110 percent of the applicable CMS Medicare FQHC Prospective Payment System rates published on the CMS website on the date the Covered Service is rendered or other successor CMS methodology as applicable.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
20
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
All other outpatient services not priced by Medicare
N
115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
% of MCD
115% of MCD
1.15
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
OP
21
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Primary Care Services: (CPT-4 Codes 99201-99499)
N
110 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
22
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
OBGYN Maternity Care and Deliveries: (CPT-4 Codes 59000-59622)
N
110 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.
% of MCR
110% of MCR
1.1
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
23
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Specialty Services
N
103.5 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.
103.% of MCR
103.5% of MCR
1.035
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
24
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Anesthesia Conversion Factor (15 Minute Time Units) (CPT-4 Codes 00100 to 01999)
N
$45 per unit
Flat Fee
$45 per unit
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
Y
1-Apr-22
25
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Telehealth Services
N
103.5 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.
103.% of MCR
103.5% of MCR
1.035
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
26
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
Allied Health Professionals
N
85 percent of the CMS Medicare Primary Care Services fee schedule referenced above for the applicable locality published on the CMS website on the date the Covered Services are rendered.
% of MCR
85% of MCR
0.85
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
27
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
All other Specialties
N
103.5 percent of the CMS Medicare physician fee schedule for the applicable locality published on the CMS website on the date the Covered Services are rendered.
103.% of MCR
103.5% of MCR
1.035
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
28
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
37
ATTACHMENT C-1 MEDICARE ADVANTAGE PROGRAM COMPENSATION (HOSPITAL AND PROFESSIONAL)
MEDICARE ADVANTAGE
Facility
Hospital
All other professional services not priced by Medicare
N
115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
% of MCD
115% of MCD
1.15
All other outpatient services not priced by Medicare | 115 percent of the applicable NYS Medicaid rate. If no price, 60% of Charges.
60% of Charges
N
N
N
29
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Skilled Nursing Facility
Health Plan's Medicare SNF Per Diem Rate Table - Level 1
N
Level 1 | $575 | 191
Flat Fee
$575
N
N
Y
1-Apr-22
30
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Skilled Nursing Facility
Health Plan's Medicare SNF Per Diem Rate Table - Level 2
N
Level 2 | $675 | 192
Flat Fee
$675
N
N
Y
1-Apr-22
31
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Skilled Nursing Facility
Health Plan's Medicare SNF Per Diem Rate Table - Level 3
N
Level 3 | $725 | 193
Flat Fee
$725
N
N
Y
1-Apr-22
IP
N
32
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Skilled Nursing Facility
Health Plan's Medicare Specialty SNF Per Diem Rate Table - Traumatic Brain Injury (Seaview Only)
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Skilled Nursing Facility
Health Plan's Medicare Specialty SNF Per Diem Rate Table - Ventilator (Harry J. Carter Only)
N
Ventilator (Harry J. Carter Only) | $1,325 | 199
Flat Fee
$1,325
N
N
Y
1-Apr-22
34
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Skilled Nursing Facility
Covered Services
N
Effective April 1, 2022, services priced at a flat rate shall be increased by 3% annually up to year 3 through March 31, 2024.
% of AC
3% of AC
0.03
N
N
Y
1-Apr-22
35
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Home Health Care - Skilled Nursing
N
Skilled Nursing | 551 | $180 per visit
Flat Fee
$180 per visit
N
N
Y
1-Apr-22
36
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Home Health Care - LPN
N
LPN | 550 | $180 per visit
Flat Fee
$180 per visit
N
N
Y
1-Apr-22
37
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Home Health Care - Medical Social Services
N
Medical Social Services | 561 | $230 per visit
Flat Fee
$230 per visit
N
N
Y
1-Apr-22
38
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Home Health Care - Physical Therapy
N
Physical Therapy | 421 | $195 per visit
Flat Fee
$195 per visit
N
N
Y
1-Apr-22
39
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Home Health Care - Speech Therapy
N
Speech Therapy | 441 | $215 per visit
Flat Fee
$215 per visit
N
N
Y
1-Apr-22
40
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
MEDICARE ADVANTAGE
Facility
Home Health Care - Occupational Therapy
N
Occupational Therapy | 431 | $200 per visit
Flat Fee
$200 per visit
N
N
Y
1-Apr-22
41
13-2655001-New York City Health and Hospitals Corporation-ICMProviderAgreement_318243_1
PARTICIPATING PROVIDER AGREEMENT
WellCare of New York, Inc., WellCare Health Insurance of New York, Inc. and American Progressive Life and Health Insurance Company of New York
New York
Yes
Yes
7.1 Term. The term of this Agreement shall begin on the Effective Date and continue for a period of one year, and thereafter shall renew for successive periods of one year each unless a Party provides notice of nonrenewal to the other at least 90 days before the end of the then current (initial or renewal)term, unless and until the Agreement is terminated in accordance with the terms and conditions of the Agreement, including those in a Program Attachment.
Evergreen
90
90
Yes
Yes
4/1/2021
13-2655001
New York City Health and Hospitals Corporation
160 Water Street 6th Flr Rm 642 New York, NY 10038
318243
43
41
ATTACHMENT C-2 MEDICARE ADVANTAGE COMPENSATION (SKILLED NURSING FACILITY & HOME HEALTH SERVICES) (FEE FOR SERVICE)
Filename,Agreement_Name (Contract Title),PAYER NAME,Health Plan State,Affiliate (Y/N),Credentialing Application Indicator,Term Clause,"Evergreen, Fixed or Hard Term",Termination Date,Termination Upon Notice - Days,Termination With Cause - Days,Amend Contract Upon notice Flag (Y/N),Timeframe to Object - Days,Assignments Clause (Y/N),Contract Effective Date,IRS #,IRS_Name,NPI (10-digits),NPI_NAME,PROV_GROUP_TIN_SIGNATORY,PROV_TIN_OTHER,PROV_NPI_OTHER,Notice to Provider Name,Notice to Provider Address,Sequestration Language,"Sequestration Reductions, included [Medicare only] (Y/N)",PROV_TIN_OTHER.1,PROV_NPI_OTHER.1,Parent Agreement Code,Pages,page_num,Attachment/Exhibit,Line of Business,Provider Type,Provider Type - Level 2,Service Type,Plan Type,"Lesser of Logic Language, included (Y/N)",Lesser of Rate,Reimb. Methodology,Reimb. Methodology_short,If rate is % of Payer or MCR [STANDARD],If rate is % of Payer or MCR [STANDARD]_Short,If rate is Flat Fee [STANDARD],Default Term,Default Rate,"Inclusion of essential RBRVS ""Fee Source"" Language (Y/N)","CDM Neutralization Language, included (Y/N)",Chargemaster Protection Language,Exclusions,Not to Exceed,Escalator or COLA (Y/N),"Escalator I, Eff. Date",IP/OP,"IP - DSH/IME/UC, included (Y/N)",IP - Stoploss Catastrophic Threshold
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,Primary Care Provider,Covered Services provided by a primary care provider to a Covered Person,,Y,100% of AC,"For Covered Services provided by a primary care provider to a Covered Person, Payor shall pay Group for the codes listed in Attachment A the lesser of: (i) Group's Allowable Charges; or (ii) the Contracted Rate listed in Attachment A - ACA Codes and Rates. For Covered Services provided by a primary care provider to a Covered Person, Payor shall pay Group for codes not listed in Attachment A the lesser of: (i) Group's Allowable Charges; or (ii) one hundred thirty-nine percent (139%) of the State's Medicaid fee schedule in effect on the date of service.",% of MCD,139% of MCD,1.39,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,Specialist,Covered Services provided by a specialist provider,,Y,100% of AC,"For Covered Services provided by a specialist provider, Payor shall pay Group the lesser of (i) Group's Allowable Charges; or (ii) one hundred forty-two percent (142%) of the State's Medicaid fee schedule in effect on the date of service.",% of MCD,142% of MCD,1.42,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,,"Covered Services as listed in Table I, laboratory services",,Y,100% of AC,"For Covered Services as listed in Table I, laboratory services will be reimbursed at the lesser of: (i) Group's Allowable Charges; or (ii) one hundred two percent (102%) of the State's Medicaid fee schedule in effect on the date of service.",% of MCD,102% of MCD,1.02,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,Specialist,pathology services,,Y,100% of AC,"For pathology services, all pathology services will be paid at the lesser of (i) Group's Allowable charges; or (ii) one hundred forty-two percent (142%) of the State's Medicaid fee schedule in effect on the date of service and specific to the Covered Services rendered.",% of MCD,142% of MCD,1.42,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,,Covered Services for which there is no established fee amount,,N,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",% of AC,35% of AC,0.35,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,,Clinical laboratory codes 80000 - 80499,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule,% of MCD,102% of MCD,1.02,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,Specialist,Professional laboratory codes 80500 - 80999,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule,% of MCD,142% of MCD,1.42,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,,Clinical laboratory codes 81000 - 81099,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule,% of MCD,102% of MCD,1.02,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,Specialist,Professional laboratory codes 81200 - 81999,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule,% of MCD,142% of MCD,1.42,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,,Clinical laboratory codes 82000 - 87999,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule,% of MCD,102% of MCD,1.02,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,Specialist,Professional laboratory codes 88000 - 88199,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule,% of MCD,142% of MCD,1.42,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,,Clinical laboratory codes 88200 - 88299,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule,% of MCD,102% of MCD,1.02,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,Specialist,Professional laboratory codes 88300 - 88399,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule,% of MCD,142% of MCD,1.42,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,3,EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID,MEDICAID,Professional,,Clinical laboratory codes 88400 - 89999,,Y,100% of AC,The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule,% of MCD,102% of MCD,1.02,,"For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.",35% of Allowable Charges,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90460,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90461,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,12.23,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90471,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90472,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,12.23,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90473,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90474,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,12.23,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90633 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90644 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90647 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90648 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90649 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90650 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90655 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90656 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,$25 ,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90658 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,$25 ,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90660 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,$25 ,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90669 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,$25 ,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90670 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,$25 ,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90672 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90680 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90681 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90685 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90686 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90696 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90698 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,3/1/2016,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90700 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90702 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90707 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90710 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90713 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90714 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90715 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90716 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90718 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90723 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90732 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90734 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90744 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,90748 SL,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,24.58,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99201,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,42.96,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99201 EP,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,42.96,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99201 GT,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,42.96,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99201 GE,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,42.96,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99202,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,73.5,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99202 EP,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,73.5,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99202 GE,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,73.5,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99202 GT,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,73.5,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99203 GT,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,106.61,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99203,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,106.61,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99203 GE,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,106.61,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99203 EP,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,106.61,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99204 EP,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,163.12,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99204,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,163.12,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99204 GT,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,163.12,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99205 52,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,204.84,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99205 UB,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,204.84,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99205 U7,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,204.84,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99205 U9,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,204.84,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99205,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,204.84,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99205 GT,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,204.84,,,N,N,,,,N,,,,
"43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3",AMENDMENT NUMBER TWO GROUP AGREEMENT,"Home State Health Plan, Inc",Missouri,No,No,,Hard Term,,,,No,,No,42430,43-0654872,Saint Louis University dba SLUCare,,,43-0654872,,,,"School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104",,No,,,92767,10,5,ATTACHMENT A,,Professional,,99205 EP,,N,,PROCEDURE | MODIFIER | CONTRACTED RATE,Flat Fee,,,204.84,,,N,N,,,,N,,,,
1
Filename
Agreement_Name (Contract Title)
PAYER NAME
Health Plan State
Affiliate (Y/N)
Credentialing Application Indicator
Term Clause
Evergreen, Fixed or Hard Term
Termination Date
Termination Upon Notice - Days
Termination With Cause - Days
Amend Contract Upon notice Flag (Y/N)
Timeframe to Object - Days
Assignments Clause (Y/N)
Contract Effective Date
IRS #
IRS_Name
NPI (10-digits)
NPI_NAME
PROV_GROUP_TIN_SIGNATORY
PROV_TIN_OTHER
PROV_NPI_OTHER
Notice to Provider Name
Notice to Provider Address
Sequestration Language
Sequestration Reductions, included [Medicare only] (Y/N)
PROV_TIN_OTHER.1
PROV_NPI_OTHER.1
Parent Agreement Code
Pages
page_num
Attachment/Exhibit
Line of Business
Provider Type
Provider Type - Level 2
Service Type
Plan Type
Lesser of Logic Language, included (Y/N)
Lesser of Rate
Reimb. Methodology
Reimb. Methodology_short
If rate is % of Payer or MCR [STANDARD]
If rate is % of Payer or MCR [STANDARD]_Short
If rate is Flat Fee [STANDARD]
Default Term
Default Rate
Inclusion of essential RBRVS "Fee Source" Language (Y/N)
CDM Neutralization Language, included (Y/N)
Chargemaster Protection Language
Exclusions
Not to Exceed
Escalator or COLA (Y/N)
Escalator I, Eff. Date
IP/OP
IP - DSH/IME/UC, included (Y/N)
IP - Stoploss Catastrophic Threshold
2
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Primary Care Provider
Covered Services provided by a primary care provider to a Covered Person
Y
100% of AC
For Covered Services provided by a primary care provider to a Covered Person, Payor shall pay Group for the codes listed in Attachment A the lesser of: (i) Group's Allowable Charges; or (ii) the Contracted Rate listed in Attachment A - ACA Codes and Rates. For Covered Services provided by a primary care provider to a Covered Person, Payor shall pay Group for codes not listed in Attachment A the lesser of: (i) Group's Allowable Charges; or (ii) one hundred thirty-nine percent (139%) of the State's Medicaid fee schedule in effect on the date of service.
% of MCD
139% of MCD
1.39
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
3
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Specialist
Covered Services provided by a specialist provider
Y
100% of AC
For Covered Services provided by a specialist provider, Payor shall pay Group the lesser of (i) Group's Allowable Charges; or (ii) one hundred forty-two percent (142%) of the State's Medicaid fee schedule in effect on the date of service.
% of MCD
142% of MCD
1.42
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
4
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Covered Services as listed in Table I, laboratory services
Y
100% of AC
For Covered Services as listed in Table I, laboratory services will be reimbursed at the lesser of: (i) Group's Allowable Charges; or (ii) one hundred two percent (102%) of the State's Medicaid fee schedule in effect on the date of service.
% of MCD
102% of MCD
1.02
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
5
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Specialist
pathology services
Y
100% of AC
For pathology services, all pathology services will be paid at the lesser of (i) Group's Allowable charges; or (ii) one hundred forty-two percent (142%) of the State's Medicaid fee schedule in effect on the date of service and specific to the Covered Services rendered.
% of MCD
142% of MCD
1.42
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
6
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Covered Services for which there is no established fee amount
N
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
% of AC
35% of AC
0.35
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
7
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Clinical laboratory codes 80000 - 80499
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule
% of MCD
102% of MCD
1.02
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
8
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Specialist
Professional laboratory codes 80500 - 80999
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule
% of MCD
142% of MCD
1.42
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
9
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Clinical laboratory codes 81000 - 81099
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule
% of MCD
102% of MCD
1.02
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
10
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Specialist
Professional laboratory codes 81200 - 81999
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule
% of MCD
142% of MCD
1.42
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
11
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Clinical laboratory codes 82000 - 87999
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule
% of MCD
102% of MCD
1.02
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
12
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Specialist
Professional laboratory codes 88000 - 88199
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule
% of MCD
142% of MCD
1.42
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
13
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Clinical laboratory codes 88200 - 88299
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule
% of MCD
102% of MCD
1.02
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
14
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Specialist
Professional laboratory codes 88300 - 88399
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 142% of State's Medicaid fee schedule
% of MCD
142% of MCD
1.42
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
15
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
3
EXHIBIT 1 GROUP COMPENSATIO SCHEDULE - MEDICAID
MEDICAID
Professional
Clinical laboratory codes 88400 - 89999
Y
100% of AC
The lesser of: (i) Group's Allowable Charges; or (ii) 102% of State's Medicaid fee schedule
% of MCD
102% of MCD
1.02
For Covered Services for which there is no established fee amount, Payor shall pay thirty-five percent (35%) of the Allowable Charges until such time as Payor establishes a fee amount.
35% of Allowable Charges
N
N
N
16
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90460
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
17
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90461
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
12.23
N
N
N
18
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90471
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
19
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90472
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
12.23
N
N
N
20
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90473
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
21
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90474
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
12.23
N
N
N
22
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90633 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
23
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90644 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
24
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90647 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
25
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90648 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
26
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90649 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
27
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90650 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
28
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90655 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
29
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90656 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
$25
N
N
N
30
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90658 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
$25
N
N
N
31
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90660 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
$25
N
N
N
32
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90669 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
$25
N
N
N
33
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90670 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
$25
N
N
N
34
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90672 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
35
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90680 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
36
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90681 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
37
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90685 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
38
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90686 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
39
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90696 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
40
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90698 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
41
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
3/1/2016
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90700 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
42
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90702 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
43
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90707 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
44
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90710 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
45
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90713 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
46
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90714 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
47
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90715 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
48
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90716 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
49
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90718 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
50
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90723 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
51
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90732 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
52
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90734 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
53
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90744 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
54
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
90748 SL
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
24.58
N
N
N
55
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99201
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
42.96
N
N
N
56
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99201 EP
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
42.96
N
N
N
57
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99201 GT
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
42.96
N
N
N
58
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99201 GE
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
42.96
N
N
N
59
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99202
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
73.5
N
N
N
60
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99202 EP
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
73.5
N
N
N
61
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99202 GE
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
73.5
N
N
N
62
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99202 GT
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
73.5
N
N
N
63
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99203 GT
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
106.61
N
N
N
64
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99203
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
106.61
N
N
N
65
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99203 GE
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
106.61
N
N
N
66
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99203 EP
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
106.61
N
N
N
67
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99204 EP
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
163.12
N
N
N
68
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99204
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
163.12
N
N
N
69
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99204 GT
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
163.12
N
N
N
70
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99205 52
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
204.84
N
N
N
71
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99205 UB
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
204.84
N
N
N
72
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99205 U7
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
204.84
N
N
N
73
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99205 U9
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
204.84
N
N
N
74
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99205
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
204.84
N
N
N
75
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
No
92767
10
5
ATTACHMENT A
Professional
99205 GT
N
PROCEDURE | MODIFIER | CONTRACTED RATE
Flat Fee
204.84
N
N
N
76
43-0654872-Saint Louis University dba SLUCare, a Missouri benevolent corporation-ICMProviderAgreement_92767_3
AMENDMENT NUMBER TWO GROUP AGREEMENT
Home State Health Plan, Inc
Missouri
No
No
Hard Term
No
No
42430
43-0654872
Saint Louis University dba SLUCare
43-0654872
School of Medicine, 2nd Floor 1402 South Grand Avenue St. Louis, MO 63104
Filename,Agreement_Name (Contract Title),PAYER NAME,Health Plan State,Affiliate (Y/N),Credentialing Application Indicator,Term Clause,"Evergreen, Fixed or Hard Term",Termination Date,Termination Upon Notice - Days,Termination With Cause - Days,Amend Contract Upon notice Flag (Y/N),Timeframe to Object - Days,Assignments Clause (Y/N),Contract Effective Date,IRS #,IRS_Name,NPI (10-digits),NPI_NAME,PROV_GROUP_TIN_SIGNATORY,PROV_TIN_OTHER,PROV_NPI_OTHER,Notice to Provider Name,Notice to Provider Address,Sequestration Language,"Sequestration Reductions, included [Medicare only] (Y/N)",PROV_TIN_OTHER.1,PROV_NPI_OTHER.1,Parent Agreement Code,Pages,page_num,Attachment/Exhibit,Line of Business,Provider Type,Provider Type - Level 2,Service Type,Plan Type,"Lesser of Logic Language, included (Y/N)",Lesser of Rate,Reimb. Methodology,Reimb. Methodology_short,If rate is % of Payer or MCR [STANDARD],If rate is % of Payer or MCR [STANDARD]_Short,If rate is Flat Fee [STANDARD],Default Term,Default Rate,"Inclusion of essential RBRVS ""Fee Source"" Language (Y/N)","CDM Neutralization Language, included (Y/N)",Chargemaster Protection Language,Exclusions,Not to Exceed,Escalator or COLA (Y/N),"Escalator I, Eff. Date",IP/OP,"IP - DSH/IME/UC, included (Y/N)",IP - Stoploss Catastrophic Threshold
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Registered Nurse,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Licensed Practical Nurse,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123),,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124),,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Home Health Aide,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Personal Care,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1030 - Skilled Nursing Registered Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1031 - Skilled Nursing Licensed Practical Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1021 - Home Health Aide,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9122 - Personal Care,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,41,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Registered Nurse,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Licensed Practical Nurse,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123),,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124),,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Home Health Aide,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Personal Care,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,1-Jan-23,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1030 - Skilled Nursing Registered Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1031 - Skilled Nursing Licensed Practical Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1021 - Home Health Aide,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9122 - Personal Care,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,3/1/2022,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,44,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Registered Nurse,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Licensed Practical Nurse,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123),,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124),,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Home Health Aide,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Personal Care,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1030 - Skilled Nursing Registered Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1031 - Skilled Nursing Licensed Practical Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1021 - Home Health Aide,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9122 - Personal Care,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,47,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Registered Nurse,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Skilled Nursing - Licensed Practical Nurse,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123),,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124),,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52",Flat Fee,,,$52 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Home Health Aide,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Personal Care,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,Y,44927,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1030 - Skilled Nursing Registered Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1031 - Skilled Nursing Licensed Practical Nurse,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day),,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule",% of MCD,158% of MCD,1.58,,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,T1021 - Home Health Aide,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,S9122 - Personal Care,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Physical Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Occupational Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Speech Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Respiratory Therapy,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,50,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH,MEDICAID,Ancillary,Home Health,Medical Social Worker Visit,,Y,100% of AC,"Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Personal Care T1004,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per 15 Minutes $4.00",Flat Fee,,,$4.00 Per 15 Minutes,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Adult Companion S5135,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per 15 Minutes $4.00",Flat Fee,,,$4.00 Per 15 Minutes,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Attendant Care S5125,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per 15 Minutes $8.75",Flat Fee,,,$8.75 Per 15 Minutes,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Homemaker S5130,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per 15 Minutes $4.00",Flat Fee,,,$4.00 Per 15 Minutes,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Respite-In Home T1005,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per 15 Minutes $4.00",Flat Fee,,,$4.00 Per 15 Minutes,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Intermittent Skilled Nursing-LPN S9124,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Hour $45.00",Flat Fee,,,$45.00 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Intermittent Skilled Nursing-RN S9123,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Hour $80.00",Flat Fee,,,$80.00 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Medication Administration T1502,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Visit $50.00",Flat Fee,,,$50.00 Per Visit,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Medication Management H2010,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per 15 Minutes $8.00",Flat Fee,,,$8.00 Per 15 Minutes,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Caregiver Training S5108,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per 15 Minutes $8.75",Flat Fee,,,$8.75 Per 15 Minutes,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,PT/OT/ST,Occupational Therapy S9129,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Visit $75.00",Flat Fee,,,$75.00 Per Visit,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,PT/OT/ST,Physical Therapy S9131,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Visit $75.00",Flat Fee,,,$75.00 Per Visit,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,PT/OT/ST,Speech Therapy S9128,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Visit $75.00",Flat Fee,,,$75.00 Per Visit,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Respiratory Therapy-Eval S5180,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Visit $75.00",Flat Fee,,,$75.00 Per Visit,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,53,Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES,MEDICAID,Ancillary,Home Health,Respiratory Treatment S5180 U2,,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Per Visit $75.00",Flat Fee,,,$75.00 Per Visit,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,55,Attachment B: Medicare MEDICARE PRODUCT ATTACHMENT,MEDICARE,Ancillary,,Covered Services,,Y,100% of AC,"The Compensation Schedule for the Medicare Product at any given time is the lesser of (i) the Allowable Charges for the particular Covered Service, or (ii) the appropriate amount for such Covered Service under the Company's fee schedule in effect on the date of service for the Medicare Product.",% of Company's fee schedule,100% of Company's fee schedule,1,,,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,72,Attachment C: Commercial-Exchange EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,COMMERCIAL-EXCHANGE,Ancillary,Home Health,home health Covered Services,,Y,100% of AC,"The maximum compensation for home health Covered Services rendered to a Covered Person shall be the ""Allowed Amount."" Except as otherwise provided in this Compensation Schedule, the Allowed Amount for home health Covered Services is the lesser of: (i) Allowable Charges; or (ii) the ""Contracted Rate"" which is seventy percent (70%) of the Payor's fee schedule.",% of Payor's fee schedule,70% of Payor's fee schedule,0.7,,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Skilled Nursing - Registered Nurse,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80",Flat Fee,,,$80 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Skilled Nursing - Licensed Practical Nurse,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45",Flat Fee,,,$45 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Private Duty Nursing - Registered Nurse,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing - Registered Nurse | Per Hour | $52",Flat Fee,,,$52 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Private Duty Nursing - Licensed Practical Nurse,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Private Duty Nursing - Licensed Practical Nurse | Per Hour | $52",Flat Fee,,,$52 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Home Health Aide,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Home Health Aide | Per Hour | $18",Flat Fee,,,$18 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Personal Care,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Personal Care | Per Hour | $18",Flat Fee,,,$18 Per Hour,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Physical Therapy,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Physical Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Occupational Therapy,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Occupational Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Speech Therapy,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Speech Therapy | Per Diem | $90",Flat Fee,,,$90 Per Diem,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Respiratory Therapy,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Respiratory Therapy | Per Diem | $75",Flat Fee,,,$75 Per Diem,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
52-1590951-Maxim Healthcare Services Inc-ICMProviderAgreement_265803_3,,,Florida,,,"7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.",evergreen,,90,90,Y,30,,44621,52-1590951,Maxim Healthcare Services Inc,,,,,"1003918483, 1043327463, 1063529923, 1083720676, 1215044227,",,,,,,,265803,78,77,Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH,,Ancillary,Home Health,Medical Social Worker Visit,Healthy Kids,Y,100% of AC,"The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the ""Allowed Amount"" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable ""Contracted Rate"" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100",Flat Fee,,,$100 Per Diem,Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.,,N,N,,,,N,,,,
1
Filename
Agreement_Name (Contract Title)
PAYER NAME
Health Plan State
Affiliate (Y/N)
Credentialing Application Indicator
Term Clause
Evergreen, Fixed or Hard Term
Termination Date
Termination Upon Notice - Days
Termination With Cause - Days
Amend Contract Upon notice Flag (Y/N)
Timeframe to Object - Days
Assignments Clause (Y/N)
Contract Effective Date
IRS #
IRS_Name
NPI (10-digits)
NPI_NAME
PROV_GROUP_TIN_SIGNATORY
PROV_TIN_OTHER
PROV_NPI_OTHER
Notice to Provider Name
Notice to Provider Address
Sequestration Language
Sequestration Reductions, included [Medicare only] (Y/N)
PROV_TIN_OTHER.1
PROV_NPI_OTHER.1
Parent Agreement Code
Pages
page_num
Attachment/Exhibit
Line of Business
Provider Type
Provider Type - Level 2
Service Type
Plan Type
Lesser of Logic Language, included (Y/N)
Lesser of Rate
Reimb. Methodology
Reimb. Methodology_short
If rate is % of Payer or MCR [STANDARD]
If rate is % of Payer or MCR [STANDARD]_Short
If rate is Flat Fee [STANDARD]
Default Term
Default Rate
Inclusion of essential RBRVS "Fee Source" Language (Y/N)
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Registered Nurse
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Licensed Practical Nurse
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123)
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124)
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Home Health Aide
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Personal Care
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1030 - Skilled Nursing Registered Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1031 - Skilled Nursing Licensed Practical Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1021 - Home Health Aide
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9122 - Personal Care
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE MANAGED MEDICAL ASSISTANCE ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Registered Nurse
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Licensed Practical Nurse
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123)
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124)
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Home Health Aide
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Personal Care
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1030 - Skilled Nursing Registered Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1031 - Skilled Nursing Licensed Practical Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1021 - Home Health Aide
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9122 - Personal Care
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILD WELFARE SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Registered Nurse
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Licensed Practical Nurse
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123)
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124)
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Home Health Aide
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Personal Care
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1030 - Skilled Nursing Registered Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1031 - Skilled Nursing Licensed Practical Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1021 - Home Health Aide
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9122 - Personal Care
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE SERIOUS MENTAL ILLNESS SPECIALTY PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Registered Nurse
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Skilled Nursing - Licensed Practical Nurse
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123)
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a RN (2 to 24 hours per day) - (S9123) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124)
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing rendered by a LPN (2 to 24 hours per day) - (S9124) | Per Hour | $52
Flat Fee
$52 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Home Health Aide
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Personal Care
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1030 - Skilled Nursing Registered Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1030 - Skilled Nursing Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1031 - Skilled Nursing Licensed Practical Nurse
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1031 - Skilled Nursing Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9123 - Private Duty Nursing rendered by an RN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day)
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9124 - Private Duty Nursing rendered by an LPN (2 to 24 hours per day) | Per Hour | 158% of the current Medicaid fee schedule
% of MCD
158% of MCD
1.58
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
T1021 - Home Health Aide
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. T1021 - Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
S9122 - Personal Care
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. S9122 - Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Physical Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Occupational Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Speech Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Respiratory Therapy
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE CHILDREN'S MEDICAL SERVICES HEALTH PLAN ANCILLARY SERVICES HOME HEALTH
MEDICAID
Ancillary
Home Health
Medical Social Worker Visit
Y
100% of AC
Should Health Plan determine Provider is not staffing cases, Health Plan reserves the right, at its sole discretion, to adjust the Contracted Rate set forth above in Table 1, to the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 2 with a thirty (30) day prior written notice. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Default Health Plan Fee Schedule. Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Personal Care T1004
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per 15 Minutes $4.00
Flat Fee
$4.00 Per 15 Minutes
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Adult Companion S5135
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per 15 Minutes $4.00
Flat Fee
$4.00 Per 15 Minutes
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Attendant Care S5125
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per 15 Minutes $8.75
Flat Fee
$8.75 Per 15 Minutes
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Homemaker S5130
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per 15 Minutes $4.00
Flat Fee
$4.00 Per 15 Minutes
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Respite-In Home T1005
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per 15 Minutes $4.00
Flat Fee
$4.00 Per 15 Minutes
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Intermittent Skilled Nursing-LPN S9124
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Hour $45.00
Flat Fee
$45.00 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Intermittent Skilled Nursing-RN S9123
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Hour $80.00
Flat Fee
$80.00 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Medication Administration T1502
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Visit $50.00
Flat Fee
$50.00 Per Visit
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Medication Management H2010
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per 15 Minutes $8.00
Flat Fee
$8.00 Per 15 Minutes
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Caregiver Training S5108
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per 15 Minutes $8.75
Flat Fee
$8.75 Per 15 Minutes
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
PT/OT/ST
Occupational Therapy S9129
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Visit $75.00
Flat Fee
$75.00 Per Visit
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
PT/OT/ST
Physical Therapy S9131
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Visit $75.00
Flat Fee
$75.00 Per Visit
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
PT/OT/ST
Speech Therapy S9128
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Visit $75.00
Flat Fee
$75.00 Per Visit
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Respiratory Therapy-Eval S5180
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Visit $75.00
Flat Fee
$75.00 Per Visit
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE LONG TERM CARE ANCILLARY SERVICES
MEDICAID
Ancillary
Home Health
Respiratory Treatment S5180 U2
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Per Visit $75.00
Flat Fee
$75.00 Per Visit
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
The Compensation Schedule for the Medicare Product at any given time is the lesser of (i) the Allowable Charges for the particular Covered Service, or (ii) the appropriate amount for such Covered Service under the Company's fee schedule in effect on the date of service for the Medicare Product.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment C: Commercial-Exchange EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
COMMERCIAL-EXCHANGE
Ancillary
Home Health
home health Covered Services
Y
100% of AC
The maximum compensation for home health Covered Services rendered to a Covered Person shall be the "Allowed Amount." Except as otherwise provided in this Compensation Schedule, the Allowed Amount for home health Covered Services is the lesser of: (i) Allowable Charges; or (ii) the "Contracted Rate" which is seventy percent (70%) of the Payor's fee schedule.
% of Payor's fee schedule
70% of Payor's fee schedule
0.7
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Skilled Nursing - Registered Nurse
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Registered Nurse | Per Hour | $80
Flat Fee
$80 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Skilled Nursing - Licensed Practical Nurse
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Skilled Nursing - Licensed Practical Nurse | Per Hour | $45
Flat Fee
$45 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Private Duty Nursing - Registered Nurse
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing - Registered Nurse | Per Hour | $52
Flat Fee
$52 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Private Duty Nursing - Licensed Practical Nurse
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Private Duty Nursing - Licensed Practical Nurse | Per Hour | $52
Flat Fee
$52 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Home Health Aide
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Home Health Aide | Per Hour | $18
Flat Fee
$18 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Personal Care
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Personal Care | Per Hour | $18
Flat Fee
$18 Per Hour
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Physical Therapy
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Physical Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Occupational Therapy
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Occupational Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Speech Therapy
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Speech Therapy | Per Diem | $90
Flat Fee
$90 Per Diem
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Respiratory Therapy
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Respiratory Therapy | Per Diem | $75
Flat Fee
$75 Per Diem
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
7.1. Term. This Agreement is effective as of the Health Plan Effective Date, and will remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated as provided in this Agreement. Termination of any Contracted Provider’s participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
Attachment D: Healthy Kids EXHIBIT 1 COMPENSATION SCHEDULE ANCILLARY SERVICES HOME HEALTH
Ancillary
Home Health
Medical Social Worker Visit
Healthy Kids
Y
100% of AC
The maximum compensation for ancillary Covered Services rendered to a Covered Person shall be the "Allowed Amount" as set forth below. Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ancillary Covered Services is the lesser of: (i) Allowable Charges; or (ii) the applicable "Contracted Rate" set forth below in Table 1. Medical Social Worker Visit | Per Diem | $100
Flat Fee
$100 Per Diem
Any authorized and/or Covered Service not noted in this Compensation Schedule will default to Health Plan's fee schedule.
Contract Name,Field Name,SF_DB_COL_NAME,Snippet,Page Number,Field Extracted Value,Actual Value,Imputed Value
Filename,Agreement_Name (Contract Title),PAYER NAME,Health Plan State,Affiliate (Y/N),Credentialing Application Indicator,Term Clause,"Evergreen, Fixed or Hard Term",Termination Date,Termination Upon Notice - Days,Termination With Cause - Days,Amend Contract Upon notice Flag (Y/N),Timeframe to Object - Days,Assignments Clause (Y/N),Contract Effective Date,IRS #,IRS_Name,NPI (10-digits),NPI_NAME,PROV_GROUP_TIN_SIGNATORY,PROV_TIN_OTHER,PROV_NPI_OTHER,Notice to Provider Name,Notice to Provider Address,Sequestration Language,"Sequestration Reductions, included [Medicare only] (Y/N)",PROV_TIN_OTHER.1,PROV_NPI_OTHER.1,Parent Agreement Code,Pages,page_num,Attachment/Exhibit,Line of Business,Provider Type,Provider Type - Level 2,Service Type,Plan Type,"Lesser of Logic Language, included (Y/N)",Lesser of Rate,Reimb. Methodology,Reimb. Methodology_short,If rate is % of Payer or MCR [STANDARD],If rate is % of Payer or MCR [STANDARD]_Short,If rate is Flat Fee [STANDARD],Default Term,Default Rate,"Inclusion of essential RBRVS ""Fee Source"" Language (Y/N)","CDM Neutralization Language, included (Y/N)",Chargemaster Protection Language,Exclusions,Not to Exceed,Escalator or COLA (Y/N),"Escalator I, Eff. Date",IP/OP,"IP - DSH/IME/UC, included (Y/N)",IP - Stoploss Catastrophic Threshold,Imputed Value
1
Contract Name
Filename
Field Name
Agreement_Name (Contract Title)
SF_DB_COL_NAME
PAYER NAME
Snippet
Health Plan State
Page Number
Affiliate (Y/N)
Field Extracted Value
Credentialing Application Indicator
Actual Value
Term Clause
Evergreen, Fixed or Hard Term
Termination Date
Termination Upon Notice - Days
Termination With Cause - Days
Amend Contract Upon notice Flag (Y/N)
Timeframe to Object - Days
Assignments Clause (Y/N)
Contract Effective Date
IRS #
IRS_Name
NPI (10-digits)
NPI_NAME
PROV_GROUP_TIN_SIGNATORY
PROV_TIN_OTHER
PROV_NPI_OTHER
Notice to Provider Name
Notice to Provider Address
Sequestration Language
Sequestration Reductions, included [Medicare only] (Y/N)
PROV_TIN_OTHER.1
PROV_NPI_OTHER.1
Parent Agreement Code
Pages
page_num
Attachment/Exhibit
Line of Business
Provider Type
Provider Type - Level 2
Service Type
Plan Type
Lesser of Logic Language, included (Y/N)
Lesser of Rate
Reimb. Methodology
Reimb. Methodology_short
If rate is % of Payer or MCR [STANDARD]
If rate is % of Payer or MCR [STANDARD]_Short
If rate is Flat Fee [STANDARD]
Default Term
Default Rate
Inclusion of essential RBRVS "Fee Source" Language (Y/N)
CDM Neutralization Language, included (Y/N)
Chargemaster Protection Language
Exclusions
Not to Exceed
Escalator or COLA (Y/N)
Escalator I, Eff. Date
IP/OP
IP - DSH/IME/UC, included (Y/N)
IP - Stoploss Catastrophic Threshold
Imputed Value
Reference in New Issue
Block a user
Blocking a user prevents them from interacting with repositories, such as opening or commenting on pull requests or issues. Learn more about blocking a user.
AARETE\agupta