updated interface_3 to add Claude model
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AMENDMENT
|
||||
to the
|
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PROVIDER PARTICIPATION AGREEMENT
|
||||
between
|
||||
HEALTH NET OF CALIFORNIA, INC.
|
||||
and
|
||||
UNITED HEALTH CENTERS
|
||||
The Provider Participation Agreement ("Agreement") dated December 1, 2000 between United Health
|
||||
Centers of the San Joaquin Valley, Inc. ("Provider") and Health Net of California, Inc. on behalf of itself
|
||||
and the subsidiaries and affiliates of Health Net, Inc. (collectively, "Health Net" or "HNI") and
|
||||
subsequently amended, is hereby further amended effective January 1, 2014.
|
||||
Health Net and Provider hereby agree to amend the Agreement as follows:
|
||||
1. A new Section 5.6 shall be added to Article V, , TERM AND TERMINATION as follows:
|
||||
5.6
|
||||
Either party may terminate Addendum B.1 of this Agreement, with or without cause,
|
||||
upon ninety (90) days prior written notice to the other party.
|
||||
2. A new Addendum B.1, COMMERCIAL BENEFIT PROGRAMS, shall be added to the
|
||||
Agreement, as attached and incorporated herein.
|
||||
3. A new Exhibit B.1-1, COMMERCIAL BENEFIT PROGRAMS PAYMENT RATES
|
||||
PROVDER FEE-FOR-SERVICE RATE EXHIBIT PAYMENT RATES, shall be added to the
|
||||
Agreement, as attached and incorporated herein.
|
||||
Except as SO amended, all other provisions of the Agreement shall remain unchanged and in effect.
|
||||
IN WITNESS WHEREOF, the parties hereto have executed this Amendment by their officers duly
|
||||
authorized to be effective on the date and year first written above.
|
||||
United Health Centers
|
||||
Health Net of California, Inc.
|
||||
Tom Hamilton 17:19:44-07'00"
|
||||
Date: 2013.09.04
|
||||
Signature Colleen CURTIS
|
||||
Signature
|
||||
Thomas Hamilton
|
||||
Print Name
|
||||
Regional Health Plan Officer
|
||||
CEO
|
||||
Title
|
||||
8/29/13
|
||||
Date
|
||||
Date
|
||||
United Health Centers
|
||||
1
|
||||
Amendment 1-1-2014
|
||||
|
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Start of Page No. = 2
|
||||
ADDENDUM B.1
|
||||
COMMERCIAL BENEFIT PROGRAMS
|
||||
I.
|
||||
Applicability. This Addendum B.1 and accompanying exhibits apply to Covered
|
||||
Services delivered to Beneficiaries covered by commercial Benefit Programs that include but are not
|
||||
limited to HMO, PPO, EPO, POS, and any leased networks. All Covered Services delivered to a
|
||||
Beneficiary covered by a commercial Benefit Program shall be paid in accordance with this Addendum B.1
|
||||
regardless of product specific name unless otherwise specifically agreed by the parties and set forth in a
|
||||
separate rate exhibit.
|
||||
II.
|
||||
Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO),
|
||||
Point of Service (POS), Leased PPO Benefit Programs, and Payor Disclosures. Provider understands and
|
||||
agrees that Health Net may sell, lease, transfer or convey a list, including Provider, to Payors.
|
||||
Payors shall actively encourage subscribers to use the list of contracted providers when obtaining medical
|
||||
care. Active encouragement includes offering subscribers direct financial incentives to use the list of
|
||||
contracted providers when obtaining medical care (such as reduced Copayments, Coinsurance and
|
||||
Deductibles), or providing or causing the provision of information to subscribers advising such subscribers
|
||||
of the existence of a list of contracted providers through a variety of advertising or marketing approaches
|
||||
that supply the names, addresses and telephone numbers of contracted providers to subscribers in advance
|
||||
of their selection of a health care provider. Nothing in this Addendum B.1 shall be construed to require a
|
||||
Payor to actively encourage such Payor's subscribers to use the list of contracted providers, including
|
||||
Provider, when obtaining medical care in the event of an Emergency.
|
||||
Health Net shall not permit Payors to access this Agreement and pay Provider's contracted rate for the
|
||||
Benefit Programs covered by this Addendum unless Payor, or Health Net on Payor's behalf, has actively
|
||||
encouraged Payor's subscribers to use the list of contracted providers in obtaining medical care.
|
||||
Provider agrees that the following commercial Benefit Program Payors are eligible to pay Provider's
|
||||
contracted rate under this Addendum B.1 as of the effective date of this Agreement:
|
||||
NOT APPLICABLE
|
||||
Health Net may modify the above list periodically. Provider may request in writing, and Health Net shall
|
||||
have thirty (30) days from the date of such request, to provide Provider with an updated listing of Payors.
|
||||
Provider understands and agrees that any Health Net company, including, but not limited to, Health Net
|
||||
Life Insurance Company, are not Payors under Exhibit B.1-1, but shall access this Agreement as Health
|
||||
Net.
|
||||
III.
|
||||
Payment Compensation. As compensation for rendering Contracted Services to
|
||||
Beneficiaries covered by commercial HMO, PPO, EPO, POS and Leased PPO Benefit Programs under this
|
||||
Addendum B.1, Health Net shall pay and Provider shall accept as payment in full the rates set forth in
|
||||
Exhibit B.1-1, subject to the compensation conditions set forth in Exhibit B.1-1. Provider shall submit
|
||||
claims for such services in accordance with the terms of this Agreement and applicable State and federal
|
||||
law. Notwithstanding any other provision in this Agreement, the parties acknowledge that each Payor is
|
||||
solely responsible for paying Provider for Covered Services rendered to those individuals for whom Payor
|
||||
provides health care coverage. For self-insured Payors, Health Net shall not be obligated to pay all or any
|
||||
portion of any Provider claim on a Payor's behalf unless and until Health Net has received sufficient funds
|
||||
from the applicable Payor to cover such claim. In the event such Payor fails to provide funds to Health
|
||||
Net, Provider may seek payment from Member up to the rates specified in this Exhibit, unless prohibited by
|
||||
applicable law.
|
||||
United Health Centers
|
||||
2
|
||||
Amendment 1-1-2014
|
||||
|
||||
Start of Page No. = 3
|
||||
EXHIBIT B.1-1
|
||||
COMMERCIAL BENEFIT PROGRAMS
|
||||
PROVIDER FEE-FOR-SERVICE RATE EXHIBIT
|
||||
1. Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in
|
||||
Addendum G.1, Health Net or Payor shall pay and Provider shall accept as payment in full for non-
|
||||
capitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant
|
||||
to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges.
|
||||
Category of Service
|
||||
Compensation
|
||||
Covered Services delivered or arranged by Provider, excluding Laboratory
|
||||
95% of CMS
|
||||
services
|
||||
Allowable
|
||||
Anesthesia Services when provided by an Anesthesiologist or Certified Registered
|
||||
Nurse Anesthetist (American Society of Anesthesiology (ASA) unit scale)
|
||||
$39 / ASA unit
|
||||
Medical/Surgical Services by an Anesthesiologist or Certified Registered Nurse
|
||||
95% of CMS
|
||||
Anesthetist
|
||||
Allowable
|
||||
Laboratory Services performed in Provider or Professional Provider office
|
||||
95% of CMS
|
||||
Allowable
|
||||
Pharmaceuticals
|
||||
With an established Medicare Value
|
||||
95% of CMS
|
||||
Allowable
|
||||
Without an established Medicare Value
|
||||
95% of the Average
|
||||
Wholesale Price
|
||||
(AWP)
|
||||
OB Services
|
||||
CPT 59400: Global Obstetric care with vaginal delivery
|
||||
$1,700.00
|
||||
CPT 59510: Global Obstetric care with cesarean delivery
|
||||
$1,700.00
|
||||
CPT 59610: Vaginal Delivery after previous cesarean delivery
|
||||
$1,700.00
|
||||
CPT 59618: Attempted vaginal delivery, resulting in cesarean
|
||||
$1,700.00
|
||||
Immunizations
|
||||
With an established Medicare Value
|
||||
95% of CMS
|
||||
Allowable
|
||||
Without an established Medicare Value
|
||||
95% of the Average
|
||||
Wholesale Price
|
||||
(AWP)
|
||||
General Health Panel
|
||||
CPT 80050:
|
||||
General Health Panel
|
||||
$20.00
|
||||
CPT 80055:
|
||||
Obstetric Panel
|
||||
$15.00
|
||||
By Report (BR) Procedures, Procedures not Listed and Procedures with
|
||||
75% of billed charges
|
||||
Relativities not Established, and Pharmaceuticals/Immunizations without an
|
||||
for Covered Services
|
||||
established Medicare or AWP value
|
||||
United Health Centers
|
||||
3
|
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Amendment 1-1-2014
|
||||
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one you Joy xej HY /q SEM ee siul
|
||||
AMENDMENT TO
|
||||
AGREEMENT
|
||||
This Amendment to the Agreement ("Amendment") is entered into and made effective as of the date shown on the
|
||||
signature page ("Effective Date"), by and between Community Health Choice, Inc. and its Affiliates, (collectively
|
||||
"Community") and
|
||||
Dr Raul Rivera & Associates
|
||||
("Provider).
|
||||
(Legal Name and DBA as it appears on W-S)
|
||||
RECITALS
|
||||
WHEREAS, Community and Provider previously entered into an Agreement, pursuant to which Provider agreed to
|
||||
provide health care services on behalf of Community;
|
||||
WHEREAS, Community has its certificate of authority to operate as a health maintenance organization under Chapter
|
||||
843 of the Texas Insurance Code, as amended and Provider is licensed or otherwise authorized to provide a health care
|
||||
service in this State, and qualified to provide Covered Services; and
|
||||
WHEREAS, the parties desire to amend the Agreement to incorporate the following provisions detailed below.
|
||||
NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which is hereby
|
||||
acknowledged, the parties agree to as follows:
|
||||
1. The parties agree to include the following programs and reimbursement for Covered Services to the Agreement:
|
||||
Program
|
||||
Reimbursement
|
||||
STAR+PLUS
|
||||
Reimbursement at the same contracted rate for STAR.
|
||||
Dual Special Needs Plan
|
||||
Reimbursement shall be 100% of the then current Medicare fee allowable.
|
||||
(DSNP)
|
||||
2. The Texas Medicaid Provider Addendum attached hereto is made part of the Agreement.
|
||||
3. The Medicare Product-CMS Regulatory Addendum attached hereto is made part of the Agreement.
|
||||
4. All other provisions in the Agreement remain in effect.
|
||||
IN WITNESS WHEREOF, the parties have and caused this Agreement to be effective on the later day and year written
|
||||
above, by a duly authorized representative of Community Health Choice, Inc. and its Affiliates, and by execution on behalf
|
||||
of Ancillary by a duly authorized representative.
|
||||
Community Health Choice, Inc.
|
||||
Dr Raul Rivera & Associates
|
||||
2636 South Loop West, Suite 125
|
||||
3808 Woodlawn
|
||||
Houston, TX 77054
|
||||
Pasadena, TX, 77504
|
||||
Phone: 713-295-2295
|
||||
Phone: 713-944-4042
|
||||
Facsimilie: 713-295-7058
|
||||
Facsimile: 713-944-524
|
||||
Signature
|
||||
Signature
|
||||
K
|
||||
RAUL A. RIVERA
|
||||
Printed Name
|
||||
Printed Name
|
||||
M.D. Internal Medicine
|
||||
Title
|
||||
Title
|
||||
5/15/19
|
||||
05/10/2019
|
||||
Date
|
||||
Date
|
||||
760528768
|
||||
TIN
|
||||
TO BE COMPLETED BY Community ONLY:
|
||||
1700803467
|
||||
JUN 0 2019
|
||||
NPI
|
||||
Effective Date:
|
||||
Wd ZLILL:D
|
||||
212 leased
|
||||
0901
|
||||
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|
||||
AMENDMENT TO THE STANDARD HEALTH SERVICES AGREEMENT
|
||||
THIS AMENDMENT TO THE PROVIDER AGREEMENT dated this 1st
|
||||
day of
|
||||
August
|
||||
2014, by and between NEW YORK STATE CATHOLIC HEALTH PLAN,
|
||||
INC., doing business as FIDELIS CARE NEW YORK, a New York not-for-profit
|
||||
corporation certified as a prepaid health services plan pursuant to Article 44 of the New York
|
||||
State Public Health Law, and including its affiliates and subsidiaries (hereinafter collectively
|
||||
referred to as, the "Plan"), and Bentley Medical PLLC (hereinafter, "Provider"), a
|
||||
professional limited liability company organized under the laws of New York State..
|
||||
WHEREAS, Plan and Provider have heretofore entered into a certain Provider
|
||||
Agreement dated June 4, 2010 (the "Agreement") pursuant to which Provider became obligated
|
||||
to provide services to Enrollees (as defined in the Agreement); and
|
||||
WHEREAS, Provider currently participates in Plan's prepaid health services plan; and
|
||||
WHEREAS, Plan and Provider wish to amend certain sections of said Agreement,
|
||||
NOW, THEREFORE, in consideration of the mutual promises and other good and
|
||||
valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties
|
||||
do agree that the Agreement shall be, and is hereby, amended as follows:
|
||||
1.
|
||||
This Amendment replaces SCHEDULE 1.19, in their entirety, with SCHEDULE 1.19A.
|
||||
2.
|
||||
Appendix A of the Agreement is hereby deleted in its entirety and replaced with
|
||||
Appendix A2, attached hereto. The New York State Department of Health Standard Clauses for
|
||||
Managed Care Provider/IPA Contracts dated March 1, 2011, attached to this agreement as
|
||||
Appendix A2, are expressly incorporated into this Agreement and are binding upon the parties to
|
||||
this Agreement. In the event of any inconsistent or contrary language between the Standard
|
||||
Clauses and any other part of the Agreement, including but not limited to appendices,
|
||||
amendments and exhibits, the parties agree that provisions of the "Standard Clauses" shall
|
||||
prevail, except to the extent applicable law requires otherwise and/or to the extent a provision of
|
||||
this Agreement exceeds the minimum requirements of the Standard Clauses.
|
||||
3.
|
||||
Submission of Electronic Claims and Acceptance of Information through Electronic
|
||||
Medium. Provider agrees to submit claims for services rendered to enrollees and to accept
|
||||
enrollee rosters, remittance advices and other Plan communications electronically through a
|
||||
medium designated by the Plan.
|
||||
4.
|
||||
This Amendment shall terminate upon the termination of the Agreement under the same
|
||||
terms and conditions specified herein.
|
||||
5.
|
||||
All other terms and conditions of the Agreement, except as amended herein, shall remain
|
||||
the same and are hereby ratified and confirmed.
|
||||
6.
|
||||
This Amendment to the Agreement may be executed in one or more counterparts, each of
|
||||
which shall be deemed an original and all of which shall constitute but one and the same
|
||||
instrument.
|
||||
7.
|
||||
With respect to services provided pursuant to the Capitated Financial Alignment
|
||||
Demonstration, Plan will provide Medicare Parts A and B services at zero cost-sharing to Plan
|
||||
1
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 2
|
||||
enrollees under its integrated package of benefits, and Provider is prohibited for billing enrollees
|
||||
for any Medicare Part A or Part B service under this demonstration.
|
||||
2
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 3
|
||||
IN WITNESS WHEREOF, the parties here have signed this AMENDMENT to become
|
||||
effective on the date referenced above.
|
||||
Bentley Medical PLLC
|
||||
NEW YORK STATE CATHOLIC HEALTH
|
||||
Provider (Please Print)
|
||||
PLAN, INC. d/b/a Fidelis Care New York
|
||||
95-25 Queens Boulevard
|
||||
9020 5th Avenue
|
||||
Rego Park, New York 11374
|
||||
Address
|
||||
By: David P. Thomas
|
||||
Brooklyn, NY, 11209
|
||||
City, State, Zip Code
|
||||
Its: Executive Vice President & Chief Operating Officer
|
||||
Entity Tax ID#: 262637727
|
||||
Date:
|
||||
7/21/14
|
||||
Entity NPI#: 1790919140
|
||||
Signature: Date
|
||||
Name:
|
||||
(Please Print)
|
||||
Bernard W Bertleyer
|
||||
Title:
|
||||
Radhi logist
|
||||
Date:
|
||||
7-1-14
|
||||
Signature:
|
||||
3
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 4
|
||||
SCHEDULE 1.19A
|
||||
ANCILLARY SERVICES REIMBURSEMENT
|
||||
PROGRAM: Medicaid Managed Care , Family Health Plus & Child Health Plus
|
||||
In addition to Primary Care and Specialist Services, Provider will provide to Enrollees, pursuant
|
||||
to the terms and conditions of this Agreement and the applicable Program Contract, all Ancillary
|
||||
Services available from Provider. Ancillary Services will be reimbursed at 85% of the prevailing
|
||||
Medicaid fee schedule existing at the time the applicable service was rendered.
|
||||
PROGRAM: Medicare Advantage
|
||||
In addition to Primary Care and Specialist Services, Provider will provide to Enrollees, pursuant
|
||||
to the terms and conditions of this Agreement and the applicable Program Contract, all Ancillary
|
||||
Services available from Provider. Ancillary Services will be reimbursed at 85% of the prevailing
|
||||
Medicare rate for Provider's geographical area effective at the date of service.
|
||||
4
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 5
|
||||
APPENDIX A2
|
||||
NEW YORK STATE DEPARTMENT OF HEALTH
|
||||
STANDARD CLAUSES
|
||||
FOR MANAGED CARE PROVIDER/IPA CONTRACTS
|
||||
March 1, 2011
|
||||
Notwithstanding any other provision of this agreement, contract, or amendment
|
||||
(hereinafter "the Agreement" or "this Agreement") the parties agree to be bound by the
|
||||
following clauses which are hereby made a part of the Agreement. Further, if this Agreement is
|
||||
between a Managed Care Organization and an IPA, or between an IPA and an IPA, such clauses
|
||||
must be included in IPA contracts with providers, and providers must agree to such clauses.
|
||||
A.
|
||||
DEFINITIONS FOR PURPOSES OF THIS APPENDIX
|
||||
"Managed Care Organization" or MCO" shall mean the person, natural or corporate, or any
|
||||
groups of such persons, certified under Public Health Law Article 44, who enter into an
|
||||
arrangement, agreement or plan or any combination of arrangements or plans which provide or
|
||||
offer, or which do provide or offer, a comprehensive health services plan.
|
||||
"Independent Practice Association" or "IPA" shall mean an entity formed for the limited purpose
|
||||
of arranging by contract for the delivery or provision of health services by individuals, entities
|
||||
and facilities licensed or certified to practice medicine and other health professions, and, as
|
||||
appropriate, ancillary medical services and equipment, by which arrangements such health care
|
||||
providers and suppliers will provide their services in accordance with and for such compensation
|
||||
as may be established by a contract between such entity and one or more MCOs. "IPA" may
|
||||
also include, for purposes of this Agreement, a pharmacy or laboratory with the legal authority to
|
||||
contract with other pharmacies or laboratories to arrange for or provide services to enrollees of a
|
||||
New York State MCO.
|
||||
"Provider" shall mean physicians, dentists, nurses, pharmacists and other health care
|
||||
professionals, pharmacies, hospitals and other entities engaged in the delivery of health care
|
||||
services which are licensed, registered and/or certified as required by applicable federal and state
|
||||
law.
|
||||
B.
|
||||
GENERAL TERMS AND CONDITIONS
|
||||
1.
|
||||
This Agreement is subject to the approval of the New York State Department of Health
|
||||
and if implemented prior to such approval, the parties agree to incorporate into this
|
||||
Agreement any and all modifications required by the Department of Health for approval
|
||||
or, alternatively, to terminate this Agreement if SO directed by the Department of Health,
|
||||
effective sixty (60) days subsequent to notice, subject to Public Health Law 4403(6) (e).
|
||||
This Agreement is the sole agreement between the parties regarding the arrangement
|
||||
established herein.
|
||||
5
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 6
|
||||
2.
|
||||
Any material amendment to this Agreement is subject to the prior approval of the
|
||||
Department of Health, and any such amendment shall be submitted for approval at least
|
||||
thirty (30) days, or ninety (90) days if the amendment adds or materially changes a risk
|
||||
sharing arrangement that is subject to Department of Health review, in advance of
|
||||
anticipated execution. To the extent the MCO provides and arranges for the provision of
|
||||
comprehensive health care services to enrollees served by the Medical Assistance
|
||||
Program, the MCO shall notify and/or submit a copy of such material amendment to
|
||||
DOH or New York City, as may be required by the Medicaid managed care contract
|
||||
between the MCO and DOH (or New York City) and/or the Family Health Plus contract
|
||||
between the MCO and DOH.
|
||||
3.
|
||||
Assignment of an agreement between an MCO and (1) an IPA, (2) institutional network
|
||||
provider, or (3) medical group provider that serves five percent or more of the enrolled
|
||||
population in a county, or the assignment of an agreement between an IPA and (1) an
|
||||
institutional provider or (2) medical group provider that serves five percent or more of the
|
||||
enrolled population in a county, requires the prior approval of the Commissioner of
|
||||
Health.
|
||||
4.
|
||||
The Provider agrees, or if the Agreement is between the MCO and an IPA or between an
|
||||
IPA and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply
|
||||
fully and abide by the rules, policies and procedures that the MCO (a) has established or
|
||||
will establish to meet general or specific obligations placed on the MCO by statute,
|
||||
regulation, or DOH or SID guidelines or policies and (b) has provided to the Provider at
|
||||
least thirty (30) days in advance of implementation, including but not limited to:
|
||||
quality improvement/management;
|
||||
utilization management, including but not limited to precertification procedures,
|
||||
referral process or protocols, and reporting of clinical encounter data;
|
||||
member grievances; and
|
||||
provider credentialing.
|
||||
5.
|
||||
The Provider or, if the Agreement is between the MCO and an IPA, or between an IPA
|
||||
and an IPA, the IPA agrees, and shall require its providers to agree, to not discriminate
|
||||
against an enrollee based on color, race, creed, age, gender, sexual orientation, disability,
|
||||
place of origin, source of payment or type of illness or condition.
|
||||
6.
|
||||
If the Provider is a primary care practitioner, the Provider agrees to provide for twenty-
|
||||
four (24) hour coverage and back up coverage when the Provider is unavailable. The
|
||||
Provider may use a twenty-four (24) hour back-up call service provided appropriate
|
||||
personnel receive and respond to calls in a manner consistent with the scope of their
|
||||
practice.
|
||||
7.
|
||||
The MCO or IPA which is a party to this Agreement agrees that nothing within this
|
||||
Agreement is intended to, or shall be deemed to, transfer liability for the MCO's or IPA's
|
||||
own acts or omissions, by indemnification or otherwise, to a provider.
|
||||
6
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 7
|
||||
8.
|
||||
Notwithstanding any other provision of this Agreement, the parties shall comply with the
|
||||
provisions of the Managed Care Reform Act of 1996 (Chapter 705 of the Laws of 1996)
|
||||
Chapter 551 of the Laws of 2006, Chapter 451 of the Laws of 2007 and Chapter 237 of
|
||||
the Laws of 2009 with all amendments thereto.
|
||||
9.
|
||||
To the extent the MCO enrolls individuals covered by the Medical Assistance and/or
|
||||
Family Health Plus programs, this Agreement incorporates the pertinent MCO
|
||||
obligations under the Medicaid managed care contract between the MCO and DOH (or
|
||||
New York City) and/or the Family Health Plus contract between the MCO and DOH as if
|
||||
set forth fully herein, including:
|
||||
a.
|
||||
the MCO will monitor the performance of the Provider or IPA under the Agreement,
|
||||
and will terminate the Agreement and/or impose other sanctions, if the Provider's or
|
||||
IPA's performance does not satisfy standards set forth in the Medicaid managed care
|
||||
and/or Family Health Plus contracts;
|
||||
b. the Provider or IPA agrees that the work it performs under the Agreement will
|
||||
conform to the terms of the Medicaid managed care contract between the MCO and
|
||||
DOH (or between the MCO and New York City) and/or the Family Health Plus
|
||||
contract between the MCO and DOH, and that it will take corrective action if the
|
||||
MCO identifies deficiencies or areas of needed improvement in the Provider's or
|
||||
IPA's performance; and
|
||||
c.
|
||||
The Provider or IPA agrees to be bound by the confidentiality requirements set forth
|
||||
in the Medicaid managed care contract between the MCO and DOH (or between the
|
||||
MCO and New York City) and/or the Family Health Plus contract between the MCO
|
||||
and DOH.
|
||||
d. The MCO and the Provider or IPA agree that a woman's enrollment in the MCO's
|
||||
Medicaid managed care or Family Health Plus product is sufficient to provide
|
||||
services to her newborn, unless the newborn is excluded from enrollment in Medicaid
|
||||
managed care or the MCO does not offer a Medicaid managed care product in the
|
||||
mother's county of fiscal responsibility.
|
||||
e. The MCO shall not impose obligations and duties on the Provider or IPA that are
|
||||
inconsistent with the Medicaid managed care and/or Family Health Plus contracts, or
|
||||
that impair any rights accorded to DOH, the local Department of Social Services, or
|
||||
the United States Department of Health and Human Services.
|
||||
f.
|
||||
The Provider or IPA agrees to provide medical records to the MCO for purposes of
|
||||
determining newborn eligibility for Supplemental Security Income where the mother
|
||||
is a member of the MCO and for quality purposes at no cost to the MCO.
|
||||
g. The Provider or IPA agrees pursuant to 31 U.S.C. § 1352 and CFR Part 93, that no
|
||||
Federally appropriated funds have been paid or will be paid to any person by or on
|
||||
behalf of the Provider/IPA for the purpose of influencing or attempting to influence
|
||||
an officer or employee of any agency, a Member of Congress, an officer or employee
|
||||
7
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 8
|
||||
of Congress, or an employee of a Member of Congress in connection with the award
|
||||
of any Federal loan, the entering into of any cooperative agreement, or the extension,
|
||||
continuation, renewal, amendment, or modification of any Federal contract, grant,
|
||||
loan, or cooperative agreement. The Provider or IPA agrees to complete and submit
|
||||
the "Certification Regarding Lobbying," Appendix B attached hereto and
|
||||
incorporated herein, if this Agreement exceeds $100,000.
|
||||
If any funds other than Federally appropriated funds have been paid or will be paid to
|
||||
any person for the purpose of influencing or attempting to influence an officer or
|
||||
employee of any agency, a Member of Congress, an officer or employee of a member
|
||||
of Congress, in connection with the award of any Federal Contract, the making of any
|
||||
Federal grant, the making of any Federal loan, the entering of any cooperative
|
||||
agreement, or the extension, continuation, renewal, amendment, or modification of
|
||||
any Federal contract, grant, loan, or cooperative agreement, and the Agreement
|
||||
exceeds $100,000 the Provider or IPA shall complete and submit Standard Form-LLL
|
||||
"Disclosure Form to Report Lobbying," in accordance with its instructions.
|
||||
h. The Provider agrees to disclose to MCO on an ongoing basis, any managing
|
||||
employee that has been convicted of a misdemeanor or felony related to the person's
|
||||
involvement in any program under Medicare, Medicaid or a Title XX services
|
||||
program (Block grant programs)
|
||||
i. The Provider agrees to monitor its employees and staff against the List of Excluded
|
||||
Individuals and Entities (LEIE) and excluded individuals posted by the OMIG on its
|
||||
Website.
|
||||
j. The Provider agrees to disclose to MCO complete ownership, control, and
|
||||
relationship information.
|
||||
k. Provider agrees to obtain for MCO ownership information from any subcontractor
|
||||
with whom the provider has had a business transaction totaling more than $25,000,
|
||||
during the 12 month period ending on the date of the request made by SDOH, OMIG
|
||||
or DHHS. The information requested shall be provided to MCO within 35 days of
|
||||
such request.
|
||||
10.
|
||||
The parties to this Agreement agree to comply with all applicable requirements of the
|
||||
Federal Americans with Disabilities Act.
|
||||
11.
|
||||
The Provider agrees, or if the Agreement is between the MCO and an IPA or between an
|
||||
IPA and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply
|
||||
with all applicable requirements of the Health Insurance Portability and Accountability
|
||||
Act; the HIV confidentiality requirements of Article 27-F of the Public Health Law and
|
||||
Mental Hygiene Law § 33.13.
|
||||
C.
|
||||
PAYMENT/RISK ARRANGEMENTS
|
||||
1.
|
||||
Enrollee Non-liability. Provider agrees that in no event, including, but nót limited to,
|
||||
nonpayment by the MCO or IPA, insolvency of the MCO or IPA, or breach of this
|
||||
8
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 9
|
||||
Agreement, shall Provider bill, charge, collect a deposit from, seek compensation,
|
||||
remuneration or reimbursement from, or have any recourse against a subscriber, an
|
||||
enrollee or person (other than the MCO or IPA) acting on his/her/their behalf, for
|
||||
services provided pursuant to the subscriber contract or Medicaid Managed Care contract
|
||||
or Family Health Plus contract and this Agreement, for the period covered by the paid
|
||||
enrollee premium. In addition, in the case of Medicaid Managed Care, Provider agrees
|
||||
that, during the time an enrollee is enrolled in the MCO, he/she/it will not bill the New
|
||||
York State Department of Health or the City of New York for Covered Services within
|
||||
the Medicaid Managed Care Benefit Package as set forth in the Agreement between the
|
||||
MCO and the New York State Department of Health. In the case of Family Health Plus,
|
||||
Provider agrees that, during the time an enrollee is enrolled in the MCO, he/she/it will not
|
||||
bill the New York State Department of Health for Covered Services within the Family
|
||||
Health Plus Benefit Package, as set forth in the Agreement between the MCO and the
|
||||
New York State Department of Health. This provision shall not prohibit the provider,
|
||||
unless the MCO is a managed long term care plan designated as a Program of All-
|
||||
Inclusive Care for the Elderly (PACE), from collecting copayments, coinsurance
|
||||
amounts, or permitted deductibles, as specifically provided in the evidence of coverage,
|
||||
or fees for uncovered services delivered on a fee-for-service basis to a covered person
|
||||
provided that Provider shall have advised the enrollee in writing that the service is
|
||||
uncovered and of the enrollee's liability therefore prior to providing the service. Where
|
||||
the Provider has not been given a list of services covered by the MCO, and/or Provider is
|
||||
uncertain as to whether a service is covered, the Provider shall make reasonable efforts to
|
||||
contact the MCO and obtain a coverage determination prior to advising an enrollee as to
|
||||
coverage and liability for payment and prior to providing the service. This provision
|
||||
shall survive termination of this Agreement for any reason, and shall supersede any oral
|
||||
or written agreement now existing or hereafter entered into between Provider and
|
||||
enrollee or person acting on his or her behalf.
|
||||
2.
|
||||
Coordination of Benefits (COB). To the extent otherwise permitted in this Agreement,
|
||||
the Provider may participate in collection of COB on behalf of the MCO, with COB
|
||||
collectibles accruing to the MCO or to the provider. However, with respect to enrollees
|
||||
eligible for medical assistance, or participating in Child Health Plus or Family Health
|
||||
Plus, the Provider shall maintain and make available to the MCO records reflecting COB
|
||||
proceeds collected by the Provider or paid directly to enrollees by third party payers, and
|
||||
amounts thereof, and the MCO shall maintain or have immediate access to records
|
||||
concerning collection of COB proceeds.
|
||||
3.
|
||||
If the Provider is a health care professional licensed, registered or certified under Title 8
|
||||
of the Education Law, the MCO or the IPA must provide notice to the Provider at least
|
||||
ninety (90) days prior to the effective date of any adverse reimbursement arrangement as
|
||||
required by Public Health Law § 4406-c(5-c). Adverse reimbursement change shall
|
||||
mean a proposed change that could reasonably be expected to have a material adverse
|
||||
impact on the aggregate level of payment to a health care professional. This provision
|
||||
does not apply if the reimbursement change is required by law, regulation or applicable
|
||||
regulatory authority; is required as a result of changes in fee schedules, reimbursement
|
||||
methodology or payment policies established by the American Medical Association
|
||||
current procedural terminology (CPT) codes, reporting guidelines and conventions; or
|
||||
9
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 10
|
||||
such change is expressly provided for under the terms of this Agreement by the inclusion
|
||||
or reference to a specific fee or fee schedule, reimbursement methodology or payment
|
||||
policy indexing scheme.
|
||||
4.
|
||||
The parties agree to comply with and incorporate the requirements of Physician Incentive
|
||||
Plan (PIP) Regulations contained in 42 CFR 438.6(h), 42 CFR § 422.208, and 42 CFR §
|
||||
422.210 into any contracts between the contracting entity (provider, IPA, hospital, etc.)
|
||||
and other persons/entities for the provision of services under this Agreement. No specific
|
||||
payment will be made directly or indirectly under the plan to a physician or physician
|
||||
group as an inducement to reduce or limit medically necessary services furnished to an
|
||||
enrollee.
|
||||
5.
|
||||
The parties agree that a claim for home health care services following an inpatient
|
||||
hospital stay cannot be denied on the basis of medical necessity or a lack of prior
|
||||
authorization while a utilization review determination is pending if all necessary
|
||||
information was provided before a member's inpatient hospital discharge, consistent with
|
||||
Public Health Law § 4903.
|
||||
D.
|
||||
RECORDS ACCESS
|
||||
1.
|
||||
Pursuant to appropriate consent/authorization by the enrollee, the Provider will make the
|
||||
enrollee's medical records and other personally identifiable information (including
|
||||
encounter data for government-sponsored programs) available to the MCO (and IPA if
|
||||
applicable), for purposes including preauthorization, concurrent review, quality
|
||||
assurance, (including Quality Assurance Reporting Requirements ("QARR")), payment
|
||||
processing, and qualification for government programs, including but not limited to
|
||||
newborn eligibility for Supplemental Security Income (SSI) and for MCO/Manager
|
||||
analysis and recovery of overpayments due to fraud and abuse. The Provider will also
|
||||
make enrollee medical records available to the State for management audits, financial
|
||||
audits, program monitoring and evaluation, licensure or certification of facilities or
|
||||
individuals, and as otherwise required by state law. The Provider shall provide copies of
|
||||
such records to DOH at no cost. The Provider (or IPA if applicable) expressly
|
||||
acknowledges that he/she/it shall also provide to the MCO and the State (at no expense to
|
||||
the State), on request, all financial data and reports, and information concerning the
|
||||
appropriateness and quality of services provided, as required by law. These provisions
|
||||
shall survive termination of the contract for any reason.
|
||||
2.
|
||||
When such records pertain to Medicaid or Family Health Plus reimbursable services the
|
||||
Provider agrees to disclose the nature and extent of services provided and to furnish
|
||||
records to DOH and/or the United States Department of Health and Human Services, the
|
||||
County Department of Social Services, the Comptroller of the State of New York, the
|
||||
Office of the Medicaid Inspector General, the New York State Attorney General, and the
|
||||
Comptroller General of the United States and their authorized representatives upon
|
||||
request. This provision shall survive the termination of this Agreement regardless of the
|
||||
reason.
|
||||
10
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 11
|
||||
3.
|
||||
The parties agree that medical records shall be retained for a period of six (6) years after
|
||||
the date of service, and in the case of a minor, for three (3) years after majority or six (6)
|
||||
years after the date of service, whichever is later, or for such longer period as specified
|
||||
elsewhere within this Agreement. This provision shall survive the termination of this
|
||||
Agreement regardless of the reason.
|
||||
4.
|
||||
The MCO and the Provider agree that the MCO will obtain consent directly from
|
||||
enrollees at the time of enrollment or at the earliest opportunity, or that the Provider will
|
||||
obtain consent from enrollees at the time service is rendered or at the earliest opportunity,
|
||||
for disclosure of medical records to the MCO, to an IPA or to third parties. If the
|
||||
Agreement is between an MCO and an IPA, or between an IPA and an IPA, the IPA
|
||||
agrees to require the providers with which it contracts to agree as provided above. If the
|
||||
Agreement is between an IPA and a provider, the Provider agrees to obtain consent from
|
||||
the enrollee if the enrollee has not previously signed consent for disclosure of medical
|
||||
records.
|
||||
E.
|
||||
TERMINATION AND TRANSITION
|
||||
1.
|
||||
Termination or non-renewal of an agreement between an MCO and an IPA, institutional
|
||||
network provider, or medical group Provider that serves five percent or more of the
|
||||
enrolled population in a county, or the termination or non-renewal of an agreement
|
||||
between an IPA and an institutional Provider or medical group Provider that serves five
|
||||
percent or more of the enrolled population in a county, requires notice to the
|
||||
Commissioner of Health. Unless otherwise provided by statute or regulation, the
|
||||
effective date of termination shall not be less than 45 days after receipt of notice by either
|
||||
party, provided, however, that termination, by the MCO may be effected on less than 45
|
||||
days notice provided the MCO demonstrates to DOH's satisfaction prior to termination
|
||||
that circumstances exist which threaten imminent harm to enrollees or which result in
|
||||
Provider being legally unable to deliver the covered services and, therefore, justify or
|
||||
require immediate termination.
|
||||
2.
|
||||
If this Agreement is between the MCO and a health care professional, the MCO shall
|
||||
provide to such health care professional a written explanation of the reasons for the
|
||||
proposed contract termination, other than non-renewal, and an opportunity for a review as
|
||||
required by state law. The MCO shall provide the health care professional 60 days notice
|
||||
of its decision to not renew this Agreement.
|
||||
3.
|
||||
If this Agreement is between an MCO and an IPA, and the Agreement does not provide
|
||||
for automatic assignment of the IPA's Provider contracts to the MCO upon termination
|
||||
of the MCO/IPA contract, in the event either party gives notice of termination of the
|
||||
Agreement, the parties agree, and the IPA's providers agree, that the IPA providers shall
|
||||
continue to provide care to the MCO's enrollees pursuant to the terms of this Agreement
|
||||
for 180 days following the effective date of termination, or until such time as the MCO
|
||||
makes other arrangements, whichever first occurs. This provision shall survive
|
||||
termination of this Agreement regardless of the reason for the termination.
|
||||
11
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 12
|
||||
4.
|
||||
Continuation of Treatment. The Provider agrees that in the event of MCO or IPA
|
||||
insolvency or termination of this contract for any reason, the Provider shall continue,
|
||||
until medically appropriate discharge or transfer, or completion of a course of treatment,
|
||||
whichever occurs first, to provide services pursuant to the subscriber contract, Medicaid
|
||||
Managed Care contract, or Family Health Plus contract, to an enrollee confined in an
|
||||
inpatient facility, provided the confinement or course of treatment was commenced
|
||||
during the paid premium period. For purposes of this clause, the term "provider"
|
||||
shall include the IPA and the IPA's contracted providers if this Agreement is
|
||||
between the MCO and an IPA. This provision shall survive termination of this
|
||||
Agreement.
|
||||
5.
|
||||
Notwithstanding any other provision herein, to the extent that the Provider is providing
|
||||
health care services to enrollees under the Medicaid Program and/or Family Health Plus,
|
||||
the MCO or IPA retains the option to immediately terminate the Agreement when the
|
||||
Provider has been terminated or suspended from the Medicaid Program.
|
||||
6.
|
||||
In the event of termination of this Agreement, the Provider agrees, and, where applicable,
|
||||
the IPA agrees to require all participating providers of its network to assist in the orderly
|
||||
transfer of enrollees to another provider.
|
||||
F.
|
||||
ARBITRATION
|
||||
1.
|
||||
To the extent that arbitration or alternative dispute resolution is authorized elsewhere in
|
||||
this Agreement, the parties to this Agreement acknowledge that the Commissioner of
|
||||
Health is not bound by arbitration or mediation decisions. Arbitration or mediation shall
|
||||
occur within New York State, and the Commissioner of Health will be given notice of all
|
||||
issues going to arbitration or mediation, and copies of all decisions.
|
||||
G.
|
||||
IPA-SPECIFIC PROVISIONS
|
||||
1.
|
||||
Any reference to IPA quality assurance (QA) activities within this Agreement is limited
|
||||
to the IPA's analysis of utilization patterns and quality of care on its own behalf and as a
|
||||
service to its contract providers.
|
||||
12
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 13
|
||||
APPENDIX B
|
||||
CERTIFICATION REGARDING LOBBYING
|
||||
The undersigned certifies, to the best of his or her knowledge, that:
|
||||
1. No Federal appropriated funds have been paid or will be paid to any person by or on behalf
|
||||
of the Provider for the purpose of influencing or attempting to influence an officer or
|
||||
employee of any agency, a Member of Congress, an officer or employee of a Member of
|
||||
Congress in connection with the award of any Federal loan, the entering into any cooperative
|
||||
agreement, or the extension, continuation, renewal, amendment, or modification of any
|
||||
Federal contract, grant, loan, or cooperative agreement.
|
||||
2. If any funds other than Federal appropriated funds have been paid or will be paid to any
|
||||
person for the purpose of influencing or attempting to influence an officer or employee of
|
||||
any agency, a Member of Congress in connection with the award of any Federal contract, the
|
||||
making of any Federal grant, the making of any Federal loan, the entering into any
|
||||
cooperative agreement, or the extension, continuation, renewal, amendment or modification
|
||||
of any Federal contract, grant, loan, or cooperative agreement, and the Agreement exceeds
|
||||
$100,000, the Provider shall complete and submit Standard Form-LLL "Disclosure Form to
|
||||
Reporting Lobby," in accordance with its instructions.
|
||||
This certification is a material representation of fact upon which reliance was placed when this
|
||||
transaction was made or entered into submission of this certification is a prerequisite for making or
|
||||
entering into this transaction pursuant to U.S.C. Section 1352. The failure to file the required
|
||||
certification shall subject the violator to a civil penalty of not less than $10,000 and not more than
|
||||
$100,000 for each such failure.
|
||||
DATE:
|
||||
TITLE:
|
||||
ORGANIZATION:
|
||||
NAME: (Please Print)
|
||||
SIGNATURE:
|
||||
Approved by OMB
|
||||
13
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 14
|
||||
0348-0046
|
||||
Appendix [b]
|
||||
Disclosure of Lobbying Activities
|
||||
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
|
||||
(See reverse for public burden disclosure)
|
||||
1. Type of Federal Action
|
||||
2. Status of Federal Action:
|
||||
3. Report Type:
|
||||
a. contract
|
||||
a. bid/offer/application
|
||||
a. initial filing
|
||||
b. grant
|
||||
b. initial award
|
||||
b. material change
|
||||
c. cooperative agreement
|
||||
C. post-award
|
||||
Select one:
|
||||
d. loan
|
||||
Select one:
|
||||
e. loan guarantee
|
||||
f. loan insurance
|
||||
For material change only:
|
||||
Select one:
|
||||
Year
|
||||
Quarter
|
||||
Date of last report
|
||||
4. Name and Address of Reporting Entity:
|
||||
5. If Reporting Entity in No. 4 is Subawardee,
|
||||
Prime
|
||||
Address
|
||||
Subawardee
|
||||
City
|
||||
Tier
|
||||
if known:
|
||||
State
|
||||
Zip code
|
||||
Congressional District, if known:
|
||||
Congressional District, if known:
|
||||
6. Federal Department/Agency:
|
||||
7. Federal Program Name/Description:
|
||||
CFDA Number, if applicable:
|
||||
8. Federal Action Number, if known:
|
||||
9. Award Amount, if known:
|
||||
$
|
||||
10. a. Name and Address of Lobbying Registrant
|
||||
10. b. Individuals Performing Services
|
||||
(including address if different from No. 10a)
|
||||
(if individual, last name, first name, MI)
|
||||
(last name, first name, MI)
|
||||
Address
|
||||
Address
|
||||
City
|
||||
City
|
||||
State
|
||||
State
|
||||
Zip code
|
||||
Zip code
|
||||
11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying
|
||||
activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was
|
||||
made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the
|
||||
Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall
|
||||
be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
|
||||
Signature
|
||||
Print/Type Name
|
||||
Title
|
||||
Telephone No.:
|
||||
Date:
|
||||
Federal Use Only
|
||||
Authorized for Local Reproduction
|
||||
Standard Form - LLL (Rev. 7-97)
|
||||
14
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 15
|
||||
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
|
||||
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the
|
||||
initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section
|
||||
1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for
|
||||
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
|
||||
employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Complete
|
||||
all items apply for both the initial filing and material change report. Refer to the implementing guidance published by the
|
||||
Office of Management and Budget for additional information.
|
||||
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the
|
||||
outcome of a covered Federal action.
|
||||
2. Identify the status of the covered Federal action.
|
||||
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the
|
||||
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
|
||||
previously submitted report by this reporting entity for this covered Federal action.
|
||||
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District if known.
|
||||
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward
|
||||
recipient. Identify the tier of the subawardee, e.g. the first subawardee of the prime is the 1st tier. Subawards include
|
||||
but are not limited to subcontracts, subgrants and contract awards under grants.
|
||||
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and
|
||||
zip code of the prime Federal recipient. Include Congressional District, if known.
|
||||
6. Enter the name of federal agency making the award or loan commitment. Include at least one organizational level
|
||||
below agency name, if known. For example, Department of Transportation, United States Coast Guard.
|
||||
7.
|
||||
Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog
|
||||
of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.
|
||||
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g.
|
||||
Request for Proposal (RFP) number, Invitations for Bid (IFB) number; grant announcement number; the contract,
|
||||
grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included
|
||||
prefixes, e.g. "RFP-DE-90-001".
|
||||
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the
|
||||
Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.
|
||||
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act
|
||||
of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action.
|
||||
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter
|
||||
Last Name, First Name and Middle Initial (MI).
|
||||
11. The certifying official shall sign and date the form, print his/her name, title and telephone number.
|
||||
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it
|
||||
displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public
|
||||
reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing
|
||||
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
|
||||
of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including
|
||||
suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046),
|
||||
Washington, DC 20503
|
||||
15
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 16
|
||||
Appendix C
|
||||
CMS Clauses
|
||||
CMS requires that specific terms and conditions be incorporated into the Agreement between a Medicare
|
||||
Advantage Organization or First Tier Entity and a First Tier Entity or Downstream Entity to comply with the
|
||||
Medicare laws, regulations, and CMS instructions, including, but not limited to, the Medicare Prescription Drug,
|
||||
Improvement and Modernization Act of 2003, Pub. L. No. 108-173, 117 Stat. 2066 ("MMA"); and
|
||||
Except as provided herein, all other provisions of the Agreement between Plan and Provider not inconsistent herein
|
||||
shall remain in full force and effect. The provisions of this Appendix shall supersede and replace any inconsistent
|
||||
provisions to the Agreement, to ensure compliance with required CMS provisions, and shall continue concurrently
|
||||
with the term of such Agreement.
|
||||
NOW, THEREFORE, the parties agree as follows:
|
||||
Definitions:
|
||||
Centers for Medicare and Medicaid Services ("CMS"): the agency within the Department of Health and Human
|
||||
Services that administers the Medicare program.
|
||||
Completion of Audit: completion of audit by the Department of Health and Human Services, the Government
|
||||
Accountability Office, or their designees of a Medicare Advantage Organization, Medicare Advantage
|
||||
Organization contractor or related entity.
|
||||
Downstream Entity: any party that enters into a written arrangement, acceptable to CMS, with persons or entities
|
||||
involved with the MA benefit, below the level of the arrangement between an MA organization (or applicant)
|
||||
and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both
|
||||
health and administrative services.
|
||||
Final Contract Period: the final term of the contract between CMS and the Medicare Advantage Organization.
|
||||
First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MA organization
|
||||
or applicant to provide administrative services or health care services for a Medicare eligible individual under
|
||||
the MA program.
|
||||
Medicare Advantage ("MA"): an alternative to the traditional Medicare program in which private plans run by
|
||||
health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly
|
||||
from the Medicare program.
|
||||
Medicare Advantage Organization ("MA organization"): a public or private entity organized and licensed by a
|
||||
State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is
|
||||
certified by CMS as meeting the MA contract requirements.
|
||||
Member or Enrollee: a Medicare Advantage eligible individual who has enrolled in or elected coverage through a
|
||||
Medicare Advantage Organization.
|
||||
16
|
||||
Benfley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 17
|
||||
Provider: (1) any individual who is engaged in the delivery of health care services in a State and is licensed or
|
||||
certified by the State to engage in that activity in the State; and (2) any entity that is engaged in the delivery
|
||||
of
|
||||
health care services in a State and is licensed or certified to deliver those services if such licensing or certification is
|
||||
required by State law or regulation.
|
||||
Related entity: any entity that is related to the MA organization by common ownership or control and (1)
|
||||
performs some of the MA organization's management functions under contract or delegation; (2) furnishes
|
||||
services to Medicare enrollees under an oral or written agreement; or (3) leases real property or sells materials
|
||||
to the MA organization at a cost of more than $2,500 during a contract period.
|
||||
Required Provisions:
|
||||
First Tier or Downstream Entity ("Provider") agrees to the following:
|
||||
1. HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any
|
||||
pertinent information for any particular contract period, including, but not limited to, any books,
|
||||
contracts, computer or other electronic systems (including medical records and documentation of the
|
||||
first tier, downstream, and entities related to CMS' contract with [Entity Name], (hereinafter, "MA
|
||||
organization") through 10 years from the final date of the final contract period of the contract entered
|
||||
into between CMS and the MA organization or from the date of completion of any audit, whichever is
|
||||
later. [42 C.F.R. § § 422.504(i)(2)(i) and (ii)]
|
||||
2. Provider will comply with the confidentiality and enrollee record accuracy requirements, including: (1)
|
||||
abiding by all Federal and State laws regarding confidentiality and disclosure of medical records, or
|
||||
other health and enrollment information, (2) ensuring that medical information is released only in
|
||||
accordance with applicable Federal or State law, or pursuant to court orders or subpoenas, (3)
|
||||
maintaining the records and information in an accurate and timely manner, and (4) ensuring timely
|
||||
access by enrollees to the records and information that pertain to them. [42 C.F.R. §§ 422.504(a)(13)
|
||||
and 422.118]
|
||||
3.
|
||||
Enrollees will not be held liable for payment of any fees that are the legal obligation of the MA
|
||||
organization. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)]
|
||||
4.
|
||||
For all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for Medicare
|
||||
Part A and B cost sharing when the State is responsible for paying such amounts. Providers will be
|
||||
informed of Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid.
|
||||
Provider may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted
|
||||
with respect to the individual under title XIX if the individual were not enrolled in such a plan.
|
||||
Providers will: (1) accept the MA plan payment as payment in full, or (2) bill the appropriate State
|
||||
source. [42 C.F.R. § 422.504(i)(3)(i) and 422.504(g)(1)(i)]
|
||||
5. Any services or other activity performed in accordance with a contract or written agreement by Provider
|
||||
are consistent and comply with the MA organization's contractual obligations. [42 C.F.R.
|
||||
422.504(i)(3)(iii)
|
||||
6. Contracts or other written agreements between the MA organization and providers or between first tier
|
||||
and downstream entities must contain a prompt payment provision, the terms of which are developed
|
||||
and agreed to by the contracting parties. The MA organization is obligated to pay contracted providers
|
||||
under the terms of the contract between the [MA organization Name/First Tier Entity Name] and
|
||||
the
|
||||
17
|
||||
Bentley Medical PLLC 6.10.14
|
||||
|
||||
Start of Page No. = 18
|
||||
provider. [42 C.F.R. § § 422.520(b)(1) and (2)]
|
||||
7. [Entity Name] and any related entity, contractor or subcontractor will comply with all applicable
|
||||
Medicare laws, regulations, and CMS instructions. [42 C.F.R. § § 422.504(i)(4)(v)]
|
||||
8. If any of the MA organization's activities or responsibilities under its contract with CMS are delegated
|
||||
to any first tier, downstream and related entity:
|
||||
(i)
|
||||
The delegated activities and reporting responsibilities are specified as follows:
|
||||
NA
|
||||
(ii)
|
||||
CMS and the MA organization reserve the right to revoke the delegation activities and reporting
|
||||
requirements or to specify other remedies in instances where CMS or the MA organization
|
||||
determine that such parties have not performed satisfactorily.
|
||||
(iii) The MA organization will monitor the performance of the parties on an ongoing basis.
|
||||
(iv) The credentials of medical professionals affiliated with the party or parties will be either reviewed
|
||||
by the MA organization or the credentialing process will be reviewed and approved by the MA
|
||||
organization and the MA organization must audit the credentialing process on an ongoing basis.
|
||||
(v)
|
||||
If the MA organization delegates the selection of providers, contractors, or subcontractor, the MA
|
||||
organization retains the right to approve, suspend, or terminate any such arrangement.
|
||||
[42 2.C.F.R. §§ 422.504(i)(4) and (5)]
|
||||
In the event of a conflict between the terms and conditions above and the terms of a related agreement, the terms
|
||||
above control.
|
||||
18
|
||||
Bentley Medical PLLC 6.10.14
|
||||
+487
@@ -0,0 +1,487 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT TO THE STANDARD HEALTH SERVICES AGREEMENT
|
||||
THIS AMENDMENT TO THE PROVIDER AGREEMENT dated this 1st day of November,
|
||||
2012, by and between NEW YORK STATE CATHOLIC HEALTH PLAN, INC., doing
|
||||
business as FIDELIS CARE NEW YORK, a New York not-for-profit corporation certified as a
|
||||
prepaid health services plan pursuant to Article 44 of the New York State Public Health Law, and
|
||||
including its affiliates and subsidiaries (hereinafter collectively referred to as, the "Plan"), and
|
||||
Boro Park Obstetrics & Gynecology, PC (hereinafter, "Provider"), a Professional Corporation
|
||||
organized under the laws of New York State.
|
||||
WHEREAS, Plan and Provider have heretofore entered into a certain Provider Agreement
|
||||
dated January 6, 2006 (the "Agreement") pursuant to which Provider became obligated to provide
|
||||
services to Enrollees (as defined in the Agreement); and
|
||||
WHEREAS, Provider currently participates in Plan's prepaid health services plan; and
|
||||
WHEREAS, Plan and Provider wish to amend certain sections of said Agreement,
|
||||
NOW, THEREFORE, in consideration of the mutual promises and other good and valuable
|
||||
consideration, the receipt and sufficiency of which are hereby acknowledged, the parties do agree
|
||||
that the Agreement shall be, and is hereby, amended as follows:
|
||||
1.
|
||||
The Schedule 1.19 is hereby deleted in its entirety and replaced with Schedule 1.19A attached
|
||||
to this amendment and hereby added to the agreement
|
||||
2.
|
||||
Appendix A is hereby deleted in its entirety and replaced with Appendix A2, attached hereto.
|
||||
The New York State Department of Health Standard Clauses for Managed Care Provider/IPA
|
||||
Contracts dated March 1, 2011, attached to this agreement as Appendix A2, are expressly
|
||||
incorporated into this Agreement and are binding upon the parties to this Agreement. In the event of
|
||||
any inconsistent or contrary language between the Standard Clauses and any other part of the
|
||||
Agreement, including but not limited to appendices, amendments and exhibits, the parties agree that
|
||||
provisions of the "Standard Clauses" shall prevail, except to the extent applicable law requires
|
||||
otherwise and/or to the extent a provision of this Agreement exceeds the minimum requirements of
|
||||
the Standard Clauses.
|
||||
3.
|
||||
Submission of Electronic Claims and Acceptance of Information through Electronic Medium.
|
||||
Provider agrees to submit claims for services rendered to enrollees and to accept enrollee rosters,
|
||||
remittance advices and other Plan communications electronically through a medium designated by
|
||||
the Plan.
|
||||
4.
|
||||
This Amendment shall terminate upon the termination of the Agreement under the same
|
||||
terms and conditions specified herein.
|
||||
5.
|
||||
All other terms and conditions of the Agreement, except as amended herein, shall remain the
|
||||
same and are hereby ratified and confirmed.
|
||||
Boro Park Obstetrics & Gynecology, PC_amend_ef 8.28.12.doc
|
||||
1
|
||||
|
||||
Start of Page No. = 2
|
||||
IN WITNESS WHEREOF, the parties here have signed this MENDMENT to become
|
||||
effective on the date referenced above.
|
||||
Boro Park Obstetrics & Gynecology, PC NEW YORK STATE CATHOLIC HEALTH
|
||||
Provider (Please Print)
|
||||
PLAN, INC. d/b/a Fillelis Care New York
|
||||
95-25 Queens Boulevard
|
||||
5925 15th Avenue
|
||||
Rego Park, New York 11374
|
||||
Address
|
||||
By: David P. Thomas
|
||||
Brooklyn, NY 11229
|
||||
City, State, Zip Code
|
||||
Its: Senior Vice President & Chief Administrative Officer
|
||||
Entity Tax ID#: 112799543
|
||||
Date:
|
||||
10/31/12
|
||||
Entity NPI#: 1467586792
|
||||
Signature: DAUR
|
||||
Name: ELLA Alexa
|
||||
(Please Print)
|
||||
Title: PRactice administrator
|
||||
Date:
|
||||
10/15/12
|
||||
Signature:
|
||||
Ealexa
|
||||
Bore Park Obstetrics Gynecology PC__amend_ml_6711
|
||||
3
|
||||
|
||||
Start of Page No. = 3
|
||||
6.
|
||||
This Amendment to the Agreement may be executed in one or more counterparts, each of
|
||||
which shall be deemed an original and all of which shall constitute but one and the same instrument.
|
||||
Bore Park Obstetrics Gynecology PC_amend_m_0712
|
||||
2
|
||||
|
||||
Start of Page No. = 4
|
||||
SCHEDULE 1.19A
|
||||
ANCILLARY SERVICES REIMBURSEME NT
|
||||
PROGRAM: Medicaid Managed Care, Family Health Plus, Child 2013 Health Plus
|
||||
In addition to Primary Care and Specialist Services, Provider will provide to Enrollees, pursuant to
|
||||
the terms and conditions of this Agreement and the applicable Program Contract, all Ancillary
|
||||
Services available from Provider. Ancillary Services will be reimbursed it 90% of the Medicaid fee
|
||||
schedule existing at the time the applicable service was rendered.
|
||||
Boro Park Obstetrics Gynecology PC_amend_mt_6712
|
||||
4
|
||||
|
||||
Start of Page No. = 5
|
||||
APPENDIX A2
|
||||
NEW YORK STATE DEPARTMENT OF HEALTH
|
||||
STANDARD CLAUSES
|
||||
FOR MANAGED CARE PROVIDER/IPA CONT RACTS
|
||||
March 1. 2011
|
||||
Notwithstanding any other provision of this agreement, contract, or amendment (hereinafter
|
||||
"the Agrèement" or "this Agreement") the parties agree to be bound by the following clauses which
|
||||
are hereby made a part of the Agreement. Further, if this Agreement is between a Managed Care
|
||||
Organization and an IPA, or between an IPA and an IPA, such clause must be included in IPA
|
||||
contracts with providers, and providers must agree to such clauses.
|
||||
A.
|
||||
DEFINITIONS FOR PURPOSES OF THIS APPENDIX
|
||||
"Managed Care Organization" or "MCO" shall mean the person, natura or corporate, or any groups
|
||||
of such persons, certified under Public Health Law Article 44, who enter into an arrangement,
|
||||
agreement or plan or any combination of arrangements or plans which provide or offer, or which do
|
||||
provide or offer, a comprehensive health services plan.
|
||||
"Independent Practice Association" or "IPA" shall mean an entity formeil for the limited purpose of
|
||||
arranging by contract for the delivery or provision of health services by individuals, entities and
|
||||
facilities licensed or certified to practice medicine and other health profe sions, and, as appropriate,
|
||||
ancillary medical services and equipment, by which arrangements such health care providers and
|
||||
suppliers will provide their services in accordance with and for such compensation as may be
|
||||
established by a contract between such entity and one or more MCOs. "PA" may also include, for
|
||||
purposes of this Agreement, a pharmacy or laboratory with the legal authority to contract with other
|
||||
pharmacies or laboratories to arrange for or provide services to enrollees of a New York State MCO.
|
||||
"Provider" shall mean physicians, dentists, nurses, pharmacists and othe health care professionals,
|
||||
pharmacies, hospitals and other entities engaged in the delivery of health care services which are
|
||||
licensed, registered and/or certified as required by applicable federal an 1 state law.
|
||||
B.
|
||||
GENERAL TERMS AND CONDITIONS
|
||||
1.
|
||||
This Agreement is subject to the approval of the New York State Department of Health and
|
||||
if implemented prior to such approval, the parties agree to incor borate into this Agreement
|
||||
any and all modifications required by the Department of Health for approval or, alternatively,
|
||||
to terminate this Agreement if SO directed by the Department of Health, effective sixty (60)
|
||||
days subsequent to notice, subject to Public Health Law §4403(6) (e). This Agreement is the
|
||||
sole agreement between the parties regarding the arrangement stablished herein.
|
||||
Boro Park Obstetries Gynecology PC_amarid_tht_6
|
||||
5
|
||||
|
||||
Start of Page No. = 6
|
||||
2.
|
||||
Any material amendment to this Agreement is subject to he prior approval of the
|
||||
Department of Health, and any such amendment shall be submitted for approval at least
|
||||
thirty (30) days, or ninety (90) days if the amendment adds O materially changes a risk
|
||||
sharing arrangement that is subject to Department of Health review, in advance of anticipated
|
||||
execution. To the extent the MCO provides and arranges for the provision of comprehensive
|
||||
health care services to enrollees served by the Medical Assistani e Program, the MCO shall
|
||||
notify and/or submit a copy of such material amendment to DOF or New York City, as may
|
||||
be required by the Médicaid managed care contract between the MCO and DOH (or New
|
||||
York City) and/or the Family Health Plus contract between the MCO and DOH.
|
||||
3.
|
||||
Assignment of an agreement between an MCO and (1) an IPA (2) institutional network
|
||||
provider, or (3) medical group provider that serves five perce it or more of the enrolled
|
||||
population in a county, or the assignment of an agreement stween an IPA and (1) an
|
||||
institutional provider or (2) medical group provider that serves five percent or more of the
|
||||
enrolled population in a county, requires the prior approval of th Commissioner of Health.
|
||||
4.
|
||||
The Provider agrees, or if the Agreement is between the MCO are an IPA or between an IPA
|
||||
and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply fully
|
||||
and abide by the rules, policies and procedures that the MCO (a) has established or will
|
||||
establish to meet general or specific obligations placed on the MCO by statute, regulation, or
|
||||
DOH or SID guidelines or policies and (b) has provided to the Provider at least thirty (30)
|
||||
days in advance of implementation, including but not limited to
|
||||
quality improvement/management;
|
||||
utilization management, including but not limited to precertification procedures,
|
||||
referral process or protocols, and reporting of clinical recounter data;
|
||||
member grievances; and
|
||||
provider credentialing.
|
||||
5.
|
||||
The Provider or, if the Agreement is between the MCO and an IPA, or between an IPA and
|
||||
an IPA, the IPA agrees, and shall require its providers to agree, to not discriminate against an
|
||||
enrollee based on color, race, creed, age, gender, sexual rientation, disability, place of
|
||||
origin, source of payment or type of illness or condition.
|
||||
6.
|
||||
If the Provider is a primary care practitioner, the Provider agrees to provide for twenty-four
|
||||
(24) hour coverage and back up coverage when the Provider is unavailable. The Provider
|
||||
may use a twenty-four (24) hour back-up call service provided appropriate personnel receive
|
||||
and respond to calls in a manner consistent with the scope of th ir practice.
|
||||
7.
|
||||
The MCO or IPA which is a party to this Agreement agrees that nothing within this
|
||||
Agreement is intended to, or shall be deemed to, transfer liabil ty for the MCO's or IPA's
|
||||
own acts or omissions, by indemnification or otherwise, to a provider.
|
||||
8.
|
||||
Notwithstanding any other provision of this Agreement, the parties shall comply with the
|
||||
provisions of the Mariaged Care Reform Act of 1996 (Chapter 705 of the Laws of 1996)
|
||||
Chapter 551 of the Laws of 2006, Chapter 451 of the Laws of 2007 and Chapter 237 of the
|
||||
Laws of 2009 with all amendments thereto.
|
||||
Boro Park Obstetrics Gynecology out
|
||||
6
|
||||
|
||||
Start of Page No. = 7
|
||||
9.
|
||||
To the extent the MCO enrolls individuals covered by the Medical Assistance and/or Family
|
||||
Health Plus programs, this Agreement incorporates the pertinent MCO obligations under the
|
||||
Medicaid managed care contract between the MCO and DOH (o New York City) and/or the
|
||||
Family Health Plus contract between the MCO and DOH a if set forth fully herein,
|
||||
including:
|
||||
a. the MCO will monitor the performance of the Provider or IP under the Agreement, and
|
||||
will terminate the Agreement and/or impose other sanctions if the Provider's or IPA's
|
||||
performance does not satisfy standards set forth in the Medicaid managed care and/or
|
||||
Family Health Plus contracts;
|
||||
b. the Provider or IPA agrees that the work it performs under the Agreement will conform
|
||||
to the terms of the Medicaid managed care contract between the MCO and DOH (or
|
||||
between the MCO and New York City) and/or the Family Health Plus contract between
|
||||
the MCO and DOH, and that it will take corrective action if the MCO identifies
|
||||
deficiencies or areas of needed improvement in the Provider or IPA's performance; and
|
||||
c. The Provider or IPA agrees to be bound by the confidential y requirements set forth in
|
||||
the Medicaid managed care contract between the MCO and DOH (or between the MCO
|
||||
and New York City) and/or the Family Health Plus contract between the MCO and DOH.
|
||||
d. The MCO and the Provider or IPA agree that a woman's enrollment in the MCO's
|
||||
Medicaid managed care or Family Health Plus product is suficient to provide services to
|
||||
hernewborn, unless the newborn is excluded from enrollment in Medicaid managed care
|
||||
or the MCO does not offer a Medicaid managed care product in the mother's county of
|
||||
fiscal responsibility
|
||||
e.
|
||||
The MCO shall not impose obligations and duties on the Provider or IPA that are
|
||||
inconsistent with the Medicaid managed care and/or Family Health Plus contracts, or that
|
||||
impair any rights accorded to DOH, the local Department of Social Services, or the
|
||||
United States Department of Health and Human Services.
|
||||
f. The Provider or IPA agrees to provide medical records to the MCO for purposes of
|
||||
determining newborn eligibility for Supplemental Security come where the mother is a
|
||||
member of the MCO and for quality purposes at no cost to the MCO.
|
||||
g. The Provider or IP.A. agrees pursuant to 31 U.S.C. § 1352 and CFR Part 93, that no
|
||||
Federally appropriated funds have been paid or will be paid to any person by or on behalf
|
||||
of the Provider/IPA for the purpose of influencing or attempting to influence an officer or
|
||||
employee of any agency, a Member of Congress, an officer or employee of Congress, or
|
||||
an employee of a Member of Congress in connection with th award of any Federal loan,
|
||||
the entering into of any cooperative agreement, or the extension, continuation, renewal,
|
||||
amendment, or modification of any Federal contract, giant, loan, or cooperative
|
||||
agreement. The Provider or IPA agrees to complete and submit the "Certification
|
||||
Boro Park Obstetrics Gynecology C__amend_mt_67]2
|
||||
7
|
||||
|
||||
Start of Page No. = 8
|
||||
Regarding Lobbying," Appendix B attached hereto and incorporated herein, if this
|
||||
Agreement exceeds $100,000.
|
||||
If any funds other than Federally appropriated funds have been paid or will be paid to any
|
||||
person for the purpose of influencing or attempting to influer be an officer or employee of
|
||||
any agency, a Member of Congress, an officer or employee dif a member of Congress, in
|
||||
connection with the award of any Federal Contract, the making of any Federal grant, the
|
||||
making of any Federal loan, the entering of any cooperative agreement, or the extension,
|
||||
continuation, renewal, amendment, or modification of any Federal contract, grant, loan,
|
||||
or cooperative agreement, and the Agreement exceeds $100,00 the Provider or IPA shall
|
||||
complete and submit Standard Form-LLL "Disclosure For a to Report Lobbying," in
|
||||
accordance with its instructions.
|
||||
h. The Provider agrees to disclose to MCO on an ongoing basis, any managing employee
|
||||
that has been convicted of a misdemeanor or felony related to the person's involvement
|
||||
in any program under Medicare, Medicaid or a Title XX services program (Block grant
|
||||
programs)
|
||||
i.
|
||||
The Provider agrees to monitor its employees and staff ainst the List of Excluded
|
||||
Individuals and Entities (LEIE) and excluded individuals posted by the OMIG on its
|
||||
Website.
|
||||
j.
|
||||
The Provider agrees to disclose to MCO complete ownership, control, and relationship
|
||||
information.
|
||||
k. Provider agrees to obtain for MCO ownership information from any subcontractor with
|
||||
whom the provider has had a business transaction totaling more than $25,000, during the
|
||||
12 month period ending on the date of the request made by SDOH, OMIG or DHHS.
|
||||
The information requested shall be provided to MCO withii 35 days of such request.
|
||||
10.
|
||||
The parties to this Agreement agree to comply with all applicable requirements of the Federal
|
||||
Americans with Disabilities Act.
|
||||
11.
|
||||
The Provider agrees, or if the Agréement is between the MCO and an IPA or between an IPA
|
||||
and an IPA, the IPA agrees and shall require the IPA's providers o agree, to comply with all
|
||||
applicable requirements of the Health Insurance Portability and / accountability Act; the HIV
|
||||
confidentiality requirements of Article 27-F of the Public Healt Law and Mental Hygiene
|
||||
Law § 33.13.
|
||||
C.
|
||||
PAYMENT / RISK ARRANGEMENTS
|
||||
1.
|
||||
Enrollee Non-liability. Provider agrees that in no event, inc uding, but not limited to,
|
||||
nonpayment by the MCO or IPA, insolvency of the MCO or IPA, or breach of this
|
||||
Agreement, shall Provider bill, charge, collect a deposit from, seek compensation,
|
||||
remuneration or reimbursement from, or have any recourse against a subscriber, an enrollee
|
||||
or person (other than the MCO or IPA) acting on his/her/their behalf, for services provided
|
||||
pursuant to the subscriber contract or Medicaid Managed Care contract or Family Health
|
||||
Bero Park Obstetries Gynecology
|
||||
8
|
||||
|
||||
Start of Page No. = 9
|
||||
Plus contract and this Agreement, for the period covered by the paid enrollee premium. In
|
||||
addition, in the case of Medicaid Managed Care, Provider agrees that, during the time an
|
||||
enrollee is enrolled in the MCO, he/she/it will not bill the New York State Department of
|
||||
Health or the City of New York for Covered Services within the Medicaid Managed Care
|
||||
Benefit Package as set forth in the Agréement between the MCD and the New York State
|
||||
Department of Health. In the case of Family Health Plus, Prov der agrees that, during the
|
||||
time an enrollee is enrolled in the MCO, he/she/it will not bill the New York State
|
||||
Department of Health for Covered Services within the Family Health Plus Benefit Package,
|
||||
as set forth in the Agreement between the MCO and the New York State Department of
|
||||
Health. This provision shall not prohibit the provider, unless the MCO is a managed long
|
||||
term care plan designated as a Program of All-Inclusive Care for the Elderly (PACE), from
|
||||
collecting copayments, coinsurance amounts, or permitted deductibles, as specifically
|
||||
provided in the evidence of coverage, or fees for uncovered serv ces delivered on a fee-for-
|
||||
service basis to a covered person provided that Provider shall have advised the enrollee in
|
||||
writing that the service is uncovered and of the enrollee's liability therefore prior to providing
|
||||
the service. Where the Provider has not been given a list of ser ices covered by the MCO,
|
||||
and/or Provider is uncertain as to whether a service is covered, the Provider shall make
|
||||
reasonable efforts to contact the MCO and obtain a coverage determination prior to advising
|
||||
an enrollee as to coverage and liability for payment and prior to providing the service. This
|
||||
provision shall survive termination of this Agreement for any reason, and shall supersede any
|
||||
oral or written agreement now existing or hereafter entered ato between Provider and
|
||||
enrollee or person acting on his or her behalf.
|
||||
2.
|
||||
Coordination of Benefits (COB). To the extent otherwise permitted in this Agreement, the
|
||||
Provider may participate in collection of COB on behalf of the MCO, with COB collectibles
|
||||
accruing to the MCO or to the provider. However, with respect to enrollees eligible for
|
||||
medical assistance, or participating in Child Health Plus or Family Health Plus, the Provider
|
||||
shall maintain and make available to the MCO records reflecting COB proceeds collected by
|
||||
the Provider or paid directly to enrollees by third party payers, an d amounts thereof, and the
|
||||
MCO shall maintain or have immediate access to records con erning collection of COB
|
||||
proceeds.
|
||||
3.
|
||||
If the Provider is a health care professional licensed, registered or certified under Title 8 of
|
||||
the Education Law, the MCO or the IPA must provide notice to the Provider at least ninety
|
||||
(90) days prior to the effective date of any adverse reimbursement arrangement as required by
|
||||
Public Health Law § 4406-c(5-c). Adverse reimbursement change shall mean a proposed
|
||||
change that could reasonably be expected to have a material adverse impact on the aggregate
|
||||
level of payment to a health care professional. This provis on does not apply if the
|
||||
reimbursement change is required by law, regulation or applica le regulatory authority; is
|
||||
required as a result of changes in fee schedules, reimbursement methodology or payment
|
||||
policies established by the American Medical Association curr nt procedural terminology
|
||||
(CPT) codes, reporting guidelines and conventions; or such charge is expressly provided for
|
||||
under the terms of this Agreement by the inclusion or refererice to a specific fee or
|
||||
fee
|
||||
schedule, reimbursement methodology or payment policy index ing scheme.
|
||||
Boro Park Obstetrics Gynecology PC_amend_mt_6712
|
||||
9
|
||||
|
||||
Start of Page No. = 10
|
||||
4.
|
||||
The parties agree to comply with and incorporate the requirements of Physician Incentive
|
||||
Plan (PIP) Regulations contained in 42 CFR 438.6(h), 42 CFI § 422.208, and 42 CFR
|
||||
§
|
||||
422.210 into any contracts between the contracting entity (provider, IPA, hospital, etc.) and
|
||||
other persons/entities for the provision of services under this Agreement. No specific
|
||||
payment will be made directly or indirectly under the plan to a jysician or physician group
|
||||
as an inducement to reduce or limit medically necessary services furnished to an enrollee.
|
||||
5.
|
||||
The parties agree that a claim for home health care services following an inpatient hospital
|
||||
stay cannot be denied on the basis of medical necessity or a lack fprior authorization while
|
||||
a utilization review determination is pending if all necessary information was provided
|
||||
before a member's inpatient hospital discharge, consistent with Public Health Law § 4903.
|
||||
D.
|
||||
RECORDS ACCESS
|
||||
1.
|
||||
Pursuant to appropriate conserit/authorization by the enrollee, he Provider will make the
|
||||
enrollee's medical records and other personally identifiable infori nation (including encounter
|
||||
data for government-sponsored programs) available to the MCO (and IPA if applicable), for
|
||||
purposes including preauthorization, concurrent review, quality surance, (including Quality
|
||||
Assurance Reporting Requirements ("QARR")), payment processing, and qualification for
|
||||
government programs, including but not limited to newborn eligibility for Supplemental
|
||||
Security Income (SSI) and for MCO/Manager analysis and recov ery of overpayments due to
|
||||
fraud and abuse. The Provider will also make enrollee medical cords available to the State
|
||||
for management audits, financial audits, program monitoring and evaluation, licensure or
|
||||
certification of facilities or individuals, and as otherwise require by state law. The Provider
|
||||
shall provide copies of such records to DOH at no cost. The Provider (or IPA if applicable)
|
||||
expressly acknowledges that he/she/it shall also provide to the MCO and the State (at no
|
||||
expense to the State), on request, all financial data and reports, and information concerning
|
||||
the appropriateness and quality of services provided, as requirei by law. These provisions
|
||||
shall survive termination of the contract for any reason.
|
||||
2.
|
||||
When such records pertain to Medicaid or Family Health Plus reimbursable services the
|
||||
Provider agrees to disclose the nature and extent of services provided and to furnish records
|
||||
to DOH and/or the United States Department of Health and H.man Services, the County
|
||||
Department of Social Services, the Comptroller of the State of New York, the Office of the
|
||||
Medicaid Inspector General, the New York State Attorney General, and the Comptroller
|
||||
General of the United States and their authorized representatives upon request. This
|
||||
provision shall survive the termination of this Agreement regar less of the reason.
|
||||
3.
|
||||
The parties agree that medical records shall be retained for a period of six (6) years after the
|
||||
date of service, and in the case of a minor, for three (3) years aft majority or six (6) years
|
||||
after the date of service, whichever is later, or for such longer period as specified elsewhere
|
||||
within this Agreement. This provision shall survive the term nation of this Agreement
|
||||
regardless of the reason.
|
||||
4.
|
||||
The MCO and the Provider agree that the MCO will obtain consent directly from enrollees at
|
||||
the time of enrollment or at the earliest opportunity, or that the Provider will obtain consent
|
||||
Boro Park Obstetrics Gynecology:PC_amend_ml_6712
|
||||
10
|
||||
|
||||
Start of Page No. = 11
|
||||
from enrollees at the time service is rendered or at the earliest or portunity, for disclosure of
|
||||
medical records to the MCO, to an IPA or to third parties. If the Agreement is between an
|
||||
MCO and an IPA, or between an IPA and an IPA, the IPA agrees to require the providers
|
||||
with which it contracts to agree as provided above. If the Agreement is between an IPA and
|
||||
a provider, the Provider agrees to obtain consent from the enrollee if the enrollee has not
|
||||
previously signed consent for disclosure of medical records.
|
||||
E.
|
||||
TERMINATION AND TRANSITION
|
||||
1.
|
||||
Termination or non-renewal of an agreement between an MCO and an IPA, institutional
|
||||
network provider, or medical group Provider that serves five percent or more of the enrolled
|
||||
population in a county, or the termination or non-renewal of an agreement between an IPA
|
||||
and an institutional Provider or medical group Provider that serves five percent or more of
|
||||
the enrolled population in a county, requires notice to the Commissioner of Health. Unless
|
||||
otherwise provided by statute or regulation, the effective date of termination shall not be less
|
||||
than 45 days after receipt of notice by either party, provided, ho wever, that termination, by
|
||||
the MCO may be effected on less than 45 days notice provided the MCO demonstrates to
|
||||
DOH's satisfaction prior to termination that circumstances exis which threaten imminent
|
||||
harm to enrollees or which result in Provider being legally un ble to deliver the covered
|
||||
services and, therefore, justify or require immediate termination
|
||||
2.
|
||||
If this Agreement is between the MCO and a health care professional the MCO shall provide
|
||||
to such health care professional a written explanation of the reaso is for the proposed contract
|
||||
termination, other than non-renewal, and an opportunity for arev ew as required by state law.
|
||||
The MCO shall provide the health care professional 60 days riotice of its decision to not
|
||||
renew this Agreement.
|
||||
3.
|
||||
If this Agreement is between an MCO and an IPA, and the Agreement does not provide for
|
||||
automatic assignment of the IPA's Provider contracts to the MCO upon termination of the
|
||||
MCO/IPA contract, in the event either party gives notice of termination of the Agreement,
|
||||
the parties agree, and the IPA's providers agree, that the IPA providers shall continue to
|
||||
provide care to the MCO's enrollees pursuant to the terms of this Agreement for 180 days
|
||||
following the effective date of termination, or until such time as the MCO makes other
|
||||
arrangements, whichever first occurs. This provision shall survive termination of this
|
||||
Agreement regardless of the reason for the termination.
|
||||
4.
|
||||
Continuation of Treatment. The Provider agrees that in the event of MCO or IPA insolvency
|
||||
or termination of this contract for any reason, the Provider sha continue, until medically
|
||||
appropriate discharge or transfer, or completion of a course of treatment, whichever occurs
|
||||
first, to provide services pursuant to the subscriber contract, Medicaid Managed Care
|
||||
contract, or Family Health Plus contract, to an enrollee confirled in an inpatient facility,
|
||||
provided the confinement or course of treatment was commence I during the paid premium
|
||||
period. For purposes of this clause, the term "provider" sha include the IPA and the
|
||||
IPA's contracted providers if this Agreement is between the MCO and an IPA. This
|
||||
provision shall survive termination of this Agreement.
|
||||
Bore Park Obstetrics Gynecology
|
||||
11
|
||||
|
||||
Start of Page No. = 12
|
||||
5,
|
||||
Notwithstanding any other provision herein, to the extent that the Provider is providing
|
||||
health care services to enrollees under the Medicaid Program and for Family Health Plus, the
|
||||
MCO or IPA retains the option to immediately terminate the Agreement when the Provider
|
||||
has been terminated or suspended from the Medicaid Program.
|
||||
6.
|
||||
In the event of termination of this Agreement, the Provider agrees, and, where applicable, the
|
||||
IPA agrees to require all participating providers of its network to assist in the orderly transfer
|
||||
of enrollees to another provider.
|
||||
F.
|
||||
ARBITRATION
|
||||
1.
|
||||
To the extent that arbitration or alternative dispute resolution is athorized elsewhere in'this
|
||||
Agreement, the parties to this Agreement acknowledge that the Commissioner of Health is
|
||||
not bound by arbitration or mediation decisions. Arbitration or n ediation shall occur within
|
||||
New York State, and the Commissioner of Health will be given otice of all issues going to
|
||||
arbitration or mediation, and copies of all decisions.
|
||||
G.
|
||||
IPA-SPECIFIC PROVISIONS
|
||||
1.
|
||||
Any reference to IPA quality assurance (QA) activities within tl is Agreement is limited to
|
||||
the IPA's analysis of utilization patterns and quality of care on its own behalf and as a service
|
||||
to its contract providers.
|
||||
Boro Park Obstetrics Gynecology PC_ainend_ms_6.7.12.
|
||||
12
|
||||
|
||||
Start of Page No. = 13
|
||||
APPENDIX B
|
||||
CERTIFICATION REGARDING LOBBYING
|
||||
The undersigned certifies, to the best of his or her knowledge, that:
|
||||
1.
|
||||
No Federal appropriated funds have been paid or will be paid to any person by or on behalf of the
|
||||
Provider for the purpose of influencing or attempting to influence an officer or employee of any
|
||||
agency, a Member of Congress, an officer or employee of a Membei of Congress in connection
|
||||
with the award of any Federal loan, the entering into any cooperative agreement, or the
|
||||
extension, continuation, renewal, amendment, or modification of any Federal contract, grant,
|
||||
loan, or cooperative agreement.
|
||||
2. If any funds other than Federal appropriated funds have been paid o) will be paid to any person
|
||||
for the purpose of influencing or attempting to influence an officer OF employee of any agency, a
|
||||
Member of Congress in connection with the award of any Federal contract, the making of any
|
||||
Federal grant, the making of any Federal loan, the entering into any cooperative agreement, or the
|
||||
extension, continuation, renewal, amendment or modification of any Federal contract, grant,
|
||||
loan, or cooperative agreement, and the Agreement exceeds $100,000, the Provider shall
|
||||
complete and submit Standard Form-LLL "Disclosure Form to Reporting Lobby," in accordance
|
||||
with its instructions.
|
||||
This certification is a material representation of fact upon which reliance was placed when this
|
||||
transaction was made or entered into submission of this certification is a prerequisite for making or
|
||||
entering into this transaction pursuant to U.S.C. Section 1352. The failure to file the required
|
||||
certification shall subject the violator to a civil penalty of not less tha $10,000 and not more than
|
||||
$100,000 for each such failure.
|
||||
DATE:
|
||||
10/15/12
|
||||
TITLE:
|
||||
Practice Administrator
|
||||
ORGANIZATION:
|
||||
BORO PaRK OB/EUN
|
||||
NAME: (Please Print)
|
||||
ELLA ALexa
|
||||
SIGNATURE:
|
||||
Ealexa
|
||||
Borb Park Obstetrics Gynecology
|
||||
13
|
||||
+163
@@ -0,0 +1,163 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
HEALTH BENEFIT EXCHANGE AMENDMENT TO
|
||||
MOLINA HEALTHCARE OF FLORIDA, INC.
|
||||
PROVIDER SERVICES AGREEMENT
|
||||
THIS HEALTH BENEFIT EXCHANGE AMENDMENT TO THE PROVIDER SERVICES
|
||||
AGREEMENT ("Amendment") is made and entered by and between Molina Healthcare of
|
||||
Florida, Inc. ("Health Plan") and North Broward Hospital District, a special taxing District of the
|
||||
State of Florida d/b/a Broward Health ("Provider").
|
||||
A. Whereas, Health Plan and Provider have entered into a Provider Services Agreement, or
|
||||
other corresponding health care services agreement or contract, as may have been
|
||||
amended from time to time ("Agreement"); and
|
||||
B. Whereas, Provider agrees to contract with Health Plan for Health Plan's Health Benefit
|
||||
Exchange products;
|
||||
Now therefore, in consideration of the rights and obligations contained herein, Health Plan and
|
||||
Provider agree to amend the Agreement as follows:
|
||||
1.
|
||||
Section 2.9 Claims Payment, subsection b, Compensation (or equivalent section of the
|
||||
Agreement), is deleted and replaced with the following subsection b:
|
||||
b. Compensation. Health Plan shall pay Provider for Clean Claims for Covered
|
||||
Services provided to Members, including Emergency Services, in accordance with
|
||||
F.S. 641.3155, all other applicable law and regulations and in accordance with the
|
||||
compensation schedule set forth in Attachment D, D-1 and D-2Compensation
|
||||
Schedule for Molina Health Benefit Exchange Product, or equivalent attachment(s) of
|
||||
the Agreement, as applicable. Provider shall accept such payment, applicable co-
|
||||
payments, deductibles, and coordination of benefits collections as payment in full for
|
||||
Covered Services. Provider shall not balance bill Members for any Covered Service.
|
||||
2. Section 2.9 Claims Payment subsection h, Compliance with Applicable Law (or
|
||||
equivalent section of the Agreement) is amended by adding the following:
|
||||
For Covered Services rendered to Members enrolled in a Molina Health Benefit
|
||||
Exchange Product, Medicaid statutes and regulations referenced in this Agreement
|
||||
are inapplicable, and Provider shall comply with all statutory and regulatory
|
||||
requirements applicable to the Health Benefit Exchange, including Chapter 641,
|
||||
Florida Statutes, and the Patient Protection and Affordable Care Act of 2010 (Pub. L.
|
||||
111-148), as amended by the Health Care and Education Reconciliation Act of 2010
|
||||
(Pub. L. 111-152, and referred to collectively as the Affordable Care Act; and
|
||||
regulations at 45 CFR Parts 153, 155, and 156.
|
||||
3. Section 5.3 Entire Agreement (or equivalent section of the Agreement) is deleted and
|
||||
replaced with the following:
|
||||
{27923198;1}
|
||||
MHFL
|
||||
Page 1 of 4
|
||||
|
||||
Start of Page No. = 2
|
||||
Entire Agreement. This Agreement, together with Attachments, Amendments and
|
||||
incorporated documents or materials, contains the entire agreement between Health Plan
|
||||
and Provider relating to the rights granted and obligations imposed by this Agreement.
|
||||
Additionally, as to the Medicaid products offered by Health Plan and listed in Attachment
|
||||
C, the contract between the State of Florida, Agency for Health Care Administration and
|
||||
the Health Plan is incorporated herein by reference and shall be the guiding and
|
||||
controlling document when interpreting the terms of this Agreement. Any prior
|
||||
agreements, promises, negotiations, or representations, either oral or written, relating to
|
||||
the subject matter of this Agreement are of no force or effect.
|
||||
4. Section 5.10 Attachments (or equivalent section of the Agreement) is amended to add
|
||||
the following to the list of Attachments which are part of the Agreement:
|
||||
"Attachment D-2 Compensation Schedule for Molina Health Benefit Exchange Product"
|
||||
5.
|
||||
Section 5.11 (or next available section following the last section of Article 5 of the
|
||||
Agreement) is added as follows:
|
||||
Conflict with Health Plan Product. Nothing in this Agreement modifies any benefits,
|
||||
terms or conditions contained in the Member's Health Plan product.. In the event of a
|
||||
conflict between this Agreement and the benefits, terms, and conditions of the Health
|
||||
Plan product, the benefits, terms or conditions contained in the Member's Health Plan
|
||||
product shall govern.
|
||||
6. All cross-references to Attachment D in the Agreement not specifically addressed by this
|
||||
Amendment are revised as follows:
|
||||
"Attachment D, D-1, or Attachment D-2 Compensation Schedule for Molina Health
|
||||
Benefit Exchange Product, or equivalent attachment(s) of the Agreement, as applicable"
|
||||
7. Attachment B Definitions (or equivalent attachment/section of the Agreement) is
|
||||
amended by adding the following defined terms:
|
||||
"Health Benefit Exchange means the federal health benefit exchange established for
|
||||
Florida pursuant to the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111
|
||||
148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L.
|
||||
111-152, and referred to collectively as the Affordable Care Act; and regulations at 45
|
||||
CFR Parts 153, 155, and 156."
|
||||
"Molina Health Benefit Exchange Product means those health benefit programs
|
||||
offered and sold by Health Plan to individuals or employers who obtain health coverage
|
||||
through the Health Benefit Exchange."
|
||||
8. Attachment C (Products/Benefits Inventory) or equivalent attachment/section of the
|
||||
Agreement, is amended by adding the following product:
|
||||
"Molina Health Benefit Exchange Product."
|
||||
{27923198;1}
|
||||
MHFL
|
||||
Page 2 of 4
|
||||
|
||||
Start of Page No. = 3
|
||||
9. Attachment A- Provider Identification Sheet attached hereto, is replaced.
|
||||
10. Attachment D-2 Compensation Schedule for Molina Health Benefit Exchange Product
|
||||
attached hereto, is added.
|
||||
11. There are no performance, bonus or special compensation programs applicable to the
|
||||
Molina Health Benefit Exchange Product. Any such additional compensation requires a
|
||||
written amendment to this Agreement.
|
||||
12. Health Plan and Provider recognize that this Amendment and/or the Agreement may
|
||||
require further amendments in the event that any federal, state or local agency,
|
||||
administration, board or other governing body requires changes to this Amendment or
|
||||
Agreement as a condition of approval. Health Plan shall be entitled to revise this
|
||||
Amendment and/or the Agreement immediately with notice to Provider, but without
|
||||
Provider's consent if an additional amendment is being effected by Health Plan to
|
||||
comply with any federal, state or local agency, administration, board or other governing
|
||||
body request and/or regulatory requirement regarding the Health Benefit Exchange.
|
||||
13. Effective Date. This Amendment shall become effective on February 1, 2015, and renew
|
||||
with and under the terms of the Agreement.
|
||||
14. Use of Defined Terms. Unless otherwise defined in this Amendment, capitalized terms
|
||||
utilized in this Amendment will have the same meaning(s) ascribed to such terms in the
|
||||
Agreement.
|
||||
15. No Other Modifications. Except as provided herein, the terms and conditions of the
|
||||
Agreement shall remain the same, in full force and effect.
|
||||
IN WITNESS WHEREOF, the parties hereto have executed this Amendment by their officers
|
||||
thereunto duly authorized.
|
||||
North Broward Hospital District
|
||||
D/B/A Broward Health.
|
||||
Molina Healthcare of Alorida Inc.
|
||||
By:
|
||||
Robert K Marty By:
|
||||
Robert K. Martin
|
||||
Its:
|
||||
Senior VP/CFO
|
||||
Its:
|
||||
President COO
|
||||
Mantza Georgero
|
||||
Date:
|
||||
1/27/15
|
||||
Date:
|
||||
3/27/15
|
||||
907939.1
|
||||
{27923198;1}
|
||||
MHFL
|
||||
Page 3 of 4
|
||||
|
||||
Start of Page No. = 4
|
||||
ATTACHMENT D-2 COMPENSATION SCHEDULE FOR
|
||||
MOLINA HEALTH BENEFIT EXCHANGE PRODUCT
|
||||
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to
|
||||
Members, in accordance with the Molina Health Benefit Exchange Product, on a fee-for-service
|
||||
basis, at the lesser of: (i) Provider's billed charges, or (ii) the amounts set forth below; less any
|
||||
applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other
|
||||
liable third parties, if any:
|
||||
Primary Care Services
|
||||
Molina Health Benefit Exchange Product. Covered Services shall be paid at an amount
|
||||
equivalent to one hundred five percent (105%) of the allowable payment rate under the
|
||||
prevailing local and geographically adjusted Medicare Fee-For-Service fee schedule, as of the
|
||||
date(s) of service.
|
||||
Specialty Care Services
|
||||
Molina Health Benefit Exchange Product. Covered Services shall be paid at an amount equivalent
|
||||
to the rates set forth below:
|
||||
Pediatric Subspecialists:
|
||||
One hundred fifty percent (150%) of the allowable payment rate under the prevailing local and
|
||||
geographically adjusted Medicare Fee-For-Service fee schedule, as of the date(s) of service.
|
||||
Neurosurgery and Orthopedic Surgery:
|
||||
One hundred twenty five percent (125%) of the allowable payment rate under the prevailing
|
||||
local and geographically adjusted Medicare Fee-For-Service fee schedule, as of the date(s) of
|
||||
service.
|
||||
All Other Specialists:
|
||||
One hundred percent (100%) of the allowable payment rate under the prevailing local and
|
||||
geographically adjusted Medicare Fee-For-Service fee schedule, as of the date(s) of service.
|
||||
Hematology/Oncology for HCPCS J CODES (J0120-J9600) - 100% of current year Medicare
|
||||
allowable locality 3
|
||||
If there is no payment rate in the prevailing local and geographically adjusted Medicare Fee-For-
|
||||
Service Program as of the date(s) of service, Provider shall be paid at an amount equivalent to
|
||||
fifty percent (50%) of provider's covered charges.
|
||||
{27923198;1}
|
||||
MHFL
|
||||
Page 4 of 4
|
||||
+223
@@ -0,0 +1,223 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
SECOND AMENDMENT TO
|
||||
MOLINA HEALTHCARE OF TEXAS, INC.
|
||||
PARTICIPATING PROVIDER GROUP AGREEMENT
|
||||
This Second Amendment to the Participating Provider Group Agreement (the "Amendment") is
|
||||
made and entered into by and between Molina Healthcare of Texas, Inc ("Health Plan") and
|
||||
Baylor College of Medicine dba Baylor Medcare ("Provider"), with respect to the following facts:
|
||||
RECITALS
|
||||
A. The parties have previously entered into that certain Participating Provider Group Agreement
|
||||
dated July 24, 2006. (the "Agreement").
|
||||
B. The parties hereby agree to amend the Agreement in accordance with the terms and
|
||||
conditions of this Amendment.
|
||||
NOW, THEREFORE, in consideration of the promises, covenants and warranties stated herein,
|
||||
Health Plan and Provider agree as follows:
|
||||
1.
|
||||
Provider Identification Sheet. -Exhibit J "Provider Identification Sheet" is made a part of the
|
||||
Agreement.
|
||||
2. Compensation Schedule. Exhibit G-1 "BCM Physicians of San Antonio Compensation
|
||||
Schedule" -is made a part of the Agreement.
|
||||
3. Use of Defined Terms. Capitalized terms utilized in this Amendment shall have the same
|
||||
meanings ascribed to such terms in the Agreement.
|
||||
4. Agreement Remains in Full Force and Effect. Except as set forth in this Amendment, the
|
||||
Agreement is unaffected and shall continue in full force and effect in accordance with its
|
||||
terms. If there is a conflict between this Amendment and the Agreement or an earlier
|
||||
Amendment, the terms of this Amendment will prevail.
|
||||
IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by
|
||||
their duly authorized officers as of the Effective Date set forth by Health Plan below.
|
||||
Baylor Medcare
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Provider
|
||||
Molina
|
||||
Signature:
|
||||
Syun
|
||||
Signature:
|
||||
Signatory Name
|
||||
Signatory Name
|
||||
(Printed):
|
||||
Stephen Sigworth, MD
|
||||
(Printed):
|
||||
JOHN J. McGuinness
|
||||
Signatory
|
||||
CMO and Vice President
|
||||
Signatory Title
|
||||
Title (Printed):
|
||||
(Printed):
|
||||
VP NETWORK MANAGEMENT
|
||||
Signature Date:
|
||||
5/13/14
|
||||
Signature Date:
|
||||
6/16/14
|
||||
APPROVED AS TO FORM
|
||||
Effective Date:
|
||||
Office of the General Counsel
|
||||
January 1, 2014
|
||||
By Baylor on P 5/13/14
|
||||
College Of Medicine
|
||||
Amendment toParticipatingProvider Group Agreement
|
||||
Provider or authorized
|
||||
MCST v020909
|
||||
Page 1 of 4
|
||||
representative's initials:
|
||||
|
||||
Start of Page No. = 2
|
||||
Exhibit G- 1
|
||||
BCM Physicians of San Antonio Compensation Schedule
|
||||
Health Plan agrees to compensate Provider for Clean Claims for Covered Services
|
||||
rendered to Members, in accordance with Health Plan's programs as specified in
|
||||
Attachment C, on a fee-for-services basis, at the lesser of; (i) Provider's allowable charge
|
||||
description master rate, or (ii) the amounts set forth below, less any applicable Member
|
||||
co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable
|
||||
third parties, if any.
|
||||
STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be
|
||||
paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-
|
||||
For-Service Program fee schedule in effect on the date of service.
|
||||
Notwithstanding the above, payment for Covered Services, including, but not limited to,
|
||||
certain Covered Services where there is no payment rate in the State of Texas Medicaid
|
||||
Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an
|
||||
amount equivalent to the Medicare Fee-For-Service Program allowable payment rate
|
||||
(adjusted for locality or geography), as of the date of service.
|
||||
Medicare Advantage (Molina Medicare Options) and MA-SNP (Molina Medicare
|
||||
Options Plus): Covered Services shall be paid at an amount equivalent to the Medicare
|
||||
Fee-For-Service Program allowable payment rates (adjusted for locality or geography), as
|
||||
of the date of service.
|
||||
Amendment toParticipatingProvider Group Agreement
|
||||
Provider or authorized
|
||||
MCST v020909
|
||||
Page 2 of 4
|
||||
representative's initials:
|
||||
|
||||
Start of Page No. = 3
|
||||
EXHIBIT J
|
||||
Provider Identification Sheet
|
||||
Mark applicable category(ies) below. For those Providers representing multiple health care
|
||||
professional(s) or entity(ies), please check all the categories that apply.
|
||||
Primary Care Physician
|
||||
Specialist:
|
||||
type
|
||||
Medical Group/PA/IPA (a list of constituent members with their License No., TPIN,
|
||||
UPIN and DEA numbers is attached and incorporated herein)
|
||||
Ancillary Provider:
|
||||
type
|
||||
Pharmacy
|
||||
Other:
|
||||
type
|
||||
Please enter "N/A" for the following if not applicable or not available:
|
||||
Provider Name
|
||||
Baylor Medcare
|
||||
Billing Address:
|
||||
Telephone No.
|
||||
PO BOX 4803
|
||||
Facsimile No.
|
||||
Houston, TX 77210
|
||||
Email Address
|
||||
Tax I.D. No.
|
||||
741613878
|
||||
License No.
|
||||
Physical Address (if different than above):
|
||||
Texas Provider Identification
|
||||
Baylor MedCare (BMC)
|
||||
Number (TPIN)
|
||||
2 Greenway Plaza #910
|
||||
NPI (or UPIN if NPI not yet
|
||||
NPI:
|
||||
Houston, TX 77046
|
||||
designated)
|
||||
UPIN:
|
||||
DEA No.
|
||||
(Use continuation pages if multiple providers under common ownership will submit bills under this
|
||||
Agreement)
|
||||
I, the undersigned, am authorized to and do hereby verify the accuracy of the foregoing Provider
|
||||
information.
|
||||
Provider
|
||||
Signature:
|
||||
Signatory Name
|
||||
(Printed):
|
||||
Stephen Sigworth, MD
|
||||
Signatory Title
|
||||
(Printed):
|
||||
CMO and President
|
||||
Signature Date:
|
||||
Amendment toParticipatingProvider Group Agreement
|
||||
Provider or authorized
|
||||
MCST v020909
|
||||
Page 3 of 4
|
||||
representative's initials:
|
||||
|
||||
Start of Page No. = 4
|
||||
EXHIBIT J
|
||||
Provider Identification Sheet Continuation Page
|
||||
Use one or more continuation pages as necessary when multiple providers under common
|
||||
ownership (the Provider is signing on behalf of all of them) are expected to bill Health Plan
|
||||
under more than one TIN.
|
||||
Provider Name
|
||||
Baylor Medcare (Orthopedic
|
||||
Billing Address:
|
||||
Surgery)
|
||||
PO BOX 4803
|
||||
Telephone No.
|
||||
Houston, TX 77210
|
||||
Facsimile No.
|
||||
Email Address
|
||||
Tax I.D. No.
|
||||
76-0417040
|
||||
License No.
|
||||
Physical Address (if different than
|
||||
Texas Provider Identification
|
||||
above):
|
||||
Number (TPIN)
|
||||
Baylor MedCare (BMC)
|
||||
NPI (or UPIN if NPI not yet
|
||||
NPI:
|
||||
2 Greenway Plaza #910
|
||||
designated)
|
||||
UPIN:
|
||||
Houston, TX 77046
|
||||
DEA No.
|
||||
Provider Name
|
||||
BMC Physicians of San
|
||||
Billing Address:
|
||||
Antonio
|
||||
PO BOX 4803
|
||||
Telephone No.
|
||||
Houston, TX 77210
|
||||
Facsimile No.
|
||||
Email Address
|
||||
Tax I.D. No.
|
||||
46-2714379
|
||||
License No.
|
||||
Physical Address (if different than
|
||||
Texas Provider Identification
|
||||
above):
|
||||
Number (TPIN)
|
||||
Baylor MedCare (BMC)
|
||||
NPI (or UPIN if NPI not yet
|
||||
NPI:
|
||||
2 Greenway Plaza #910
|
||||
designated)
|
||||
UPIN:
|
||||
Houston, TX 77046
|
||||
DEA No.
|
||||
Provider Name
|
||||
Billing Address:
|
||||
Telephone No.
|
||||
Facsimile No.
|
||||
Email Address
|
||||
Tax I.D. No.
|
||||
License No.
|
||||
Physical Address (if different than
|
||||
Texas Provider Identification
|
||||
above):
|
||||
Number (TPIN)
|
||||
NPI (or UPIN if NPI not yet
|
||||
NPI:
|
||||
designated)
|
||||
UPIN:
|
||||
DEA No.
|
||||
(Add additional Att. A continuation pages as needed).
|
||||
Amendment toParticipatingProvider Group Agreement
|
||||
Provider or authorized
|
||||
MCST v020909
|
||||
Page 4 of 4
|
||||
representative's initials:
|
||||
+1358
File diff suppressed because it is too large
Load Diff
+187
@@ -0,0 +1,187 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT TO THE STANDARD ANCILLARY SERVICES
|
||||
AGREEMENT
|
||||
This AMENDMENT TO THE STANDARD ANCILLARY SERVICES
|
||||
AGREEMENT dated this 1st day of August, 2017, by and between NEW YORK STATE
|
||||
CATHOLIC HEALTH PLAN, INC., doing business as FIDELIS CARE NEW YORK, a
|
||||
New York not-for-profit corporation certified as a prepaid health services plan pursuant to
|
||||
Article 44 of the New York State Public Health Law, and including its affiliates and subsidiaries
|
||||
(hereinafter collectively referred to as, the "Plan"), and BIO-REFERENCE
|
||||
LABORATORIES, INC. (hereinafter, "Provider"), a Corporation organized under the laws
|
||||
of New York State.
|
||||
WHEREAS, Plan and Provider entered into a certain Provider Agreement dated March
|
||||
5, 2004 ("the Agreement") pursuant to which Provider became obligated to provide health
|
||||
services to Enrollees (as defined in the Agreement); and subsequently amended by the parties on
|
||||
March 12, 2009, December 1, 2010, September 9, 2013, and January 1, 2015; and
|
||||
WHEREAS, Provider currently participates in Plan's prepaid health services plan; and
|
||||
WHEREAS, Plan and Provider wish to amend certain sections of said Agreement,
|
||||
NOW THEREFORE, in consideration of the premises and provisions herein, Plan and
|
||||
Provider covenant and agree as follows:
|
||||
1.
|
||||
Schedule 1.1 is hereby deleted in its entirety and is replaced with Schedule 1.1A.
|
||||
Schedule 1.14 is hereby deleted in its entirety and is replaced with Schedule 1.14A.
|
||||
Schedule 5.2C is hereby deleted in its entirety and is replaced with Schedule 5.2E.
|
||||
Schedule 5.2D is hereby deleted in its entirety and is replaced with Schedule 5.2F.
|
||||
2.
|
||||
Submission of Electronic Claims and Acceptance of Information through Electronic
|
||||
Medium. Provider agrees to submit claims for services rendered to enrollees and to
|
||||
accept enrollee rosters, remittance advices and other Plan communications electronically
|
||||
through a medium designated by the Plan.
|
||||
3.
|
||||
This Amendment shall terminate upon the termination of the Agreement under the same
|
||||
terms and conditions specified herein.
|
||||
4.
|
||||
All other terms and conditions of the Agreement, except as amended herein, shall remain
|
||||
the same and are hereby ratified and confirmed.
|
||||
5.
|
||||
This Amendment to the Agreement may be executed in one or more counterparts, each of
|
||||
which shall be deemed an original and all of which shall constitute but one and the same
|
||||
instrument.
|
||||
BioReference 60% Amendment 07282017
|
||||
1
|
||||
|
||||
Start of Page No. = 2
|
||||
IN WITNESS WHEREOF, the parties here have signed this AMENDMENT on the
|
||||
date referenced above.
|
||||
BIO-REFERENCE LABORATORIES, INC.
|
||||
NEW YORK STATE CATHOLIC HEALTH
|
||||
Provider (Please Print)
|
||||
PLAN, INC. d/b/a Fidelis Care New York
|
||||
95-25 Queens Boulevard
|
||||
Rego Park, New York 11374
|
||||
481 Edward H. Ross Drive
|
||||
By: Alicia L. Delmont
|
||||
Address
|
||||
Elmwood Park, NJ 07407
|
||||
Its:
|
||||
Senior Vice President
|
||||
City, State, Zip Code
|
||||
Entity Tax ID#: 222405059
|
||||
Date: 8/11/17
|
||||
Entity NPI#: 1134277494
|
||||
Signature
|
||||
Name: Jane Pinewood
|
||||
(Please Print)
|
||||
Title: VP, Legal and Compliance
|
||||
Date:
|
||||
8/1/17
|
||||
Signature:
|
||||
BR
|
||||
BioReference 60% Amendment_07282017
|
||||
2
|
||||
IF
|
||||
|
||||
Start of Page No. = 3
|
||||
SCHEDULE 1.1A
|
||||
ANCILLARY SERVICES
|
||||
Provider will provide to Enrollees, pursuant to the terms and conditions of this Agreement and
|
||||
the applicable Program Contract, the following Ancillary Services:
|
||||
Laboratory & Pathology Services
|
||||
BioReference 60% Amendment_07282017
|
||||
3
|
||||
|
||||
Start of Page No. = 4
|
||||
SCHEDULE 1.14A
|
||||
IDENTIFICATION OF THE PROGRAMS AND PROGRAM CONTRACTS
|
||||
Program:
|
||||
Medicaid Managed Care
|
||||
Program Contract: The contract for the provision of Medicaid managed care services entered
|
||||
into by and between New York State Catholic Health Plan, Inc., and the
|
||||
New York State Department of Health, including all attachments thereto.
|
||||
Program:
|
||||
Health And Recovery Plan (HARP)
|
||||
Program Contract: The contract for the provision of managed care services under the New
|
||||
York State Health and Recovery Plan program entered into by and
|
||||
between New York State Catholic Health Plan, Inc., and the New York
|
||||
State Department of Health including all attachments thereto.
|
||||
Program:
|
||||
Essential Plan Program (EPP)
|
||||
Program Contract: The contract for the provision of managed care services under the New
|
||||
York State Essential Plan Program entered into by and between New York
|
||||
State Catholic Health Plan, Inc., and the New York State Department of
|
||||
Health/New York State of Health, including all attachments thereto.
|
||||
Program:
|
||||
Child Health Plus
|
||||
Program Contract: The contract for the provision of managed care services under the New
|
||||
York State Child Health Plus program entered into by and between New
|
||||
York State Catholic Health Plan, Inc., and the New York State Department
|
||||
of Health including all attachments thereto.
|
||||
Program:
|
||||
Medicare Advantage
|
||||
Program Contract: The contract for the provision of Medicare Advantage services entered
|
||||
into by and between New York State Catholic Health Plan, Inc., and
|
||||
Center for Medicare and Medicaid Services, including all attachments
|
||||
thereto.
|
||||
Program:
|
||||
Managed Long Term Care
|
||||
Program
|
||||
Contract:
|
||||
The contract for the provision of managed long term care services entered
|
||||
into by and between the New York State Catholic Health Plan, d/b/a
|
||||
Fidelis Care New York, and the New York State Department of Health
|
||||
including all attachments thereto.
|
||||
Program:
|
||||
Health Benefit Exchange
|
||||
Program Contract: Health insurance program created under the Patient Protection and
|
||||
Affordable Care Act through which individuals and small businesses can
|
||||
purchase qualified coverage.
|
||||
Plan may amend this schedule to include additional Programs from time to time. Provider agrees
|
||||
that Provider will participate in all new Programs for which Provider is qualified as determined
|
||||
by Plan. Provider's participation in any new Program will be effective upon thirty (30) calendar
|
||||
days notice of Plan's amendment of this Schedule 1.14A.
|
||||
BioReference 60% Amendment_07282017
|
||||
4
|
||||
|
||||
Start of Page No. = 5
|
||||
SCHEDULE 5.2E
|
||||
ANCILLARY SERVICES REIMBURSEMENT
|
||||
Programs: Medicaid Managed Care, Health And Recovery Plan, Essential Plan Program-
|
||||
Aliessa, and Child Health Plus
|
||||
Ancillary Services will be reimbursed at 60% of the prevailing Medicaid fee schedule existing at
|
||||
the time the applicable service was rendered.
|
||||
For Ancillary Services not on prevailing Medicaid fee schedule, services will be reimbursed
|
||||
at 42% of the 2017 Medicare rate.
|
||||
For Ancillary Services not on either the prevailing Medicaid fee schedule or Medicare Lab
|
||||
fee schedule, services will be reimbursed at 30% of billed charges.
|
||||
Programs: Medicare Advantage and Managed Long Term Care-Medicaid Advantage Plus:
|
||||
Ancillary Services will be reimbursed at 42% of the 2017 Medicare fee schedule existing at the
|
||||
time the applicable service was rendered.
|
||||
Programs: Health Benefit Exchange and Essential Plan Program-QHP
|
||||
Ancillary Services will be reimbursed at 60% of the prevailing Medicaid fee schedule existing at
|
||||
the time the applicable service was rendered.
|
||||
For Ancillary Services not on prevailing Medicaid fee schedule, services will be reimbursed
|
||||
at 42% of the 2017 Medicare rate.
|
||||
For Ancillary Services not on either the prevailing Medicaid fee schedule or Medicare Lab
|
||||
fee schedule, services will be reimbursed at 30% of billed charges.
|
||||
The rates for Health Benefit Exchange and Essential Plan Program-QHP will be
|
||||
reimbursed less all applicable Enrollee cost sharing amounts
|
||||
BioReference 60% Amendment_07282017
|
||||
5
|
||||
|
||||
Start of Page No. = 6
|
||||
SCHEDULE 5.2F
|
||||
ANCILLARY SERVICES REIMBURSEMENT
|
||||
Pathology Physicians will be reimbursed as follows:
|
||||
Programs: Medicaid Managed Care, Health And Recovery Plan, Essential Plan Program-
|
||||
Aliessa, and Child Health Plus
|
||||
Ancillary Services will be reimbursed at 60% of the prevailing Medicaid fee schedule existing at
|
||||
the time the applicable service was rendered.
|
||||
For Ancillary Services not on prevailing Medicaid fee schedule, services will be reimbursed
|
||||
at 42% of the 2017 Medicare rate.
|
||||
For Ancillary Services not on either the prevailing Medicaid fee schedule or Medicare Lab
|
||||
fee schedule, services will be reimbursed at 30% of billed charges.
|
||||
Programs: Medicare Advantage and Managed Long Term Care-Medicaid Advantage Plus:
|
||||
Ancillary Services will be reimbursed at 42% of the 2017 Medicare fee schedule existing at the
|
||||
time the applicable service was rendered.
|
||||
Programs: Health Benefit Exchange and Essential Plan Program-QHP
|
||||
Ancillary Services will be reimbursed at 60% of the prevailing Medicaid fee schedule existing at
|
||||
the time the applicable service was rendered.
|
||||
For Ancillary Services not on prevailing Medicaid fee schedule, services will be reimbursed
|
||||
at 42% of the 2017 Medicare rate.
|
||||
For Ancillary Services not on either the prevailing Medicaid fee schedule or Medicare Lab
|
||||
fee schedule, services will be reimbursed at 30% of billed charges.
|
||||
The rates for Health Benefit Exchange and Essential Plan Program-QHP will be
|
||||
reimbursed less all applicable Enrollee cost sharing amounts
|
||||
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|
||||
6
|
||||
+656
@@ -0,0 +1,656 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT TO THE STANDARD ANCILLARY SERVICES
|
||||
AGREEMENT 2.0
|
||||
This AMENDMENT TO THE STANDARD ANCILLARY SERVICES
|
||||
AGREEMENT dated this 15th day of July 2012, by and between NEW YORK STATE
|
||||
CATHOLIC HEALTH PLAN, INC., doing business as FIDELIS CARE NEW YORK, a
|
||||
New York not-for-profit corporation certified as a prepaid health services plan pursuant to
|
||||
Article 44 of the New York State Public Health Law, and including its affiliates and subsidiaries
|
||||
(hereinafter collectively referred to as, the "Plan"), and Borbas Surgical Supply, Inc.
|
||||
(hereinafter, "Provider"), a corporation organized under the laws of New York State
|
||||
WHEREAS, Plan and Provider entered into the Agreement dated August 15, 2007 ("the
|
||||
Agreement") pursuant to which Provider became obligated to provide health services to
|
||||
Enrollees (as defined in the Agreement); and
|
||||
WHEREAS, Provider currently participates in Plan's prepaid health services plan; and
|
||||
WHEREAS, Plan and Provider wish to amend certain sections of said Agreement,
|
||||
NOW THEREFORE, in consideration of the premises and provisions herein, Plan and
|
||||
Provider covenant and agree as follows:
|
||||
1. Schedules 1.14 and 5.2 are being replaced in their entirety with Schedule 1.14A and
|
||||
Schedule 5.2A attached to this Amendment.
|
||||
2. Appendix A of the Agreement, dated August 15, 2007, is hereby deleted in its entirety
|
||||
and replaced with Appendix A2, attached hereto. The New York State Department of
|
||||
Health Standard Clauses for Managed Care Provider/IPA Contracts dated March 1, 2011,
|
||||
attached to this agreement as Appendix A2, are expressly incorporated into this
|
||||
Agreement and are binding upon the parties to this Agreement. In the event of any
|
||||
inconsistent or contrary language between the Standard Clauses and any other part of the
|
||||
Agreement, including but not limited to appendices, amendments and exhibits, the parties
|
||||
agree that provisions of the "Standard Clauses" shall prevail, except to the extent
|
||||
applicable law requires otherwise and/or to the extent a provision of this Agreement
|
||||
exceeds the minimum requirements of the Standard Clauses.
|
||||
3.
|
||||
Submission of Electronic Claims and Acceptance of Information through Electronic
|
||||
Medium. Provider agrees to submit claims for services rendered to enrollees and to
|
||||
accept enrollee rosters, remittance advices and other Plan communications electronically
|
||||
through a medium designated by the Plan.
|
||||
4. This Amendment shall terminate upon the termination of the Agreement under the same
|
||||
terms and conditions specified herein.
|
||||
5. Except as modified by the terms of the Amendment, all terms and provisions of the
|
||||
Agreement, including any previous Amendments thereto, shall remain in full force and
|
||||
effect.
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
1
|
||||
|
||||
Start of Page No. = 2
|
||||
07/20/2012 FRI 10:00 FAX
|
||||
002/003
|
||||
IN WITNESS WHEREOF, the parties here have signed this AMENDMENT on the
|
||||
date referenced above.
|
||||
Borbas Surgical Supply, Inc.
|
||||
NEW YORK STATE CATHOLIC HEALTH
|
||||
Provider (Please Print)
|
||||
PLAN, INC. d/b/a Fidelis Care New York
|
||||
95-25 Queens Boulevard
|
||||
Rego Park, New York 11374
|
||||
2046 Bath Avenue
|
||||
By: David P. Thomas
|
||||
Address
|
||||
Brooklyn, NY 11214
|
||||
Its: Senior Vicc President & Chief Administrative Officer
|
||||
City, State, Zip Code
|
||||
Entity Tax ID#: 113568895
|
||||
Date:
|
||||
7/26/12
|
||||
Entity NPI#: 1134259328
|
||||
Signature:
|
||||
David
|
||||
Name:
|
||||
Kanstanda Bas
|
||||
(Please Print)
|
||||
Title: President
|
||||
Signature: Date: 7-20-17
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
2
|
||||
|
||||
Start of Page No. = 3
|
||||
Schedule 1.14A
|
||||
IDENTIFICATION OF THE PROGRAMS AND PROGRAM CONTRACTS
|
||||
Program:
|
||||
Medicaid Managed Care program.
|
||||
Program Contract: The contract for the provision of Medicaid managed care services entered
|
||||
into by and between New York State Catholic Health Plan, Inc., and the
|
||||
New York State Department of Health, including all attachments thereto.
|
||||
Program:
|
||||
Child Health Plus program.
|
||||
Program Contract: The contract for the provision of managed care services under the New
|
||||
York State Child Health Plus program entered into by and between New
|
||||
York State Catholic Health Plan, Inc., and the New York State Department
|
||||
of Health including all attachments thereto.
|
||||
Program:
|
||||
Family Health Plus program.
|
||||
Program Contract: The contract for the provision of managed care services under the New
|
||||
York State Family Health Plus program entered into by and between New
|
||||
York State Catholic Health Plan, Inc., and the New York State Department
|
||||
of Health including all attachments thereto.
|
||||
Program :
|
||||
Medicare Advantage program
|
||||
Program Contract: The contract for the provision of Medicare Advantage services entered
|
||||
into by and between New York State Catholic Health Plan, Inc., and
|
||||
Center for Medicare and Medicaid Services, including all attachments
|
||||
thereto.
|
||||
Program:
|
||||
Managed Long Term Care program
|
||||
Program Contract: The contract for the provision of managed long term care services entered
|
||||
into by and between the New York State Catholic Health Plan, d/b/a
|
||||
Fidelis Care New York, and the New York State Department of Health
|
||||
including all attachments thereto.
|
||||
Plan may amend this schedule to include additional Programs from time to time. Provider agrees
|
||||
that Provider will participate in all new Programs for which Provider is qualified as determined
|
||||
by Plan. Provider's participation in any new Program will be effective upon thirty (30) calendar
|
||||
days notice of Plan's amendment of this Schedule 1.14.
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
3
|
||||
|
||||
Start of Page No. = 4
|
||||
Schedule 5.2A
|
||||
ANCILLARY SERVICES REIMBURSEMENT
|
||||
Programs: Medicaid Managed Care, Child Health Plus, Family Health Plus Rates, &
|
||||
Managed Long Term Care
|
||||
Ancillary Services will be reimbursed at 73.5% of the prevailing Medicaid fee schedule existing
|
||||
at the time the applicable service was rendered.
|
||||
Program: Medicare Advantage
|
||||
Ancillary Services will be reimbursed at 73.5% of the prevailing Medicare rate for Provider's
|
||||
geographical area effective at the date of service.
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
4
|
||||
|
||||
Start of Page No. = 5
|
||||
APPENDIX A2
|
||||
NEW YORK STATE DEPARTMENT OF HEALTH
|
||||
STANDARD CLAUSES
|
||||
FOR MANAGED CARE PROVIDER/IPA CONTRACTS
|
||||
March 1, 2011
|
||||
Notwithstanding any other provision of this agreement, contract, or amendment
|
||||
(hereinafter "the Agreement" or "this Agreement") the parties agree to be bound by the
|
||||
following clauses which are hereby made a part of the Agreement. Further, if this Agreement is
|
||||
between a Managed Care Organization and an IPA, or between an IPA and an IPA, such clauses
|
||||
must be included in IPA contracts with providers, and providers must agree to such clauses.
|
||||
A.
|
||||
DEFINITIONS FOR PURPOSES OF THIS APPENDIX
|
||||
"Managed Care Organization" or "MCO" shall mean the person, natural or corporate, or any
|
||||
groups of such persons, certified under Public Health Law Article 44, who enter into an
|
||||
arrangement, agreement or plan or any combination of arrangements or plans which provide or
|
||||
offer, or which do provide or offer, a comprehensive health services plan.
|
||||
"Independent Practice Association" or "IPA" shall mean an entity formed for the limited purpose
|
||||
of arranging by contract for the delivery or provision of health services by individuals, entities
|
||||
and facilities licensed or certified to practice medicine and other health professions, and, as
|
||||
appropriate, ancillary medical services and equipment, by which arrangements such health care
|
||||
providers and suppliers will provide their services in accordance with and for such compensation
|
||||
as may be established by a contract between such entity and one or more MCOs. "IPA" may
|
||||
also include, for purposes of this Agreement, a pharmacy or laboratory with the legal authority to
|
||||
contract with other pharmacies or laboratories to arrange for or provide services to enrollees of a
|
||||
New York State MCO.
|
||||
"Provider" shall mean physicians, dentists, nurses, pharmacists and other health care
|
||||
professionals, pharmacies, hospitals and other entities engaged in the delivery of health care
|
||||
services which are licensed, registered and/or certified as required by applicable federal and state
|
||||
law.
|
||||
B.
|
||||
GENERAL TERMS AND CONDITIONS
|
||||
1.
|
||||
This Agreement is subject to the approval of the New York State Department of Health
|
||||
and if implemented prior to such approval, the parties agree to incorporate into this
|
||||
Agreement any and all modifications required by the Department of Health for approval
|
||||
or, alternatively, to terminate this Agreement if SO directed by the Department of Health,
|
||||
effective sixty (60) days subsequent to notice, subject to Public Health Law 4403(6) (e).
|
||||
This Agreement is the sole agreement between the parties regarding the arrangement
|
||||
established herein.
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
5
|
||||
|
||||
Start of Page No. = 6
|
||||
2.
|
||||
Any material amendment to this Agreement is subject to the prior approval of the
|
||||
Department of Health, and any such amendment shall be submitted for approval at least
|
||||
thirty (30) days, or ninety (90) days if the amendment adds or materially changes a risk
|
||||
sharing arrangement that is subject to Department of Health review, in advance of
|
||||
anticipated execution. To the extent the MCO provides and arranges for the provision of
|
||||
comprehensive health care services to enrollees served by the Medical Assistance
|
||||
Program, the MCO shall notify and/or submit a copy of such material amendment to
|
||||
DOH or New York City, as may be required by the Medicaid managed care contract
|
||||
between the MCO and DOH (or New York City) and/or the Family Health Plus contract
|
||||
between the MCO and DOH.
|
||||
3.
|
||||
Assignment of an agreement between an MCO and (1) an IPA, (2) institutional network
|
||||
provider, or (3) medical group provider that serves five percent or more of the enrolled
|
||||
population in a county, or the assignment of an agreement between an IPA and (1) an
|
||||
institutional provider or (2) medical group provider that serves five percent or more of the
|
||||
enrolled population in a county, requires the prior approval of the Commissioner of
|
||||
Health.
|
||||
4.
|
||||
The Provider agrees, or if the Agreement is between the MCO and an IPA or between an
|
||||
IPA and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply
|
||||
fully and abide by the rules, policies and procedures that the MCO (a) has established or
|
||||
will establish to meet general or specific obligations placed on the MCO by statute,
|
||||
regulation, or DOH or SID guidelines or policies and (b) has provided to the Provider at
|
||||
least thirty (30) days in advance of implementation, including but not limited to:
|
||||
quality improvement/management;
|
||||
utilization management, including but not limited to precertification procedures,
|
||||
referral process or protocols, and reporting of clinical encounter data;
|
||||
member grievances; and
|
||||
provider credentialing.
|
||||
5.
|
||||
The Provider or, if the Agreement is between the MCO and an IPA, or between an IPA
|
||||
and an IPA, the IPA agrees, and shall require its providers to agree, to not discriminate
|
||||
against an enrollee based on color, race, creed, age, gender, sexual orientation, disability,
|
||||
place of origin, source of payment or type of illness or condition.
|
||||
6.
|
||||
If the Provider is a primary care practitioner, the Provider agrees to provide for twenty-
|
||||
four (24) hour coverage and back up coverage when the Provider is unavailable. The
|
||||
Provider may use a twenty-four (24) hour back-up call service provided appropriate
|
||||
personnel receive and respond to calls in a manner consistent with the scope of their
|
||||
practice.
|
||||
7.
|
||||
The MCO or IPA which is a party to this Agreement agrees that nothing within this
|
||||
Agreement is intended to, or shall be deemed to, transfer liability for the MCO's or IPA's
|
||||
own acts or omissions, by indemnification or otherwise, to a provider.
|
||||
8.
|
||||
Notwithstanding any other provision of this Agreement, the parties shall comply with the
|
||||
provisions of the Managed Care Reform Act of 1996 (Chapter 705 of the Laws of 1996)
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
6
|
||||
|
||||
Start of Page No. = 7
|
||||
Chapter 551 of the Laws of 2006, Chapter 451 of the Laws of 2007 and Chapter 237 of
|
||||
the Laws of 2009 with all amendments thereto.
|
||||
9.
|
||||
To the extent the MCO enrolls individuals covered by the Medical Assistance and/or
|
||||
Family Health Plus programs, this Agreement incorporates the pertinent MCO
|
||||
obligations under the Medicaid managed care contract between the MCO and DOH
|
||||
(or
|
||||
New York City) and/or the Family Health Plus contract between the MCO and DOH as if
|
||||
set forth fully herein, including:
|
||||
a. the MCO will monitor the performance of the Provider or IPA under the Agreement,
|
||||
and will terminate the Agreement and/or impose other sanctions, if the Provider's or
|
||||
IPA's performance does not satisfy standards set forth in the Medicaid managed care
|
||||
and/or Family Health Plus contracts;
|
||||
b. the Provider or IPA agrees that the work it performs under the Agreement will
|
||||
conform to the terms of the Medicaid managed care contract between the MCO and
|
||||
DOH (or between the MCO and New York City) and/or the Family Health Plus
|
||||
contract between the MCO and DOH, and that it will take corrective action if the
|
||||
MCO identifies deficiencies or areas of needed improvement in the Provider's or
|
||||
IPA's performance; and
|
||||
c. The Provider or IPA agrees to be bound by the confidentiality requirements set forth
|
||||
in the Medicaid managed care contract between the MCO and DOH (or between the
|
||||
MCO and New York City) and/or the Family Health Plus contract between the MCO
|
||||
and DOH.
|
||||
d. The MCO and the Provider or IPA agree that a woman's enrollment in the MCO's
|
||||
Medicaid managed care or Family Health Plus product is sufficient to provide
|
||||
services to her newborn, unless the newborn is excluded from enrollment in Medicaid
|
||||
managed care or the MCO does not offer a Medicaid managed care product in the
|
||||
mother's county of fiscal responsibility.
|
||||
e. The MCO shall not impose obligations and duties on the Provider or IPA that are
|
||||
inconsistent with the Medicaid managed care and/or Family Health Plus contracts, or
|
||||
that impair any rights accorded to DOH, the local Department of Social Services, or
|
||||
the United States Department of Health and Human Services.
|
||||
f. The Provider or IPA agrees to provide medical records to the MCO for purposes of
|
||||
determining newborn eligibility for Supplemental Security Income where the mother
|
||||
is a member of the MCO and for quality purposes at no cost to the MCO.
|
||||
g.
|
||||
The Provider or IPA agrees pursuant to 31 U.S.C. § 1352 and CFR Part 93, that no
|
||||
Federally appropriated funds have been paid or will be paid to any person by or on
|
||||
behalf of the Provider/IPA for the purpose of influencing or attempting to influence
|
||||
an officer or employee of any agency, a Member of Congress, an officer or employee
|
||||
of Congress, or an employee of a Member of Congress in connection with the award
|
||||
of any Federal loan, the entering into of any cooperative agreement, or the extension,
|
||||
continuation, renewal, amendment, or modification of any Federal contract, grant,
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
7
|
||||
|
||||
Start of Page No. = 8
|
||||
loan, or cooperative agreement. The Provider or IPA agrees to complete and submit
|
||||
the "Certification Regarding Lobbying," Appendix B attached hereto and
|
||||
incorporated herein, if this Agreement exceeds $100,000.
|
||||
If any funds other than Federally appropriated funds have been paid or will be paid to
|
||||
any person for the purpose of influencing or attempting to influence an officer or
|
||||
employee of any agency, a Member of Congress, an officer or employee of a member
|
||||
of Congress, in connection with the award of any Federal Contract, the making of any
|
||||
Federal grant, the making of any Federal loan, the entering of any cooperative
|
||||
agreement, or the extension, continuation, renewal, amendment, or modification of
|
||||
any Federal contract, grant, loan, or cooperative agreement, and the Agreement
|
||||
exceeds $100,000 the Provider or IPA shall complete and submit Standard Form-LLL
|
||||
"Disclosure Form to Report Lobbying," in accordance with its instructions.
|
||||
h. The Provider agrees to disclose to MCO on an ongoing basis, any managing
|
||||
employee that has been convicted of a misdemeanor or felony related to the person's
|
||||
involvement in any program under Medicare, Medicaid or a Title XX services
|
||||
program (Block grant programs)
|
||||
i. The Provider agrees to monitor its employees and staff against the List of Excluded
|
||||
Individuals and Entities (LEIE) and excluded individuals posted by the OMIG on its
|
||||
Website.
|
||||
j. The Provider agrees to disclose to MCO complete ownership, control, and
|
||||
relationship information.
|
||||
k. Provider agrees to obtain for MCO ownership information from any subcontractor
|
||||
with whom the provider has had a business transaction totaling more than $25,000,
|
||||
during the 12 month period ending on the date of the request made by SDOH, OMIG
|
||||
or DHHS. The information requested shall be provided to MCO within 35 days of
|
||||
such request.
|
||||
10.
|
||||
The parties to this Agreement agree to comply with all applicable requirements of the
|
||||
Federal Americans with Disabilities Act.
|
||||
11.
|
||||
The Provider agrees, or if the Agreement is between the MCO and an IPA or between an
|
||||
IPA and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply
|
||||
with all applicable requirements of the Health Insurance Portability and Accountability
|
||||
Act; the HIV confidentiality requirements of Article 27-F of the Public Health Law and
|
||||
Mental Hygiene Law § 33.13.
|
||||
C.
|
||||
PAYMENT / RISK ARRANGEMENTS
|
||||
1.
|
||||
Enrollee Non-liability. Provider agrees that in no event, including, but not limited to,
|
||||
nonpayment by the MCO or IPA, insolvency of the MCO or IPA, or breach of this
|
||||
Agreement, shall Provider bill, charge, collect a deposit from, seek compensation,
|
||||
remuneration or reimbursement from, or have any recourse against a subscriber, an
|
||||
enrollee or person (other than the MCO or IPA) acting on his/her/their behalf, for
|
||||
services provided pursuant to the subscriber contract or Medicaid Managed Care contract
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
8
|
||||
|
||||
Start of Page No. = 9
|
||||
or Family Health Plus contract and this Agreement, for the period covered by the paid
|
||||
enrollee premium. In addition, in the case of Medicaid Managed Care, Provider agrees
|
||||
that, during the time an enrollee is enrolled in the MCO, he/she/it will not bill the New
|
||||
York State Department of Health or the City of New York for Covered Services within
|
||||
the Medicaid Managed Care Benefit Package as set forth in the Agreement between the
|
||||
MCO and the New York State Department of Health. In the case of Family Health Plus,
|
||||
Provider agrees that, during the time an enrollee is enrolled in the MCO, he/she/it will not
|
||||
bill the New York State Department of Health for Covered Services within the Family
|
||||
Health Plus Benefit Package, as set forth in the Agreement between the MCO and the
|
||||
New York State Department of Health. This provision shall not prohibit the provider,
|
||||
unless the MCO is a managed long term care plan designated as a Program of All-
|
||||
Inclusive Care for the Elderly (PACE), from collecting copayments, coinsurance
|
||||
amounts, or permitted deductibles, as specifically provided in the evidence of coverage,
|
||||
or fees for uncovered services delivered on a fee-for-service basis to a covered person
|
||||
provided that Provider shall have advised the enrollee in writing that the service is
|
||||
uncovered and of the enrollee's liability therefore prior to providing the service. Where
|
||||
the Provider has not been given a list of services covered by the MCO, and/or Provider is
|
||||
uncertain as to whether a service is covered, the Provider shall make reasonable efforts to
|
||||
contact the MCO and obtain a coverage determination prior to advising an enrollee as to
|
||||
coverage and liability for payment and prior to providing the service. This provision
|
||||
shall survive termination of this Agreement for any reason, and shall supersede any oral
|
||||
or written agreement now existing or hereafter entered into between Provider and
|
||||
enrollee or person acting on his or her behalf.
|
||||
2.
|
||||
Coordination of Benefits (COB). To the extent otherwise permitted in this Agreement,
|
||||
the Provider may participate in collection of COB on behalf of the MCO, with COB
|
||||
collectibles accruing to the MCO or to the provider. However, with respect to enrollees
|
||||
eligible for medical assistance, or participating in Child Health Plus or Family Health
|
||||
Plus, the Provider shall maintain and make available to the MCO records reflecting COB
|
||||
proceeds collected by the Provider or paid directly to enrollees by third party payers, and
|
||||
amounts thereof, and the MCO shall maintain or have immediate access to records
|
||||
concerning collection of COB proceeds.
|
||||
3.
|
||||
If the Provider is a health care professional licensed, registered or certified under Title 8
|
||||
of the Education Law, the MCO or the IPA must provide notice to the Provider at least
|
||||
ninety (90) days prior to the effective date of any adverse reimbursement arrangement as
|
||||
required by Public Health Law § 4406-c(5-c). Adverse reimbursement change shall
|
||||
mean a proposed change that could reasonably be expected to have a material adverse
|
||||
impact on the aggregate level of payment to a health care professional. This provision
|
||||
does not apply if the reimbursement change is required by law, regulation or applicable
|
||||
regulatory authority; is required as a result of changes in fee schedules, reimbursement
|
||||
methodology or payment policies established by the American Medical Association
|
||||
current procedural terminology (CPT) codes, reporting guidelines and conventions; or
|
||||
such change is expressly provided for under the terms of this Agreement by the inclusion
|
||||
or reference to a specific fee or fee schedule, reimbursement methodology or payment
|
||||
policy indexing scheme.
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
9
|
||||
|
||||
Start of Page No. = 10
|
||||
4.
|
||||
The parties agree to comply with and incorporate the requirements of Physician Incentive
|
||||
Plan (PIP) Regulations contained in 42 CFR 438.6(h), 42 CFR § 422.208, and 42 CFR §
|
||||
422.210 into any contracts between the contracting entity (provider, IPA, hospital, etc.)
|
||||
and other persons/entities for the provision of services under this Agreement. No specific
|
||||
payment will be made directly or indirectly under the plan to a physician or physician
|
||||
group as an inducement to reduce or limit medically necessary services furnished to an
|
||||
enrollee.
|
||||
5.
|
||||
The parties agree that a claim for home health care services following an inpatient
|
||||
hospital stay cannot be denied on the basis of medical necessity or a lack of prior
|
||||
authorization while a utilization review determination is pending if all necessary
|
||||
information was provided before a member's inpatient hospital discharge, consistent with
|
||||
Public Health Law § 4903.
|
||||
D.
|
||||
RECORDS ACCESS
|
||||
1.
|
||||
Pursuant to appropriate consent/authorization by the enrollee, the Provider will make the
|
||||
enrollee's medical records and other personally identifiable information (including
|
||||
encounter data for government-sponsored programs) available to the MCO (and IPA if
|
||||
applicable), for purposes including preauthorization, concurrent review, quality
|
||||
assurance, (including Quality Assurance Reporting Requirements ("QARR")), payment
|
||||
processing, and qualification for government programs, including but not limited to
|
||||
newborn eligibility for Supplemental Security Income (SSI) and for MCO/Manager
|
||||
analysis and recovery of overpayments due to fraud and abuse. The Provider will also
|
||||
make enrollee medical records available to the State for management audits, financial
|
||||
audits, program monitoring and evaluation, licensure or certification of facilities or
|
||||
individuals, and as otherwise required by state law. The Provider shall provide copies of
|
||||
such records to DOH at no cost. The Provider (or IPA if applicable) expressly
|
||||
acknowledges that he/she/it shall also provide to the MCO and the State (at no expense to
|
||||
the State), on request, all financial data and reports, and information concerning the
|
||||
appropriateness and quality of services provided, as required by law. These provisions
|
||||
shall survive termination of the contract for any reason.
|
||||
2.
|
||||
When such records pertain to Medicaid or Family Health Plus reimbursable services the
|
||||
Provider agrees to disclose the nature and extent of services provided and to furnish
|
||||
records to DOH and/or the United States Department of Health and Human Services, the
|
||||
County Department of Social Services, the Comptroller of the State of New York, the
|
||||
Office of the Medicaid Inspector General, the New York State Attorney General, and the
|
||||
Comptroller General of the United States and their authorized representatives upon
|
||||
request. This provision shall survive the termination of this Agreement regardless of the
|
||||
reason.
|
||||
3.
|
||||
The parties agree that medical records shall be retained for a period of six (6) years after
|
||||
the date of service, and in the case of a minor, for three (3) years after majority or six (6)
|
||||
years after the date of service, whichever is later, or for such longer period as specified
|
||||
elsewhere within this Agreement. This provision shall survive the termination of this
|
||||
Agreement regardless of the reason.
|
||||
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|
||||
10
|
||||
|
||||
Start of Page No. = 11
|
||||
4.
|
||||
The MCO and the Provider agree that the MCO will obtain consent directly from
|
||||
enrollees at the time of enrollment or at the earliest opportunity, or that the Provider will
|
||||
obtain consent from enrollees at the time service is rendered or at the earliest opportunity,
|
||||
for disclosure of medical records to the MCO, to an IPA or to third parties. If the
|
||||
Agreement is between an MCO and an IPA, or between an IPA and an IPA, the IPA
|
||||
agrees to require the providers with which it contracts to agree as provided above. If the
|
||||
Agreement is between an IPA and a provider, the Provider agrees to obtain consent from
|
||||
the enrollee if the enrollee has not previously signed consent for disclosure of medical
|
||||
records.
|
||||
E.
|
||||
TERMINATION AND TRANSITION
|
||||
1.
|
||||
Termination or non-renewal of an agreement between an MCO and an IPA, institutional
|
||||
network provider, or medical group Provider that serves five percent or more of the
|
||||
enrolled population in a county, or the termination or non-renewal of an agreement
|
||||
between an IPA and an institutional Provider or medical group Provider that serves five
|
||||
percent or more of the enrolled population in a county, requires notice to the
|
||||
Commissioner of Health. Unless otherwise provided by statute or regulation, the
|
||||
effective date of termination shall not be less than 45 days after receipt of notice by either
|
||||
party, provided, however, that termination, by the MCO may be effected on less than 45
|
||||
days notice provided the MCO demonstrates to DOH's satisfaction prior to termination
|
||||
that circumstances exist which threaten imminent harm to enrollees or which result in
|
||||
Provider being legally unable to deliver the covered services and, therefore, justify or
|
||||
require immediate termination.
|
||||
2.
|
||||
If this Agreement is between the MCO and a health care professional, the MCO shall
|
||||
provide to such health care professional a written explanation of the reasons for the
|
||||
proposed contract termination, other than non-renewal, and an opportunity for a review as
|
||||
required by state law. The MCO shall provide the health care professional 60 days notice
|
||||
of its decision to not renew this Agreement.
|
||||
3.
|
||||
If this Agreement is between an MCO and an IPA, and the Agreement does not provide
|
||||
for automatic assignment of the IPA's Provider contracts to the MCO upon termination
|
||||
of the MCO/IPA contract, in the event either party gives notice of termination of the
|
||||
Agreement, the parties agree, and the IPA's providers agree, that the IPA providers shall
|
||||
continue to provide care to the MCO's enrollees pursuant to the terms of this Agreement
|
||||
for 180 days following the effective date of termination, or until such time as the MCO
|
||||
makes other arrangements, whichever first occurs. This provision shall survive
|
||||
termination of this Agreement regardless of the reason for the termination.
|
||||
4.
|
||||
Continuation of Treatment. The Provider agrees that in the event of MCO or IPA
|
||||
insolvency or termination of this contract for any reason, the Provider shall continue,
|
||||
until medically appropriate discharge or transfer, or completion of a course of treatment,
|
||||
whichever occurs first, to provide services pursuant to the subscriber contract, Medicaid
|
||||
Managed Care contract, or Family Health Plus contract, to an enrollee confined in an
|
||||
inpatient facility, provided the confinement or course of treatment was commenced
|
||||
during the paid premium period. For purposes of this clause, the term "provider"
|
||||
shall include the IPA and the IPA's contracted providers if this Agreement is
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
11
|
||||
|
||||
Start of Page No. = 12
|
||||
between the MCO and an IPA. This provision shall survive termination of this
|
||||
Agreement.
|
||||
5.
|
||||
Notwithstanding any other provision herein, to the extent that the Provider is providing
|
||||
health care services to enrollees under the Medicaid Program and/or Family Health Plus,
|
||||
the MCO or IPA retains the option to immediately terminate the Agreement when the
|
||||
Provider has been terminated or suspended from the Medicaid Program.
|
||||
6.
|
||||
In the event of termination of this Agreement, the Provider agrees, and, where applicable,
|
||||
the IPA agrees to require all participating providers of its network to assist in the orderly
|
||||
transfer of enrollees to another provider.
|
||||
F.
|
||||
ARBITRATION
|
||||
1.
|
||||
To the extent that arbitration or alternative dispute resolution is authorized elsewhere in
|
||||
this Agreement, the parties to this Agreement acknowledge that the Commissioner of
|
||||
Health is not bound by arbitration or mediation decisions. Arbitration or mediation shall
|
||||
occur within New York State, and the Commissioner of Health will be given notice of all
|
||||
issues going to arbitration or mediation, and copies of all decisions.
|
||||
G.
|
||||
IPA-SPECIFIC PROVISIONS
|
||||
1.
|
||||
Any reference to IPA quality assurance (QA) activities within this Agreement is limited
|
||||
to the IPA's analysis of utilization patterns and quality of care on its own behalf and as a
|
||||
service to its contract providers.
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
12
|
||||
|
||||
Start of Page No. = 13
|
||||
07/20/2012 FRI 10:00 FAX
|
||||
003/003
|
||||
APPENDIX B
|
||||
CERTIFICATION REGARDING LOBBYING
|
||||
The undersigned certifies, to the best of his or her knowledge, that:
|
||||
1. No Federal appropriated funds have been paid or will be paid to any person by or on behalf
|
||||
of the Provider for the purpose of influencing or attempting to influence an officer or
|
||||
employee of any agency, a Member of Congress, an officer or employee of a Member of
|
||||
Congress in connection with the award of any Federal loan, the entering into any cooperative
|
||||
agreement, or the extension, continuation, renewal, amendment, or modification of any
|
||||
Federal contract, grant, loan, or cooperative agreement.
|
||||
2. If any funds other than Federal appropriated funds have been paid or will be paid to any
|
||||
person for the purpose of influencing or attempting to influence an officer or employee of
|
||||
any agency, a Member of Congress in connection with the award of any Federal contract, the
|
||||
making of any Federal grant, the making of any Federal loan, the entering into any
|
||||
cooperative agreement, or the extension, continuation, renewal, amendment or modification
|
||||
of any Federal contract, grant, loan, or cooperative agreement, and the Agreement exceeds
|
||||
$100,000, the Provider shall complete and submit Standard Form-LLL "Disclosure Form to
|
||||
Reporting Lobby," in accordance with its instructions.
|
||||
This certification is a material representation of fact upon which reliance was placed when this
|
||||
transaction was made or entered into submission of this certification is a prerequisite for making or
|
||||
entering into this transaction pursuant to U.S.C. Section 1352. The failure to file the required
|
||||
certification shall subject the violator to a civil penalty of not less than $10,000 and not more than
|
||||
$100,000 for each such failure.
|
||||
DATE:
|
||||
7-20-12
|
||||
TITLE:
|
||||
President
|
||||
ORGANIZATION:
|
||||
Borbas Surgeral Supply
|
||||
NAME: (Please Print)
|
||||
Kenstentin Bas
|
||||
SIGNATURE:
|
||||
you
|
||||
BorbasSurgicalSupply,Inc.AMD.07.20.12
|
||||
13
|
||||
|
||||
Start of Page No. = 14
|
||||
Approved by OMB
|
||||
0348-0046
|
||||
Appendix [b]
|
||||
Disclosure of Lobbying Activities
|
||||
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
|
||||
(See reverse for public burden disclosure)
|
||||
1. Type of Federal Action
|
||||
2. Status of Federal Action:
|
||||
3. Report Type:
|
||||
a. contract
|
||||
a. bid/offer/application
|
||||
a. initial filing
|
||||
b. grant
|
||||
b. initial award
|
||||
b. material change
|
||||
c. cooperative agreement
|
||||
C. post-award
|
||||
Select one:
|
||||
d. loan
|
||||
Select one:
|
||||
e. loan guarantee
|
||||
f. loan insurance
|
||||
For material change only:
|
||||
Select one:
|
||||
Year
|
||||
Quarter
|
||||
Date of last report
|
||||
4. Name and Address of Reporting Entity:
|
||||
5. If Reporting Entity in No. 4 is Subawardee,
|
||||
Prime
|
||||
Address
|
||||
Subawardee
|
||||
City
|
||||
Tier
|
||||
if known:
|
||||
State
|
||||
Zip code
|
||||
Congressional District, if known:
|
||||
Congressional District, if known:
|
||||
6. Federal Department/Agency:
|
||||
7. Federal Program Name/Description:
|
||||
CFDA Number, if applicable:
|
||||
8. Federal Action Number, if known:
|
||||
9. Award Amount, if known:
|
||||
$
|
||||
10. a. Name and Address of Lobbying Registrant
|
||||
10. b. Individuals Performing Services
|
||||
(including address if different from No. 10a)
|
||||
(if individual, last name, first name, MI)
|
||||
(last name, first name, MI)
|
||||
Address
|
||||
Address
|
||||
City
|
||||
City
|
||||
State
|
||||
State
|
||||
Zip code
|
||||
Zip code
|
||||
11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a
|
||||
material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This
|
||||
disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available
|
||||
for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not
|
||||
more than $100,000 for each such failure.
|
||||
Signature
|
||||
Print/Type Name
|
||||
Title
|
||||
Telephone No.:
|
||||
Date:
|
||||
Federal Use Only
|
||||
Authorized for Local Reproduction
|
||||
Standard Form - LLL (Rev. 7-97)
|
||||
|
||||
Start of Page No. = 15
|
||||
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
|
||||
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the
|
||||
initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section
|
||||
1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for
|
||||
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
|
||||
employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Complete
|
||||
all items apply for both the initial filing and material change report. Refer to the implementing guidance published by the
|
||||
Office of Management and Budget for additional information.
|
||||
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the
|
||||
outcome of a covered Federal action.
|
||||
2. Identify the status of the covered Federal action.
|
||||
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the
|
||||
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
|
||||
previously submitted report by this reporting entity for this covered Federal action.
|
||||
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District if known.
|
||||
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward
|
||||
recipient. Identify the tier of the subawardee, e.g. the first subawardee of the prime is the 1st tier. Subawards include
|
||||
but are not limited to subcontracts, subgrants and contract awards under grants.
|
||||
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and
|
||||
zip code of the prime Federal recipient. Include Congressional District, if known.
|
||||
6.
|
||||
Enter the name of federal agency making the award or loan commitment. Include at least one organizational level
|
||||
below agency name, if known. For example, Department of Transportation, United States Coast Guard.
|
||||
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog
|
||||
of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.
|
||||
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g.
|
||||
Request for Proposal (RFP) number, Invitations for Bid (IFB) number; grant announcement number; the contract,
|
||||
grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included
|
||||
prefixes, e.g. "RFP-DE-90-001"
|
||||
9.
|
||||
For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the
|
||||
Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.
|
||||
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act
|
||||
of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action.
|
||||
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter
|
||||
Last Name, First Name and Middle Initial (MI).
|
||||
11. The certifying official shall sign and date the form, print his/her name, title and telephone number.
|
||||
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it
|
||||
displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public
|
||||
reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing
|
||||
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
|
||||
of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including
|
||||
suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046),
|
||||
Washington, DC 20503
|
||||
File diff suppressed because it is too large
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+1282
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+678
@@ -0,0 +1,678 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT TO AGREEMENT BETWEEN
|
||||
NEW YORK STATE CATHOLIC HEALTH PLAN, INC. d/b/a Fidelis Care New York
|
||||
AND
|
||||
BETHPAGE MEDICAL, PLLC
|
||||
This Amendment to the Provider Agreement dated this 23rd day of September 2013,
|
||||
by and between NEW YORK STATE CATHOLIC HEALTH PLAN, INC., doing business as
|
||||
FIDELIS CARE NEW YORK, a New York not-for-profit corporation certified as a prepaid health
|
||||
services plan pursuant to Article 44 of the New York State Public Health Law, and including its
|
||||
affiliates and subsidiaries (hereinafter collectively referred to as, the "Plan"), and BETHPAGE
|
||||
MEDICAL, PLLC (hereinafter, "Provider"), a Professional Limited Liability Corporation
|
||||
organized under the laws of New York State.
|
||||
WHEREAS, Plan and Provider have heretofore entered into a certain Provider Agreement,
|
||||
dated December 7, 2009, (the "Agreement");
|
||||
WHEREAS, both parties wish to amend the Agreement between Plan and Provider;
|
||||
NOW, THEREFORE, in consideration of the mutual promises and other good and valuable
|
||||
consideration, the receipt and sufficiency of which are hereby acknowledged, the parties do agree
|
||||
that the Agreement shall be, and is hereby, amended as follows:
|
||||
1.
|
||||
This Amendment to the Agreement dated December 7, 2009, replaces Schedule 5.2B of the
|
||||
Agreement with Schedule 5.2C in entirety.
|
||||
2.
|
||||
The Agreement is amended to include the following Programs:
|
||||
Program: Managed Long Term Care program
|
||||
Program Contract: The contract for the provision of managed long term care
|
||||
services entered into by and between the New York State Catholic Health Plan, d/b/a
|
||||
Fidelis Care New York, and the New York State Department of Health including all
|
||||
attachments thereto. Provider shall be reimbursed for these services in accordance
|
||||
with Attachment A.
|
||||
3.
|
||||
The following clauses shall be added to this Agreement:
|
||||
The specific terms and conditions required by CMS to be incorporated into all Agreements between
|
||||
a Medicare Advantage Organization or First Tier Entity and a First Tier Entity or Downstream Entity
|
||||
to comply with the Medicare laws, regulations, and CMS instructions shall be referred to as the
|
||||
"CMS Clauses" and are attached to this Agreement as Appendix C. The CMS Clauses are hereby
|
||||
expressly incorporated into this Agreement and are binding upon the parties to this Agreement with
|
||||
respect to all services provided to Medicare enrollees. In the event of any inconsistent or contrary
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
1
|
||||
|
||||
Start of Page No. = 2
|
||||
language between the CMS Clauses, and any other part of this Agreement, including but not limited
|
||||
to appendix amendments and exhibits, the provisions of the CMS Clauses shall supersede and
|
||||
replace any inconsistent provisions to this Agreement in order to ensure compliance with required
|
||||
CMS provisions, and shall continue concurrently with the term of this Agreement.
|
||||
a) Plan and Provider and any contractor, subcontractor, or its transferee that provide
|
||||
any services under this Agreement, agree to provide the Center for Medicare and
|
||||
Medicaid Services (CMS), or its designees, the right to audit or evaluate, through
|
||||
inspection or otherwise, any and all books, contracts, medical records, patient
|
||||
care documentation, facilities, and equipment.
|
||||
b) Plan and Provider, as well as all contractors and subcontractors of Provider, agree
|
||||
to maintain for a minimum of ten (10) years records relating to Medicare
|
||||
Enrollees, books, other records, documents and other evidence of accounting
|
||||
procedures and practices, physical facilities and equipment, and any additional
|
||||
relevant information CMS may require.
|
||||
c) Plan and Provider, as well as all subcontractors of Provider, agree to abide by all
|
||||
Federal and State laws regarding confidentiality and disclosure of Medicare
|
||||
Enrollee medical records, or other Medicare Enrollee health and enrollment
|
||||
information.
|
||||
d) Under no circumstances (including, but not limited to, non-payment by or
|
||||
insolvency of Plan) shall Provider, Provider's Personnel, or any subcontractor
|
||||
carrying out Provider's obligations under this Agreement, bill, charge, collect a
|
||||
deposit from, seek compensation, remuneration or reimbursement from, have any
|
||||
recourse against, or make any other claim against a Medicare Enrollee, except for
|
||||
deductibles and/or co-payments (if any) expressly permitted by Plan. Provider
|
||||
further agrees that this section shall survive termination of this Agreement
|
||||
regardless of the cause giving rise to said termination.
|
||||
e) Provider, as well as any Provider subcontractors carrying out Providers
|
||||
obligations under this Agreement, shall be obligated to continue and complete
|
||||
any course of treatment to any individual Medicare Enrollee hospitalized on the
|
||||
date the CMS contract ends, through the date of discharge. Provider
|
||||
acknowledges that it will continue and complete any course of treatment for a
|
||||
hospitalized Medicare Enrollee even in the event of the Plan's insolvency,
|
||||
through the date of discharge.
|
||||
f)
|
||||
Submission of Electronic Claims and Acceptance of Information through
|
||||
Electronic Medium. Provider agrees to submit claims for services rendered to
|
||||
enrollees and to accept enrollee rosters, remittance advices and other Plan
|
||||
communications electronically through a medium designated by the Plan.
|
||||
g) Plan and Provider, as well as all subcontractors of Provider, shall comply with
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
2
|
||||
|
||||
Start of Page No. = 3
|
||||
the applicable Medicare laws and regulations.
|
||||
h) Plan shall oversee and be accountable to CMS for all required CMS contract
|
||||
functions and responsibilities.
|
||||
i)
|
||||
Plan and Provider agree that this amendment will not be effective until all
|
||||
necessary approvals, including but not limited to all State and Federal regulatory
|
||||
approvals, have been received.
|
||||
4.
|
||||
All other terms and conditions of the Agreement, except as amended herein, shall remain the
|
||||
same and are hereby ratified and confirmed.
|
||||
5.
|
||||
This amendment to the Agreement may be executed in one or more counterparts, each of
|
||||
which shall be deemed an original and all of which shall constitute but one and the same
|
||||
instrument.
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
3
|
||||
|
||||
Start of Page No. = 4
|
||||
IN WITNESS WHEREOF, the parties here have signed this AMENDMENT on the date
|
||||
referenced above.
|
||||
BETHPAGE MEDICAL, PLLC
|
||||
NEW YORK STATE CATHOLIC HEALTH
|
||||
Provider (Please Print)
|
||||
PLAN, INC. d/b/a Fidelis Care New York
|
||||
95-25 Queens Boulevard
|
||||
Rego Park, New York 11374
|
||||
P.O. Box 234641
|
||||
By: David P. Thomas
|
||||
Address
|
||||
Great Neck, NY 11023
|
||||
Its: Executive Vice President and Chief Operating
|
||||
City, State, Zip Code
|
||||
Officer
|
||||
Entity Tax ID#: 263847741
|
||||
Date:
|
||||
9/12/13
|
||||
Entity NPI#: 1205074739
|
||||
Signature:
|
||||
Name:X Michael Terrani, M.D.
|
||||
(Please Print)
|
||||
Title:X MEDICAL DiRector
|
||||
Date:X
|
||||
8/7/15
|
||||
Signature:X
|
||||
The
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
4
|
||||
|
||||
Start of Page No. = 5
|
||||
SCHEDULE 5.2C
|
||||
PRIMARY AND SPECIALTY CARE SERVICES REIMBURSEMENT
|
||||
Primary & Specialty Care Physicians will be reimbursed as follows:
|
||||
PROGRAMS: Medicaid Managed Care & Family Health Plus
|
||||
Provider shall be reimbursed at 80% of the prevailing Medicare RBRVS rate for Provider's
|
||||
geographical area effective at the date of service. If adjustments in the payment are required for any
|
||||
reason, they shall be made in due course during subsequent regular payment cycles. All payments to
|
||||
Provider shall be subject to coordination of benefits and other non-duplication of payments rules.
|
||||
Provider understands and agrees that the Plan Primary & Specialty Care Services Reimbursement
|
||||
Schedule shall be established by Plan, and may be modified from time to time, in the sole discretion
|
||||
of Plan.
|
||||
PROGRAM: Child Health Plus
|
||||
Provider shall be reimbursed at 80% of the prevailing Medicare RBRVS rate for the
|
||||
Provider's geographical area effective at the date of service. If adjustments in the payment are
|
||||
required for any reason, they shall be made in due course during subsequent regular payment cycles.
|
||||
All payments to Provider shall be subject to coordination of benefits and other non-duplication of
|
||||
payments rules. Provider understands and agrees that the Plan Primary & Specialty Care Services
|
||||
Reimbursement Schedule shall be established by Plan, and may be modified from time to time, in the
|
||||
sole discretion of Plan.
|
||||
PROGRAMS: Medicare Advantage & Managed Long Term Care - Medicaid Advantage
|
||||
Plus
|
||||
Provider shall be reimbursed at 95% of the prevailing Medicare RBRVS rate for Provider's
|
||||
geographical area effective at the date of service. If adjustments in the payment are required for any
|
||||
reason, they shall be made in due course during subsequent regular payment cycles. All payments to
|
||||
Provider shall be subject to coordination of benefits and other non-duplication of payments rules.
|
||||
Provider understands and agrees that the Plan Primary & Specialty Care Services Reimbursement
|
||||
Schedule shall be established by Plan, and may be modified from time to time, in the sole discretion
|
||||
of Plan.
|
||||
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|
||||
5
|
||||
|
||||
Start of Page No. = 6
|
||||
APPENDIX A
|
||||
NEW YORK STATE DEPARTMENT OF HEALTH
|
||||
STANDARD CLAUSES
|
||||
FOR MANAGED CARE PROVIDER/IPA CONTRACTS
|
||||
March 1, 2011
|
||||
Notwithstanding any other provision of this agreement, contract, or amendment (hereinafter
|
||||
"the Agreement" or "this Agreement") the parties agree to be bound by the following clauses which
|
||||
are hereby made a part of the Agreement. Further, if this Agreement is between a Managed Care
|
||||
Organization and an IPA, or between an IPA and an IPA, such clauses must be included in IPA
|
||||
contracts with providers, and providers must agree to such clauses.
|
||||
A.
|
||||
DEFINITIONS FOR PURPOSES OF THIS APPENDIX
|
||||
"Managed Care Organization" or "MCO" shall mean the person, natural or corporate, or any groups
|
||||
of such persons, certified under Public Health Law Article 44, who enter into an arrangement,
|
||||
agreement or plan or any combination of arrangements or plans which provide or offer, or which do
|
||||
provide or offer, a comprehensive health services plan.
|
||||
"Independent Practice Association" or "IPA" shall mean an entity formed for the limited purpose of
|
||||
arranging by contract for the delivery or provision of health services by individuals, entities and
|
||||
facilities licensed or certified to practice medicine and other health professions, and, as appropriate,
|
||||
ancillary medical services and equipment, by which arrangements such health care providers and
|
||||
suppliers will provide their services in accordance with and for such compensation as may be
|
||||
established by a contract between such entity and one or more MCOs. "IPA" may also include, for
|
||||
purposes of this Agreement, a pharmacy or laboratory with the legal authority to contract with other
|
||||
pharmacies or laboratories to arrange for or provide services to enrollees of a New York State MCO.
|
||||
"Provider" shall mean physicians, dentists, nurses, pharmacists and other health care professionals,
|
||||
pharmacies, hospitals and other entities engaged in the delivery of health care services which are
|
||||
licensed, registered and/or certified as required by applicable federal and state law.
|
||||
B.
|
||||
GENERAL TERMS AND CONDITIONS
|
||||
1.
|
||||
This Agreement is subject to the approval of the New York State Department of Health and
|
||||
if implemented prior to such approval, the parties agree to incorporate into this Agreement
|
||||
any and all modifications required by the Department of Health for approval or, alternatively,
|
||||
to terminate this Agreement if so directed by the Department of Health, effective sixty (60)
|
||||
days subsequent to notice, subject to Public Health Law 4403(6) (e). This Agreement is the
|
||||
sole agreement between the parties regarding the arrangement established herein.
|
||||
2.
|
||||
Any material amendment to this Agreement is subject to the prior approval of the
|
||||
Department of Health, and any such amendment shall be submitted for approval at least
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
6
|
||||
|
||||
Start of Page No. = 7
|
||||
thirty (30) days, or ninety (90) days if the amendment adds or materially changes a risk
|
||||
sharing arrangement that is subject to Department of Health review, in advance of anticipated
|
||||
execution. To the extent the MCO provides and arranges for the provision of comprehensive
|
||||
health care services to enrollees served by the Medical Assistance Program, the MCO shall
|
||||
notify and/or submit a copy of such material amendment to DOH or New York City, as may
|
||||
be required by the Medicaid managed care contract between the MCO and DOH (or New
|
||||
York City) and/or the Family Health Plus contract between the MCO and DOH.
|
||||
3.
|
||||
Assignment of an agreement between an MCO and (1) an IPA, (2) institutional network
|
||||
provider, or (3) medical group provider that serves five percent or more of the enrolled
|
||||
population in a county, or the assignment of an agreement between an IPA and (1) an
|
||||
institutional provider or (2) medical group provider that serves five percent or more of the
|
||||
enrolled population in a county, requires the prior approval of the Commissioner of Health.
|
||||
4.
|
||||
The Provider agrees, or if the Agreement is between the MCO and an IPA or between an IPA
|
||||
and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply fully
|
||||
and abide by the rules, policies and procedures that the MCO (a) has established or will
|
||||
establish to meet general or specific obligations placed on the MCO by statute, regulation, or
|
||||
DOH or SID guidelines or policies and (b) has provided to the Provider at least thirty (30)
|
||||
days in advance of implementation, including but not limited to:
|
||||
quality improvement/management;
|
||||
utilization management, including but not limited to precertification procedures,
|
||||
referral process or protocols, and reporting of clinical encounter data;
|
||||
member grievances; and
|
||||
provider credentialing.
|
||||
5.
|
||||
The Provider or, if the Agreement is between the MCO and an IPA, or between an IPA and
|
||||
an IPA, the IPA agrees, and shall require its providers to agree, to not discriminate against an
|
||||
enrollee based on color, race, creed, age, gender, sexual orientation, disability, place of
|
||||
origin, source of payment or type of illness or condition.
|
||||
6.
|
||||
If the Provider is a primary care practitioner, the Provider agrees to provide for twenty-four
|
||||
(24) hour coverage and back up coverage when the Provider is unavailable. The Provider
|
||||
may use a twenty-four (24) hour back-up call service provided appropriate personnel receive
|
||||
and respond to calls in a manner consistent with the scope of their practice.
|
||||
7.
|
||||
The MCO or IPA which is a party to this Agreement agrees that nothing within this
|
||||
Agreement is intended to, or shall be deemed to, transfer liability for the MCO's or IPA's
|
||||
own acts or omissions, by indemnification or otherwise, to a provider.
|
||||
8.
|
||||
Notwithstanding any other provision of this Agreement, the parties shall comply with the
|
||||
provisions of the Managed Care Reform Act of 1996 (Chapter 705 of the Laws of 1996)
|
||||
Chapter 551 of the Laws of 2006, Chapter 451 of the Laws of 2007 and Chapter 237 of the
|
||||
Laws of 2009 with all amendments thereto.
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
7
|
||||
|
||||
Start of Page No. = 8
|
||||
9.
|
||||
To the extent the MCO enrolls individuals covered by the Medical Assistance and/or Family
|
||||
Health Plus programs, this Agreement incorporates the pertinent MCO obligations under the
|
||||
Medicaid managed care contract between the MCO and DOH (or New York City) and/or the
|
||||
Family Health Plus contract between the MCO and DOH as if set forth fully herein,
|
||||
including:
|
||||
a. the MCO will monitor the performance of the Provider or IPA under the Agreement, and
|
||||
will terminate the Agreement and/or impose other sanctions, if the Provider's or IPA's
|
||||
performance does not satisfy standards set forth in the Medicaid managed care and/or
|
||||
Family Health Plus contracts;
|
||||
b. the Provider or IPA agrees that the work it performs under the Agreement will conform
|
||||
to the terms of the Medicaid managed care contract between the MCO and DOH (or
|
||||
between the MCO and New York City) and/or the Family Health Plus contract between
|
||||
the MCO and DOH, and that it will take corrective action if the MCO identifies
|
||||
deficiencies or areas of needed improvement in the Provider's or IPA's performance; and
|
||||
c. The Provider or IPA agrees to be bound by the confidentiality requirements set forth in
|
||||
the Medicaid managed care contract between the MCO and DOH (or between the MCO
|
||||
and New York City) and/or the Family Health Plus contract between the MCO and DOH.
|
||||
d. The MCO and the Provider or IPA agree that a woman's enrollment in the MCO's
|
||||
Medicaid managed care or Family Health Plus product is sufficient to provide services to
|
||||
her newborn, unless the newborn is excluded from enrollment in Medicaid managed care
|
||||
or the MCO does not offer a Medicaid managed care product in the mother's county of
|
||||
fiscal responsibility.
|
||||
e. The MCO shall not impose obligations and duties on the Provider or IPA that are
|
||||
inconsistent with the Medicaid managed care and/or Family Health Plus contracts, or that
|
||||
impair any rights accorded to DOH, the local Department of Social Services, or the
|
||||
United States Department of Health and Human Services.
|
||||
f. The Provider or IPA agrees to provide medical records to the MCO for purposes of
|
||||
determining newborn eligibility for Supplemental Security Income where the mother is a
|
||||
member of the MCO and for quality purposes at no cost to the MCO.
|
||||
g. The Provider or IPA agrees pursuant to 31 U.S.C. § 1352 and CFR Part 93, that no
|
||||
Federally appropriated funds have been paid or will be paid to any person by or on behalf
|
||||
of the Provider/IPA for the purpose of influencing or attempting to influence an officer or
|
||||
employee of any agency, a Member of Congress, an officer or employee of Congress, or
|
||||
an employee of a Member of Congress in connection with the award of any Federal loan,
|
||||
the entering into of any cooperative agreement, or the extension, continuation, renewal,
|
||||
amendment, or modification of any Federal contract, grant, loan, or cooperative
|
||||
agreement. The Provider or IPA agrees to complete and submit the "Certification
|
||||
Regarding Lobbying," Appendix B attached hereto and incorporated herein, if this
|
||||
Agreement exceeds $100,000.
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
8
|
||||
|
||||
Start of Page No. = 9
|
||||
If any funds other than Federally appropriated funds have been paid or will be paid to any
|
||||
person for the purpose of influencing or attempting to influence an officer or employee of
|
||||
any agency, a Member of Congress, an officer or employee of a member of Congress, in
|
||||
connection with the award of any Federal Contract, the making of any Federal grant, the
|
||||
making of any Federal loan, the entering of any cooperative agreement, or the extension,
|
||||
continuation, renewal, amendment, or modification of any Federal contract, grant, loan,
|
||||
or cooperative agreement, and the Agreement exceeds $100,000 the Provider or IPA shall
|
||||
complete and submit Standard Form-LLL "Disclosure Form to Report Lobbying," in
|
||||
accordance with its instructions.
|
||||
h. The Provider agrees to disclose to MCO on an ongoing basis, any managing employee
|
||||
that has been convicted of a misdemeanor or felony related to the person's involvement
|
||||
in any program under Medicare, Medicaid or a Title XX services program (Block grant
|
||||
programs)
|
||||
i.
|
||||
The Provider agrees to monitor its employees and staff against the List of Excluded
|
||||
Individuals and Entities (LEIE) and excluded individuals posted by the OMIG on its
|
||||
Website.
|
||||
j.
|
||||
The Provider agrees to disclose to MCO complete ownership, control, and relationship
|
||||
information.
|
||||
k. Provider agrees to obtain for MCO ownership information from any subcontractor with
|
||||
whom the provider has had a business transaction totaling more than $25,000, during the
|
||||
12 month period ending on the date of the request made by SDOH, OMIG or DHHS.
|
||||
The information requested shall be provided to MCO within 35 days of such request.
|
||||
10.
|
||||
The parties to this Agreement agree to comply with all applicable requirements of the Federal
|
||||
Americans with Disabilities Act.
|
||||
11.
|
||||
The Provider agrees, or if the Agreement is between the MCO and an IPA or between an IPA
|
||||
and an IPA, the IPA agrees and shall require the IPA's providers to agree, to comply with all
|
||||
applicable requirements of the Health Insurance Portability and Accountability Act; the HIV
|
||||
confidentiality requirements of Article 27-F of the Public Health Law and Mental Hygiene
|
||||
Law § 33.13.
|
||||
C.
|
||||
PAYMENT / RISK ARRANGEMENTS
|
||||
1.
|
||||
Enrollee Non-liability. Provider agrees that in no event, including, but not limited to,
|
||||
nonpayment by the MCO or IPA, insolvency of the MCO or IPA, or breach of this
|
||||
Agreement, shall Provider bill, charge, collect a deposit from, seek compensation,
|
||||
remuneration or reimbursement from, or have any recourse against a subscriber, an enrollee
|
||||
or person (other than the MCO or IPA) acting on his/her/their behalf, for services provided
|
||||
pursuant to the subscriber contract or Medicaid Managed Care contract or Family Health
|
||||
Plus contract and this Agreement, for the period covered by the paid enrollee premium. In
|
||||
addition, in the case of Medicaid Managed Care, Provider agrees that, during the time an
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
9
|
||||
|
||||
Start of Page No. = 10
|
||||
enrollee is enrolled in the MCO, he/she/it will not bill the New York State Department of
|
||||
Health or the City of New York for Covered Services within the Medicaid Managed Care
|
||||
Benefit Package as set forth in the Agreement between the MCO and the New York State
|
||||
Department of Health. In the case of Family Health Plus, Provider agrees that, during the
|
||||
time an enrollee is enrolled in the MCO, he/she/it will not bill the New York State
|
||||
Department of Health for Covered Services within the Family Health Plus Benefit Package,
|
||||
as set forth in the Agreement between the MCO and the New York State Department of
|
||||
Health. This provision shall not prohibit the provider, unless the MCO is a managed long
|
||||
term care plan designated as a Program of All-Inclusive Care for the Elderly (PACE), from
|
||||
collecting copayments, coinsurance amounts, or permitted deductibles, as specifically
|
||||
provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-
|
||||
service basis to a covered person provided that Provider shall have advised the enrollee in
|
||||
writing that the service is uncovered and of the enrollee's liability therefore prior to providing
|
||||
the service. Where the Provider has not been given a list of services covered by the MCO,
|
||||
and/or Provider is uncertain as to whether a service is covered, the Provider shall make
|
||||
reasonable efforts to contact the MCO and obtain a coverage determination prior to advising
|
||||
an enrollee as to coverage and liability for payment and prior to providing the service. This
|
||||
provision shall survive termination of this Agreement for any reason, and shall supersede any
|
||||
oral or written agreement now existing or hereafter entered into between Provider and
|
||||
enrollee or person acting on his or her behalf.
|
||||
2.
|
||||
Coordination of Benefits (COB). To the extent otherwise permitted in this Agreement, the
|
||||
Provider may participate in collection of COB on behalf of the MCO, with COB collectibles
|
||||
accruing to the MCO or to the provider. However, with respect to enrollees eligible for
|
||||
medical assistance, or participating in Child Health Plus or Family Health Plus, the Provider
|
||||
shall maintain and make available to the MCO records reflecting COB proceeds collected by
|
||||
the Provider or paid directly to enrollees by third party payers, and amounts thereof, and the
|
||||
MCO shall maintain or have immediate access to records concerning collection of COB
|
||||
proceeds.
|
||||
3.
|
||||
If the Provider is a health care professional licensed, registered or certified under Title 8 of
|
||||
the Education Law, the MCO or the IPA must provide notice to the Provider at least ninety
|
||||
(90) days prior to the effective date of any adverse reimbursement arrangement as required by
|
||||
Public Health Law § 4406-c(5-c). Adverse reimbursement change shall mean a proposed
|
||||
change that could reasonably be expected to have a material adverse impact on the aggregate
|
||||
level of payment to a health care professional. This provision does not apply if the
|
||||
reimbursement change is required by law, regulation or applicable regulatory authority; is
|
||||
required as a result of changes in fee schedules, reimbursement methodology or payment
|
||||
policies established by the American Medical Association current procedural terminology
|
||||
(CPT) codes, reporting guidelines and conventions; or such change is expressly provided for
|
||||
under the terms of this Agreement by the inclusion or reference to a specific fee or fee
|
||||
schedule, reimbursement methodology or payment policy indexing scheme.
|
||||
4.
|
||||
The parties agree to comply with and incorporate the requirements of Physician Incentive
|
||||
Plan (PIP) Regulations contained in 42 CFR 438.6(h), 42 CFR § 422.208, and 42 CFR §
|
||||
422.210 into any contracts between the contracting entity (provider, IPA, hospital, etc.) and
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
10
|
||||
|
||||
Start of Page No. = 11
|
||||
other persons/entities for the provision of services under this Agreement. No specific
|
||||
payment will be made directly or indirectly under the plan to a physician or physician group
|
||||
as an inducement to reduce or limit medically necessary services furnished to an enrollee.
|
||||
5.
|
||||
The parties agree that a claim for home health care services following an inpatient hospital
|
||||
stay cannot be denied on the basis of medical necessity or a lack of prior authorization while
|
||||
a utilization review determination is pending if all necessary information was provided
|
||||
before a member's inpatient hospital discharge, consistent with Public Health Law § 4903.
|
||||
D.
|
||||
RECORDS ACCESS
|
||||
1.
|
||||
Pursuant to appropriate consent/authorization by the enrollee, the Provider will make the
|
||||
enrollee's medical records and other personally identifiable information (including encounter
|
||||
data for government-sponsored programs) available to the MCO (and IPA if applicable), for
|
||||
purposes including preauthorization, concurrent review, quality assurance, (including Quality
|
||||
Assurance Reporting Requirements ("QARR")), payment processing, and qualification for
|
||||
government programs, including but not limited to newborn eligibility for Supplemental
|
||||
Security Income (SSI) and for MCO/Manager analysis and recovery of overpayments due to
|
||||
fraud and abuse. The Provider will also make enrollee medical records available to the State
|
||||
for management audits, financial audits, program monitoring and evaluation, licensure or
|
||||
certification of facilities or individuals, and as otherwise required by state law. The Provider
|
||||
shall provide copies of such records to DOH at no cost. The Provider (or IPA if applicable)
|
||||
expressly acknowledges that he/she/it shall also provide to the MCO and the State (at no
|
||||
expense to the State), on request, all financial data and reports, and information concerning
|
||||
the appropriateness and quality of services provided, as required by law. These provisions
|
||||
shall survive termination of the contract for any reason.
|
||||
2.
|
||||
When such records pertain to Medicaid or Family Health Plus reimbursable services the
|
||||
Provider agrees to disclose the nature and extent of services provided and to furnish records
|
||||
to DOH and/or the United States Department of Health and Human Services, the County
|
||||
Department of Social Services, the Comptroller of the State of New York, the Office of the
|
||||
Medicaid Inspector General, the New York State Attorney General, and the Comptroller
|
||||
General of the United States and their authorized representatives upon request. This
|
||||
provision shall survive the termination of this Agreement regardless of the reason.
|
||||
3.
|
||||
The parties agree that medical records shall be retained for a period of six (6) years after the
|
||||
date of service, and in the case of a minor, for three (3) years after majority or six (6) years
|
||||
after the date of service, whichever is later, or for such longer period as specified elsewhere
|
||||
within this Agreement. This provision shall survive the termination of this Agreement
|
||||
regardless of the reason.
|
||||
4.
|
||||
The MCO and the Provider agree that the MCO will obtain consent directly from enrollees at
|
||||
the time of enrollment or at the earliest opportunity, or that the Provider will obtain consent
|
||||
from enrollees at the time service is rendered or at the earliest opportunity, for disclosure of
|
||||
medical records to the MCO, to an IPA or to third parties. If the Agreement is between an
|
||||
MCO and an IPA, or between an IPA and an IPA, the IPA agrees to require the providers
|
||||
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|
||||
11
|
||||
|
||||
Start of Page No. = 12
|
||||
with which it contracts to agree as provided above. If the Agreement is between an IPA and
|
||||
a provider, the Provider agrees to obtain consent from the enrollee if the enrollee has not
|
||||
previously signed consent for disclosure of medical records.
|
||||
E.
|
||||
TERMINATION AND TRANSITION
|
||||
1.
|
||||
Termination or non-renewal of an agreement between an MCO and an IPA, institutional
|
||||
network provider, or medical group Provider that serves five percent or more of the enrolled
|
||||
population in a county, or the termination or non-renewal of an agreement between an IPA
|
||||
and an institutional Provider or medical group Provider that serves five percent or more of
|
||||
the enrolled population in a county, requires notice to the Commissioner of Health. Unless
|
||||
otherwise provided by statute or regulation, the effective date of termination shall not be less
|
||||
than 45 days after receipt of notice by either party, provided, however, that termination, by
|
||||
the MCO may be effected on less than 45 days notice provided the MCO demonstrates to
|
||||
DOH's satisfaction prior to termination that circumstances exist which threaten imminent
|
||||
harm to enrollees or which result in Provider being legally unable to deliver the covered
|
||||
services and, therefore, justify or require immediate termination.
|
||||
2.
|
||||
If this Agreement is between the MCO and a health care professional, the MCO shall provide
|
||||
to such health care professional a written explanation of the reasons for the proposed contract
|
||||
termination, other than non-renewal, and an opportunity for a review as required by state law.
|
||||
The MCO shall provide the health care professional 60 days notice of its decision to not
|
||||
renew this Agreement.
|
||||
3.
|
||||
If this Agreement is between an MCO and an IPA, and the Agreement does not provide for
|
||||
automatic assignment of the IPA's Provider contracts to the MCO upon termination of the
|
||||
MCO/IPA contract, in the event either party gives notice of termination of the Agreement,
|
||||
the parties agree, and the IPA's providers agree, that the IPA providers shall continue to
|
||||
provide care to the MCO's enrollees pursuant to the terms of this Agreement for 180 days
|
||||
following the effective date of termination, or until such time as the MCO makes other
|
||||
arrangements, whichever first occurs. This provision shall survive termination of this
|
||||
Agreement regardless of the reason for the termination.
|
||||
4.
|
||||
Continuation of Treatment. The Provider agrees that in the event of MCO or IPA insolvency
|
||||
or termination of this contract for any reason, the Provider shall continue, until medically
|
||||
appropriate discharge or transfer, or completion of a course of treatment, whichever occurs
|
||||
first, to provide services pursuant to the subscriber contract, Medicaid Managed Care
|
||||
contract, or Family Health Plus contract, to an enrollee confined in an inpatient facility,
|
||||
provided the confinement or course of treatment was commenced during the paid premium
|
||||
period. For purposes of this clause, the term "provider" shall include the IPA and the
|
||||
IPA's contracted providers if this Agreement is between the MCO and an IPA. This
|
||||
provision shall survive termination of this Agreement.
|
||||
5.
|
||||
Notwithstanding any other provision herein, to the extent that the Provider is providing
|
||||
health care services to enrollees under the Medicaid Program and/or Family Health Plus, the
|
||||
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|
||||
12
|
||||
|
||||
Start of Page No. = 13
|
||||
MCO or IPA retains the option to immediately terminate the Agreement when the Provider
|
||||
has been terminated or suspended from the Medicaid Program.
|
||||
6.
|
||||
In the event of termination of this Agreement, the Provider agrees, and, where applicable, the
|
||||
IPA agrees to require all participating providers of its network to assist in the orderly transfer
|
||||
of enrollees to another provider.
|
||||
F.
|
||||
ARBITRATION
|
||||
1.
|
||||
To the extent that arbitration or alternative dispute resolution is authorized elsewhere in this
|
||||
Agreement, the parties to this Agreement acknowledge that the Commissioner of Health is
|
||||
not bound by arbitration or mediation decisions. Arbitration or mediation shall occur within
|
||||
New York State, and the Commissioner of Health will be given notice of all issues going to
|
||||
arbitration or mediation, and copies of all decisions.
|
||||
G.
|
||||
IPA-SPECIFIC PROVISIONS
|
||||
1.
|
||||
Any reference to IPA quality assurance (QA) activities within this Agreement is limited to
|
||||
the IPA's analysis of utilization patterns and quality of care on its own behalf and as a service
|
||||
to its contract providers.
|
||||
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|
||||
13
|
||||
|
||||
Start of Page No. = 14
|
||||
APPENDIX B
|
||||
CERTIFICATION REGARDING LOBBYING
|
||||
The undersigned certifies, to the best of his or her knowledge, that:
|
||||
1. No Federal appropriated funds have been paid or will be paid to any person by or on behalf of the
|
||||
Provider for the purpose of influencing or attempting to influence an officer or employee of any
|
||||
agency, a Member of Congress, an officer or employee of a Member of Congress in connection
|
||||
with the award of any Federal loan, the entering into any cooperative agreement, or the
|
||||
extension, continuation, renewal, amendment, or modification of any Federal contract, grant,
|
||||
loan, or cooperative agreement.
|
||||
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person
|
||||
for the purpose of influencing or attempting to influence an officer or employee of any agency, a
|
||||
Member of Congress in connection with the award of any Federal contract, the making of any
|
||||
Federal grant, the making of any Federal loan, the entering into any cooperative agreement, or the
|
||||
extension, continuation, renewal, amendment or modification of any Federal contract, grant,
|
||||
loan, or cooperative agreement, and the Agreement exceeds $100,000, the Provider shall
|
||||
complete and submit Standard Form-LLL "Disclosure Form to Reporting Lobby," in accordance
|
||||
with its instructions.
|
||||
This certification is a material representation of fact upon which reliance was placed when this
|
||||
transaction was made or entered into submission of this certification is a prerequisite for making or
|
||||
entering into this transaction pursuant to U.S.C. Section 1352. The failure to file the required
|
||||
certification shall subject the violator to a civil penalty of not less than $10,000 and not more than
|
||||
$100,000 for each such failure.
|
||||
DATE:
|
||||
X
|
||||
8/7/13
|
||||
TITLE:
|
||||
X MEDICAL DIRECTOR
|
||||
ORGANIZATION:
|
||||
X BETHPAGE MEDICAL PLLC
|
||||
NAME: (Please Print)
|
||||
X
|
||||
Michael Terrani . m.s
|
||||
SIGNATURE:
|
||||
X
|
||||
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|
||||
14
|
||||
|
||||
Start of Page No. = 15
|
||||
Appendix C
|
||||
CMS Clauses
|
||||
CMS requires that specific terms and conditions be incorporated into the Agreement between a
|
||||
Medicare Advantage Organization or First Tier Entity and a First Tier Entity or Downstream Entity to
|
||||
comply with the Medicare laws, regulations, and CMS instructions, including, but not limited to, the
|
||||
Medicare Prescription Drug, Improvement and Modernization Act of 2003, Pub. L. No. 108-173, 117
|
||||
Stat. 2066 ("MMA"); and
|
||||
Except as provided herein, all other provisions of the Agreement between Plan and Provider not
|
||||
inconsistent herein shall remain in full force and effect. The provisions of this Appendix shall
|
||||
supersede and replace any inconsistent provisions to the Agreement, to ensure compliance with
|
||||
required CMS provisions, and shall continue concurrently with the term of such Agreement.
|
||||
NOW, THEREFORE, the parties agree as follows:
|
||||
Definitions:
|
||||
Centers for Medicare and Medicaid Services ("CMS"): the agency within the Department of Health and
|
||||
Human Services that administers the Medicare program.
|
||||
Completion of Audit: completion of audit by the Department of Health and Human Services, the
|
||||
Government Accountability Office, or their designees of a Medicare Advantage Organization,
|
||||
Medicare Advantage Organization contractor or related entity.
|
||||
Downstream Entity: any party that enters into a written arrangement, acceptable to CMS, with
|
||||
persons or entities involved with the MA benefit, below the level of the arrangement between an MA
|
||||
organization (or applicant) and a first tier entity. These written arrangements continue down to the
|
||||
level of the ultimate provider of both health and administrative services.
|
||||
Final Contract Period: the final term of the contract between CMS and the Medicare Advantage
|
||||
Organization.
|
||||
First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MA
|
||||
organization or applicant to provide administrative services or health care services for a Medicare
|
||||
eligible individual under the MA program.
|
||||
Medicare Advantage ("MA"): an alternative to the traditional Medicare program in which private plans
|
||||
run by health insurance companies provide health care benefits that eligible beneficiaries would
|
||||
otherwise receive directly from the Medicare program.
|
||||
Medicare Advantage Organization ("MA organization"): a public or private entity organized and
|
||||
licensed by a State as a risk-bearing entity (with the exception of provider-sponsored organizations
|
||||
receiving waivers) that is certified by CMS as meeting the MA contract requirements.
|
||||
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|
||||
15
|
||||
|
||||
Start of Page No. = 16
|
||||
Member or Enrollee: a Medicare Advantage eligible individual who has enrolled in or elected coverage
|
||||
through a Medicare Advantage Organization.
|
||||
Provider: (1) any individual who is engaged in the delivery of health care services in a State and is
|
||||
licensed or certified by the State to engage in that activity in the State; and (2) any entity that is engaged
|
||||
in the delivery of health care services in a State and is licensed or certified to deliver those services if
|
||||
such licensing or certification is required by State law or regulation.
|
||||
Related entity: any entity that is related to the MA organization by common ownership or control and
|
||||
(1) performs some of the MA organization's management functions under contract or delegation; (2)
|
||||
furnishes services to Medicare enrollees under an oral or written agreement; or (3) leases real
|
||||
property or sells materials to the MA organization at a cost of more than $2,500 during a contract
|
||||
period.
|
||||
Required Provisions:
|
||||
First Tier or Downstream Entity ("Provider") agrees to the following:
|
||||
1. HHS, the Comptroller General, or their designees have the right to audit, evaluate, and
|
||||
inspect any pertinent information for any particular contract period, including, but not limited
|
||||
to, any books, contracts, computer or other electronic systems (including medical records and
|
||||
documentation of the first tier, downstream, and entities related to CMS' contract with
|
||||
[Entity Name], (hereinafter, "MA organization") through 10 years from the final date of the
|
||||
final contract period of the contract entered into between CMS and the MA organization or
|
||||
from the date of completion of any audit, whichever is later. [42 C.F.R. §§ 422.504(i)(2)(i)
|
||||
and (ii)]
|
||||
2. Provider will comply with the confidentiality and enrollee record accuracy requirements,
|
||||
including: (1) abiding by all Federal and State laws regarding confidentiality and disclosure
|
||||
of medical records, or other health and enrollment information, (2) ensuring that medical
|
||||
information is released only in accordance with applicable Federal or State law, or pursuant
|
||||
to court orders or subpoenas, (3) maintaining the records and information in an accurate and
|
||||
timely manner, and (4) ensuring timely access by enrollees to the records and information
|
||||
that pertain to them. [42 C.F.R. §§ 422.504(a)(13) and 422.118]
|
||||
3. Enrollees will not be held liable for payment of any fees that are the legal obligation of the
|
||||
MA organization. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)]
|
||||
4. For all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for
|
||||
Medicare Part A and B cost sharing when the State is responsible for paying such amounts.
|
||||
Providers will be informed of Medicare and Medicaid benefits and rules for enrollees eligible
|
||||
for Medicare and Medicaid. Provider may not impose cost-sharing that exceeds the amount
|
||||
of cost-sharing that would be permitted with respect to the individual under title XIX if the
|
||||
individual were not enrolled in such a plan. Providers will: (1) accept the MA plan payment
|
||||
as payment in full, or (2) bill the appropriate State source. C.F.R. §§ 422.504(i)(3)(i) and
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
16
|
||||
|
||||
Start of Page No. = 17
|
||||
422.504(g)(1)(i)]
|
||||
5. Any services or other activity performed in accordance with a contract or written agreement
|
||||
by Provider are consistent and comply with the MA organization's contractual obligations.
|
||||
[42 C.F.R. § 422.504(i)(3)(iii)
|
||||
6. Contracts or other written agreements between the MA organization and providers or
|
||||
between first tier and downstream entities must contain a prompt payment provision, the
|
||||
terms of which are developed and agreed to by the contracting parties. The MA organization
|
||||
is obligated to pay contracted providers under the terms of the contract between the [MA
|
||||
organization Name/First Tier Entity Name] and the provider. [42 C.F.R. §§ 422.520(b)(1)
|
||||
and (2)]
|
||||
7. [Entity Name] and any related entity, contractor or subcontractor will comply with all
|
||||
applicable Medicare laws, regulations, and CMS instructions. [42 C.F.R.
|
||||
§§
|
||||
422.504(i)(4)(v)]
|
||||
8. If any of the MA organization's activities or responsibilities under its contract with CMS are
|
||||
delegated to any first tier, downstream and related entity:
|
||||
(i)
|
||||
The delegated activities and reporting responsibilities are specified as follows:
|
||||
NA
|
||||
(ii)
|
||||
CMS and the MA organization reserve the right to revoke the delegation activities
|
||||
and reporting requirements or to specify other remedies in instances where CMS or the
|
||||
MA organization determine that such parties have not performed satisfactorily.
|
||||
(iii)
|
||||
The MA organization will monitor the performance of the parties on an ongoing
|
||||
basis.
|
||||
(iv)
|
||||
The credentials of medical professionals affiliated with the party or parties will be
|
||||
either reviewed by the MA organization or the credentialing process will be reviewed
|
||||
and approved by the MA organization and the MA organization must audit the
|
||||
credentialing process on an ongoing basis.
|
||||
(v)
|
||||
If the MA organization delegates the selection of providers, contractors, or
|
||||
subcontractor, the MA organization retains the right to approve, suspend, or terminate
|
||||
any such arrangement.
|
||||
[42 C.F.R. §§ 422.504(i)(4) and (5)]
|
||||
In the event of a conflict between the terms and conditions above and the terms of a related agreement,
|
||||
the terms above control.
|
||||
BethpageMedicalPLLC.cs.08.06.13
|
||||
17
|
||||
+317
@@ -0,0 +1,317 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
MEDICARE- MEDICAID PROGRAM AND MEDICARE AMENDMENT TO
|
||||
MOLINA HEALTHCARE OF TEXAS, INC.
|
||||
PROVIDER SERVICES AGREEMENT
|
||||
This MEDICARE-MEDICAID PROGRAM AND MEDICARE AMENDMENT to the Hospital Services Agreement
|
||||
("Amendment") is made and entered into effective by the parties as set forth below.
|
||||
This Amendment includes the following attached hereto and incorporated herein:
|
||||
MEDICARE-MEDICAID PROGRAM AND MEDICARE AMENDMENT
|
||||
Attachment D-1- Medicare-Medicaid Program Compensation Schedule
|
||||
Attachment G-Medicare Program Requirements-Health Care Services
|
||||
Attachment G-1-Medicare Program Requirements-Delegated Services
|
||||
SIGNATURE AUTHORIZATION
|
||||
IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their officers thereunto
|
||||
duly authorized as of the Effective Date set forth in the Amendment. The individual signing below on behalf of
|
||||
Provider acknowledges, warrants, and represents that said individual has the authority and proper authorization to
|
||||
execute this Amendment on behalf of Provider and its constituent providers, if any, and does so freely with the intent
|
||||
to fully bind Provider, and its constituent providers, if any, to the provisions of this Amendment.
|
||||
Provider Name: Mid Valley Physicians Association Molina Healthcare of Texas, Inc.,
|
||||
("Provider")
|
||||
("Health Plan")
|
||||
Provider
|
||||
Health Plan
|
||||
Signature:
|
||||
Mrs
|
||||
Signature:
|
||||
Signatory
|
||||
Signatory
|
||||
Name
|
||||
Name
|
||||
(Printed):
|
||||
Miguel A. Tello, M.D.
|
||||
(Printed):
|
||||
John McGuinness
|
||||
Signatory
|
||||
Signatory
|
||||
Title
|
||||
Title
|
||||
(Printed):
|
||||
Chairman
|
||||
(Printed):
|
||||
NP Network Management
|
||||
Signature
|
||||
Signature
|
||||
Date:
|
||||
10/2/14
|
||||
Date:
|
||||
10/13/14
|
||||
Mailing
|
||||
Mid Valley Physicians Association
|
||||
Mailing
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Name and
|
||||
1401 E. 8th Street
|
||||
Name and
|
||||
5605 MacArthur Blvd, Suite 400
|
||||
Address:
|
||||
Address:
|
||||
Weslaco, TX 78596
|
||||
Irving, TX 75038
|
||||
Attention: Executive Director
|
||||
Attention: President
|
||||
Page 1 of 7
|
||||
TX Medicare & MMP Amendment. Dual June.2014
|
||||
MHT20140623
|
||||
|
||||
Start of Page No. = 2
|
||||
MEDICARE- MEDICAID PROGRAM AND MEDICARE AMENDMENT TO
|
||||
MOLINA HEALTHCARE OF TEXAS, INC.
|
||||
PROVIDER SERVICES AGREEMENT
|
||||
THIS MEDICARE-MEDICAID PROGRAM AND MEDICARE AMENDMENT to the Provider Services Agreement
|
||||
("Amendment") is made and entered by and between Molina Healthcare of Texas, Inc. ("Health Plan") and Mid Valley
|
||||
Physicians Association ("Provider").
|
||||
A. Whereas, Health Plan and Provider have entered into a Provider Services Agreement, or other corresponding health
|
||||
care services agreement or contract, as may have been amended from time to time ("Agreement"); and
|
||||
B. Whereas, Provider agrees to contract with Health Plan for Health Plan's Medicare-Medicaid Program and Medicare
|
||||
products.
|
||||
Now therefore, in consideration of the rights and obligations contained herein, Health Plan and Provider agree to amend the
|
||||
Agreement as follows:
|
||||
1.
|
||||
If Provider has previously received an amendment(s) pertaining to the Medicare-Medicaid Program Product and/or the
|
||||
Medicare Product, such amendment(s) shall be null and void, and are no longer part of the Agreement.
|
||||
2. Section 5.11, Attachments, or equivalent section of the Agreement, is amended to add the following to the list of
|
||||
Attachments which are part of the Agreement. If the Agreement already includes such Attachments, such Attachments are
|
||||
deleted in their entirety and replaced with the following Attachments:
|
||||
"Attachment D-1, Medicare-Medicaid Program Compensation Schedule"
|
||||
"Attachment G-Medicare Program Requirements-Health Care Services"
|
||||
"Attachment G-1-Medicare Program Requirements-Delegated Services"
|
||||
3.
|
||||
Attachment B, Definitions (or equivalent attachment/section of the Agreement), is amended by adding the following
|
||||
defined terms. If the following terms are already part of the Agreement, such terms will be deleted in their entirety and
|
||||
replaced with the following:
|
||||
"CMS means the Centers for Medicare and Medicaid Services, and administrative agency of the United States
|
||||
government, responsible for administering the Medicare program."
|
||||
"CMS Agreement means the Medicare Advantage contract between Health Plan and CMS."
|
||||
"Medicare means the Hospital Insurance Plan (Part A) and the Supplementary Medical Insurance Plan (Part B)
|
||||
provided under Title XVIII of the Social Security Act, as amended."
|
||||
"Medicare Advantage means the managed care program established by the Medicare Modernization Act of 2003 to
|
||||
serve Medicare eligible beneficiaries. Medicare Advantage plans generally cover Part A and Part B services and may
|
||||
also include Part D services."
|
||||
"Medicare Advantage Special Needs Plan (MA-SNP) means the managed care program established by the Medicare
|
||||
Modernization Act of 2003 which allows health plans to create specialized plans for beneficiaries who are eligible for
|
||||
Medicare and Medicaid."
|
||||
"Medicare- Medicaid Program (MMP) means the managed care program established by the Centers for Medicare
|
||||
and Medicaid Services (CMS) through the capitated financial alignment demonstration in which the state, CMS and
|
||||
Health Plan will enter into a three-way contract that will allow the health plan to provide care to beneficiaries eligible
|
||||
for both Medicaid and Medicare."
|
||||
4. Attachment C, Products/Programs, or equivalent attachment/section of the Agreement, is amended to add the following
|
||||
Products/Programs. If the Agreement already contains such Products/Programs, such Products/Programs will be deleted in
|
||||
their entirety and replaced with the following Products/Programs:
|
||||
Medicare - includes but is not limited to Molina Medicare Options (Medicare Advantage) and Molina Medicare
|
||||
Options Plus (MA-SNP).
|
||||
Mcdicare-Medicaid Programs (MMP) - includes but is not limited to Dual Options (Capitated Financial Alignment
|
||||
Demonstration (CFAD)).
|
||||
5.
|
||||
Attachment D, Compensation Schedule, or equivalent attachment/section of the Agreement, is amended to add the
|
||||
following compensation for the Medicare Program. If the Agreement already contains such compensation for the Medicare
|
||||
Product, such compensation is deleted in its entirety and replaced with the following compensation:
|
||||
Page 2 of 7
|
||||
TX Medicare & MMP Amendment. Dual June.2014
|
||||
MHT20140623
|
||||
|
||||
Start of Page No. = 3
|
||||
Medicare: Covered Services shall be paid at an amount equivalent to the Medicare Fee-For-Service Program allowable
|
||||
payment rates (adjusted for locality or geography), as of the date(s) of service.
|
||||
6. Attachment D-1, Medicare-Medicaid Compensation Schedule, attached hereto, is added to this Amendment.
|
||||
7. Attachment G, Medicare Program Requirements-Health Care Services, attached hereto, is added to this Amendment. If
|
||||
Provider already has an Attachment G, Medicare Program Requirements-Health Care Services, or such equivalent
|
||||
attachment as part of their Agreement, such Attachment is deleted in its entirety, and replaced with the Attachment G,
|
||||
Medicare Program Requirements-Health Care Services, attached hereto, that is part of this Amendment.
|
||||
8.
|
||||
If applicable, Attachment G-1, Medicare Program Requirements- Delegated Services, attached hereto, is added to this
|
||||
Amendment if Provider performs any delegated services. If Provider already has an Attachment G-1, Medicare Program
|
||||
Requirements- Delegated Services, or such equivalent attachment as part of their Agreement, such Attachment is deleted in
|
||||
its entirety, and replaced with the Attachment G-1, Medicare Program Requirement- Delegated Services, attached hereto,
|
||||
that is part of this Amendment.
|
||||
9.
|
||||
Any reference to UMCC or UMCM in the Agreement shall be applicable to the Medicare- Medicaid Program Product and
|
||||
the Medicare Product, unless stated otherwise by this Amendment, determined to be a violation of state or federal law or
|
||||
regulations related to the Medicare- Medicaid Program Product and/or the Medicare Product, or identified as specific to a
|
||||
product other than the Medicare-Medicaid Program Product and the Medicare Product in the Agreement.
|
||||
10. Pursuant to Section 5.6, Amendment, or equivalent section of the Agreement, Health Plan is amending this Agreement by
|
||||
providing thirty (30) days prior written notice to Provider. If Provider does not deliver to Health Plan a written notice of
|
||||
rejection of this amendment within that thirty (30) day period, this amendment will be deemed accepted by and will be
|
||||
binding upon Provider.
|
||||
11. Pursuant to the terms of the Agreement, there are no performance, bonus or special compensation programs applicable to
|
||||
the Medicare- Medicaid Program Product and the Medicare Product. Any such additional compensation requires a written
|
||||
amendment to the Agreement.
|
||||
12. Effective Date. This Amendment will become effective on the date it is executed by both parties.
|
||||
13. Counterparts. This Amendment may be executed in one or more counterparts, each of which shall be deemed an
|
||||
original, but all of which taken together shall constitute one and the same instrument.
|
||||
14. Use of Defined Terms. Unless otherwise defined in this Amendment, capitalized terms utilized in this Amendment will
|
||||
have the same meaning(s) ascribed to such terms in the Agreement.
|
||||
15. No Other Modifications. Except as provided herein, and regardless of any citations or references to the UMCC or UMCM,
|
||||
the terms and conditions of the Agreement will remain the same, in full force and effect.
|
||||
Page 3 of 7
|
||||
TX Medicare & MMP Amendment, Dual June.2014
|
||||
MHT20140623
|
||||
|
||||
Start of Page No. = 4
|
||||
ATTACHMENT D-1
|
||||
MEDICARE-MEDICAID PROGRAM COMPENSATION SCHEDULE
|
||||
Medicare and Medicaid Program (MMP): Health Plan agrees to compensate Provider for Covered Services rendered to
|
||||
Members, in accordance with Medicare-Medicaid Program (MMP) as specified in Attachment C, that are submitted on a
|
||||
Clean Claim and determined by Health Plan to be payable, on a fee-for-service basis, at the lesser of: (i) Provider's billed
|
||||
charges, or (ii) pursuant to the methodology described below. Provider will receive an amount equivalent to the Medicare
|
||||
Fee-For-Service Program allowable payment rates (adjusted for place of service or geography) set forth by CMS in effect
|
||||
on the Date(s) of Service, and any portion, if any, that the Medicaid agency or Medicaid managed care plan would have
|
||||
been responsible for paying if the Member was enrolled in the Medicare Fee-For-Service Program. The Medicare Fee-For-
|
||||
Service Program allowable payment rate deducts any cost sharing amounts, including but not limited to co-payments,
|
||||
deductibles, co-insurance, or amounts paid or to be paid by other liable third parties that would have been deducted if the
|
||||
Member were enrolled in the Medicare Fee-For-Service Program.
|
||||
In the event a Covered Service is covered by Medicaid or is primary to Medicaid, but not Medicare, Health Plan agrees to
|
||||
compensate Provider for such Covered Services rendered to Members, that are submitted on a Clean Claim and determined
|
||||
by Health Plan to be payable, on a fee-for-service basis, at the lesser of: (i) Provider's billed charges, or (ii) at an amount
|
||||
equivalent to the Medicaid Fee-For-Service Program allowable payment rates set forth by the State of Texas in effect on the
|
||||
Date(s) of Service, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by
|
||||
other liable third parties, if any.
|
||||
Provider acknowledges that CMS and the State of Texas have not released the joint-capitation rate to be paid to Health Plan
|
||||
for this product/program. If, after the capitation rate is released, Health Plan determines that the above compensation for
|
||||
this product/program is unsustainable, Provider agrees to negotiate a new compensation rate for this product/program with
|
||||
Health Plan in good faith. If Health Plan and Provider cannot agree to a new rate before this product/program begins,
|
||||
Health Plan or Provider may immediately terminate this product/program from this Agreement, in compliance with
|
||||
applicable Laws.
|
||||
Page 4 of 7
|
||||
TX Medicare & MMP Amendment, Dual Junc.2014
|
||||
MUT20140623
|
||||
|
||||
Start of Page No. = 5
|
||||
ATTACHMENT G
|
||||
MEDICARE PROGRAM REQUIREMENTS--HEALTH CARE SERVICES
|
||||
This Attachment sets forth the applicable Government Program requirements, covering the provision of health care services,
|
||||
that are required by CMS to be included in contracts and/or agreements between; (i) health plans / health maintenance
|
||||
organizations, and (ii) providers of health care services, authorized assignees, delegates or subcontractors. This attachment is
|
||||
hereby incorporated into the Agreement, and both will be automatically modified to conform to subsequent changes or
|
||||
amendments by CMS to any Government Program requirements set forth herein. All terms and conditions of the Agreement not
|
||||
specifically modified by this attachment remain unchanged and will control. In the event of any inconsistency between this
|
||||
attachment and the Agreement, the terms and conditions of this attachment will control, notwithstanding anything to the
|
||||
contrary in the Agreement. Capitalized terms utilized in this attachment will have the same meanings ascribed to them in the
|
||||
Agreement unless otherwise set forth in this attachment and the applicable statute(s).
|
||||
1. Downstream Compliance. Provider agrees to require all of its downstream, related entity(ies), and transferees that provide
|
||||
any services benefiting Health Plan's Medicare Members to agree in writing to all of the terms provided herein. (42 CFR
|
||||
422.504(i)(3)(iii)).
|
||||
2. Right to Audit. HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any pertinent
|
||||
information, including books, contracts, records, including medical records and documentation that pertain to any aspect of
|
||||
services performed, reconciliation of benefit liabilities, and determination of amounts payable under Health Plan's contract with
|
||||
CMS, or as the Secretary may deem necessary to enforce Health Plan's contract with CMS. Provider agrees to make available,
|
||||
for the purposes specified in this paragraph, its premises, physical facilities and equipment, records relating to its Medicare
|
||||
Members, and any additional relevant information that CMS may require. HHS, the Comptroller General, or their designee's
|
||||
right to inspect, evaluate, and audit extends through ten (10) years from the end of the final contract period between Health Plan
|
||||
and CMS or completion of audit, whichever is later. (42 CFR 422.504(e)(2), 42 CFR 422.504(e)(3), 42 CFR 422.504(e)(4) and
|
||||
42 CFR422.504(i)(2)(ii).).
|
||||
3. Confidentiality. Provider will comply with the confidentiality and Member record accuracy requirements set forth in 42
|
||||
CFR 422.118. (42 CFR 422.504(a)(13).)
|
||||
4. Hold Harmless/Cost Sharing. Provider agrees it may not under any circumstances, including nonpayment of moneys due to
|
||||
the providers by the Health Plan, insolvency of the Health Plan, or breach of this Agreement, bill, charge, collect a deposit, seek
|
||||
compensation, remuneration, or reimbursement from, or have any recourse against the Member, or any persons other than the
|
||||
Health Plan acting on their behalf, for services provided in accordance with this Agreement. The Hold Harmless clause will
|
||||
survive the termination of this Agreement, regardless of the cause of termination. (42 CFR 422.504(g)(1)(i)) and (42 CFR
|
||||
422.504(g)(1)(iii).) In addition, for Members who are dually eligible for Medicare and Medicaid and enrolled in a:
|
||||
a.
|
||||
Medicare Advantage Special Needs Plan will not be held liable for Medicare Part A and B cost sharing when the State or
|
||||
another payor such as a Medicaid Managed Care Plan is responsible for paying such amounts. Health Plan will inform
|
||||
providers of applicable Medicare and Medicaid benefits and rules for eligible Members. Provider agrees to accept payment
|
||||
from Health Plan as payment in full, or bill the appropriate State source, for any Medicare Part A and B cost sharing that is
|
||||
covered by Medicaid. Collection from the Member of copayments or supplemental charges in accordance with the terms of
|
||||
the Member's contract with the Health Plan, or charges for services not covered under the Member's contract, may be
|
||||
excluded from this provision.
|
||||
b. Capitated Financial Alignment Demonstration/Medicare-Medicaid Plan will not be held liable for any Medicare Part A and
|
||||
B cost sharing. Specifically, Medicare Parts A and B services will be provided at zero-cost share to the Member.
|
||||
5. Accountability. Health Plan may only delegate activities or functions to a first tier, downstream, or related entity, in a
|
||||
manner that is consistent with the provisions set forth in Attachment G-I of this Agreement. (42 CFR 422.504(i)(3)(ii).)
|
||||
6. Delegation. Any services or other activity performed by a first tier, downstream, or related entity in accordance with a
|
||||
contract or written agreement will be consistent and comply with the Health Plan's contract with CMS. (42 CFR
|
||||
422.504(i)(3)(iii) and 42 CFR 422.504(i)(4).)
|
||||
7. Prompt Payment. Health Plan and Provider agree that Health Plan will pay all Clean Claims for services that are covered by
|
||||
Medicare within thirty (30) days of the date such Claim is delivered by Provider to Health Plan and Health Plan determines such
|
||||
Claim is complete/clean. Any Claims for services that are covered by Medicare that are not submitted to Health Plan within six
|
||||
(6) months of providing the services that are subject of the Claim will not be eligible for payment, and Provider hereby waives
|
||||
any right to payment therefore. Health Plan reserves the right to deny any Claims that are not in accordance with the Medicare
|
||||
Claims Processing Manual and Medicare rules for billing. (42 CFR 422.520(b).)
|
||||
Page 5 of 7
|
||||
TX Medicare & MMP Amendment. Dual Junc.2014
|
||||
MHT20140623
|
||||
|
||||
Start of Page No. = 6
|
||||
8. Reporting. Provider agrees to provide relevant data to support Health Plan in complying with the requirements set forth in
|
||||
42 CFR 422.516 and 42 CFR 422.310. (42 CFR 504(a)(8).)
|
||||
9. Compliance with Medicare Laws and Regulations. Provider will comply with all applicable Medicare laws, regulations, and
|
||||
CMS instructions. (42 CFR 422.504(i)(4)(v).)
|
||||
10. Benefit Continuation. Provider agrees to provide for continuation of Member health care benefits (i) for all Members, for
|
||||
the duration of the period for which CMS has made payments to Health Plan for Medicare services; and (ii) for Members who
|
||||
are hospitalized on the date Health Plan's contract with CMS terminates, or, in the event of insolvency, through discharge. (42
|
||||
CFR 422.504(g)(2)(i), 42 CFR 422.504(g)(2)(ii) and 42 CFR 422.504(g)(3).)
|
||||
11. Cultural Considerations. Provider agrees that services are provided in a culturally competent manner to all members,
|
||||
including those with limited English proficiency or reading skills, and diverse cultural and ethnic backgrounds. (42 CFR
|
||||
422.112(a)(8).)
|
||||
Page 6 of 7
|
||||
TX Medicare & MMP Amendment. Dual June.2014
|
||||
MHT20140623
|
||||
|
||||
Start of Page No. = 7
|
||||
ATTACHMENT G-1
|
||||
MEDICARE PROGRAM REQUIREMENTS--DELEGATED SERVICES
|
||||
This Attachment sets forth the applicable Government Program requirements, covering the delegation to Provider of any
|
||||
management responsibilities or administrative services if any, that are required by CMS to be included in contracts and/or
|
||||
agreements between; (i) health plans / health maintenance organizations, and (ii) providers of health care services, authorized
|
||||
assignees, delegates or subcontractors. This Attachment is hereby incorporated into the Agreement, and both will be
|
||||
automatically modified to conform to subsequent changes or amendments by CMS to any Government Program requirements
|
||||
set forth herein. All terms and conditions of the Agreement not specifically modified by this attachment remain unchanged and
|
||||
will control. In the event of any inconsistency between this attachment and the Agreement, the terms and conditions of this
|
||||
attachment will control, notwithstanding anything to the contrary in the Agreement. Capitalized terms utilized in this attachment
|
||||
will have the same meanings ascribed to them in the Agreement unless otherwise set forth in this attachment and the applicable
|
||||
statute(s).
|
||||
1. Downstream Compliance. Provider agrees to require all of its downstream, related entity(s), and transferees that provide
|
||||
any services benefiting Health Plan's Medicare Members to agree in writing to all of the terms provided herein. (42 CFR
|
||||
422.504(i)(3)(iii))
|
||||
2. Medicare Compliance. Provider agrees to require all of its downstream, related entity(s) and transferees to comply with all
|
||||
applicable Medicare laws, regulations, and CMS instructions. (42 CFR 422.504(i)(4)(v).)
|
||||
3. Confidentiality. Provider will comply with the confidentiality and Member record accuracy requirements set forth in 42
|
||||
CFR 422.118. (42 CFR 422.504(a)(13).)
|
||||
4. Right to Audit. HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any books,
|
||||
contracts, records, including medical records and documentation that pertain to any aspect of services performed, reconciliation
|
||||
of benefit liabilities, and determination of amounts payable under the contract, or as the Secretary may deem necessary to
|
||||
enforce Health Plan's contract with CMS. Provider agrees to make available, for the purposes specified in this paragraph, its
|
||||
premises, physical facilities and equipment, records relating to its Medicare Members, and any additional relevant information
|
||||
that CMS may require. HHS, the Comptroller General, or their designee's right to inspect, evaluate, and audit extends through
|
||||
ten (10) years from the end of the final contract period or completion of audit, whichever is later. (42 CFR 422.504(e)(2), 42
|
||||
CFR 422.504(e)(3), 42 CFR 422.504(e)(4) and 42 CFR 422.504(i)(2)(ii).)
|
||||
5. Responsibilities and Reporting Arrangements. The Agreement specifies the delegated activities and reporting
|
||||
responsibilities if any. To the extent applicable, Provider will support Health Plan in complying with the reporting requirements
|
||||
set forth in 42 CFR 422.516 and 42 CFR 310 by providing relevant data. (42 CFR 422.504(i)(4)(i) and 42 CFR 422.504(a)(8).)
|
||||
6. Revocation of Delegated Activities. In the event CMS or Health Plan determines, in its sole discretion, that Provider has not
|
||||
performed the delegated activities or functions satisfactorily, the delegated activities will be revoked. (42 CFR
|
||||
422.504(i)(4)(ii).)
|
||||
7. Accountability. Notwithstanding any relationship(s) Health Plan may have with first tier, downstream, and related entities,
|
||||
Health Plan maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its
|
||||
contract with CMS. Any services or other activity performed by a first tier, downstream, or related entity in accordance with a
|
||||
contract or written agreement will be consistent and comply with the Health Plan's contract with CMS. (42 CFR 422.504(i)(1)
|
||||
and 42 CFR 422.504(i)(3)(iii).)
|
||||
8. Credentialing. If Provider is delegated credentialing activities, Provider's credentialing process will be reviewed and
|
||||
approved by Health Plan, and such credentialing process will be audited by Health Plan on an ongoing basis; further, Provider
|
||||
agrees that its credentialing process will comply with all applicable NCQA standards. Health Plan retains the right to approve,
|
||||
suspend, or terminate any credentialing delegation arrangement. (42 CFR 422.504(i)(4) and 42 CFR 422.504(i)(5).)
|
||||
9. Monitoring. Notwithstanding any relationship(s) Health Plan may have with first tier, downstream, and related entities,
|
||||
Health Plan maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its
|
||||
contract with CMS. Any services or other activity performed by a first tier, downstream, or related entity in accordance with a
|
||||
contract or written agreement will be consistent and comply with the Health Plan's contractual obligations. Health Plan will
|
||||
monitor the performance of first tier, downstream, and related entities. (42 CFR 422.504(i)(1) and 42 CFR 422.504(i)(4).)
|
||||
10. Further Requirements. Any services or other activity performed by a first tier, downstream, or related entity in accordance
|
||||
with a contract or written agreement will be consistent and comply with Health Plan's contractual obligations. If Health Plan
|
||||
delegates selection of the providers, contractors, or subcontractor to another organization, Health Plan retains the right to
|
||||
approve, suspend, or terminate any such arrangement. (42 CFR 422.504(i)(3)(iii), 42 CFR 422.504(i)(4) and 42 CFR
|
||||
422.504(i)(5).)
|
||||
Page 7 of 7
|
||||
TX Medicare & MMP Amendment. Dual June.2014
|
||||
MHT20140623
|
||||
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+73
@@ -0,0 +1,73 @@
|
||||
|
||||
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|
||||
THIRD AMENDMENT
|
||||
TO THE AGREEMENT
|
||||
BETWEEN
|
||||
CARESOURCE
|
||||
AND
|
||||
PREMIER HEALTH SPECIALISTS, INC.
|
||||
This Amendment ("Amendment") is made by and between CareSource (CareSource or
|
||||
Plan) and Premier Health Specialists, Inc (Group Practice).
|
||||
WHEREAS, Plan and Group Practice are parties to the CareSource Group Practice Agreement
|
||||
dated the 22nd day of June 2005, as amended (Agreement); and
|
||||
WHEREAS, Plan and Group Practice desire to amend the Agreement pursuant to Section 6.4 of
|
||||
the Agreement.
|
||||
NOW THEREFORE, the parties agreed to amend the Agreement effective as of January 1,
|
||||
2016 ("Third Amendment Effective Date) as follows:
|
||||
1)
|
||||
As of the Third Amendment Effective Date, ATTACHMENT A.4- titled, "Reimbursement
|
||||
for CareSource Just4Me" (Former Attachment A.4) is hereby deleted in its entirety and
|
||||
replaced with the attached ATTACHMENT A.4, titled "Reimbursement for CareSource
|
||||
Just4Me" ("Third Amendment A.4 Attachment"). Group Practice and Plan agree that
|
||||
Plan will pay Group Practice for any Covered Services provided by Group Practice to
|
||||
Covered Persons on dates of service prior to the Effective Date in accordance with the
|
||||
terms of the Former Attachment A.4. Group Practice and Plan agree that Plan will pay
|
||||
Group Practice for any Covered Services provided by Group Practice to Covered
|
||||
Persons on dates of service after the Effective Date in accordance with the terms of the
|
||||
Third Amendment Attachment A.4 attached hereto.
|
||||
2) This amendment can be separately terminated from the Agreement by either party
|
||||
without cause with 60 days written notice.
|
||||
3) Except as expressly amended herein, the remaining terms and conditions of the
|
||||
Agreement shall remain in full effect.
|
||||
IN WITNESS WHEREOF, the parties have executed this Amendment as of the Effective Date:
|
||||
CareSource
|
||||
Premier Health Specialists, Inc.
|
||||
Cohum
|
||||
By
|
||||
By
|
||||
Craig Thiele, M.D.
|
||||
Mark W. Shaw
|
||||
Printed Name
|
||||
Printed Name
|
||||
Chief Medical Officer
|
||||
VP Managed Care & Chief Revenue Officer
|
||||
Title
|
||||
Title
|
||||
10-19-15
|
||||
10/16/15
|
||||
Date
|
||||
Date
|
||||
06-1744704
|
||||
Tax ID No.
|
||||
|
||||
Start of Page No. = 2
|
||||
ATTACHMENT A.4
|
||||
REIMBURSEMENT FOR CareSource Just4Me TM
|
||||
Addendum to Agreement
|
||||
For Medically Necessary Covered Services rendered to Covered Persons by Group
|
||||
Practice or by Group Practice Providers in accordance with the terms of this Agreement,
|
||||
Group Practice shall accept as payment in full the lesser of:
|
||||
(i)
|
||||
Group Practice or Group Practice Providers Allowable Billed Charges; or
|
||||
(ii)
|
||||
One-hundred and fifty percent (150%) of the Medicare Fee Schedule
|
||||
applicable to Providers as published annually in the Federal Register and
|
||||
based on valid codes recognized by the Centers for Medicare and Medicaid
|
||||
Services ("CMS") in effect on the date of service. (Any co-payment, co-
|
||||
insurance or deductible shall be offset against the allowed amount for
|
||||
Covered Services without regard to whether Group Practice Providers has
|
||||
collected such amounts.).
|
||||
Fee Schedule
|
||||
To determine unit prices for any specific code or service, please refer to the Medicare link
|
||||
below:
|
||||
Medicare: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx
|
||||
+123
@@ -0,0 +1,123 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT NUMBER 2014-01 TO
|
||||
MOLINA HEALTHCARE OF TEXAS, INC.
|
||||
PROVIDER SERVICES AGREEMENT
|
||||
This Amendment to Provider Services Agreement (the "Amendment") is made and entered into
|
||||
by and between Molina Healthcare of Texas, Inc. ("Health Plan") and Mission Health Network
|
||||
("Provider"), with respect to the following facts:
|
||||
RECITALS
|
||||
A. The parties have previously entered into that certain Provider Service Agreement dated
|
||||
11-1-2011 (the "Agreement").
|
||||
B. The parties hereby agree to amend the Agreement in accordance with the terms
|
||||
and conditions of this Amendment.
|
||||
NOW, THEREFORE, in consideration of the promises, covenants and warranties stated herein,
|
||||
Health Plan and Provider agree as follows:
|
||||
1. Attachment C (Products/Programs) is hereby deleted in its entirety and shall be replaced with
|
||||
a new Attachment C (Products/Programs) attached hereto and incorporated herein.
|
||||
2. Attachment D (Compensation Schedule) is hereby modified to include reimbursement for the
|
||||
Medicare Advantage Products/Programs and shall be replaced with a new Attachment D
|
||||
(Compensation Schedule) attached hereto and incorporated herein.
|
||||
3. Use of Defined Terms. Capitalized terms utilized in this Amendment shall have the same
|
||||
meanings ascribed to such terms in the Agreement.
|
||||
4. Agreement Remains in Full Force and Effect. Except as specifically amended by this
|
||||
Amendment, the Agreement shall continue in full force and effect.
|
||||
IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by
|
||||
their duly authorized officers as of the Effective Date set forth by Health Plan below.
|
||||
Mission Health Network
|
||||
Molina Healthcare of Texas, Inc
|
||||
Provider
|
||||
Molina
|
||||
Signature:
|
||||
Nich Epin 18
|
||||
Signature:
|
||||
Anne P Rote
|
||||
Signatory Name
|
||||
Signatory Name
|
||||
(Printed):
|
||||
wich Ecpinisa
|
||||
(Printed):
|
||||
Anne Rote
|
||||
Signatory
|
||||
MHW Director
|
||||
Signatory Title
|
||||
Title (Printed):
|
||||
(Printed):
|
||||
VP of Plan Operations
|
||||
Signature Date:
|
||||
2-25-14
|
||||
Signature Date:
|
||||
03-12-2014
|
||||
Provider TIN
|
||||
Effective Date:
|
||||
4-01-2014
|
||||
Amendment to
|
||||
Page 1 of 3
|
||||
PSA - NSS PCSS 12282011
|
||||
Molina Healthcare of Texas, Inc. - Mission Health Network
|
||||
N.C.
|
||||
|
||||
Start of Page No. = 2
|
||||
ATTACHMENT C
|
||||
Products/Programs
|
||||
Provider hereby elects to participate as a panel provider for each of the Health Plan products
|
||||
indicated below. Health Plan acknowledges that healthcare professionals contracted with
|
||||
Provider will have the option to individually accept or reject participation in each of the products
|
||||
in this Attachment C.
|
||||
STAR-STAR or STAR Program means the State of Texas Access Reform program and
|
||||
is administered through HMOs throughout the State of Texas. HHSC contracts with
|
||||
HMOs to provide, arrange, and coordinate preventive, primary, and acute care covered
|
||||
services to non-disabled, low-income children and families, and pregnant women, SSI
|
||||
and SSI- related adults and children who do not receive Medicare, pursuant to Title XIX
|
||||
of the Social Security Act and Texas Administrative Code, Title !, Part 15, Chapter 353.
|
||||
CHIP HMO - Children's Health Insurance Program or CHIP means the health
|
||||
insurance program authorized and funded pursuant to Title XXI, Social Security Act (42
|
||||
U.S.C. §§ 1397aa-1397jj) and administered by HHSC. (UMCC Att. A, Article 2.
|
||||
Definitions).
|
||||
STAR+PLUS - STAR+PLUS or STAR+PLUS Program means the State of Texas
|
||||
Medicaid managed care program in which HHSC contracts with HMOs to provide,
|
||||
arrange, and coordinate preventive, primary, acute and long term care Covered Services
|
||||
to adult persons with disabilities and elderly persons age 65 and over who qualify for
|
||||
Medicaid through the SSI program and/or the MAO program. Children under age 21, who
|
||||
qualify for Medicaid through the SSI program, may voluntarily participate in the
|
||||
STAR+PLUS program. (UMCC Att. A, Article 2. Definitions)
|
||||
CHIP PERINATE - CHIP Perinatal Program means the State of Texas program in
|
||||
which HHSC contracts with HMOs to provide, arrange for, and coordinate Covered
|
||||
Services for enrolled CHIP Perinate and CHIP Perinate Newborn Members. Although the
|
||||
CHIP Perinatal Program is part of the CHIP Program, for Contract administration
|
||||
purposes it is identified independently in this Contract. An HMO must specifically
|
||||
contract with HHSC as a CHIP Perinatal HMO in order to participate in this part of the
|
||||
CHIP Program. (UMCC Att. A, Article 2. Definitions).
|
||||
Medicare Advantage (Molina Medicare Options)
|
||||
Medicare Advantage-Special Needs Plan (Molina Medicare Options Plus)
|
||||
Amendment to
|
||||
Page 2 of 3
|
||||
PSA - NSS PCSS 12282011
|
||||
Molina Healthcare of Texas, Inc. - Mission Health Network
|
||||
N.E.
|
||||
|
||||
Start of Page No. = 3
|
||||
ATTACHMENT D
|
||||
Compensation Schedule
|
||||
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to
|
||||
Members, in accordance with products/programs as specified in Attachment C, on a fee-for-
|
||||
service basis, at the lesser of; (i) Provider's billed charges, or (ii) the allowable amounts set forth
|
||||
below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to
|
||||
be paid by other liable third parties, if any.
|
||||
STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be
|
||||
paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-
|
||||
For-Service Program fee schedule in effect on the date of service.
|
||||
Notwithstanding the above, payment for Covered Services, including, but not limited to,
|
||||
certain Covered Services where there is no payment rate in the State of Texas Medicaid
|
||||
Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an
|
||||
amount equivalent to the Medicare Fee-For-Service Program allowable payment rate
|
||||
(adjusted for locality or geography), as of the date of service.
|
||||
Medicare Advantage (Molina Medicare Options) and MA-SNP (Molina Medicare
|
||||
Options Plus): Covered Services shall be paid at an amount equivalent to the Medicare
|
||||
Fee-For-Service Program allowable payment rates (adjusted for locality or geography), as
|
||||
of the date of service.
|
||||
Amendment to
|
||||
Page 3 of 3
|
||||
PSA - NSS PCSS 1228201 I
|
||||
Molina Healthcare of Texas, Inc. - Mission Health Network
|
||||
N.E
|
||||
+675
@@ -0,0 +1,675 @@
|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT TO THE STANDARD ANCILLARY SERVICES
|
||||
AGREEMENT
|
||||
This AMENDMENT TO THE STANDARD ANCILLARY SERVICES
|
||||
AGREEMENT dated this 1st day of January 2019, by and between NEW YORK QUALITY
|
||||
HEALTHCARE CORPORATION, NEW YORK STATE CATHOLIC HEALTH PLAN,
|
||||
INC., corporations certified as health plans pursuant to Article 44 of the New York State Public
|
||||
Health Law, and including its affiliates and subsidiaries (hereinafter referred to individually as,
|
||||
"Plan" or collectively as "Plans"), and Behavioral Analyst Professional Services, PLLC
|
||||
hereinafter, "Provider") a Professional Limited Liability Corporation organized under the Laws
|
||||
of New York State.
|
||||
WHEREAS, Plan(s) and Provider entered into a certain Provider Agreement dated
|
||||
December 9th, 2016 ("the Agreement") pursuant to which Provider became obligated to provide
|
||||
health services to Enrollees (as defined in the Agreement); and subsequently amended by the
|
||||
parties on January 1, 2019;
|
||||
WHEREAS, Provider currently participates in Plans' prepaid health services plan; and
|
||||
WHEREAS, Plan(s) and Provider wish to amend certain sections of said Agreement,
|
||||
NOW THEREFORE, in consideration of the premises and provisions herein, Plan(s) and
|
||||
Provider covenant and agree as follows:
|
||||
1. The Lines of Business are, The Essential Plan, Child Health Plus, and The Health Benefit
|
||||
Exchange: The following codes have been added and are effective January 1, 2019.
|
||||
CPT Code 97151
|
||||
CPT Code 97152
|
||||
CPT Code 97153
|
||||
CPT Code 97154
|
||||
CPT Code 97155
|
||||
CPT Code 97156
|
||||
CPT Code 97157
|
||||
CPT Code 97158
|
||||
CPT Code 0362T
|
||||
CPT Code 0373T
|
||||
2. CPT Codes - H2014, H2019, H0031, H0032, and G9012, are hereby deleted effective
|
||||
1/1/2019
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
1
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 2
|
||||
3. Appendix A dated (05/01/2015), is hereby deleted in its entirety and replaced with Appendix
|
||||
A4, attached hereto. The New York State Department of Health Standard Clauses for Managed
|
||||
Care Provider/IPA Contracts dated April 1, 2017, attached to this agreement as Appendix A4, are
|
||||
expressly incorporated into this Agreement and are binding upon the parties to this Agreement. In
|
||||
the event of any inconsistent or contrary language between the Standard Clauses and any other
|
||||
part of the Agreement, including but not limited to appendices, amendments and exhibits, the
|
||||
parties agree that provisions of the "Standard Clauses" shall prevail, except to the extent applicable
|
||||
law requires otherwise and/or to the extent a provision of this Agreement exceeds the minimum
|
||||
requirements of the Standard Clauses.
|
||||
4. Submission of Electronic Claims and Acceptance of Information through Electronic Medium.
|
||||
Provider agrees to submit claims for services rendered to enrollees and to accept enrollee rosters,
|
||||
remittance advices and other Plan communications electronically through a medium designated by
|
||||
the Plan.
|
||||
5. This Amendment shall terminate upon the termination of the Agreement under the same terms
|
||||
and conditions specified herein.
|
||||
6. All other terms and conditions of the Agreement, except as amended herein, shall remain the
|
||||
same and are hereby ratified and confirmed.
|
||||
7. This Amendment to the Agreement may be executed in one or more counterparts, each of which
|
||||
shall be deemed an original and all of which shall constitute but one and the same instrument.
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
2
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 3
|
||||
IN WITNESS WHEREOF, the parties here have signed this AMENDMENT on the date
|
||||
referenced above.
|
||||
PROVIDER
|
||||
PLANS
|
||||
Behavioral Analyst Professional Services,
|
||||
NEW YORK STATE CATHOLIC HEALTH
|
||||
PLLC
|
||||
PLAN, INC.
|
||||
Provider (Please Print)
|
||||
NEW YORK QUALITY HEALTHCARE
|
||||
CORPORATION
|
||||
95-25 Queens Boulevard
|
||||
1326 East 10th Street
|
||||
Rego Park, New York 11374
|
||||
Address
|
||||
By: Alicia Delmont
|
||||
Brooklyn, N.Y 11230
|
||||
City, State, Zip Code
|
||||
Its: Chief Provider Operations Officer and
|
||||
Entity Tax ID#: 813535131
|
||||
Authorized Signatory, respectively
|
||||
Date:
|
||||
Entity NPI#: 1427502939
|
||||
Signature
|
||||
Name: Yocheved Wassermen
|
||||
(Please Print)
|
||||
Title:
|
||||
BCBA
|
||||
Date:
|
||||
2/1/19
|
||||
Signature:
|
||||
M n
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
3
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 4
|
||||
SCHEDULE 1.1
|
||||
ANCILLARY SERVICES
|
||||
Provider will provide to Enrollees, pursuant to the terms and conditions of this Agreement and
|
||||
the applicable Program Contract, the following Ancillary Services:
|
||||
Autism Services
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
4
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 5
|
||||
SCHEDULE 1.14
|
||||
IDENTIFICATION OF THE PROGRAMS AND PROGRAM CONTRACTS
|
||||
Program:
|
||||
Essential Plan Program (EPP)
|
||||
Program Contract:
|
||||
The contract for the provision of managed care services under the New York State
|
||||
Essential Plan Program entered into by and between New York Quality Healthcare
|
||||
Corporation, and the New York State Department of Health/New York State of
|
||||
Health, including all attachments thereto.
|
||||
Program:
|
||||
Child Health Plus
|
||||
Program Contract:
|
||||
The contract for the provision of managed care services under the New York State
|
||||
Child Health Plus program entered into by and New York Quality Healthcare
|
||||
Corporation, and the New York State Department of Health including all
|
||||
attachments thereto.
|
||||
Program:
|
||||
Health Benefit Exchange
|
||||
Program Contract:
|
||||
The contract for the provision of health care services pursuant to the health
|
||||
insurance program created under the Patient Protection and Affordable Care Act
|
||||
through which individuals and small businesses can purchase qualified coverage,
|
||||
entered into between the New York State Department of Health and New York
|
||||
Quality Healthcare Corporation.
|
||||
The Plan(s) may amend this schedule to include additional Programs from time to time. Provider agrees
|
||||
that Provider will participate in all new Programs for which Provider is qualified as determined by Plan.
|
||||
Provider's participation in any new Program will be effective upon thirty (30) calendar days notice of Plan's
|
||||
amendment of this Schedule 1.14.
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
5
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 6
|
||||
Fee Schedule for ABA CPT Codes
|
||||
CPT Code 97151, Behavioral assessment by
|
||||
$12.50 per 15 min unit
|
||||
Professional per 15 Min Unit
|
||||
CPT Code 97152, Behavioral assessment by
|
||||
$12.50 per 15 min unit
|
||||
Technician per 15 Min Unit
|
||||
CPT Code 97153, Behavior treatment by
|
||||
$12.50 per 15 min unit
|
||||
Technician under the direction of a physician
|
||||
or other qualified healthcare professional, face
|
||||
to face with one patient per 15 Min Unit
|
||||
CPT Code 97154, Group behavioral treatment
|
||||
$12.50 per 15 min unit
|
||||
by technician per 15 Min Unit
|
||||
CPT Code 97155, Behavioral treatment by
|
||||
$12.50 per 15 min unit
|
||||
professional (May include simultaneous
|
||||
supervision of technician) per 15 Min Unit
|
||||
CPT Code 97156, Caregiver guidance by
|
||||
$12.50 per 15 min unit
|
||||
professional 15 min unit
|
||||
CPT Code 97157 , Multiple family behavioral
|
||||
$12.50 per 15 min unit
|
||||
guidance (caregivers of >1 clients) without
|
||||
client present by professional per 15 min unit
|
||||
CPT Code 97158, Group behavioral treatment
|
||||
$12.50 per 15 min unit
|
||||
by professional with multiple clients per 15 min
|
||||
Unit
|
||||
CPT Code 0362T, Assessment by professional
|
||||
$12.50 - per 15 min unit
|
||||
+ 2 or more technicians for destructive patient
|
||||
per 15 min unit.
|
||||
CPT Code 0373T, Treatment by professional
|
||||
$12.50 - per 15 min unit
|
||||
+ 2 or more technicians for destructive patient
|
||||
per 15 minute unit.
|
||||
If QHP is directing the technician without the client present, this is a bundled service and is
|
||||
captured by the new codes listed. If the QHP is directing a technician or caregiver with the
|
||||
client present, report using the code 97155.
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
6
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 7
|
||||
APPENDIX A4
|
||||
NEW YORK STATE DEPARTMENT OF HEALTH
|
||||
STANDARD CLAUSES
|
||||
FOR MANAGED CARE PROVIDER/IPA CONTRACTS
|
||||
(Revised 4/1/2017)
|
||||
Notwithstanding any other provision of this agreement, contract, or amendment (hereinafter
|
||||
"the Agreement or "this Agreement ") the Article 44 plans and providers that contract with
|
||||
such plans, and who are a party agree to be bound by the following clauses which are hereby
|
||||
made a part of the Agreement. Further, if this Agreement is between a Managed Care
|
||||
Organization and an IPA/ACO, or between an IPA/ACO and an IPA/ACO, such clauses must
|
||||
be included in IPA/ACO contracts with Providers, and Providers must agree to such clauses.
|
||||
A. Definitions for Purposes of this Appendix
|
||||
"Managed Care Organization" or "MCO" shall mean the person, natural or corporate,
|
||||
or any groups of such persons, certified under Public Health Law Article 44, who
|
||||
enter into an arrangement, agreement or plan or any combination of arrangements or
|
||||
plans which provide or offer a comprehensive health services plan, or a health and
|
||||
long term care services plan.
|
||||
"Independent Practice Association" or "IPA" shall mean an entity formed for the
|
||||
limited purpose of contracting for the delivery or provision of health services by
|
||||
individuals, entities and facilities licensed and/or certified to practice medicine and
|
||||
other health professions, and, as appropriate, ancillary medical services and
|
||||
equipment. Under these arrangements, such health care Providers and suppliers will
|
||||
provide their service in accordance with and for such compensation as may be
|
||||
established by a contract between such entity and one or more MCOs. "IPA" may also
|
||||
include, for purposes of this Agreement, a pharmacy or laboratory with the legal
|
||||
authority to contract with other pharmacies or laboratories to arrange for or provide
|
||||
services to enrollees of a New York State MCO.
|
||||
"Provider" shall mean physicians, dentists, nurses, pharmacists and other health care
|
||||
professionals, pharmacies, hospitals and other entities engaged in the delivery of
|
||||
Health Care Services which are licensed, registered and/or certified as required by
|
||||
applicable federal and state law.
|
||||
B. General Terms and Conditions
|
||||
1. This agreement is subject to the approval of the New York State Department of
|
||||
Health (DOH) and if implemented prior to such approval, the parties agree to
|
||||
incorporate into this Agreement any and all modifications required by DOH for
|
||||
approval or, alternatively, to terminate this Agreement if so directed by DOH,
|
||||
effective sixty (60) days subsequent to notice, subject to Public Health Law $4403
|
||||
Behavioral Analyst Professional Service PLLC
|
||||
7
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 8
|
||||
(6)(e). This Agreement is the sole agreement between the parties regarding the
|
||||
arrangement established herein
|
||||
2. Any material amendment to this Agreement is subject to the prior approval of
|
||||
DOH, and any such amendment shall be submitted for approval in accordance with
|
||||
the appropriate procedures and timelines described in Sections III and VII of the
|
||||
New York State Department of Health Provider Contract Guidelines for MCOs and
|
||||
IPA/ACOs. To the extent the MCO provides and arranges for the provision of
|
||||
comprehensive Health Care Services to enrollees served by the Medical Assistance
|
||||
Program, the MCO shall notify and/or submit a copy of such material amendment
|
||||
to DOH, as may be required by the Medicaid Managed Care contract between the
|
||||
MCO and DOH.
|
||||
3. Assignment of an agreement between an MCO and (1) an IPA/ACO, (2) an
|
||||
institutional network Provider, or (3) a medical group Provider that serves five
|
||||
percent or more of the enrolled population in a county, or the assignment of an
|
||||
agreement between an IPA/ACO and (1) an institutional Provider or (2) a medical
|
||||
group Provider that serves five percent or more of the enrolled population in a
|
||||
county, requires the prior approval of the Commissioner of Health.
|
||||
4. The Provider agrees, or if the Agreement is between the MCO and an IPA/ACO or
|
||||
between an IPA/ACO and an IPA/ACO, the IPA/ACO agrees and shall require the
|
||||
IPA/ACO's Providers to agree, to comply fully and abide by the rules, policies and
|
||||
procedures that the MCO (a) has established or will establish to meet general or
|
||||
specific obligations placed on the MCO by statute, regulation, contract, or DOH or
|
||||
DFS guidelines or policies and (b) has provided to the Provider at least thirty days
|
||||
in advance of implementation, including but not limited to:
|
||||
quality improvement/management;
|
||||
utilization management, including but not limited to precertification
|
||||
procedures, referral process or protocols, and reporting of clinical
|
||||
encounter data;
|
||||
member grievances; and
|
||||
Provider credentialing.
|
||||
5. The Provider or, if the Agreement is between the MCO and an IPA/ACO, or
|
||||
between an IPA/ACO and an IPA/ACO, the IPA/ACO agrees, and shall require
|
||||
its Providers to agree, to not discriminate against an enrollee based on color, race,
|
||||
creed, age, gender, sexual orientation, disability, place of origin, source of
|
||||
payment or type of illness or condition.
|
||||
6. If the Provider is a primary care practitioner, the Provider agrees to provide twenty-
|
||||
four (24) hour coverage and back-up coverage when the Provider is unavailable.
|
||||
The Provider may use a twenty-four (24) hour back-up call service provided
|
||||
appropriate personnel receive and respond to calls in a manner consistent with the
|
||||
scope of their practice.
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
8
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 9
|
||||
7. The MCO or IPA/ACO that is a party to this Agreement agrees that nothing within
|
||||
this Agreement is intended to, or shall be deemed to, transfer liability for the
|
||||
MCO's or IPA/ACO's own acts or omissions, by indemnification or otherwise, to a
|
||||
Provider.
|
||||
8. Notwithstanding any other provision of this Agreement, the parties shall comply
|
||||
with the provisions of the Managed Care Reform Act of 1996 (Chapter 705 of the
|
||||
Laws of 1996) Chapter 551 of the Laws of 2006, Chapter 451 of the Laws of
|
||||
2007, Chapter 237 of the Laws of 2009, Chapter 297 of the Laws of 2012,
|
||||
Chapter 199 of the Laws of 2014, Part H, Chapter 60, of the Laws of 2014 and
|
||||
Chapter 6 of the Laws of 2015 with all amendments thereto.
|
||||
9. To the extent the MCO enrolls individuals covered by the Medical Assistance
|
||||
Program, this Agreement incorporates the pertinent MCO obligations under the
|
||||
Medicaid Managed Care contract between the MCO and DOH as set forth fully
|
||||
herein, including:
|
||||
a. The MCO will monitor the performance of the Provider or IPA/ACO under
|
||||
the Agreement and will terminate the Agreement and/or impose other
|
||||
sanctions if the Provider's or IPA/ACO's performance does not satisfy the
|
||||
standards set forth in the Medicaid Managed Care contract.
|
||||
b.
|
||||
The Provider or IPA/ACO agrees that the work it performs under the
|
||||
Agreement will conform to the terms of the Medicaid managed care
|
||||
contract between the MCO and DOH and that it will take corrective action
|
||||
if the MCO identifies deficiencies or areas of needed improvement in the
|
||||
Provider's or IPA/ACO's performance.
|
||||
c.
|
||||
The Provider or IPA/ACO agrees to be bound by the confidentiality
|
||||
requirements set forth in the Medicaid Managed Care contract between
|
||||
the MCO and DOH.
|
||||
d. The MCO and the Provider or IPA/ACO agree that a woman's enrollment
|
||||
in the MCO's Medicaid Managed Care product is sufficient to provide
|
||||
services to her newborn, unless the newborn is excluded from the
|
||||
enrollment in Medicaid Managed Care or the MCO does not offer a
|
||||
Medicaid Managed Care product in the mother's county of fiscal
|
||||
responsibility.
|
||||
e. The MCO shall not impose obligations and duties on the Provider or
|
||||
IPA/ACO that are inconsistent with the Medicaid Managed Care contract or
|
||||
that impair any rights accorded to DOH, the local Department of Social
|
||||
Services, or the United States Department of Health and Human Services.
|
||||
f. The Provider or IPA/ACO agrees to provide medical records to the MCO
|
||||
for purposes of determining newborn eligibility for Supplemental Security
|
||||
Income where the mother is a member of the MCO and for quality
|
||||
purposes at no cost to the MCO.
|
||||
g. The Provider or IPA/ACO agrees, pursuant to 31 U.S.C. $1352 and CFR
|
||||
Part 93, that no federally appropriated funds have been paid or will be paid
|
||||
Behavioral Analyst Professional Service PLLC
|
||||
9
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 10
|
||||
to any person by or on behalf of the Provider/IPA/ACO for the purpose of
|
||||
influencing or attempting to influence an officer or employee of any agency,
|
||||
a Member of Congress, an officer or employee of Congress, or an employee
|
||||
of any Member of Congress in connection with the award of any federal
|
||||
loan, the entering into of any cooperative agreement, or the extension,
|
||||
continuation, renewal, amendment, or modification of any federal contract,
|
||||
grant, loan, or cooperative agreement. The Provider or IPA/ACO agrees to
|
||||
complete and submit the "Certification Regarding Lobbying," Appendix, B
|
||||
attached hereto and incorporated herein, if this Agreement exceeds
|
||||
$100,000. If any funds other than federally appropriated funds have been
|
||||
paid or will be paid to any person for the purpose of influencing or
|
||||
attempting to influence an officer or employee of any agency, a Member of
|
||||
Congress, an officer or employee of a member of Congress, in connection
|
||||
with the award of any federal contract, the making of any federal grant, the
|
||||
making of any federal loan, the entering of any cooperative agreement, or
|
||||
the extension, continuation, renewal, amendment, or modification of any
|
||||
federal contract, grant loan, or cooperative agreement, and the Agreement
|
||||
exceeds $100,000 the Provider or IPA/ACO shall complete and submit
|
||||
Standard Form-LLL "Disclosure Form to Report Lobbying," in accordance
|
||||
with its instructions.
|
||||
h. The Provider or IPA/ACO agrees to disclose to the MCO, on an ongoing
|
||||
basis, any managing employee who has been convicted of a misdemeanor
|
||||
or felony in relation to the employee's involvement in any program under
|
||||
Medicare, Medicaid or a Title XX services program (block grant
|
||||
programs).
|
||||
i.
|
||||
The Provider or IPA/ACO agrees to monitor its employees and staff against
|
||||
the List of Excluded Individuals and Entities (LEIE), the Social Security
|
||||
Administration Death Master List, and the National Plan Provider
|
||||
Enumeration System (NPPES).
|
||||
j. The Provider or IPA/ACO agrees to disclose to the MCO complete
|
||||
ownership, control, and relationship information.
|
||||
k. The Provider or IPA/ACO agrees to obtain for the MCO ownership
|
||||
information from any subcontractor with whom the Provider has had a
|
||||
business transaction totaling more than $25,000 during the 12-month period
|
||||
ending on the date of the request made by DOH, Office of the Medicaid
|
||||
Inspector General (OMIG) or the United States Department of Health and
|
||||
Human Services (DHHS). The information requested shall be provided to
|
||||
the MCO within 35 days of such request.
|
||||
1.
|
||||
The Provider or IPA/ACO agrees to have an officer, director or partner of
|
||||
the Provider execute and deliver to DOH a certification, using a form
|
||||
provided by DOH through OMIG's website, within five (5) days of
|
||||
executing this agreement, stating that:
|
||||
The Provider or IPA/ACO is subject to the statutes, rules,
|
||||
regulations, and applicable Medicaid Updates of the Medicaid
|
||||
program and of DOH related to the furnishing of care, services or
|
||||
supplies provided directly by, or under the supervision of, or
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
10
|
||||
ABA New Code Amendment
|
||||
|
||||
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|
||||
ordered, referred or prescribed by the Provider. This includes 18
|
||||
NYCRR 515.2 except to the extent that any reference in the
|
||||
regulation establishing rates, fees, and claiming instructions will
|
||||
refer to the rates, fees and claiming instructions set by the MCO.
|
||||
All claims submitted for payment by the Provider/IPA/ACO are for
|
||||
care, services or medical supplies that have been provided.
|
||||
Payment requests are submitted in accordance with applicable
|
||||
law.
|
||||
m. The Provider or IPA/ACO agrees to require that an officer, director or
|
||||
partner of all subcontractors if they are not natural persons, or the
|
||||
subcontractor itself if it is a natural person, execute a certification, using a
|
||||
form provided by DOH through OMIG's website, before the subcontractor
|
||||
requests payment under the subcontract, acknowledging that:
|
||||
The subcontractor is subject to the statutes, rules, regulations, and
|
||||
applicable Medicaid Updates of the Medicaid program and of DOH
|
||||
related to the furnishing of care, services or supplies provided
|
||||
directly by, or under the supervision of, or ordered, referred or
|
||||
prescribed by the subcontractor. This includes 18 NYCRR 515.2
|
||||
except to the extent that any reference in the regulation establishing
|
||||
rates, fees, and claiming instructions will refer to the rates, fees and
|
||||
claiming instructions set by the MCO.
|
||||
All claims submitted for payment by the subcontractor are for care,
|
||||
services or medical supplies that have been provided.
|
||||
Payment requests are submitted in accordance with applicable
|
||||
law.
|
||||
10. The parties to this Agreement agree to comply with all applicable requirements of
|
||||
the federal Americans with Disabilities Act.
|
||||
11. The Provider agrees, or if the Agreement is between the MCO and an IPA/ACO or
|
||||
between an IPA/ACO and an IPA/ACO, the IPA/ACO agrees and shall require the
|
||||
IPA's Providers to agree, to comply with all applicable requirements of the Health
|
||||
Insurance Portability and Accountability Act, the HIV confidentiality requirements
|
||||
of Article 27-F of the Public Health Law, and Mental Hygiene Law § 33.13.
|
||||
12. Compliance Program. The Provider agrees that if it claims, orders, or is paid
|
||||
$500,000 or more per year from the Medical Assistance Program, including, in the
|
||||
aggregate, claims submitted to or paid directly by the Medical Assistance Program
|
||||
and/or claims submitted to or paid by any MCO under the Medicaid Managed Care
|
||||
Program, that it shall adopt and implement a compliance program which meets the
|
||||
requirements of New York State Social Services Law § 363-d(2) and 18 NYCRR §
|
||||
521.3.
|
||||
13. Compliance Program Certification. The Provider agrees that if it is subject to the
|
||||
requirements of Section B (12) of this Appendix, it shall certify to DOH, using a
|
||||
form provided by OMIG on its website, within 30 days of entering into a Provider
|
||||
Behavioral Analyst Professional Service PLLC
|
||||
11
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 12
|
||||
Agreement with the MCO, if they have not so certified within the past year that a
|
||||
compliance program meeting the requirements of 18 NYCRR $521.3 and Social
|
||||
Services Law § 363-d(2) is in place. The Provider shall recertify during the month
|
||||
of December each year thereafter using a form provided by OMIG on OMIG's
|
||||
website.
|
||||
C. Payment and Risk Arrangements
|
||||
1. Enrollee Non-liability. Provider agrees that in no event, including, but not limited to,
|
||||
nonpayment by the MCO or IPA/ACO, insolvency of the MCO or IPA/ACO, or
|
||||
breach of this Agreement, shall Provider bill; charge; collect a deposit from; seek
|
||||
compensation, remuneration or reimbursement from; or have any recourse against a
|
||||
subscriber, an enrollee or person (other than the MCO or IPA/ACO) acting on
|
||||
his/her/their behalf, for services provided pursuant to the subscriber contract or
|
||||
Medicaid Managed Care contract and this Agreement, for the period covered by the
|
||||
paid enrollee premium. In addition, in the case of Medicaid Managed Care, Provider
|
||||
agrees that, during the time an enrollee is enrolled in the MCO, Provider will not bill
|
||||
DOH or the City of New York for covered services within the Medicaid Managed
|
||||
Care benefit package as set forth in the Agreement between the MCO and DOH.
|
||||
This provision shall not prohibit the Provider, unless the MCO is a Managed Long
|
||||
Term Care plan designated as a Program of All-Inclusive Care for the Elderly
|
||||
(PACE), from collecting copayments, coinsurance amounts, or permitted
|
||||
deductibles, as specifically provided in the evidence of coverage, or fees for
|
||||
uncovered services delivered on a fee-for-service basis to a covered person,
|
||||
provided that Provider shall have advised the enrollee in writing that the service is
|
||||
uncovered and of the enrollee's liability therefore prior to providing the service.
|
||||
Where the Provider has not been given a list of services covered by the MCO,
|
||||
and/or Provider is uncertain as to whether a service is covered, the Provider shall
|
||||
make reasonable efforts to contact the MCO and obtain a coverage determination
|
||||
prior to advising an enrollee as to coverage and liability for payment and prior to
|
||||
providing the service. This provision shall survive termination of this Agreement for
|
||||
any reason and shall supersede any oral or written agreement now existing or
|
||||
hereafter entered into between Provider and enrollee or person acting on his or her
|
||||
behalf.
|
||||
2.
|
||||
Coordination of Benefits (COB). To the extent otherwise permitted in this
|
||||
Agreement, the Provider may participate in collection of COB on behalf of the
|
||||
MCO, with COB collectibles accruing to the MCO or to the Provider. However,
|
||||
with respect to enrollees eligible for medical assistance or participating in Child
|
||||
Health Plus, the Provider shall maintain and make available to the MCO records
|
||||
reflecting COB proceeds collected by the Provider or paid directly to enrollees by
|
||||
third party payers, and amounts thereof, and the MCO shall maintain or have
|
||||
immediate access to records concerning collection of COB proceeds.
|
||||
3. If the Provider is a health care professional licensed, registered or certified under
|
||||
Title 8 of the Education Law, the MCO or the IPA/ACO must provide notice to the
|
||||
Behavioral Analyst Professional Service PLLC
|
||||
12
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 13
|
||||
Provider at least ninety (90) days prior to the effective date of any adverse
|
||||
reimbursement arrangement as required by Public Health Law 4406-c(5-c).
|
||||
Adverse reimbursement change shall mean a proposed change that could reasonably
|
||||
be expected to have a material adverse impact on the aggregate level of payment to a
|
||||
health care professional. This provision does not apply if the reimbursement change
|
||||
is required by law, regulation or applicable regulatory authority; is required as a
|
||||
result of changes in fee schedules, reimbursement methodology or payment policies
|
||||
established by the American Medical Association current procedural terminology
|
||||
(CPT) codes, reporting guidelines and conventions; or such change is expressly
|
||||
provided for under the terms of this Agreement by the inclusion or reference to a
|
||||
specific fee or fee schedule, reimbursement methodology, or payment policy
|
||||
indexing scheme.
|
||||
4. The parties agree to comply with and incorporate the requirements of Physician
|
||||
Incentive Plan (PIP) Regulations contained in 42 CFR 438.6(h), 42 CFR
|
||||
422.208, and 42 CFR $422.210 into any contracts between the contracting entity
|
||||
(Provider, IPA/ACO, hospital, etc.) and other persons/entities for the provision of
|
||||
services under this Agreement. No specific payment will be made directly or
|
||||
indirectly under the plan to a physician or physician group as an inducement to
|
||||
reduce or limit medically necessary services furnished to an enrollee.
|
||||
5. The parties agree that, where required by Public Health Law 4903, a claim for
|
||||
certain continued, extended, or additional health care services cannot be denied on
|
||||
the basis of medical necessity or a lack of prior authorization while a utilization
|
||||
review determination is pending if all necessary information was provided within the
|
||||
required timeframes and under the circumstances described in Public Health Law
|
||||
4903.
|
||||
6. The parties agree to follow Section 3224-a of the Insurance Law providing
|
||||
timeframes for the submission and payment of Provider claims to the MCO.
|
||||
7. The parties agree to follow Section 3224-b(a) of the Insurance Law requiring an
|
||||
MCO to accept and initiate the processing of all claims submitted by physicians that
|
||||
conform to the American Medical Association's Current Procedural Technology
|
||||
(CPT) codes, reporting guidelines and conventions, or to the Centers for Medicare
|
||||
and Medicaid Services' Healthcare Common Procedure Coding System (HCPCS).
|
||||
8. The parties agree to follow Section 3224-b(b) of the Insurance Law prohibiting an
|
||||
MCO from initiating overpayment recovery efforts more than 24 months after the
|
||||
original payment was received by a health care Provider, except where: (1) the plan
|
||||
makes overpayment recovery efforts that are based on a reasonable belief of fraud or
|
||||
other intentional misconduct or abusive billing; (2) for the Medicaid Managed Care
|
||||
and Family Health Plus programs, the overpayment recovery period for such
|
||||
programs is six years from date payment was received by the health care Provider
|
||||
with written notice 30 days prior to engaging in overpayment recovery efforts. Such
|
||||
notice must state the patient's name, service date, payment amount, proposed
|
||||
Behavioral Analyst Professional Service PLLC
|
||||
13
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 14
|
||||
adjustment, and a reasonably specific explanation of the proposed adjustment.
|
||||
9. The parties agree to follow Section 3224-c of the Insurance Law providing that
|
||||
claims cannot be denied solely on the basis that the MCO has not received from the
|
||||
member information concerning other insurance coverage.
|
||||
10. The parties agree that this contract does not waive, limit, disclaim, or in any way
|
||||
diminish the rights that any Provider may have pursuant to Section 3238 of the
|
||||
Insurance Law to the receipt of claims payment for services where preauthorization
|
||||
was required and received from the appropriate person or entity prior to the
|
||||
rendering of the service.
|
||||
11. The parties agree that for a contract involving Tier 2 or 3 arrangements as
|
||||
described in Section VII.B of the Guidelines, the contract must:
|
||||
a. Provide for the MCO's ongoing monitoring of Provider financial capacity
|
||||
and/or periodic Provider financial reporting to the MCO to support the
|
||||
transfer of risk to the Provider; and
|
||||
b. Include a provision to address circumstance where the Provider's financial
|
||||
condition indicates an inability to continue accepting such risk; and
|
||||
C. Address MCO monitoring of the financial security deposit, describing the
|
||||
method and frequency of monitoring and recourse for correcting
|
||||
underfunding of the deposit to be maintained by the MCO; and
|
||||
d. Include a provision that the Provider will submit any additional documents
|
||||
or information related to its financial condition to the MCO, if requested by
|
||||
DOH.
|
||||
12. The parties agree that for any contract involving an MCO and IPA/ACO, the
|
||||
contract must include provisions whereby:
|
||||
a. The parties expressly agree to amend or terminate the contract at the
|
||||
direction of DOH (applies to Tier 1, Tier 2, and Tier 3);
|
||||
b. The IPA/ACO will submit annual financial statements to the MCO, as well
|
||||
as any additional documents required by the MCO as necessary to assess the
|
||||
IPA/ACO's progress towards achieving value based payment goals as
|
||||
specified in the Roadmap, and the MCO will notify DOH of any substantial
|
||||
change in the financial condition of the IPA/ACO (applies to Tier 2 and
|
||||
Tier 3); and
|
||||
C. The IPA/ACO will submit any additional documents or information related
|
||||
to its financial condition to the MCO, if requested by DOH (applies to Tier
|
||||
2 and Tier 3); and
|
||||
d. The parties agree that all Provider contracts will contain provision
|
||||
prohibiting Providers, in the event of a default by the IPA/ACO, from
|
||||
demanding payment from the MCO for any covered services rendered to
|
||||
the MCO's enrollees for which payment was made by the MCO to the
|
||||
IPA/ACO pursuant to the risk agreement (applies to tier 2 and Tier 3).
|
||||
D. Records and Access
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
14
|
||||
ABA New Code Amendment
|
||||
|
||||
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|
||||
1. Pursuant to appropriate consent/authorization by the enrollee, the Provider will make
|
||||
the enrollee's medical records and other personally identifiable information
|
||||
(including encounter data for government-sponsored programs) available to the
|
||||
MCO (and IPA/ACO if applicable) for purposes including preauthorization,
|
||||
concurrent review, quality assurance, (including Quality Assurance Reporting
|
||||
Requirements (QARR)), payment processing, and qualification for government
|
||||
programs, including but not limited to newborn eligibility for Supplemental Security
|
||||
Income (SSI) and for MCO/Manager analysis and recovery of overpayments due to
|
||||
fraud and abuse. The Provider will also make enrollee's medical records available to
|
||||
the State for management audits, financial audits, program monitoring and
|
||||
evaluation, licensure or certification of facilities or individuals, and as otherwise
|
||||
required by state law. The Provider shall provide copies of such records to DOH at
|
||||
no cost. The Provider (or IPA/ACO if applicable) expressly acknowledges that the
|
||||
Provider shall also provide to the MCO and the State (at no expense to the State), on
|
||||
request, all financial data and reports, and information concerning the
|
||||
appropriateness and quality of services provided, as required by law. These
|
||||
provisions shall survive termination of the contract for any reason.
|
||||
2. When such records pertain to Medicaid reimbursable services, the Provider
|
||||
agrees to disclose the nature and extent of services provided and to furnish
|
||||
records to DOH and/or the United States Department of Health and Human
|
||||
Services, the County Department of Social Services, the Comptroller of the
|
||||
State of New York, the Office of the Medicaid Inspector General, the New York
|
||||
State Attorney General, and the Comptroller General of the United States and
|
||||
their authorized representatives upon request. This provision shall survive the
|
||||
termination of this Agreement regardless of the reason.
|
||||
3. The parties agree that medical records shall be retained for a period of six years
|
||||
after the date of service, and in the case of a minor, for three years after majority or
|
||||
six years after the date of service, whichever is later, or for such longer period as
|
||||
specified elsewhere within this Agreement. This provision shall survive the
|
||||
termination of this Agreement regardless of the reason.
|
||||
4. The MCO and the Provider agree that the MCO will obtain consent directly from
|
||||
enrollees at the time of enrollment or at the earliest opportunity, or that the Provider
|
||||
will obtain consent from enrollees at the time of service is rendered or at the earliest
|
||||
opportunity, for disclosure of medical records to the MCO, to an IPA/ACO or to
|
||||
third parties. If the Agreement is between an MCO and an IPA/ACO, or between an
|
||||
IPA/ACO and an IPA/ACO, the IPA/ACO agrees to require the Providers with
|
||||
which it contracts to agree as provided above. If the Agreement is between an
|
||||
IPA/ACO and a Provider, the Provider agrees to obtain consent from the enrollee if
|
||||
the enrollee has not previously signed consent for disclosure of medical records.
|
||||
E. Termination and Transition
|
||||
Behavioral Analyst Professional Service PLLC
|
||||
15
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 16
|
||||
1. Termination or non-renewal of an agreement between an MCO and an IPA/ACO,
|
||||
institutional network Provider, or medical group Provider that serves five percent or
|
||||
more of the enrolled population in a county, or the termination or non-renewal of an
|
||||
agreement between an IPA/ACO and an institutional Provider or medical group
|
||||
Provider that serves five percent or more of the enrolled population in a county,
|
||||
requires notice to the Commissioner of Health. Unless otherwise provided by
|
||||
statute or regulation, the effective date of termination shall not be less than 45 days
|
||||
after receipt of notice by either party, provided, however, that termination by the
|
||||
MCO may be effected on less than 45 days' notice provided the MCO demonstrates
|
||||
to the satisfaction of DOH, prior to termination, that circumstances exist which
|
||||
threaten imminent harm to enrollees or which result in Provider being legally unable
|
||||
to deliver the covered services and, therefore, justify or require immediate
|
||||
termination.
|
||||
2.
|
||||
If this Agreement is between the MCO and a health care professional, the MCO
|
||||
shall provide to such health care professional a written explanation of the reasons
|
||||
for the proposed contract termination, other than non-renewal, and an opportunity
|
||||
for a review as required by state law. The MCO shall provide the health care
|
||||
professional 60 days' notice of its decision to not renew this Agreement.
|
||||
3. If this Agreement is between an MCO and an IPA/ACO, and the Agreement does
|
||||
not provide for automatic assignment of the IPA/ACO's Provider contracts to the
|
||||
MCO upon termination of the MCO/IPA/ACO contract, in the event either party
|
||||
gives notice of termination of the Agreement, the parties agree, and the IPA/ACO's
|
||||
Providers agree, that the IPA/ACO Providers shall continue to provide care to the
|
||||
MCO's enrollees pursuant to the terms of this Agreement for 180 days following the
|
||||
effective date of termination, or until such time as the MCO makes other
|
||||
arrangements, whichever occurs first. This provision shall survive termination of this
|
||||
Agreement regardless of the reason for the termination.
|
||||
4.
|
||||
Continuation of Treatment. The Provider agrees that in the event of MCO or
|
||||
IPA/ACO insolvency or termination of this contract for any reason, the Provider
|
||||
shall continue, until medically appropriate discharge or transfer, or completion of a
|
||||
course of treatment, whichever occurs first, to provide services pursuant to the
|
||||
subscriber contract or Medicaid Managed Care contract, to an enrollee confined in
|
||||
an inpatient facility, provided the confinement or course of treatment was
|
||||
commenced during the paid premium period. For purposes of this clause, the
|
||||
term "Provider" shall include the IPA/ACO and the IPA/ACO's contracted
|
||||
Providers if this Agreement is between the MCO and an IPA/ACO. This
|
||||
provision shall survive termination of this Agreement.
|
||||
5. Notwithstanding any other provision herein, to the extent that the Provider is
|
||||
providing Health Care Services to enrollees under the Medicaid Program, the
|
||||
MCO or IPA/ACO retains the option to immediately terminate the Agreement
|
||||
when the Provider has been terminated or suspended from the Medicaid
|
||||
Program.
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
16
|
||||
ABA New Code Amendment
|
||||
|
||||
Start of Page No. = 17
|
||||
6. In the event of termination of this Agreement, the Provider agrees, and, where
|
||||
applicable, the IPA/ACO agrees to require all participating Providers of its
|
||||
network to assist in the orderly transfer of enrollees to another Provider.
|
||||
F. Arbitration
|
||||
To the extent that arbitration or alternative dispute resolution is authorized elsewhere in
|
||||
this Agreement, the parties to this Agreement acknowledge that the Commissioner of
|
||||
Health is not bound by arbitration or mediation decisions. Arbitration or mediation shall
|
||||
occur within New York State, and the Commissioner of Health will be given notice of all
|
||||
issues going to arbitration or mediation and copies of all decisions.
|
||||
G. IPA/ACO-Specific Provisions
|
||||
Any reference to IPA/ACO Quality Assurance (QA) activities within this Agreement is
|
||||
limited to the IPA/ACO's analysis of utilization patterns and quality of care on its own
|
||||
behalf and as a service to its contractual Providers.
|
||||
Behavioral Analyst Professional Service PLLC -
|
||||
17
|
||||
ABA New Code Amendment
|
||||
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|
||||
|
||||
Start of Page No. = 1
|
||||
HEALTH BENEFIT EXCHANGE AMENDMENT TO
|
||||
MOLINA HEALTHCARE OF TEXAS, INC.
|
||||
PROVIDER SERVICES AGREEMENT
|
||||
This Health Benefit Exchange Amendment to the Provider Services Agreement ("Amendment") is made
|
||||
and entered into effective by the parties as set forth below.
|
||||
This Amendment includes the following attached hereto and incorporated herein:
|
||||
Health Benefit Exchange Amendment
|
||||
Attachment D-Compensation Schedule For Molina Health Benefit Exchange Product
|
||||
Attachment H-Molina Health Benefit Exchange Requirements
|
||||
SIGNATURE AUTHORIZATION *
|
||||
IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their
|
||||
officers thereunto duly authorized as of the Effective Date set forth in the Amendment. The individual
|
||||
signing below on behalf of Provider acknowledges, warrants, and represents that said individual has
|
||||
the authority and proper authorization to execute this Amendment on behalf of Provider and its
|
||||
constituent providers, if any, and does SO freely with the intent to fully bind Provider, and its
|
||||
constituent providers, if any, to the provisions of this Amendment.
|
||||
Provider Name: Mission Health Network
|
||||
Molina Healthcare of Texas, Inc.,
|
||||
("Provider")
|
||||
("Health Plan")
|
||||
Provider
|
||||
Health Plan
|
||||
Signature:
|
||||
Nil Espra
|
||||
Signature:
|
||||
Signatory Name
|
||||
Nich Espinas
|
||||
Signatory Name
|
||||
(Printed):
|
||||
(Printed):
|
||||
JOAN RobNett
|
||||
Signatory Title
|
||||
Signatory Title
|
||||
MHN Director
|
||||
Vice
|
||||
(Printed):
|
||||
(Printed):
|
||||
President PNMO
|
||||
Signature
|
||||
4/23/13
|
||||
Signature
|
||||
Date:
|
||||
Date:
|
||||
7/17/2013
|
||||
Mailing Name
|
||||
MHN
|
||||
Mailing Name
|
||||
Molina Healthcare of Texas, Inc.
|
||||
and Address:
|
||||
910s. BryanRd Ste301
|
||||
and Address:
|
||||
5605 MacArthur Blvd, Suite 400
|
||||
Mission,TX78512
|
||||
Irving, TX 75038
|
||||
Attention: President
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 1 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
MHT_HIX_PSA_Amend_Sig_v.031913
|
||||
|
||||
Start of Page No. = 2
|
||||
HEALTH BENEFIT EXCHANGE AMENDMENT
|
||||
This Amendment is made and entered by and between Health Plan and Provider with respect to the
|
||||
following facts:
|
||||
A. Whereas, Health Plan and Provider have entered into a Provider Services Agreement, or other
|
||||
corresponding health care services agreement or contract, as may have been amended from time to
|
||||
time ("Agreement"); and
|
||||
B. Whereas, Provider agrees to contract with Health Plan for Health Plan's Health Benefit Exchange
|
||||
products;
|
||||
Now therefore, in consideration of the rights and obligations contained herein, Health Plan and Provider
|
||||
agree to amend the Agreement as follows:
|
||||
1. Section 2.8 Claims Payment, subsection c, Compensation (or equivalent section of the Agreement),
|
||||
is deleted and replaced with the following subsection c:
|
||||
c. Compensation. Health Plan will pay Provider for Clean Claims for Covered Services provided
|
||||
to Members, including Emergency Services, in accordance with applicable law and regulations
|
||||
and in accordance with the compensation schedule set forth in Attachment D and Attachment D-
|
||||
Compensation Schedule for Molina Health Benefit Exchange Product, or equivalent
|
||||
attachment(s) of the Agreement, as applicable. Provider will accept such payment, applicable
|
||||
copayments, deductibles, and coordination of benefits collections as payment in full for services
|
||||
provided under this Agreement. Health Plan will adjudicate (finalize as paid or denied
|
||||
adjudicated) Clean Claims within thirty (30) days from the date the claim is received for
|
||||
Members enrolled in Health Plan's STAR or STAR Program, STAR+Plus or STAR+Plus
|
||||
Program, Children's Health Insurance Program, and Children's Health Insurance Program
|
||||
Perinatal Program. For any Clean Claims that are not adjudicated within thirty (30) days, Health
|
||||
Plan will pay eighteen percent (18%) interest calculated annually for Members enrolled in Health
|
||||
Plan's STAR or STAR Program, STAR+Plus or STAR+Plus Program, Children's Health
|
||||
Insurance Program, and Children's Health Insurance Program Perinatal Program. However,
|
||||
duplicate claims filed prior to the expiration of thirty-one (31) days are not subject to any interest
|
||||
payment if not processed within thirty (30) days for Members enrolled in Health Plan's STAR or
|
||||
STAR Program, STAR+Plus or STAR+Plus Program, Children's Health Insurance Program, and
|
||||
Children's Health Insurance Program Perinatal Program.
|
||||
2. Section 2.9 Compliance with Applicable Law (or equivalent section of the Agreement) is amended
|
||||
by adding the following subsection f:
|
||||
f.
|
||||
For Covered Services rendered to Members enrolled in a Molina Health Benefit Exchange
|
||||
Product, Provider will comply with all statutory and regulatory requirements applicable to the
|
||||
Health Benefit Exchange, including the Patient Protection and Affordable Care Act of 2010 (Pub.
|
||||
L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L.
|
||||
111-152, and referred to collectively as the Affordable Care Act; regulations at 45 CFR Parts 153,
|
||||
155, and 156; Title 6, Chapter 843 of the Texas Insurance Code; and Title 28, T.A.C. 11.901.
|
||||
3.
|
||||
Section 5.3 Entire Agreement (or equivalent section of the Agreement) is deleted and replaced with
|
||||
the following:
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 2 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
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|
||||
|
||||
Start of Page No. = 3
|
||||
5.3 Entire Agreement. This Agreement, together with Attachments, Amendments and incorporated
|
||||
documents or materials, contains the entire agreement between Health Plan and Provider relating
|
||||
to the rights granted and obligations imposed by this Agreement. Additionally, as to the
|
||||
Medicaid and CHIP products offered by Health Plan and listed in Attachment C, the UMCC is
|
||||
incorporated herein by reference and will be the guiding and controlling document when
|
||||
interpreting the terms of this Agreement. Any prior agreements, promises, negotiations, or
|
||||
representations, either oral or written, relating to the subject matter of this Agreement are of no
|
||||
force or effect.
|
||||
4.
|
||||
Section 5.11 Attachments (or equivalent section of the Agreement) is amended to add the following
|
||||
to the list of Attachments which are part of the Agreement:
|
||||
"Attachment D-Compensation Schedule for Molina Health Benefit Exchange Product"
|
||||
"Attachment H-Molina Health Benefit Exchange Product Requirements"
|
||||
5. Section 5.12 (or next available section following the last section of Article 5 of the Agreement) is
|
||||
added as follows:
|
||||
5.12 Conflict with Health Plan Product. Nothing in this Agreement modifies any benefits, terms
|
||||
or conditions contained in the Member's Health Plan product. In the event of a conflict
|
||||
between this Agreement and the benefits, terms, and conditions of the Health Plan product, the
|
||||
benefits, terms or conditions contained in the Member's Health Plan product will govern.
|
||||
6.
|
||||
All cross-references to Attachment D in the Agreement not specifically addressed by this Amendment
|
||||
are revised as follows:
|
||||
"Attachment D or Attachment D-Compensation Schedule for Molina Health Benefit Exchange
|
||||
Product, as applicable"
|
||||
7.
|
||||
Attachment B, Definitions (or equivalent attachment/section of the Agreement), is amended by
|
||||
adding the following defined terms:
|
||||
"Health Benefit Exchange means the federal health benefit exchange established for Texas pursuant
|
||||
to the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148), as amended by the
|
||||
Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152, and referred to collectively
|
||||
as the Affordable Care Act; and regulations at 45 CFR Parts 153, 155, and 156."
|
||||
"Molina Health Benefit Exchange Product means those health benefit programs offered and sold
|
||||
by Health Plan to individuals or employers who obtain health coverage through the Health Benefit
|
||||
Exchange."
|
||||
8. Attachment C (Products/Benefits Inventory), or equivalent attachment/section of the Agreement, is
|
||||
amended by adding the following product:
|
||||
"Molina Health Benefit Exchange Product."
|
||||
9.
|
||||
Attachment D-Compensation Schedule for Molina Health Benefit Exchange Product, attached hereto,
|
||||
is added.
|
||||
10. Attachment H-Molina Health Benefit Exchange Requirements, attached hereto, is added.
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 3 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
MHT_HIX_PSA_Amend_Sig_v.031913
|
||||
|
||||
Start of Page No. = 4
|
||||
11. Any reference to UMCC or UMCM in the Agreement will be applicable to the Molina Health Benefit
|
||||
Exchange Product, unless stated otherwise by this Amendment, determined to be a violation of state
|
||||
or federal law or regulations related to the Molina Health Benefit Exchange Product, or identified as
|
||||
specific to a product other than the Health Benefit Exchange Product in the Agreement.
|
||||
12. The following Sections (or equivalent sections of the Agreement) are not applicable to the Molina
|
||||
Health Benefit Exchange Product and are replaced, for purposes of the Molina Health Benefit
|
||||
Exchange Product only, by Attachment H-Molina Health Benefit Exchange Requirements, attached
|
||||
hereto:
|
||||
Section 2.8, Claims Payment, subsection a, Submitting Claims
|
||||
Section 2.8, Claims Payment, subsection d, Copayments and Deductibles
|
||||
Section 2.8, Claims Payment, subsection e, Coordination of Benefits
|
||||
Section 2.8, Claims Payment, subsection f, Offset
|
||||
Section 2.8, Claims Payment, subsection h, Member Billing
|
||||
Section 5.9, Arbitration
|
||||
13. There are no performance, bonus or special compensation programs applicable to the Molina Health
|
||||
Benefit Exchange Product. Any such additional compensation requires a written amendment to this
|
||||
Agreement.
|
||||
14. Health Plan and Provider recognize that this Amendment and/or the Agreement may require further
|
||||
amendments in the event that any federal, state or local agency, administration, board or other
|
||||
governing body requires changes to this Amendment or Agreement as a condition of approval. Health
|
||||
Plan will be entitled to revise this Amendment and/or the Agreement immediately without Provider's
|
||||
consent, if an additional amendment is being effected by Health Plan to comply with any federal,
|
||||
state or local agency, administration, board or other governing body request and/or regulatory
|
||||
requirement regarding the Health Benefit Exchange.
|
||||
15. Effective Date. This Amendment will become effective on January 1, 2014, and renew with and
|
||||
under the terms of the Agreement.
|
||||
16. Use of Defined Terms. Unless otherwise defined in this Amendment, capitalized terms utilized in
|
||||
this Amendment will have the same meaning(s) ascribed to such terms in the Agreement.
|
||||
17. No Other Modifications. Except as provided herein, and regardless of any citations or references to
|
||||
the UMCC or UMCM, the terms and conditions of the Agreement will remain the same, in full force
|
||||
and effect.
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 4 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
HT_HIX_PSA_Amend_Sig_v.031913
|
||||
|
||||
Start of Page No. = 5
|
||||
ATTACHMENT D-COMPENSATION SCHEDULE FOR MOLINA HEALTH BENEFIT
|
||||
EXCHANGE PRODUCT
|
||||
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members,
|
||||
in accordance with the Molina Health Benefit Exchange Product, on a fee-for-service basis, at the lesser
|
||||
of: (i) Provider's billed charges, or (ii) the amounts set forth below; less any applicable Member co-
|
||||
payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any:
|
||||
Molina Health Benefit Exchange Product. Covered Services will be paid at an amount equivalent to
|
||||
one hundred percent (100%) of the payment Provider would otherwise been entitled to had the Covered
|
||||
Services been billed directly under the prevailing State of Texas Medicaid Fee-For-Service Program
|
||||
allowable payment rates, as of the date(s) of service.
|
||||
If there is no payment rate in the prevailing State of Texas Medicaid Fee-For-Service Program as of the
|
||||
date(s) of service, payment will be at seventy (70%) percent of the prevailing local and geographically
|
||||
adjusted Medicare Fee-For-Service fee schedule, as of the date(s) of service.
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 5 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
MHT_HIX_PSA_Amend_Sig_v.031913
|
||||
|
||||
Start of Page No. = 6
|
||||
ATTACHMENT H- MOLINA HEALTH BENEFIT EXCHANGE REOUIREMENTS
|
||||
This Attachment H sets forth the Molina Health Benefit Exchange Product requirements. The provisions
|
||||
of this Attachments will apply to all Members enrolled in Molina's Health Benefit Exchange Product or
|
||||
other product governed by the Texas Insurance Code. All of the provisions listed in this Attachment are
|
||||
inapplicable to Members in Health Plan's STAR or STAR Program, STAR+Plus or STAR+Plus Program,
|
||||
Children's Health Insurance Program, Children's Health Insurance Program Perinatal Program, Medicare
|
||||
Advantage or Medicare Advantage Special Needs Plan. In the event that any of the provisions in the
|
||||
Agreement conflict with the provisions of this Attachment, the provisions of this Attachment will control
|
||||
for all Members enrolled in Molina's Health Benefit Exchange Product. The Agreements and this
|
||||
Attachment will be automatically modified to conform to subsequent regulatory requirements.
|
||||
1.
|
||||
Claim Submission. Provider will submit all claims to Health Plan no later than the ninety-fifth (95th)
|
||||
day after the date the Provider provides health care services for which the claim is made. Provider
|
||||
may: (1) mail a claim by United States mail, first class, or by overnight delivery service; (2) submit
|
||||
the claim electronically; (3) fax the claim; or (4) hand deliver the claim. If the Provider fails to
|
||||
submit the claim within ninety five (95) days of the date the Provider provides health care services,
|
||||
the Provider forfeits the right to payment, unless the failure is a result of a catastrophic event that
|
||||
substantially interferes with the normal business operations of the Provider. All claims will be
|
||||
submitted in a form acceptable to and approved by Health Plan, and will include any and all medical
|
||||
records pertaining to the claim if requested by Health Plan or otherwise required by Health Plan's
|
||||
policies and procedures.
|
||||
2.
|
||||
Duplicate Claim Submission. A Provider may not submit a duplicate claim for payment
|
||||
before the forty-sixth (46th) day after the original claim was submitted.
|
||||
3.
|
||||
Determination of Claim. Health Plan is required to make a determination of whether a claim
|
||||
is payable not later than the forty-fifth (45th) day after the date on which the Health Plan
|
||||
receives a Clean Claim from a Provider in a non-electronic format, or the thirtieth (30th) day
|
||||
after the date the Health Plan receives a Clean Claim from a Provider that is electronically
|
||||
submitted.
|
||||
If Health Plan determines the entire claim is payable, Health Plan will pay the total amount of the
|
||||
claim not later than the forty-fifth (45th) day after the date on which the Health Plan receives a Clean
|
||||
Claim from a Provider in a non-electronic format, or the thirtieth (30th) day after the date the Health
|
||||
Plan receives a Clean Claim from a Provider that is electronically submitted.
|
||||
If Health Plan determines a portion of the claim is payable, Health Plan will pay the portion of the
|
||||
claim that is not in dispute not later than the forty-fifth (45th) day after the date on which the Health
|
||||
Plan receives a Clean Claim from a Provider in a non-electronic format, or the thirtieth (30th) day
|
||||
after the date the Health Plan receives a Clean Claim from a Provider that is electronically submitted
|
||||
and notify the Provider in writing why the remaining portion will not be paid.
|
||||
If Health Plan determines the entire claim is not payable, Health Plan will deny the total amount of
|
||||
the claim not later than the forty-fifth (45th) day after the date on which the Health Plan receives a
|
||||
Clean Claim from a Provider in a non-electronic format, or the thirtieth (30th) day after the date the
|
||||
Health Plan receives a Clean Claim from a Provider that is electronically submitted.
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 6 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
MHT_HIX_PSA_Amend_Sig_v.031913
|
||||
|
||||
Start of Page No. = 7
|
||||
4. Additional Information to Make Determination of Claim. If Health Plan needs additional
|
||||
information from a Provider to determine payment on a Clean Claim, Health Plan must request the
|
||||
additional information not later than the thirtieth calendar day after the date the Health Plan receives
|
||||
the Clean Claim. Health Plan will determine whether the claim is payable on or before the later of the
|
||||
15th day after the date the Health Plan receives the requested attachment or the latest date for
|
||||
determining whether the claim is payable as a Clean Claim. Health Plan may not make more than one
|
||||
request in connection with a claim. The Provider may (1) mail the additional information by United
|
||||
States mail, first class, or by overnight delivery service; (2) submit the additional information
|
||||
electronically; (3) fax the additional information; or (4) hand deliver the additional information.
|
||||
5. Penalties for Late Payment of Claims. If Health Plan fails to make a payment on a Clean Claim
|
||||
within the required time frames, Health Plan will pay the following penalties:
|
||||
a. Payment is made on or after the 1st day and before the 46th after the Health Plan is required
|
||||
to make a determination and make payment of claim: Health Plan will pay the Provider
|
||||
making the claim the contracted rate owed on the claim plus a penalty in the amount of the lesser
|
||||
of: (1) 50 percent of the difference between the billed charges, as submitted on the claim, and the
|
||||
contracted rate or (2) $100,000.
|
||||
b. Payment is made on or after the 46th day and before the 91st days after the Health Plan is
|
||||
required to make a determination and make payment of claim: Health Plan will pay the
|
||||
Provider making the claim the contracted rate owed on the claim plus a penalty in the amount of
|
||||
the lesser of: (1) 100 percent of the difference between the billed charges, as submitted on the
|
||||
claim, and the contracted rate or (2) $200,000.
|
||||
c.
|
||||
Payment is made on or after the 91st day after the Health Plan is required to make a
|
||||
determination and make payment of claim: Health Plan will pay a penalty in the amount of the
|
||||
lesser of: (1) 100 percent of the difference between the billed charges, as submitted on the claim,
|
||||
and the contracted rate or (2) $200,000, plus 18 percent annual interest on that amount. Interest
|
||||
accrues beginning on the date the Health Plan was required to pay the claim and ending on the
|
||||
date the claim and the penalty are paid in full.
|
||||
If Health Plan pays only a portion of the amount of a Clean Claim within the required time frames,
|
||||
Health Plan will pay the following penalties:
|
||||
a.
|
||||
Payment is made on or after the 1st say and before the 46th after the Health Plan is required
|
||||
to make a determination and make payment of claim: Health Plan will pay the Provider
|
||||
making the claim the remainder of the contracted rate owed on the claim plus a penalty on the
|
||||
amount not timely paid in the amount of the lesser of: (1) 50 percent of the difference between the
|
||||
billed charges, as submitted on the claim, and the contracted rate or (2) $100,000. The underpaid
|
||||
amount is calculated on the ratio of the amount underpaid on the contracted rate to the contracted
|
||||
rate as applied to an amount equal to the billed charges as submitted on the claim minus the
|
||||
contracted rate.
|
||||
b. Payment is made on or after the 46th day and before the 91st days after the Health Plan is
|
||||
required to make a determination and make payment of claim: Health Plan will pay the
|
||||
Provider making the claim the remainder of the contracted rate owed on the claim plus a penalty
|
||||
on the amount not timely paid in the amount of the lesser of: (1) 100 percent of the difference
|
||||
between the billed charges, as submitted on the claim, and the contracted rate or (2) $200,000.
|
||||
c. Payment is made on or after the 91st day after the Health Plan is required to make a
|
||||
determination and make payment of claim: Health Plan will pay a penalty on the balance of
|
||||
the claim computed in the amount of the lesser of: (1) 100 percent of the underpaid amount or (2)
|
||||
$200,000, plus 18 percent annual interest on that amount. Interest accrues beginning on the date
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 7 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
MHT_HIX_PSA_Amend_Sig_v.031913
|
||||
|
||||
Start of Page No. = 8
|
||||
the Health Plan was required to pay the claim and ending on the date the claim and the penalty
|
||||
are paid in full.
|
||||
For a penalty relating to a Clean Claim submitted by a Provider other than an institutional provider,
|
||||
the Health Plan will pay the entire penalty to the Provider. However, any interest paid for a Clean
|
||||
Claim that is payable and that the Health Plan does not pay on or after the 91st day after the date the
|
||||
Health Plan is required to make a determination or adjudication of the claim will be paid to the Texas
|
||||
Health Insurance Risk Pool. For a penalty relating to a Clean Claim submitted by an institutional
|
||||
provider, the Health Plan will pay 50 percent of the total penalty amount, including interest, to the
|
||||
institutional provider and the remaining 50 percent of that amount to the Texas Health Insurance Risk
|
||||
Pool. For purposes of assessing penalties, "Institutional provider" means a hospital or other medical
|
||||
or health-related service facility that provides care for the sick or injured or other care that may be
|
||||
covered in an evidence of coverage.
|
||||
Notwithstanding the above, Health Plan is not liable for a penalty if 1) the failure to pay the claim is a
|
||||
result of a catastrophic event that substantially interferes with the normal business operations of the
|
||||
Health Plan or (2) if the claim was paid in accordance with the Texas Insurance Code, but for less
|
||||
than the contracted rate, and: the Provider notifies the Health Plan of the underpayment after the
|
||||
270th day after the date the underpayment was received and the Health Plan pays the balance of the
|
||||
claim on or before the 30th day after the date the Health Plan received the notice.
|
||||
6.
|
||||
Coordination of Benefits. Provider is required to maintain updated information concerning other
|
||||
health benefit plan coverage for a Member and to provide the information to the Health Plan. If
|
||||
Provider submits claims for particular health care services to more than one Health Plan, Provider
|
||||
will provide written notice on the claim submitted to each Health Plan of the identity of each other
|
||||
Health Plan with which the same claim is being filed.
|
||||
If Health Plan is secondary payer and pays a portion of a claim that should have been paid by the
|
||||
Health Plan, HMO or insurer that is the primary payer, Health Plan may recover payment from the
|
||||
Health Plan, HMO or insurer that is primarily responsible for that amount. If Health Plan is secondary
|
||||
payer and overpaid a portion of the claim in which the primary Health Plan, HMO or insurer also
|
||||
overpaid, the secondary Health Plan may recover the amount of the overpayment from Provider
|
||||
7. Offset. Health Plan may recover an overpayment to Provider if Health Plan provides written notice
|
||||
of the overpayment to the Provider that includes the basis and specific reasons for the request for
|
||||
recovery of funds not later than the 180th day after the date the Provider receives the payment, and the
|
||||
Provider does not make arrangements for repayment of the funds on or before the 45th day after the
|
||||
date the physician or provider receives the notice. The Provider may choose to appeal the request if
|
||||
the Provider disagrees with the request for recovery.
|
||||
8.
|
||||
Arbitration. Any claim or controversy arising out of or in connection with this Agreement will be
|
||||
resolved, to the extent possible, within forty-five (45) days through informal meetings and
|
||||
discussions between appropriate representatives of the parties. Any remaining claim or controversy
|
||||
will be resolved through binding arbitration conducted by a single arbitrator in accordance with the
|
||||
American Arbitration Association (AAA) Commercial Arbitration Rules, then in effect, in San
|
||||
Antonio, Texas; provided, however, matters that primarily involve Provider's professional
|
||||
competence or conduct will not be eligible for arbitration. If possible, the arbitrator will be an
|
||||
attorney with at least fifteen (15) years' experience, including at least five (5) years' experience in
|
||||
managed health care. The parties will conduct a mandatory settlement conference at the initiation of
|
||||
arbitration, to be administered by AAA. The arbitrator will have no authority to award damages or
|
||||
provide a remedy that would not be available to such prevailing party in a court of law or award
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 8 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
MHT_HIX_PSA_Amend_Sig_v.031913
|
||||
|
||||
Start of Page No. = 9
|
||||
punitive damages. Each party will bear its own costs and expenses, including its own attorneys' fees,
|
||||
and will bear an equal share of the arbitrator's and administrative fees. For actions pertaining to
|
||||
recover payment pursuant to Texas Insurance Code Chapter 843, Subchapter J, each party will have
|
||||
the opportunity to recover reasonable attorney's fees and court costs from arbitrator. The parties
|
||||
agree to accept any decision by the arbitrator as a final determination of the matter in dispute, and
|
||||
judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction.
|
||||
Arbitration must be initiated within (1) one year of the earlier of the date the claim or controversy
|
||||
arose, was discovered, or should have been discovered with reasonable diligence; otherwise it will be
|
||||
deemed waived. The use of binding arbitration will not preclude a request for equitable and
|
||||
injunctive relief made to a court of appropriate jurisdiction.
|
||||
9. Member Hold Harmless. Provider hereby agrees that in no event, including, but not limited
|
||||
to non-payment by the Health Plan, Health Plan insolvency, or breach of this agreement, will
|
||||
Provider bill, charge, collect a deposit from, seek compensation, remuneration, or
|
||||
reimbursement from, or have any recourse against subscriber, enrollee, or persons other than
|
||||
Health Plan acting on their behalf for services provided pursuant to this agreement. This
|
||||
provision will not prohibit collection of supplemental charges or copayments made in
|
||||
accordance with the terms of the Agreement between Health Plan and Member. Provider
|
||||
further agrees that:
|
||||
(i) this provision will survive the termination of this agreement regardless of the cause giving rise to
|
||||
termination and will be construed to be for the benefit of the Health Plan Member; and
|
||||
(ii) this provision supersedes any oral or written contrary agreement now existing or hereafter entered
|
||||
into between Provider and Member, or persons acting on their behalf. Any modification, addition,
|
||||
or deletion to the provisions of this clause will be effective on a date no earlier than 15 days after
|
||||
the commissioner has received written notice of such proposed changes.
|
||||
10. Deductibles and Copayments. Provider may bill a Member for any co-payment, deductible or co-
|
||||
insurance obligation applicable to Member's Health Plan product. Provider may not waive a
|
||||
deductible or copayment by the acceptance of an assignment.
|
||||
Molina Healthcare of Texas, Inc.
|
||||
Page 9 of 9
|
||||
Molina Health Benefit Exchange Product
|
||||
Amendment to Provider Services Agreement
|
||||
MHT_HIX_PSA_Amend_Sig_v.031913
|
||||
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|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT FOUR
|
||||
TO THE MOLINA HEALTHCARE OF
|
||||
TEXAS, INC. HOSPITAL SERVICES
|
||||
AGREEMENT
|
||||
Health Benefit Exchange
|
||||
Reimbursement for Professional Services
|
||||
THIS HEALTH BENEFIT EXCHANGE AMENDMENT TO THE HOSPITAL SERVICES
|
||||
AGREEMENT ("Amendment") is made and entered by and between Molina Healthcare of
|
||||
Texas, Inc. ("Health Plan") and Dallas County Hospital District, dba Parkland Health &
|
||||
Hospital System, a political subdivision of the State of Texas and Hospital District of Dallas County,
|
||||
Texas ("Provider").
|
||||
A. Whereas, Health Plan and Provider have entered into a Hospital Services Agreement, or other
|
||||
corresponding health care services agreement or contract, as may have been amended
|
||||
from time to time ("Agreement"); and
|
||||
B. Whereas, Provider agrees to contract with Health Plan for Health Plan's Health Benefit
|
||||
Exchange products;
|
||||
Now therefore, in consideration of the rights and obligations contained herein, Health Plan and Provider
|
||||
agree to amend the previously executed Health Benefits Exchange Amendment (Amendment Two) as
|
||||
follows:
|
||||
1. Attachment D-2 Compensation Schedule for Molina Health Benefit Exchange Product -
|
||||
Professional Services is added and details the reimbursement terms for the services
|
||||
rendered by UTSW practitioners in a Parkland Clinic setting.
|
||||
Parkland Health & Hospital System, where appropriate and where authorized by
|
||||
University of Texas Southwestern Medical School (UTSW), will bill on behalf
|
||||
of those UTSW practitioners providing services to Molina Members in a
|
||||
Parkland Clinic setting. Parkland will compensate UTSW directly for the
|
||||
professional services rendered via their executed Service Agreement with
|
||||
UTSW.
|
||||
2. Section 15 (Effective Date) is amended.
|
||||
This Amendment will become effective on January 1,2016, and renew with and under
|
||||
the terms of the Agreement for so long as the UTSW practitioners agree to provide their
|
||||
professional services per the terms of this Amendment.
|
||||
SIGNATURE AUTHORIZATION
|
||||
IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their
|
||||
officers thereunto duly authorized as of the Effective Date set forth in the Amendment. The individual
|
||||
signing below on behalf of Provider acknowledges, warrants, and represents that said individual has the
|
||||
|
||||
Start of Page No. = 2
|
||||
authority and proper authorization to execute this Amendment on behalf of Provider , if any, and does SO
|
||||
freely with the intent to fully bind Provider if any, to the provisions of this Amendment.
|
||||
Parkland Health & Hospital System
|
||||
Molina Healthcare of Texas, Inc.,
|
||||
("Provider")
|
||||
("Health Plan")
|
||||
Provider
|
||||
Signature:
|
||||
Signatory Name
|
||||
John Moore
|
||||
John Moore
|
||||
(Printed): Name John J. McGuinness
|
||||
Signatory
|
||||
(Printed):
|
||||
Signatory Title
|
||||
Signatory Title
|
||||
COO
|
||||
(Printed):
|
||||
Chief Financial Officer
|
||||
(Printed):
|
||||
Signature Date:
|
||||
6/9/16
|
||||
Signature Date:
|
||||
6/15/16
|
||||
Effective Date:
|
||||
1/1/16
|
||||
|
||||
Start of Page No. = 3
|
||||
ATTACHMENT D-2
|
||||
COMPENSATION SCHEDULE FOR MOLINA
|
||||
HEALTH BENEFIT EXCHANGE PRODUCT
|
||||
PHYSICIAN SERVICES
|
||||
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members,
|
||||
in accordance with the Molina Health Benefit Exchange Product, on a fee-for-service basis, at the lesser
|
||||
of: (i) Provider's billed charges (the amount written on the claim), or (ii) the amounts set forth below; less
|
||||
any applicable Member co-payments, deductibles, co-insurance, or amounts paid by other liable third
|
||||
parties, if any:
|
||||
Compensation for Health Insurance Marketplace (Professional Services). Health Plan agrees to
|
||||
compensate Provider for Covered Services provided under the Health Insurance Marketplace Product, that
|
||||
are submitted on a Clean Claim (as defined by Texas law), on a fee-for-service basis, less any applicable
|
||||
Member co-payments, deductibles, co-insurance, or amounts paid by other liable third parties, if any, at the
|
||||
lesser of: (i) Provider's billed charges; or (ii) at One Hundred Forty-Five (145%) percent of the Medicare
|
||||
Fee-For-Service Program allowable payment rates for Dallas County, as of the Date of Service. In the
|
||||
event that there is no payment rate in the Medicare Fee-For-Service Program fee schedule as of the Date of
|
||||
Service, Covered Services submitted on a Clean Claim will be paid on a fee-for-service basis less any
|
||||
applicable Member co-payments, deductibles, co-insurance, or amounts paid by other liable third parties,
|
||||
if any, at the lesser of: (i) Provider's billed charges; or (ii) at an amount equivalent to the allowable rate
|
||||
under the applicable Medicaid Fee-For-Service Program fee schedule set forth by the State of Texas, in
|
||||
effect on the Date of Service.
|
||||
Note: The above reimbursement will be reimbursed to Parkland Health & Hospital System for services
|
||||
rendered by a UTSW practitioner in a Parkland Clinic setting where appropriate and agreed to by
|
||||
Parkland and UTSW.
|
||||
+2815
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+256
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|
||||
|
||||
Start of Page No. = 1
|
||||
AMENDMENT
|
||||
TO THE CARE1ST HEALTH PLAN ARIZONA, INC.
|
||||
PROVIDER AGREEMENT
|
||||
This Amendment is effective the
|
||||
1st
|
||||
day of January
|
||||
2022
|
||||
and modifies the
|
||||
,
|
||||
CARE1st HEALTH PLAN ARIZONA, INC. PROVIDER AGREEMENT (hereinafter "Agreement") by
|
||||
and between CARE1st HEALTH PLAN ARIZONA, INC., an Arizona Corporation, (hereinafter "Plan"),
|
||||
and West Yavapai Guidance Clinic Inc., (hereafter "PROVIDER").
|
||||
Whereas, Plan and PROVIDER entered into a Contract (hereafter "Agreement") on September 6, 2018;
|
||||
and
|
||||
Whereas, Plan and PROVIDER agree to amend the Agreement as follows:
|
||||
Replace ATTACHMENT A PROVIDER SERVICES AND COMPENSATION with the attached
|
||||
ATTACHMENT A PROVIDER SERVICES AND COMPENSATION.
|
||||
INTEGRATION; CONFLICTS
|
||||
This Amendment represents the complete agreement between the parties regarding the subject matter
|
||||
hereof, and no other changes or modifications of the Agreement are intended nor shall any such other
|
||||
changes or modifications exist. In the event of a conflict between the terms of the Agreement and this
|
||||
Amendment, the terms of this Amendment shall control.
|
||||
IN WITNESS WHEREOF, CARE1st HEALTH PLAN ARIZONA, INC. executes this Amendment as of
|
||||
the date set forth below to be effective on the effective date specified above.
|
||||
Plan
|
||||
PROVIDER
|
||||
12/8/21
|
||||
By:
|
||||
Jamara Player
|
||||
Scott Cummings
|
||||
Date
|
||||
State Plan President
|
||||
Signature
|
||||
Tamara Player
|
||||
Printed Name
|
||||
President and CEO
|
||||
Title
|
||||
West Yavapai Guidance Clinic Inc.
|
||||
Address for Plan Notices:
|
||||
Contracting Entity/Group Name
|
||||
86-0206928
|
||||
Care1st Health Plan Arizona, Inc.
|
||||
Contracting Entity/Group Tax I.D.
|
||||
Attention: Director, Network Management
|
||||
86-0206928
|
||||
1870 W. Rio Salado Parkway
|
||||
Date 12/8/2021
|
||||
Tempe, Arizona 85281
|
||||
Address for Provider Notices:
|
||||
3343 N. Windsong Drive
|
||||
Prescott Valley, AZ 86314
|
||||
1 of 1
|
||||
|
||||
Start of Page No. = 2
|
||||
ATTACHMENT A
|
||||
PROVIDER SERVICES AND COMPENSATION
|
||||
PROVIDER is responsible for providing all necessary Covered Health Care Services (prior authorized, if
|
||||
required) to referred Plan Members, in a manner consistent with the standards of PROVIDER's specialty,
|
||||
dependent on the level of training the Provider has received, the limitations of scope of practice and
|
||||
consistent with State and Federal rules and regulations.
|
||||
Plan's Fee Schedule may be revised with fifteen (15) days written notification to PROVIDER by Plan. Plan
|
||||
shall implement changes to Plan's Fee Schedule within sixty days of receipt of AHCCCS confirmation
|
||||
of rate changes. PROVIDER shall be reimbursed within sixty (vu) days of the Plan's receipt of a clean claim.
|
||||
Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) Payment. FQHC/RHC payment shall
|
||||
be effective as determined by AHCCCS and is dependent upon successful completion of the required
|
||||
AHCCCS registration process. Per AHCCCS guidelines, the FQHC/RHC payment shall be applied only
|
||||
when both the effective date and registration conditions are met. Claims for dates of service prior to the
|
||||
AHCCCS determined effective date and/or prior to successful completion of the registration process shall be
|
||||
processed under the prior Fee-For-Service methodology and not the PPS methodology.
|
||||
PROVIDER shall follow the billing guidelines outlined by AHCCCS and Plan shall reimburse PROVIDER
|
||||
the lesser of the unique FQHC PPS rate established by AHCCCS for PROVIDER for applicable Covered
|
||||
Health Care Services provided by PROVIDER to Plan Members or PROVIDER's charges, less any
|
||||
applicable Co-Payments, Deductibles and Coinsurance. The FQHC PPS rate is an all inclusive visit rate that
|
||||
shall be paid per visit and shall serve as the full reimbursement for the visit and other related services. At no
|
||||
time shall Plan pay an amount that exceeds PROVIDER's billed charges. Covered Health Care Services not
|
||||
qualifying for payment under the FQHC PPS rate shall be reimbursed according to the Fee-For-Service
|
||||
Payment section below.
|
||||
Fee-For-Service Payment. Payment for Covered Health Care Services provided by PROVIDER to Plan
|
||||
Members that do not qualify for FQHC/RHC Payment shall be based on the lesser of the Plan's Fee Schedule
|
||||
defined in the table below or PROVIDER's charges, less any applicable Co-Payments, Deductibles and
|
||||
Coinsurance. Services with no rates shall be reimbursed according to Plan's criteria until rates are
|
||||
established. At no time shall Plan pay an amount that exceeds PROVIDER's billed charges.
|
||||
Practitioner Type, Specialty or Service
|
||||
Care1st AHCCCS Complete Care Reimbursement
|
||||
Physicians/Clinical Psychologists (MD, DO, Phd,
|
||||
300% of the AHCCCS Physician Fee For Service
|
||||
DPM) ( OBGYNs: Also see Obstetrical Service
|
||||
rates prevailing as of the date of service
|
||||
Package below)
|
||||
See Behavioral Health Fee Schedule below
|
||||
Audiologists, Chiropractors, Registered Dieticians
|
||||
85% of the AHCCCS Physician Fee For Service
|
||||
(AUDs, DCs, RDs)
|
||||
rates prevailing as of the date of service
|
||||
Board Certified Behavioral Analyst (BCBA)
|
||||
100% of the AHCCCS Physician Fee For Service
|
||||
rates prevailing as of the date of service
|
||||
See Behavioral Health Fee Schedule below
|
||||
Mid-level Practitioners (e.g. NPs, PAs, CNMs,
|
||||
300% of the AHCCCS Physician Fee For Service
|
||||
CRNAs, (license permitting), etc.)
|
||||
rates prevailing as of the date of service
|
||||
See Behavioral Health Fee Schedule below
|
||||
Independent Licensures (LPC, LMFT, LISAC,
|
||||
300% of the AHCCCS Physician Fee For Service
|
||||
LCSW)
|
||||
rates prevailing as of the date of service
|
||||
See Behavioral Health Fee Schedule below
|
||||
A.1 of A.4
|
||||
Amendment 01.22.2020
|
||||
|
||||
Start of Page No. = 3
|
||||
ATTACHMENT A
|
||||
PROVIDER SERVICES AND COMPENSATION
|
||||
Behavioral Health Outpatient Clinics/Integrated
|
||||
300% of the AHCCCS Physician Fee For Service
|
||||
Clinics
|
||||
rates prevailing as of the date of service
|
||||
See Behavioral Health Fee Schedule below
|
||||
Physical, Occupational, Speech Therapists
|
||||
All inclusive per visit rate of $65.00. This applies to
|
||||
(PTs/OTs/STs)
|
||||
physical, occupational and speech therapy. If more than
|
||||
one type of therapy is received on the same day (e.g. PT
|
||||
and OT), reimbursement shall be $65.00 per therapy
|
||||
Radiology Services
|
||||
90% of the AHCCCS Physician Fee For Service
|
||||
rates prevailing as of the date of service
|
||||
Contrast material/isotopes for PET scans with no
|
||||
established rates - $250 per PET scan
|
||||
In Office Lab Testing
|
||||
70% of the AHCCCS Physician Fee For Service rates
|
||||
prevailing as of the date of service
|
||||
Transportation Services
|
||||
A0160 - 398% of the AHCCCS Physician Fee For
|
||||
Service rates prevailing as of the date of service
|
||||
The following services are excluded from Plan's Fee Schedule and paid at Plan's defined rates less Co-Payments,
|
||||
Deductibles and Coinsurance: VFC administration, certain obstetrical pre/post/delivery services, certain Covered
|
||||
Services coded with HCPCS codes, and injectable drugs.
|
||||
Vaccines For Children (VFC) Program. Plan shall not reimburse PROVIDER for the costs of immunizations
|
||||
available free-of-charge to PROVIDER through the VFC program. Plan shall reimburse PROVIDER for the
|
||||
administration of these vaccines according to Plan's defined rates.
|
||||
Surgical Assists. Prior authorized surgical assists will be paid on a Fee-For-Service basis for PROVIDER's
|
||||
assigned Plan Members. Payment will be made at the lesser of twenty percent (20%) of the surgical assist's
|
||||
approved reimbursement or the PROVIDER's charges for each procedure. PROVIDER shall make all necessary
|
||||
prior arrangements to ensure Prior Authorization of PROVIDER's surgical assist(s). Primary surgeon shall reserve
|
||||
the right to select the assistant surgeon. Plan shall retrospectively review all surgical assist services for medical
|
||||
necessity.
|
||||
Behavioral Health Fee Schedule.
|
||||
HCPCS CODE
|
||||
Care1st AHCCCS Complete Care Reimbursement
|
||||
H0004
|
||||
240% of the AHCCCS Behavioral Health Fee for
|
||||
Service rates prevailing as of the date of service
|
||||
H2014
|
||||
240% of the AHCCCS Behavioral Health Fee for
|
||||
Service rates prevailing as of the date of service
|
||||
S5150
|
||||
240% of the AHCCCS Behavioral Health Fee for
|
||||
Service rates prevailing as of the date of service
|
||||
S5151
|
||||
240% of the AHCCCS Behavioral Health Fee for
|
||||
Service rates prevailing as of the date of service
|
||||
T1016
|
||||
240% of the AHCCCS Behavioral Health Fee for
|
||||
Service rates prevailing as of the date of service
|
||||
All other HCPCS codes/modifier combinations not
|
||||
275% of the AHCCCS Behavioral Health Fee for
|
||||
defined above
|
||||
Service rates prevailing as of the date of service
|
||||
A.2 of A.4
|
||||
Amendment 01.22.2020
|
||||
|
||||
Start of Page No. = 4
|
||||
ATTACHMENT A
|
||||
PROVIDER SERVICES AND COMPENSATION
|
||||
Obstetrical Service Package. For the Obstetrical Service Package, PROVIDER shall obtain a single, global
|
||||
prior authorization number and shall be reimbursed according to Plan's Fee Schedule (defined above) for the
|
||||
services listed in Table I. This reimbursement shall only apply if the PROVIDER has seen the Member a
|
||||
minimum number of visits (according to AHCCCSA guidelines) prior to delivery. This reimbursement
|
||||
applies to single births. Second and subsequent deliveries shall be reimbursed at fifty percent (50%) of the
|
||||
Plan's Fee Schedule.
|
||||
In the event that the provider of record for delivery is not the PROVIDER to whom the Member and global
|
||||
Prior Authorization number are assigned, the Obstetrical Service Package shall not apply, and PROVIDER
|
||||
shall be reimbursed according to Services actually performed.
|
||||
In the event that delivery is performed by a Mid-level practitioner employed by the PROVIDER,
|
||||
PROVIDER shall be reimbursed eighty-five percent (85%) of the Obstetrical Service Package rate.
|
||||
A.3 of A.4
|
||||
Amendment 01.22.2020
|
||||
|
||||
Start of Page No. = 5
|
||||
ATTACHMENT A
|
||||
PROVIDER SERVICES AND COMPENSATION
|
||||
TABLE 1
|
||||
Reimbursed
|
||||
Included in
|
||||
Separately *
|
||||
Package
|
||||
Physical Exam
|
||||
X
|
||||
Initial and subsequent history
|
||||
X
|
||||
Weight and blood pressure
|
||||
X
|
||||
Breast Stimulation studies
|
||||
X
|
||||
Genetic counseling (not testing)
|
||||
X
|
||||
Artificial rupture of membranes
|
||||
X
|
||||
EPSDT & sick visits
|
||||
X
|
||||
Fetal scalp monitoring
|
||||
X
|
||||
Induction of labor
|
||||
X
|
||||
Delivery (includes multiple births)
|
||||
X
|
||||
5+ prenatal visits and 1 postpartum visit (including pap smear) are included in
|
||||
X
|
||||
total OB package
|
||||
Laboratory services and Handling Fees performed by PROVIDER or Plan's
|
||||
contracted laboratory
|
||||
X
|
||||
Family planning
|
||||
X
|
||||
Maternity counseling
|
||||
X
|
||||
Nutritional evaluations
|
||||
X
|
||||
Non-Stress Test (NST)
|
||||
X
|
||||
OB Ultrasounds
|
||||
X
|
||||
RhoGAM injections
|
||||
X
|
||||
Amniocentesis
|
||||
X
|
||||
Inpatient & Observation services
|
||||
X
|
||||
Wet preps and wet mounts
|
||||
X
|
||||
External cephalic versions
|
||||
X
|
||||
Amnioinfusion
|
||||
X
|
||||
Post-partum tubal ligation
|
||||
X
|
||||
Prostaglandin Gel Insertion
|
||||
X
|
||||
* All items, procedures and services are reimbursed based on the lesser of Plan's Fee Schedule or the
|
||||
PROVIDER's charges.
|
||||
A.4 of A.4
|
||||
Amendment 01.22.2020
|
||||
File diff suppressed because it is too large
Load Diff
+869
-869
File diff suppressed because one or more lines are too long
@@ -0,0 +1,6 @@
|
||||
Field Name,# Contracts Tested,Username,Date/Time,Accuracy,Attempt #
|
||||
Associated Base Contract Effective Date,20,,2024-03-05 20:08:44,,1
|
||||
Associated Base Contract Effective Date,10,,2024-03-05 20:09:20,,1
|
||||
Associated Base Contract Effective Date,10,,2024-03-05 20:10:33,,1
|
||||
Associated Base Contract Effective Date,10,,2024-03-05 20:11:30,0.0,1
|
||||
Associated Base Contract Effective Date,10,,2024-03-05 20:17:56,0.0,1
|
||||
|
+87
-57
@@ -32,13 +32,10 @@ with st.sidebar:
|
||||
# st.write("Doczy")
|
||||
|
||||
fields = pd.read_csv('contract_fields.csv', encoding='unicode_escape', skipinitialspace=True)
|
||||
fields = fields[fields['PRIORITY'] == 'A']
|
||||
fields = fields[fields['PRIORITY'].isin(['A','C'])]
|
||||
field_values = pd.read_csv('contract_field_values.csv', encoding='unicode_escape', skipinitialspace=True)
|
||||
fields = fields.drop_duplicates(subset='Field Name', keep="first").sort_values('Field Name')
|
||||
# attribute_list = ['Agreement Name', 'Agreement Type', 'Contract State', 'Contract Type', 'Create Date', 'Effective Date', 'Gold Carded',
|
||||
# 'Modify Date', 'National Contract', 'Provider State', 'Summary', 'Termination Date', 'TIN', 'Value-Based Contract']
|
||||
# sample = sample[sample['Attribute'].isin(attribute_list)]
|
||||
# field_prompt_mapping = sample[['Attribute', 'Query']].drop_duplicates().dropna()
|
||||
fields = fields[~fields['Field Name'].isnull()]
|
||||
field_prompt_mapping = dict(zip(fields['Field Name'], fields['Interrogation Question?']))
|
||||
|
||||
field_row = st.columns([0.15, 0.45, 0.4])
|
||||
@@ -51,19 +48,20 @@ contract_count_row = st.columns([0.15, 0.45, 0.4])
|
||||
with contract_count_row[0]:
|
||||
st.write("**# of Contracts**")
|
||||
with contract_count_row[1]:
|
||||
contract_count = st.selectbox('Contract count',('3', '5', '10', '20', 'All'), index=0, label_visibility = "collapsed")
|
||||
contract_count = st.selectbox('Contract count',('10', '20', '30', '50', 'All'), index=0, label_visibility = "collapsed")
|
||||
|
||||
seed_row = st.columns([0.15, 0.45, 0.4])
|
||||
with seed_row[0]:
|
||||
st.write("**Seed Value**")
|
||||
with seed_row[1]:
|
||||
seed_value = st.text_input("**Seed Value**", value = 10, label_visibility = "collapsed")
|
||||
seed_value = st.text_input("**Seed Value**", value = 20, label_visibility = "collapsed")
|
||||
|
||||
llm_row = st.columns([0.15, 0.45, 0.4])
|
||||
with llm_row[0]:
|
||||
st.write("**Langauge Model**")
|
||||
with llm_row[1]:
|
||||
llm_selected = st.selectbox('Langauge Model',('Llama 2 Chat 13B', 'Llama 2 Chat 70B', 'Titan Text Express'), label_visibility = "collapsed")
|
||||
llm_selected = st.selectbox('Langauge Model',('Claude 2', 'Claude Instant', 'Llama 2 Chat 13B', 'Llama 2 Chat 70B'
|
||||
, 'Titan Text Express'), label_visibility = "collapsed")
|
||||
|
||||
st.write("**Prompt**")
|
||||
sequence_input = field_prompt_mapping.get(field)
|
||||
@@ -79,9 +77,12 @@ with prompt_row[0]:
|
||||
|
||||
random.seed(seed_value)
|
||||
try:
|
||||
contract_list = sorted(random.choices(os.listdir("RAW_DOCUMENTS"), k=int(contract_count)))
|
||||
contract_list = sorted(random.choices(os.listdir(SOURCE_DIRECTORY), k=int(contract_count)))
|
||||
except:
|
||||
contract_list = sorted(os.listdir("RAW_DOCUMENTS"))
|
||||
contract_list = sorted(os.listdir(SOURCE_DIRECTORY))
|
||||
|
||||
# to be deleted later
|
||||
contract_list = [contract for contract in contract_list if contract.replace(' MU','').replace('_MU','').replace('.txt','') in list(field_values['(internal) Document Name'])]
|
||||
|
||||
page_list_all = []
|
||||
for contract in contract_list:
|
||||
@@ -103,6 +104,8 @@ if column_name+'_PG' in list(field_values.columns):
|
||||
field_values = field_values[column_list]
|
||||
field_values.rename(columns={'(internal) Document Name': 'Contract Name', column_name: 'Actual Value Stored'
|
||||
, '(Internal) Carveout ID': 'Contract ID', column_name+'_PG': 'Original Page Number'}, inplace=True)
|
||||
field_values = field_values.drop_duplicates(subset='Contract Name', keep="first").sort_values('Contract Name')
|
||||
|
||||
# sample = dict(zip(sample.Filename, sample.Answer))
|
||||
# actual_value_list = [sample.get(contract.rsplit('.',1)[0]+'.txt', ' ') for contract in contract_list]
|
||||
|
||||
@@ -113,7 +116,7 @@ field_values.rename(columns={'(internal) Document Name': 'Contract Name', column
|
||||
# Setup bedrock
|
||||
bedrock_runtime = boto3.client(
|
||||
service_name="bedrock-runtime",
|
||||
region_name="us-east-1"
|
||||
region_name="us-east-1",
|
||||
)
|
||||
|
||||
# Define the retreiver
|
||||
@@ -138,39 +141,59 @@ if "DB" not in st.session_state:
|
||||
# RETRIEVER = DB.as_retriever(search_kwargs={"filter": { "source": { '$eq': "SOURCE_DOCUMENTS\\A.1_UH_Health_System_eff_2_1_08 (1)_page0.txt"} }, "k": 2})
|
||||
# st.session_state.RETRIEVER = RETRIEVER
|
||||
|
||||
if "LLM" not in st.session_state:
|
||||
if llm_selected == 'Titan Text Express':
|
||||
LLM = Bedrock(
|
||||
model_id="amazon.titan-text-express-v1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
"maxTokenCount": 4096,
|
||||
"stopSequences": [],
|
||||
"temperature": 0,
|
||||
"topP": 1,
|
||||
}
|
||||
)
|
||||
elif llm_selected == 'Llama 2 Chat 70B':
|
||||
LLM = Bedrock(
|
||||
model_id="meta.llama2-70b-chat-v1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
"max_gen_len": 512,
|
||||
"temperature": 0,
|
||||
# "topP": 0.9,
|
||||
}
|
||||
)
|
||||
else:
|
||||
LLM = Bedrock(
|
||||
model_id="meta.llama2-13b-chat-v1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
"max_gen_len": 512,
|
||||
"temperature": 0,
|
||||
# "topP": 0.9,
|
||||
}
|
||||
)
|
||||
st.session_state["LLM"] = LLM
|
||||
# if "LLM" not in st.session_state:
|
||||
if llm_selected == 'Titan Text Express':
|
||||
LLM = Bedrock(
|
||||
model_id="amazon.titan-text-express-v1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
"maxTokenCount": 512,
|
||||
"stopSequences": [],
|
||||
"temperature": 0,
|
||||
"topP": 1,
|
||||
}
|
||||
)
|
||||
elif llm_selected == 'Llama 2 Chat 70B':
|
||||
LLM = Bedrock(
|
||||
model_id="meta.llama2-70b-chat-v1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
"max_gen_len": 512,
|
||||
"temperature": 0,
|
||||
# "topP": 0.9,
|
||||
}
|
||||
)
|
||||
elif llm_selected == 'Llama 2 Chat 13B':
|
||||
LLM = Bedrock(
|
||||
model_id="meta.llama2-13b-chat-v1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
"max_gen_len": 512,
|
||||
"temperature": 0,
|
||||
# "topP": 0.9,
|
||||
}
|
||||
)
|
||||
elif llm_selected == 'Claude Instant':
|
||||
LLM = Bedrock(
|
||||
model_id="anthropic.claude-instant-v1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
# "max_tokens_to_sample": 512,
|
||||
"temperature": 0,
|
||||
# "topP": 0.9,
|
||||
}
|
||||
)
|
||||
elif llm_selected == 'Claude 2':
|
||||
LLM = Bedrock(
|
||||
model_id="anthropic.claude-v2:1",
|
||||
client=bedrock_runtime,
|
||||
model_kwargs={
|
||||
# "max_tokens_to_sample": 512,
|
||||
"temperature": 0,
|
||||
# "topP": 0.9,
|
||||
}
|
||||
)
|
||||
st.session_state["LLM"] = LLM
|
||||
|
||||
# if "QA" not in st.session_state:
|
||||
# prompt, memory = model_memory()
|
||||
@@ -203,7 +226,7 @@ if st.button("Test Configuration"):
|
||||
attempt = attempt + 1
|
||||
|
||||
for page_list in page_list_all:
|
||||
RETRIEVER = st.session_state.DB.as_retriever(search_kwargs={"filter": {"$or": page_list}, "k": 4})
|
||||
RETRIEVER = st.session_state.DB.as_retriever(search_kwargs={"filter": {"$or": page_list}, "k": 14})
|
||||
QA = RetrievalQA.from_chain_type(
|
||||
llm=st.session_state["LLM"],
|
||||
chain_type="stuff",
|
||||
@@ -211,7 +234,7 @@ if st.button("Test Configuration"):
|
||||
return_source_documents=True,
|
||||
# chain_type_kwargs={"prompt": prompt, "memory": None},
|
||||
)
|
||||
score = st.session_state.DB.similarity_search_with_relevance_scores(prompt, k=4, filter={"$or": page_list})
|
||||
score = st.session_state.DB.similarity_search_with_relevance_scores(prompt, k=14, filter={"$or": page_list})
|
||||
score_list.append(max(d[1] for d in score))
|
||||
response = QA(prompt)
|
||||
answer, docs = response["result"], response["source_documents"]
|
||||
@@ -219,15 +242,7 @@ if st.button("Test Configuration"):
|
||||
doc_list.append(docs)
|
||||
response_list.append(response)
|
||||
|
||||
# st.write(answer_list)
|
||||
# st.write(column_name)
|
||||
# st.write(doc_list)
|
||||
# st.write("============")
|
||||
# st.write(response_list)
|
||||
# st.write("============")
|
||||
# # st.write(st.session_state.DB.get().keys())
|
||||
# # st.write(len(st.session_state.DB.get()["ids"]))
|
||||
|
||||
# post-processing
|
||||
if 'Date' in field:
|
||||
date_list = []
|
||||
for answer in answer_list:
|
||||
@@ -236,10 +251,16 @@ if st.button("Test Configuration"):
|
||||
except:
|
||||
extracted_date = "N/A"
|
||||
date_list.append(extracted_date)
|
||||
|
||||
answer_list = date_list
|
||||
else:
|
||||
answer_list = [answer.rstrip(".") for answer in answer_list]
|
||||
# I don't know; does not contain; "None"; Not specified in the contract; Not applicable; N/A
|
||||
# answer_list = [str(x).rsplit(':',1)[0] if len(str(x).rsplit(':',1)) < 2 else str(x).rsplit(':',1)[1] for x in answer_list]
|
||||
|
||||
df['Contract Name'] = contract_list
|
||||
# to be deleted later
|
||||
df['Contract Name'] = [contract.replace(' MU','').replace('_MU','').replace('.txt','') for contract in contract_list]
|
||||
|
||||
df['New Extracted value'] = answer_list
|
||||
df['Confidence Level'] = [round(score, 2) for score in score_list]
|
||||
df['Snippet'] = [str(doc[0].page_content) for doc in doc_list]
|
||||
@@ -251,6 +272,7 @@ if st.button("Test Configuration"):
|
||||
actual_value_list = list(df['Actual Value Stored'])
|
||||
result_list = [i==j for i, j in zip(actual_value_list, answer_list)]
|
||||
df['Result'] = [str(x) for x in result_list]
|
||||
df = df[~df['Contract ID'].isnull()]
|
||||
|
||||
if 'Original Page Number' in df.columns:
|
||||
df = df[['Contract Name','Contract ID','Actual Value Stored','New Extracted value','Confidence Level','Snippet'
|
||||
@@ -259,8 +281,13 @@ if st.button("Test Configuration"):
|
||||
df = df[['Contract Name','Contract ID','Actual Value Stored','New Extracted value','Confidence Level','Snippet'
|
||||
, 'New Page Number', 'Revised Prompt', 'Result']]
|
||||
|
||||
accuracy = round(sum(bool(x) for x in result_list) * 100 / len(list(df['Result'])), 2)
|
||||
try:
|
||||
accuracy = round(sum(bool(x) for x in result_list) * 100 / len(list(df['Result'])), 2)
|
||||
except:
|
||||
accuracy = 'NA'
|
||||
|
||||
history.loc[len(history.index)] = [field, str(contract_count), None, datetime.now().strftime("%Y-%m-%d %H:%M:%S"), accuracy, attempt]
|
||||
# df.to_csv(field.replace("?","").replace("/","_")+'-'+llm_selected+'.csv', index=False)
|
||||
history.to_csv('history.csv', index=False)
|
||||
|
||||
# df_copy = df.set_index(df.columns[0]).copy()
|
||||
@@ -284,4 +311,7 @@ st.dataframe(history)
|
||||
# st.button("Kickoff Database Integration")
|
||||
|
||||
|
||||
st.write(column_name)
|
||||
st.write(len(contract_list))
|
||||
|
||||
|
||||
|
||||
Reference in New Issue
Block a user