diff --git a/streamlit/contract_fields.csv b/streamlit/contract_fields.csv index 40cd936..52fa4ea 100644 --- a/streamlit/contract_fields.csv +++ b/streamlit/contract_fields.csv @@ -1,1097 +1,1046 @@ Interrogation Question?,Field Name,SF_DB_COL_NAME,DATA_TYPE,PRIORITY,FLAG,Related Generic Data Pipeline Field Name?,Source of Data,Theme,Required Field?,Use of Field Beyond Contract Config? -Does the contract include a carve out for Ambulatory Surgery (Yes/No)?,Ambulatory Surgery Carve Out (Y/N)?,AMBULATORY_SURGERY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Ambulatory Surgery, list the applicable codes or code ranges ",Ambulatory Surgery Codes or Code Range ,AMBULATORY_SURGERY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Ambulatory Surgery, describe how these codes are reimbursed",Ambulatory Surgery Reimbursement Methodology,AMBULATORY_SURGERY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for anesthesia (Yes/No)?,Anesthesia Carve Out (Y/N)?,ANESTHESIA_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for anesthesia, list the applicable codes or code ranges ",Anesthesia Codes or Code Range,ANESTHESIA_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for anesthesia, describe how these codes are reimbursed",Anesthesia Reimbursement Methodology ,ANESTHESIA_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the Primary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges",Applicable Admit Type Codes - Primary,PRIMARY_REIMBURSEMENT_ADMITTYPE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges",Applicable Admit Type Codes - Secondary,SECONDARY_REIMBURSEMENT_ADMITTYPE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges",Applicable Admit Type Codes - Tertiary,TERTIARY_REIMBURSEMENT_ADMITTYPE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Primary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges",Applicable Diagnosis Codes - Primary,PRIMARY_REIMBURSEMENT_DIAG_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges",Applicable Diagnosis Codes - Secondary,SECONDARY_REIMBURSEMENT_DIAG_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges",Applicable Diagnosis Codes - Tertiary,TERTIARY_REIMBURSEMENT_DIAG_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Primary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges",Applicable Grouper Codes - Primary,PRIMARY_REIMBURSEMENT_GROUPER_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges",Applicable Grouper Codes - Secondary,SECONDARY_REIMBURSEMENT_GROUPER_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges",Applicable Grouper Codes - Tertiary,TERTIARY_REIMBURSEMENT_GROUPER_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Primary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges",Applicable Place of Service Codes - Primary,PRIMARY_REIMBURSEMENT_PLACEOFSERVICE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges",Applicable Place of Service Codes - Secondary,SECONDARY_REIMBURSEMENT_PLACEOFSERVICE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges",Applicable Place of Service Codes - Tertiary,TERTIARY_REIMBURSEMENT_PLACEOFSERVICE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Primary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges",Applicable Procedure Codes - Primary,PRIMARY_REIMBURSEMENT_PROC_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges",Applicable Procedure Codes - Secondary,SECONDARY_REIMBURSEMENT_PROC_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges",Applicable Procedure Codes - Tertiary,TERTIARY_REIMBURSEMENT_PROC_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Primary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations",Applicable Revenue /Procedure Code Combinations - Primary,PRIMARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations",Applicable Revenue /Procedure Code Combinations - Secondary,SECONDARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations",Applicable Revenue /Procedure Code Combinations - Tertiary,TERTIARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Primary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges",Applicable Revenue Codes - Primary,PRIMARY_REIMBURSEMENT_REVENUE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges",Applicable Revenue Codes - Secondary,SECONDARY_REIMBURSEMENT_REVENUE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges",Applicable Revenue Codes - Tertiary,TERTIARY_REIMBURSEMENT_REVENUE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Primary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges",Applicable Status Indicator Codes - Primary,PRIMARY_REIMBURSEMENT_STATUS_INDICATOR_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges",Applicable Status Indicator Codes - Secondary,SECONDARY_REIMBURSEMENT_STATUS_INDICATOR_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges",Applicable Status Indicator Codes - Tertiary,TERTIARY_REIMBURSEMENT_STATUS_INDICATOR_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If this agreement is not the base contract, then what is the effective date of the associated base contract? This date is earlier than today's date and is a long date format.",Associated Base Contract Effective Date,CONTRACT_BASE_EFFECTIVE_DT,DATE,C,ACTIVE,No,Preamble ,Contract ,Required Only If Agreement Is NOT the Base Contract , -"If this agreement is not the base contract, then what is the title of the associated base contract? This field will be present if there is an amendment or if the amendment is numbered. It is text that likely contains some of the following keywords: agreement, participating provider, participating hospital, provider agreement, or hospital agreement. Only say the title. Do not provide any context or explanation for it. Do not introduce what it is either, simply state the title. ",Associated Base Contract Title,CONTRACT_BASE_TITLE,VARCHAR,C,ACTIVE,No,Preamble ,Contract ,Required Only If Agreement Is NOT the Base Contract , -"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",Associated Provider Full Names,PROV_DOING_BUSINESS_AS,VARCHAR,A,ACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +What is the title of the contract?,Contract Title,CONTRACT_TITLE,VARCHAR,C,ACTIVE,No,Title,Contract ,Always Required , +What is the title of the contract? (Page #),,CONTRACT_TITLE_PG,NUMERIC,C,ACTIVE,,,,, +What type of contract or agreement is the document?,Contract Type,CONTRACT_HEADER,VARCHAR,A,ACTIVE,No,Title or Preamble,Contract ,Always Required ,UNIQUE KEY +What type of contract or agreement is the document? (Page #),,CONTRACT_HEADER_PG,NUMERIC,A,ACTIVE,,,,, +"If the contract is numbered, which number is it (e.g., if contract is titled Amendment #1, then enter ""1"")?","Number or Letter Used to Name Amendment, Addendum, Rider, Exhibit, Attachment, Schedule",CONTRACT_NUM,VARCHAR,A,ACTIVE,No,Title or Preamble,Contract ,Required Only If Agreement NOT the Base Contract,"GREEN LIGHT - IF SEQUENCE OF AMENDMENTS OR ADDENDUMS IS MISSING A NUMBER OR LETTER THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNTIL ALL AMENDMENTS AND ADDENDUMS ARE RECEIVED UNIQUE KEY" +"If the contract is numbered, which number is it (e.g., if contract is titled Amendment #1, then enter ""1"")? (Page #)",,CONTRACT_NUM_PG,NUMERIC,A,ACTIVE,,,,, +"If this agreement is not the base contract, then what is the title of the associated base contract?",Associated Base Contract Title,CONTRACT_BASE_TITLE,VARCHAR,C,ACTIVE,No,Preamble ,Contract ,Required Only If Agreement Is NOT the Base Contract , +"If this agreement is not the base contract, then what is the title of the associated base contract? (Page#) ",,CONTRACT_BASE_TITLE_PG,NUMERIC,C,ACTIVE,,,,, +"If this agreement is not the base contract, then what is the effective date of the associated base contract?",Associated Base Contract Effective Date,CONTRACT_BASE_EFFECTIVE_DT,DATE,C,ACTIVE,No,Preamble ,Contract ,Required Only If Agreement Is NOT the Base Contract , +"If this agreement is not the base contract, then what is the effective date of the associated base contract? (Page#) ",,CONTRACT_BASE_EFFECTIVE_DT_PG,NUMERIC,C,ACTIVE,,,,, +Is the contract the final version of the contract as evidenced by whether all signature lines in the signatory section of the agreement are signed?,Contract Signatory Complete (Y/N)?,CONTRACT_SIGNATORY_IND,BOOLEAN,A,ACTIVE,No,Signature Page,Contract ,Always Required ,"GREEN LIGHT - IF NOT ALL SIGNATURES ARE COMPLETE THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNTIL FINAL VERSION OF CONTRACT IS RECEIVED UNIQUE KEY" +Is the contract the final version of the contract as evidenced by whether all signature lines in the signatory section of the agreement are signed? (Page#) ,,CONTRACT_SIGNATORY_IND_PG,NUMERIC,A,ACTIVE,,,,, +What is the name of the payer that is a party to the contract as stated in the Preamble?,Payer Name per Preamble,PAYER_NAME,VARCHAR,A,ACTIVE,Yes,Preamble ,Payer,Always Required ,"GREEN LIGHT - IF PAYER NAME DOES NOT EQUAL ""CLIENT NAME"" THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION; UNIQUE KEY" +What is the name of the payer that is a party to the contract as stated in the Preamble? (Page#) ,,PAYER_NAME_PG,NUMERIC,A,ACTIVE,,,,, +What is the name of the Group provider that is a party to the contract as stated in the Preamble?,Group Provider Name per Preamble,PROV_GROUP_NAME,VARCHAR,A,ACTIVE,Yes,Preamble ,Provider ,Always Required ,UNIQUE KEY +What is the name of the Group provider that is a party to the contract as stated in the Preamble? (Page#) ,,PROV_GROUP_NAME_PG,NUMERIC,A,ACTIVE,,,,, +What is the Group provider's taxpayer identification number stated in the Preamble?,Group Provider Taxpayer Identification Number per Preamble,PROV_GROUP_TIN,VARCHAR,A,ACTIVE,Yes,Preamble ,Provider ,Required Only If Available ,UNIQUE KEY +What is the Group provider's taxpayer identification number stated in the Preamble? (Page#) ,,PROV_GROUP_TIN_PG,NUMERIC,A,ACTIVE,,,,, +What is the name of the Group provider that is a party to the contract as stated in the Signatory Section?,Group Provider Name per Signatory,PROV_GROUP_NAME_SIGNATORY,VARCHAR,A,ACTIVE,Yes,Signature Page,Provider ,Always Required ,"UNIQUE KEY PDM" -What are the provider national provider identifier numbers for each of the other providers associated with this agreement? They consist of 10 digits. Provide only the 10 digit NPI.,Associated Provider National Provider Identifiers,PROV_NPI_OTHER,VARIANT,A,ACTIVE,No (but please use GDP NPI format throughout),"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +What is the name of the Group provider that is a party to the contract as stated in the Signatory Section? (Page#) ,,PROV_GROUP_NAME_SIGNATORY_PG,NUMERIC,A,ACTIVE,,,,, +What is the group provider's taxpayer identification number stated in the Signatory Section?,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,VARCHAR,A,ACTIVE,Yes,Signature Page,Provider ,Always Required ,"UNIQUE KEY PDM" -What are the provider taxpayer identification numbers (TIN) for each of the other providers associated with this agreement? They consist of 9 digits and may contain a hyphen after the first 2 digits. This is usually listed on the signature page or on a roster. Provide only the 9 digit TIN.,Associated Provider Taxpayer Identification Numbers,PROV_TIN_OTHER,VARIANT,A,ACTIVE,No (but please use GDP TIN format throughout),"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +What is the group provider's taxpayer identification number stated in the Signatory Section? (Page#) ,,PROV_GROUP_TIN_SIGNATORY_PG,NUMERIC,A,ACTIVE,,,,, +What is the group provider's national provider identifier number?,Group Provider National Provider Identifier,PROV_GROUP_NPI,VARCHAR,A,ACTIVE,Yes,"Signature Page, Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY PDM" -Does the contract include a carve out for Behavioral Health & Substance Abuse Services (Yes/No)?,Behavioral Health & Substance Abuse Carve Out (Y/N)?,BEH_HEALTH_SUB_ABUSE_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Behavioral Health & Substance Abuse Services, list the applicable codes or code ranges ",Behavioral Health & Substance Abuse Codes or Code Range ,BEH_HEALTH_SUB_ABUSE_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Behavioral Health & Substance Abuse Services, describe how these codes are reimbursed",Behavioral Health & Substance Abuse Reimbursement Methodology,BEH_HEALTH_SUB_ABUSE_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"Does the contract include a carve out for bundled or unbundled codes (e.g., bundling, unbundling) (Yes/No)?",Bundled Services Carve Out (Y/N)?,BUNDLED_UNBUNDLED_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for bundling or unbundling, list the applicable codes or code ranges ",Bundled Services Codes or Code Range,BUNDLED_UNBUNDLED_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for bundling or unbundling, describe how these codes are reimbursed",Bundled Services Reimbursement Methodology ,BUNDLED_UNBUNDLED_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Cancer (Yes/No)?,Cancer Carve Out (Y/N)?,CANCER_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Cancer, list the applicable codes or code ranges ",Cancer Codes or Code Range ,CANCER_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Cancer, describe how these codes are reimbursed",Cancer Reimbursement Methodology,CANCER_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does contract include terms for discounts applied to total claim (Yes/No)?,Claim Discount (Y/N),CLAIM_DISCOUNT_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim discount rate?,Claim Discount Rate,CLM_DISC_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim discount start date?,Claim Discount Start Date,CLAIM_DISCOUNT_START_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim discount termination date?,Claim Discount Termination Date,CLAIM_DISCOUNT_TERMINATION_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does contract include terms for premiums applied to total claim (Yes/No)?,Claim Premium (Y/N),CLAIM_PREMIUM_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim premium rate?,Claim Premium Rate,CLAIM_PREMIUM_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim premium start date?,Claim Premium Start Date,CLAIM_PREMIUM_START_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim premium termination date?,Claim Premium Termination Date,CLAIM_PREMIUM_TERMINATION_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does contract include terms for sequestration amounts applied to total claim (Yes/No)?,Claim Sequestration (Y/N),CLAIM_SEQUESTRATION_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim sequestration rate?,Claim Sequestration Rate,CLAIM_SEQUESTRATION_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim sequestration start date?,Claim Sequestration Start Date,CLAIM_SEQUESTRATION_START_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is claim sequestration termination date?,Claim Sequestration Termination Date,CLAIM_SEQUESTRATION_TERMINATION_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the contract includes Vaccine for Children carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #1 Codes or Code Range,VACCINE_CHILDREN_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Vaccine for Children client-specific carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #1 Reimbursement Methodology,VACCINE_CHILDREN_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include other Vaccine for Children carve outs (Yes/No)?,Client-Specific Carve Out #1 (Y/N),VACCINE_CHILDREN_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include Surgical Assist/Assistant carve outs (Yes/No)?,Client-Specific Carve Out #2 (Y/N),SURGICAL_ASSIST_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Surgical Assist/Assistant carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #2 Codes or Code Range,SURGICAL_ASSIST_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes other client-specific carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #2 Reimbursement Methodology,,VARCHAR,,INACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"Does the contract include Physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs (Yes/No)?",Client-Specific Carve Out #3 (Y/N),PHY_CLINICAL_PSYCHOLOGIST_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #3 Codes or Code Range,PHY_CLINICAL_PSYCHOLOGIST_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #3 Reimbursement Methodology,PHY_CLINICAL_PSYCHOLOGIST_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"Does the contract include Audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs)carve outs (Yes/No)?",Client-Specific Carve Out #4-25 (Y/N),AUDIO_CHIRO_DIETICIAN_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include Board Certified Behavioral Analyst (BCBA) carve outs (Yes/No)?,Client-Specific Carve Out #4-25 (Y/N),CERT_BH_ANALYST_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"Does the contract include Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs (Yes/No)?",Client-Specific Carve Out #4-25 (Y/N),INDEPENDENT_LICENSURES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include Behavioral Health Outpatient Clinics/Integrated Clinics carve outs (Yes/No)?,Client-Specific Carve Out #4-25 (Y/N),BH_OP_CLINICS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"Does the contract include Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs (Yes/No)?",Client-Specific Carve Out #4-25 (Y/N),POS_THERAPISTS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include Transportation Services carve outs (Yes/No)?,Client-Specific Carve Out #4-25 (Y/N),TRANSPORTATION_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,AUDIO_CHIRO_DIETICIAN_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Board Certified Behavioral Analyst (BCBA) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,CERT_BH_ANALYST_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,INDEPENDENT_LICENSURES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Behavioral Health Outpatient Clinics/Integrated Clinics carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,BH_OP_CLINICS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,POS_THERAPISTS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Transportation Services carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,TRANSPORTATION_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs), describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,AUDIO_CHIRO_DIETICIAN_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Board Certified Behavioral Analyst (BCBA) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,CERT_BH_ANALYST_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,INDEPENDENT_LICENSURES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Behavioral Health Outpatient Clinics/Integrated Clinics carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,BH_OP_CLINICS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,POS_THERAPISTS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes Transportation Services carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,TRANSPORTATION_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If contract automatically renews, then then what is the adjusted contract termination date?",Contract Adjusted Termination Date Resulting from Auto Renewal,AA_CONTRACT_ADJUSTED_TERMINATION_DT_FROM_AUTO_RENEWAL,DATE,,ACTIVE,No,AArete Derived from Contract Termination Date As Adjusted for Renewals ,Key Dates,Always Required,"GREEN LIGHT - IF DATE IS LESS THAN TODAY'S DATE THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNLESS THERE IS AN EFFECTIVE AMENDMENT" -"Does the contract automatically renew? Answer with either a Yes or No, do not provide anything more that this one word answer.",Contract Auto Renewal (Y/N)?,CONTRACT_AUTO_RENEWAL_IND,BOOLEAN,A,ACTIVE,No,Term & Termination Section of Contract ,Key Dates,Required Only If Available ,PAYMENT ACCURACY UNIQUE KEY -"If contract automatically renews, then what is the length of the renewal term? This is related to the term and termination agreement section of the contract. This should a one or two word statement, typically around renewal, automatic renewal, or auto-renewal. Only return the length of time for the renewal, do not provide any context.",Contract Auto Renewal Terms?,CONTRACT_AUTO_RENEWAL_TERM_LENGTH,VARCHAR,A,ACTIVE,No,Term & Termination Section of Contract ,Key Dates,Required Only If Available ,PAYMENT ACCURACY UNIQUE KEY -Are the contract effective dates in the Preamble and the final signatory section consistent?,Contract Effective Date Consistency (Y/N)?,AAR_IS_EFFECTIVE_DT_CONSISTENT_IND,BOOLEAN,,ACTIVE,No,AArete Derived (Does Column D = Column E)?,Key Dates,Always Required ,PAYMENT ACCURACY -"What is the contract effective date mentioned in the preamble of the agreement? It should be in a long date format and should be earlier that today's date. Only return this date, do not add any context.",Contract Effective Date per Preamble,CONTRACT_EFFECTIVE_DT,DATE,A,ACTIVE,No (but please use GDP date format throughout),Preamble ,Key Dates,Always Required ,PAYMENT ACCURACY UNIQUE KEY -"What is the contract effective date as stated in the signatory section of the agreement? It should be in a long date format and should be earlier that today's date. Only return this date, do not add any context.",Contract Effective Date per Signatory,CONTRACT_EFFECTIVE_DT_SIGNATORY,DATE,A,ACTIVE,No (but please use GDP date format throughout),Signature Page,Key Dates,Always Required ,PAYMENT ACCURACY UNIQUE KEY -"A contract is the final version if all the signature lines in the signatory section of the agreement are signed. Is this the case? Answer with a Yes or No, do not provide any other context.",Contract Signatory Complete (Y/N)?,CONTRACT_SIGNATORY_IND,BOOLEAN,A,ACTIVE,No,Signature Page,Contract ,Always Required ,"GREEN LIGHT - IF NOT ALL SIGNATURES ARE COMPLETE THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNTIL FINAL VERSION OF CONTRACT IS RECEIVED UNIQUE KEY" -"What is the contract termination date? This is usually listed within the Terms and Terms Agreement of the contract. Only return the date, do not return any context.",Contract Termination Date,CONTRACT_TERMINATION_DT,DATE,A,ACTIVE,No (but please use GDP date format throughout),Term & Termination Section of Contract ,Key Dates,Always Required ,PAYMENT ACCURACY UNIQUE KEY -"What is the title of the contract? It generally contains the word Agreement. This will be filled out if there is an amendment or numbered amendment. It typically contains the words agreement, amendment, or contract. Only return the title, do not return any context.",Contract Title,CONTRACT_TITLE,VARCHAR,C,ACTIVE,No,Title,Contract ,Always Required , -"What type of contract or agreement is the document? Answers must contain one of three values: ""Base Agreement"", ""Amendment"" or ""Addendum"". Only return one of these three values, do not return any other context.",Contract Type,CONTRACT_HEADER,VARCHAR,A,ACTIVE,No,Title or Preamble,Contract ,Always Required ,UNIQUE KEY -Does the contract include a carve out for diagnostic services (Yes/No)?,Diagnostic Services Carve Out (Y/N)?,DIAGNOSTIC_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for diagnostic services, list the applicable codes or code ranges ",Diagnostic Services Codes or Code Range,DIAGNOSTIC_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for diagnostic services, describe how these codes are reimbursed",Diagnostic Services Reimbursement Methodology ,DIAGNOSTIC_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Durable Medical Equipment (Yes/No)?,Durable Medical Equipment Carve Out (Y/N)?,DME_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Durable Medical Equipment, list the applicable codes or code ranges ",Durable Medical Equipment Codes or Code Range,DME_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Durable Medical Equipment, describe how these codes are reimbursed",Durable Medical Equipment Reimbursement Methodology ,DME_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"What is start date of line of business specific compensation exhibit? If one is not explicitly stated, this is the same as the contract's effective date. This should be in a long date format and should be earlier than today. Only return the date, do not return any other content.",Effective Date of Pricing Terms,LOB_PRICING_TERMS_EFFECTIVE_DT,D,A,ACTIVE,No (but please use GDP date format throughout),"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,PAYMENT ACCURACY UNIQUE KEY -Does the contract include a carve out for Emergency Department (Yes/No)?,Emergency Carve Out (Y/N)?,EMERGENCY_DEPARTMENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Emergency Department, list the applicable codes or code ranges ",Emergency Codes or Code Range ,EMERGENCY_DEPARTMENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Emergency Department, describe how these codes are reimbursed",Emergency Reimbursement Methodology,EMERGENCY_DEPARTMENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for experimental procedures, list the applicable codes or code ranges ",Experimental Codes or Code Range,EXPERIMENTAL_PROCEDURES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for experimental procedures (Yes/No)?,Experimental Procedures Carve Out (Y/N)?,EXPERIMENTAL_PROCEDURES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for experimental procedures, describe how these codes are reimbursed",Experimental Reimbursement Methodology ,EXPERIMENTAL_PROCEDURES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the primary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based?",Fee Schedule - Primary,PRIMARY_REIMBURSEMENT_FEE_SCHEDULE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the secondary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based?",Fee Schedule - Secondary,SECONDARY_REIMBURSEMENT_FEE_SCHEDULE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the tertiary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based?",Fee Schedule - Tertiary,TERTIARY_REIMBURSEMENT_FEE_SCHEDULE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the primary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based?",Fee Schedule Version - Primary,PRIMARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the secondary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based?",Fee Schedule Version - Secondary,SECONDARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the tertiary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based?",Fee Schedule Version - Tertiary,TERTIARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does the contract include a carve out for global services (Yes/No)?,Global Services Carve Out (Y/N)?,GLOBAL_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for global services, list the applicable codes or code ranges ",Global Services Codes or Code Range,GLOBAL_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for global services, describe how these codes are reimbursed",Global Services Reimbursement Methodology ,GLOBAL_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the Reimbursement methodology include greater of language (Yes/No)?,Greater Of Language (Y/N)?,GREATER_OF_LANGUAGE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Always Required ,"PAYMENT ACCURACY -NETWORK" +What is the group provider's national provider identifier number? (Page#) ,,PROV_GROUP_NPI_PG,NUMERIC,A,ACTIVE,,,,, What is the contact information of the Group provider named in this contract?,Group Provider Address Line 1,PROV_GROUP_ADDRESS_LINE1,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" ,Group Provider Address Line 2,PROV_GROUP_ADDRESS_LINE2,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" -What are the group providers identification numbers other than TIN and NPI?,Group Provider CAQH Number ,PROV_GROUP_CAQH_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM ,Group Provider City,PROV_GROUP_CITY,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" -,Group Provider Fax Number,PROV_GROUP_FAX_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -,Group Provider Marketplace Number,PROV_GROUP_MARKETPLACE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -,Group Provider Medicaid Number,PROV_GROUP_MEDICAID_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -,Group Provider Medicare Number,PROV_GROUP_MEDICARE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -"What is the name of the Group provider that is a party to the contract as stated in the Preamble? This is likely in the first paragraph of the contract and is followed with provider. Answer with one or two words, do not provide any other context/content but the provider name.",Group Provider Name per Preamble,PROV_GROUP_NAME,VARCHAR,A,ACTIVE,Yes,Preamble ,Provider ,Always Required ,UNIQUE KEY -"What is the name of the Group provider that is a party to the contract as stated in the Preamble? This is in the signature page of the contract. Answer with one or two words, do not provide any other context/content but the provider name.",Group Provider Name per Signatory,PROV_GROUP_NAME_SIGNATORY,VARCHAR,A,ACTIVE,Yes,Signature Page,Provider ,Always Required ,"UNIQUE KEY -PDM" -"What is the group provider's national provider identifier number? This can be found on the signature page or on the roster. It consists of 10 digits. Only return these 10 digits, do not return any other content.",Group Provider National Provider Identifier,PROV_GROUP_NPI,VARCHAR,A,ACTIVE,Yes,"Signature Page, Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY -PDM" -,Group Provider Phone Number,PROV_GROUP_PHONE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM ,Group Provider State,PROV_GROUP_STATE_CD,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM UNIQUE KEY" -What is the Group provider's taxpayer identification number stated in the Preamble?,Group Provider Taxpayer Identification Number per Preamble,PROV_GROUP_TIN,VARCHAR,A,ACTIVE,Yes,Preamble ,Provider ,Required Only If Available ,UNIQUE KEY -What is the group provider's taxpayer identification number stated in the Signatory Section?,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,VARCHAR,A,ACTIVE,Yes,Signature Page,Provider ,Always Required ,"UNIQUE KEY -PDM" ,Group Provider ZIP,PROV_GROUP_POSTAL_CD,NUMERIC,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" -Does the contract include a carve out for Hearing Aids & Hearing Services (Yes/No)?,Hearing Aids & Hearing Services Carve Out (Y/N)?,HEARING_AID_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Hearing Aids & Hearing Services, list the applicable codes or code ranges ",Hearing Aids & Hearing Services Codes or Code Range,HEARING_AID_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Hearing Aids & Hearing Services, describe how these codes are reimbursed",Hearing Aids & Hearing Services Reimbursement Methodology ,HEARING_AID_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for HIV (Yes/No)?,HIV Carve Out (Y/N)?,HIV_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for HIV, list the applicable codes or code ranges ",HIV Codes or Code Range ,HIV_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for HIV, describe how these codes are reimbursed",HIV Reimbursement Methodology,HIV_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for implants (Yes/No)?,Implants Carve Out (Y/N)?,IMPLANTS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for implants, list the applicable codes or code ranges ",Implants Codes or Code Range,IMPLANTS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for implants, describe how these codes are reimbursed",Implants Reimbursement Methodology ,IMPLANTS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " +,Group Provider Phone Number,PROV_GROUP_PHONE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Group Provider Fax Number,PROV_GROUP_FAX_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +What is the contact information of the Group provider named in this contract? (Page#) ,,PROV_GROUP_PG,NUMERIC,D,ACTIVE,,,,, +What are the group providers identification numbers other than TIN and NPI?,Group Provider CAQH Number ,PROV_GROUP_CAQH_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Group Provider Medicaid Number,PROV_GROUP_MEDICAID_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Group Provider Medicare Number,PROV_GROUP_MEDICARE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Group Provider Marketplace Number,PROV_GROUP_MARKETPLACE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Other Group Provider Identifiers,PROV_GROUP_OTHER_NUM,VARCHAR,D,ACTIVE,No,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +What are the group providers identification numbers other than TIN and NPI? (Page#) ,,PROV_GROUP_NUM_PG,NUMERIC,D,ACTIVE,,,,, +What are the names of other providers associated with this agreement? (Note that amendments are needed to capture TINs added through acquisition/merger),Associated Provider Full Names,PROV_DOING_BUSINESS_AS,VARCHAR,A,ACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +PDM" +,Individual Provider First Name,PROV_FIRST_NAME_OTHER,VARCHAR,A,INACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +PDM" +,Individual Provider Middle Initial,PROV_MIDDLE_NAME_OTHER,VARCHAR,A,INACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +PDM" +,Individual Provider Last Name,PROV_LAST_NAME_OTHER,VARCHAR,A,INACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +PDM" +What are the names of other providers associated with this agreement? (Note that amendments are needed to capture TINs added through acquisition/merger) (Page#) ,,PROV_OTHER_PG,NUMERIC,A,ACTIVE,,,,, +What are the provider taxpayer identification numbers for each of the other providers associated with this agreement?,Associated Provider Taxpayer Identification Numbers,PROV_TIN_OTHER,VARIANT,A,ACTIVE,No (but please use GDP TIN format throughout),"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +PDM" +What are the provider taxpayer identification numbers for each of the other providers associated with this agreement? (Page#) ,,PROV_TIN_OTHER_PG,NUMERIC,A,ACTIVE,,,,, +What are the provider national provider identifier numbers for each of the other providers associated with this agreement?,Associated Provider National Provider Identifiers,PROV_NPI_OTHER,VARIANT,A,ACTIVE,No (but please use GDP NPI format throughout),"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY +PDM" +What are the provider national provider identifier numbers for each of the other providers associated with this agreement? (Page#) ,,PROV_NPI_OTHER_PG,NUMERIC,A,ACTIVE,,,,, What is the contact information for each of the other providers associated with this agreement?,Individual Provider Address Line 1,PROV_OTHER_ADDRESS_LINE1,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" ,Individual Provider Address Line 2,PROV_OTHER_ADDRESS_LINE2,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" -What are the individual providers identification numbers other than TIN and NPI?,Individual Provider CAQH Number ,PROV_OTHER_CAQH_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM ,Individual Provider City,PROV_OTHER_CITY,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" -,Individual Provider Fax Number,PROV_OTHER_FAX_NUM,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -"If a provider roster exists in the contract, list the first names of all human providers on the roster. Only return the first name, and do not include the names of any non-human providers.",Individual Provider First Name,PROV_FIRST_NAME_OTHER,VARCHAR,A,INACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY -PDM" -"If a provider roster exists in the contract, list the last names of all human providers on the roster. Only return the last name, and do not include the names of any non-human providers.",Individual Provider Last Name,PROV_LAST_NAME_OTHER,VARCHAR,A,INACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY -PDM" -,Individual Provider Marketplace Number,PROV_OTHER_MARKETPLACE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -,Individual Provider Medicaid Number,PROV_OTHER_MEDICAID_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -,Individual Provider Medicare Number,PROV_OTHER_MEDICARE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -"If a provider roster exists in the contract, list the middle initials of all human providers on the roster, such as the ""G"" in ""John G. Smith."" Only return the middle initial, and do not include the names of any non-human providers.",Individual Provider Middle Initial,PROV_MIDDLE_NAME_OTHER,VARCHAR,A,INACTIVE,Yes,"Preamble, contract signatory section, and/or Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"UNIQUE KEY -PDM" -,Individual Provider Phone Number,PROV_OTHER_PHONE_NUM,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -What is individual provider specialty as mapped by AArete?,Individual Provider Specialty as Mapped,AAR_PROV_SPECIALTY_AARETE_MAPPED,VARCHAR,,ACTIVE,Yes,AArete Derived,Provider ,Always Required ,"PAYMENT ACCURACY -INTELLIGENT EDITS -PDM PRICING" -What is individual provider specialty per contract?,Individual Provider Specialty per Contract,PROV_SPECIALTY,VARIANT,B,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS -PDM PRICING" ,Individual Provider State,PROV_OTHER_STATE_CD,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" ,Individual Provider ZIP,PROV_OTHER_POSTAL_CD,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"LOCAL COVERAGE DETERMINATION (LCD) PAYMENT ACCURACY PDM" -Does the contract include a carve out for Intensive Care Unit (Yes/No)?,Intensive Care Carve Out (Y/N)?,INTENSIVE_CARE_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Intensive Care Unit, list the applicable codes or code ranges ",Intensive Care Codes or Code Range ,INTENSIVE_CARE_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Intensive Care Unit, describe how these codes are reimbursed",Intensive Care Reimbursement Methodology,INTENSIVE_CARE_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for invalid codes, describe how these codes are reimbursed",Invalid Code Reimbursement Methodology ,INVALID_CODES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for invalid codes (Yes/No)?,Invalid Codes Carve Out (Y/N)?,INVALID_CODES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for invalid codes, list the applicable codes or code ranges ",Invalid Codes or Code Range,INVALID_CODES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for investigational procedures, list the applicable codes or code ranges ",Investigational Codes or Code Range,INVESTIGATIONAL_PROCEDURES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for investigational procedures (Yes/No)?,Investigational Procedures Carve Out (Y/N)?,INVESTIGATIONAL_PROCEDURES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for investigational procedures, describe how these codes are reimbursed",Investigational Reimbursement Methodology ,INVESTIGATIONAL_PROCEDURES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Major Joint Replacement (Yes/No)?,Joint Replacement Carve Out (Y/N)?,JOINT_REPLACE_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Major Joint Replacement, list the applicable codes or code ranges ",Joint Replacement Codes or Code Range ,JOINT_REPLACE_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Major Joint Replacement, describe how these codes are reimbursed",Joint Replacement Reimbursement Methodology,JOINT_REPLACE_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Laboratory / Pathology (Yes/No)?,Laboratory / Pathology Carve Out (Y/N)?,LAB_PATHOLOGY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Laboratory / Pathology , list the applicable codes or code ranges ",Laboratory / Pathology Codes or Code Range,LAB_PATHOLOGY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Laboratory / Pathology , describe how these codes are reimbursed",Laboratory / Pathology Reimbursement Methodology ,LAB_PATHOLOGY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the Reimbursement methodology include lesser of language (Yes/No)?,Lesser Of Language (Y/N)?,LESSER_OF_LANGUAGE_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Always Required ,"PAYMENT ACCURACY -NETWORK" -"If the contract is based on line of business, then list all lines of business. The most common lines of business that contracts cover are Medicare, Medicaid, Commercial, and Marketplace.",Line of Business,CONTRACT_LOB,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,UNIQUE KEY -"If the Primary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate?",Medicaid $ Rate - Primary,PRIMARY_REIMBURSEMENT_MEDICAID_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate?",Medicaid $ Rate - Secondary,SECONDARY_REIMBURSEMENT_MEDICAID_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate?",Medicaid $ Rate - Tertiary,TERTIARY_REIMBURSEMENT_MEDICAID_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does Medicaid agreement allow offshore (Yes/No)?,Medicaid Offshore (Y/N)? ,MEDICAID_ALLOW_OFFSHORE,VARCHAR,,INACTIVE,No,Medicaid Agreement ,,Required Only If Available , -Does the contract include a carve out for medical pharmacy and/or physician administered drugs (Yes/No)?,Medical Pharmacy Carve Out (Y/N)?,ADMINISTERED_DRUGS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for medical pharmacy and/or physician administered drugs, list the applicable codes or code ranges ",Medical Pharmacy Codes or Code Range,ADMINISTERED_DRUGS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for medical pharmacy and/or physician administered drugs, describe how these codes are reimbursed",Medical Reimbursement Methodology ,ADMINISTERED_DRUGS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the Primary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate?",Medicare $ Rate - Primary,PRIMARY_REIMBURSEMENT_CMS_MEDICARE_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate?",Medicare $ Rate - Secondary,SECONDARY_REIMBURSEMENT_CMS_MEDICARE_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate?",Medicare $ Rate - Tertiary,TERTIARY_REIMBURSEMENT_CMS_MEDICARE_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does Medicare agreement allow offshore (Yes/No)?,Medicare Offshore (Y/N)? ,MEDICARE_ALLOW_OFSHORE,VARCHAR,E,ACTIVE,No,Medicare Agreement ,,Required Only If Available , -Does the contract include a carve out for Mid-Level Professionals (Yes/No)? ,Mid-Level Carve Out (Y/N)?,MID_LEVEL_PROFESSIONAL_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Mid-Level Professionals, list the applicable codes or code ranges ",Mid-Level Codes or Code Range,MID_LEVEL_PROFESSIONAL_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Mid-Level Professionals, describe how these codes are reimbursed",Mid-Level Reimbursement Methodology ,MID_LEVEL_PROFESSIONAL_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Neonatal Services (Yes/No)?,Neonatal Carve Out (Y/N)?,NEONATAL_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Neonatal Services, list the applicable codes or code ranges ",Neonatal Codes or Code Range ,NEONATAL_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Neonatal Services, describe how these codes are reimbursed",Neonatal Reimbursement Methodology,NEONATAL_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract is based on network type, then list them for each impacted line of business for each specifically listed network.",Network,CONTRACT_NETWORK,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY -Does the contract include a carve out for never events (Yes/No)?,Never Event Carve Out (Y/N)?,NEVER_EVENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for never events, list the applicable codes or code ranges ",Never Event Codes or Code Range,NEVER_EVENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for never events, describe how these codes are reimbursed",Never Event Reimbursement Methodology ,NEVER_EVENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for procedures that are not medically necessary, describe how these codes are reimbursed",Not Medically Necessary Reimbursement Methodology ,NOT_MED_NECESSARY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for procedures that are not medically necessary, list the applicable codes or code ranges ",Not Medically Necessary Codes or Code Range,NOT_MED_NECESSARY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for procedures that are not medically necessary (Yes/No)?,Not Medically Necessary Procedures Carve Out (Y/N)?,NOT_MED_NECESSARY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract is numbered, which number is it (e.g., if contract is titled Amendment #1, then enter ""1"")?","Number or Letter Used to Name Amendment, Addendum, Rider, Exhibit, Attachment, Schedule",CONTRACT_NUM,VARCHAR,A,ACTIVE,No,Title or Preamble,Contract ,Required Only If Agreement NOT the Base Contract,"GREEN LIGHT - IF SEQUENCE OF AMENDMENTS OR ADDENDUMS IS MISSING A NUMBER OR LETTER THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNTIL ALL AMENDMENTS AND ADDENDUMS ARE RECEIVED UNIQUE KEY" -Does the contract include a carve out for OB/GYN Services (Yes/No)?,OB/GYN Carve Out (Y/N)?,OBGYN_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for OB/GYN Services, list the applicable codes or code ranges ",OB/GYN Codes or Code Range ,OBGYN_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for OB/GYN Services, describe how these codes are reimbursed",OB/GYN Reimbursement Methodology,OBGYN_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Observation, list the applicable codes or code ranges ",Observation Codes or Code Range ,OBSERVATION_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Observation, describe how these codes are reimbursed",Observation Reimbursement Methodology,OBSERVATION_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Ophthalmology & Vision Services (Yes/No)?,Ophthalmology & Vision Services Carve Out (Y/N)?,OPHTHAMOLOGY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Ophthalmology & Vision Services, list the applicable codes or code ranges ",Ophthalmology & Vision Services Codes or Code Range ,OPHTHAMOLOGY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Ophthalmology & Vision Services, describe how these codes are reimbursed",Ophthalmology & Vision Services Reimbursement Methodology,OPHTHAMOLOGY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -,Other Group Provider Identifiers,PROV_GROUP_OTHER_NUM,VARCHAR,D,ACTIVE,No,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Individual Provider Phone Number,PROV_OTHER_PHONE_NUM,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Individual Provider Fax Number,PROV_OTHER_FAX_NUM,VARCHAR,D,TRANSFORMED,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +What is the contact information for each of the other providers associated with this agreement? (Page#) ,,PROV_OTHER_PG,NUMERIC,D,TRANSFORMED,,,,, +What are the individual providers identification numbers other than TIN and NPI?,Individual Provider CAQH Number ,PROV_OTHER_CAQH_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Individual Provider Medicaid Number,PROV_OTHER_MEDICAID_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Individual Provider Medicare Number,PROV_OTHER_MEDICARE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM +,Individual Provider Marketplace Number,PROV_OTHER_MARKETPLACE_NUM,VARCHAR,D,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM ,Other Individual Provider Identifiers,PROV_OTHER_NUM,VARCHAR,D,ACTIVE,No,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,PDM -"If the contract includes a carve out for outlier provisions, what is the reimbursement method?",Outlier Allowed Amount,OUTLIER_PROVISIONS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does the contract include a carve out for outlier provisions (Yes/No)?,Outlier Provisions (Y/N)?,OUTLIER_PROVISIONS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the contract includes a carve out for outlier provisions, what is the outlier threshold?",Outlier Threshold,OUTLIER_PROVISIONS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"Is the provider contracted to participate in the line of business, network, plan, program for the given provider type?",Participation Status,PROV_PARTICIPATION_STATUS,VARCHAR,A,ACTIVE,Yes,"Derived From Combination of LOB, Network, Metal Level, Service Area, Program and/or Type of Provider Fields ",LOB/Provider Type Specific,Always Required ,UNIQUE KEY -What is the name of the payer that is a party to the contract as stated in the Preamble?,Payer Name per Preamble,PAYER_NAME,VARCHAR,A,ACTIVE,Yes,Preamble ,Payer,Always Required ,"GREEN LIGHT - IF PAYER NAME DOES NOT EQUAL ""CLIENT NAME"" THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION; UNIQUE KEY" -Does the contract include terms for penalties and interest (Yes/No)?,Penalties & Interest (Y/N)?,PENALTIES_INTEREST_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is rate charged for penalties and interest?,Penalties & Interest Rate,PENALTIES_INTEREST_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What triggers computation of penalties and interest?,Penalties & Interest Trigger,PENALTIES_INTEREST_TRIGGER,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the contract is for Marketplace line of business, then list all metal levels , such as platinum, bronze, silver, and gold.",Plan - Metal Level,CONTRACT_MARKETPLACE_METAL_LEVEL,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY -"If the contract is based on service areas, then list each specifically listed area, county, ZIP, etc. for each impacted line of business.",Plan- Service Area,CONTRACT_SERVICE_AREA,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY -Does the contract include a carve out for post-discharge procedures (Yes/No)?,Post-Discharge Procedures Carve Out (Y/N)?,POSTDISCHARGE_PROC_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for post-discharge procedures, list the applicable codes or code ranges",Post-Discharge Services Codes or Code Range,POSTDISCHARGE_PROC_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for post-discharge procedures, describe how these codes are reimbursed",Post-Discharge Services Reimbursement Methodology ,POSTDISCHARGE_PROC_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for post-discharge procedures, how long is the post-discharge window?",Post-Discharge Window,POSTDISCHARGE_PROC_CARVEOUT_WINDOW,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for pre-admission procedures (Yes/No)? ,Pre-Admission Procedures Carve Out (Y/N)?,PREADMISSION_PROC_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for pre-admission procedures, list the applicable codes or code ranges ",Pre-Admission Services Codes or Code Range,PREADMISSION_PROC_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for pre-admission procedures, describe how these codes are reimbursed",Pre-Admission Services Reimbursement Methodology ,PREADMISSION_PROC_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for pre-admissions procedures, how long is the pre-admission window?",Pre-Admission Window,PREADMISSION_PROC_CAREVEOUT_WINDOW,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Professional Component (Yes/No)? ,Professional Component Carve Out (Y/N)?,PROFESSIONAL_COMPONENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Professional Component, list the applicable codes or code ranges ",Professional Component Codes or Code Range,PROFESSIONAL_COMPONENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Professional Component, describe how these codes are reimbursed",Professional Component Reimbursement Methodology ,PROFESSIONAL_COMPONENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract is for Medicare or Medicaid line of business, then list the programs for each line of business.",Program,MEDICARE_MEDICAID_LOB,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY -Does the contract include a carve out for prosthetics (Yes/No)?,Prosthetics Carve Out (Y/N)?,PROSTHETICS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for prosthetics, list the applicable codes or code ranges ",Prosthetics Codes or Code Range,PROSTHETICS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for prosthetics, describe how these codes are reimbursed",Prosthetics Reimbursement Methodology ,PROSTHETICS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract is limited to certain Professional specialties, then list each specialty and the line of business it applies to.",Provider Specialty,PROV_SPECIALTYTY,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY -Does the contract include a carve out for Radiology/Imaging Services (Yes/No)?,Radiology/Imaging Carve Out (Y/N)?,RADIOLOGY_IMAGING_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Radiology/Imaging Services, list the applicable codes or code ranges ",Radiology/Imaging Codes or Code Range,RADIOLOGY_IMAGING_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Radiology/Imaging Services, describe how these codes are reimbursed",Radiology/Imaging Reimbursement Methodology ,RADIOLOGY_IMAGING_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If contract includes annual rate escalators based on % rate increase, then what is the yearly percentage increase? ",Rate Escalator %,RATE_ESCALATOR_YEARLY_PERCENT_INCREASE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If contract includes annual rate escalators, on what are they based?",Rate Escalator Basis,RATE_ESCALATOR_BASIS,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK PRICING" -"If contract automatically renews, then does the contract include annual rate escalators for year-over-year rate increases (Yes/No)?",Rate Escalators (Y/N)?,RATE_ESCALATOR_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY -NETWORK PRICING" -Does the contract include a carve out for readmissions (Yes/No)?,Readmissions Carve Out (Y/N)?,READMISSIONS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for readmissions, list the applicable codes or code ranges ",Readmissions Codes or Code Range,READMISSIONS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for readmissions, describe how these codes are reimbursed",Readmissions Reimbursement Methodology ,READMISSIONS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for readmissions, how long is the readmission window?",Readmissions Window,READMISSIONS_CAREVEOUT_WINDOW,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Multiple Procedure Reductions, which types of reductions apply?",Reduced Services Codes or Code Range,MULTIPLE_PROCEDURE_REDUCTIONS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract address Multiple Procedure Reductions, for each type of reduction, what reimbursement methodology applies?",Reduced Services Reimbursement Methodology ,MULTIPLE_PROCEDURE_REDUCTIONS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"Does the contract include a carve out for Multiple Procedure Reductions (i.e., discounted procedures) (Yes/No)?",Reductions Carve Out (Y/N)?,MULTIPLE_PROCEDURE_REDUCTIONS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the primary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount?",Reimbursement $ Rate - Primary,PRIMARY_REIMBURSEMENT_FLAT_FEE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount?",Reimbursement $ Rate - Secondary,SECONDARY_REIMBURSEMENT_FLAT_FEE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount?",Reimbursement $ Rate - Tertiary,TERTIARY_REIMBURSEMENT_FLAT_FEE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the primary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage?",Reimbursement % Rate - Primary,PRIMARY_REIMBURSEMENT_RATE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage?",Reimbursement % Rate - Secondary,SECONDARY_REIMBURSEMENT_RATE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage?",Reimbursement % Rate - Tertiary,TERTIARY_REIMBURSEMENT_RATE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"Deprecated - See columns PD, PE, PF - -Are there any carve outs or exceptions to the primary reimbursement methodology?",Reimbursement Exceptions - Primary ,PRIMARY_REIMBURSEMENT_EXCEPTION_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Are there any exceptions to the Secondary reimbursement methodology?,Reimbursement Exceptions - Secondary ,SECONDARY_REIMBURSEMENT_EXCEPTION_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Are there any exceptions to the Tertiary reimbursement methodology?,Reimbursement Exceptions - Tertiary ,TERTIARY_REIMBURSEMENT_EXCEPTION_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the primary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology?",Reimbursement Grouper - Primary ,PRIMARY_REIMBURSEMENT_GROUPER,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Secondary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology?",Reimbursement Grouper - Secondary,SECONDARY_REIMBURSEMENT_GROUPER,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the Tertiary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology?",Reimbursement Grouper - Tertiary,TERTIARY_REIMBURSEMENT_GROUPER,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -What is the primary Reimbursement methodology?,Reimbursement Methodology - Primary,PRIMARY_REIMBURSEMENT_METHODOLOGY,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Always Required ,"PAYMENT ACCURACY -NETWORK" -"If the contract includes lesser of or greater of language, what is the tertiary Reimbursement methodology (if any)?",Reimbursement Methodology - Tertiary,TERTIARY_REIMBURSEMENT_METHODOLOGY,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the contract includes lesser of or greater of language, what is the secondary Reimbursement methodology?",Reimbursement Methodology -Secondary,SECONDARY_REIMBURSEMENT_METHODOLOGY,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does the contract include a carve out for second surgeries and/or procedures (Yes/No)?,Second Surgery/Procedure Carve Out (Y/N)?,SECOND_SURGERIES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for second surgeries and/or procedures, list the applicable codes or code ranges ",Second Surgery/Procedure Codes or Code Range,SECOND_SURGERIES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for second surgeries and/or procedures, describe how these codes are reimbursed",Second Surgery/Procedure Reimbursement Methodology ,SECOND_SURGERIES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does State Marketplace agreement allow offshore (Yes/No)?,State Marketplace Offshore (Y/N)? ,MARKETPLACE_ALLOW_OFFSHORE,VARCHAR,,INACTIVE,No,State Marketplace Agreement ,,Required Only If Available , -Does the contract include a carve out for certain Status Indicators (Yes/No)?,Status Indicator Carve Out (Y/N)?,STATUS_INDICATORS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for certain Status Indicators, list the applicable codes or code ranges ",Status Indicator Codes or Code Range,STATUS_INDICATORS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for certain Status Indicators, describe how these codes are reimbursed",Status Indicator Reimbursement Methodology ,STATUS_INDICATORS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contact include a carve out for stop loss (Yes/No)?,Stop Loss (Y/N)?,STOP_LOSS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the contract includes a carve out for stop loss, what is the percent allowed above the stop loss threshold?",Stop Loss Allowed Amount,STOP_LOSS_CARVEOUT_PERCENT_ALLOWED,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -"If the contract includes a carve out for stop loss, what is the stop loss threshold?",Stop Loss Threshold,STOP_LOSS_CAREVOUT_THRESHOLD,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -NETWORK" -Does the contract include a carve out for subsequent surgeries and/or procedures (Yes/No)?,Subsequent Surgery/Procedure Carve Out (Y/N)?,SUBSEQUENT_SURGERIES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for subsequent surgeries and/or procedures, list the applicable codes or code ranges ",Subsequent Surgery/Procedure Codes or Code Range,SUBSEQUENT_SURGERIES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for subsequent surgeries and/or procedures, describe how these codes are reimbursed",Subsequent Surgery/Procedure Reimbursement Methodology ,SUBSEQUENT_SURGERIES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Technical Component (Yes/No)? ,Technical Component Carve Out (Y/N)?,TECHNICAL_COMPONENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Technical Component, list the applicable codes or code ranges ",Technical Component Codes or Code Range,TECHNICAL_COMPONENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Technical Component, describe how these codes are reimbursed",Technical Component Reimbursement Methodology ,TECHNICAL_COMPONENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Identify the specific date upon which the compensation specific to each line of business terminates.,Termination Date of Pricing Terms,LOB_PRICING_TERMS_TERMINATION_DT,D,A,ACTIVE,No (but please use GDP date format throughout),"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,"GREEN LIGHT - IF DATE IS LESS THAN TODAY'S DATE THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNLESS THERE IS AN EFFECTIVE AMENDMENT UNIQUE KEY" -What is timeline for payer to audit claims per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Claim Audit ,R156,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for payer to identify overpayments in paid claims per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Overpayment Identification,R164,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for payer to give notice of policy changes to provider per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Policy Change Notice ,R146,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY -COST AVOIDANCE" -What is timeline for payer to prompt pay electronic claims to the provider per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Prompt Payment Electronic ,R154,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for payer to prompt pay paper claims to the provider per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Prompt Payment Paper ,R152,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for provider timely filing of claims submitted to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Claim Timely Filing ,R148,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for provider to file a corrected claim with the payer per the Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Corrected Claim Filing ,R150,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for provider to submit an overpayment appeal to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Overpayment Appeal,R166,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment appeal to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Payment Appeal,R158,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment dispute to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Payment Dispute,R160,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment reconsideration request to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Payment Reconsideration,R162,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for payer to audit claims per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Claim Audit ,R134,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for payer to identify overpayments in paid claims per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Overpayment Identification,R142,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for payer to give notice of policy changes to provider per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Policy Change Notice ,R124,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY -COST AVOIDANCE" -What is timeline for payer to prompt pay electronic claims to the provider per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Prompt Payment Electronic ,R132,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for payer to prompt pay paper claims to the provider per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Prompt Payment Paper ,R130,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for provider timely filing of claims submitted to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Claim Timely Filing ,R126,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for provider to file a corrected claim with the payer per the Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Corrected Claim Filing ,R128,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for provider to submit an overpayment appeal to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Overpayment Appeal,R144,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment appeal to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Payment Appeal,R136,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment dispute to the payer per Medicare agreement (INSERT NUMBER) ?,Timeline Medicare Provider Payment Dispute,R138,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment reconsideration request to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Payment Reconsideration,R140,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for payer to audit claims per base agreement (INSERT NUMBER)?,Timeline Payer Claim Audit ,R112,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for payer to identify overpayments in paid claims per base agreement (INSERT NUMBER)?,Timeline Payer Overpayment Identification,R120,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY +What are the individual providers identification numbers other than TIN and NPI? (Page#) ,,PROV_OTHER_NUM_PG,NUMERIC,D,ACTIVE,,,,, +What is individual provider specialty per contract?,Individual Provider Specialty per Contract,PROV_SPECIALTY,VARIANT,B,ACTIVE,Yes,"Exhibit, Attachment, or Schedule to contract",Provider ,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS +PDM PRICING" +What is individual provider specialty per contract? (Page#) ,,PROV_SPECIALTY_PG,NUMERIC,B,ACTIVE,,,,, +What is individual provider specialty as mapped by AArete?,Individual Provider Specialty as Mapped,AAR_PROV_SPECIALTY_AARETE_MAPPED,VARCHAR,,ACTIVE,Yes,AArete Derived,Provider ,Always Required ,"PAYMENT ACCURACY +INTELLIGENT EDITS +PDM PRICING" +What is individual provider specialty as mapped by AArete? (Page#) ,,,,,INACTIVE,,,,, +What is the contract effective date as stated in Preamble of the agreement?,Contract Effective Date per Preamble,CONTRACT_EFFECTIVE_DT,DATE,A,ACTIVE,No (but please use GDP date format throughout),Preamble ,Key Dates,Always Required ,PAYMENT ACCURACY UNIQUE KEY +What is the contract effective date as stated in Preamble of the agreement? (Page#) ,,CONTRACT_EFFECTIVE_DT_PG,NUMERIC,A,ACTIVE,,,,, +What is the contract effective date as stated in the signatory section of the agreement?,Contract Effective Date per Signatory,CONTRACT_EFFECTIVE_DT_SIGNATORY,DATE,A,ACTIVE,No (but please use GDP date format throughout),Signature Page,Key Dates,Always Required ,PAYMENT ACCURACY UNIQUE KEY +What is the contract effective date as stated in the signatory section of the agreement? (Page#) ,,CONTRACT_EFFECTIVE_DT_SIGNATORY_PG,NUMERIC,A,ACTIVE,,,,, +Are the contract effective dates in the Preamble and the final signatory section consistent?,Contract Effective Date Consistency (Y/N)?,AAR_IS_EFFECTIVE_DT_CONSISTENT_IND,BOOLEAN,,ACTIVE,No,AArete Derived (Does Column D = Column E)?,Key Dates,Always Required ,PAYMENT ACCURACY +Are the contract effective dates in the Preamble and the final signatory section consistent? (Page#) ,,R100,,,INACTIVE,,,,, +What is the contract termination date?,Contract Termination Date,CONTRACT_TERMINATION_DT,DATE,A,ACTIVE,No (but please use GDP date format throughout),Term & Termination Section of Contract ,Key Dates,Always Required ,PAYMENT ACCURACY UNIQUE KEY +What is the contract termination date? (Page#) ,,CONTRACT_TERMINATION_DT_PG,NUMERIC,,ACTIVE,,,,, +Does the contract automatically renew (Yes/No)?,Contract Auto Renewal (Y/N)?,CONTRACT_AUTO_RENEWAL_IND,BOOLEAN,A,ACTIVE,No,Term & Termination Section of Contract ,Key Dates,Required Only If Available ,PAYMENT ACCURACY UNIQUE KEY +Does the contract automatically renew (Yes/No)? (Page#) ,,CONTRACT_AUTO_RENEWAL_IND_PG,NUMERIC,,ACTIVE,,,,, +"If contract automatically renews, then what is the length of the renewal term?",Contract Auto Renewal Terms?,CONTRACT_AUTO_RENEWAL_TERM_LENGTH,VARCHAR,A,ACTIVE,No,Term & Termination Section of Contract ,Key Dates,Required Only If Available ,PAYMENT ACCURACY UNIQUE KEY +"If contract automatically renews, then what is the length of the renewal term? (Page#) ",,CONTRACT_AUTO_RENEWAL_TERM_LENGTH_PG,NUMERIC,A,ACTIVE,,,,, +"If contract automatically renews, then then what is the adjusted contract termination date?",Contract Adjusted Termination Date Resulting from Auto Renewal,AA_CONTRACT_ADJUSTED_TERMINATION_DT_FROM_AUTO_RENEWAL,DATE,,ACTIVE,No,AArete Derived from Contract Termination Date As Adjusted for Renewals ,Key Dates,Always Required,"GREEN LIGHT - IF DATE IS LESS THAN TODAY'S DATE THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNLESS THERE IS AN EFFECTIVE AMENDMENT" +"If contract automatically renews, then then what is the adjusted contract termination date? (Page#) ",,R101,,,INACTIVE,,,,, What is timeline for payer to give notice of policy changes to provider per base agreement? (INSERT NUMBER),Timeline Payer Policy Change Notice ,R102,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY COST AVOIDANCE" -What is timeline for payer to prompt pay electronic claims to the provider per base agreement (INSERT NUMBER)?,Timeline Payer Prompt Payment Electronic ,R110,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for payer to prompt pay paper claims to the provider per base agreement (INSERT NUMBER)?,Timeline Payer Prompt Payment Paper ,R108,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for provider timely filing of claims submitted to the payer per base agreement (INSERT NUMEBER)?,Timeline Provider Claim Timely Filing ,R104,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS" -What is timeline for provider to file a corrected claim with the payer per the base agreement (INSERT NUMBER)?,Timeline Provider Corrected Claim Filing ,R106,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for provider to submit an overpayment appeal to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Overpayment Appeal,R122,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment appeal to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Payment Appeal,R114,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment dispute to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Payment Dispute,R116,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment reconsideration request to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Payment Reconsideration,R118,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for payer to audit claims per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Payer Claim Audit ,R178,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for payer to identify overpayments in paid claims per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Payer Overpayment Identification,R186,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for payer to give notice of policy changes to provider per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Payer Policy Change Notice ,R168,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY -COST AVOIDANCE" -Does the contract include a carve out for timeline for payer to implement changes in regulations per LOB Specific agreement?,Timeline State Marketplace Payer Policy Change Notice ,CARVEOUT_IND_IMPLEMENT_POLICY_CHANGE,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Key Dates,Required Only If Available ,"PAYMENT ACCURACY -COST AVOIDANCE" -What is timeline for payer to prompt pay electronic claims to the provider per State Marketplace agreement (INSERT NUMBER) ?,Timeline State Marketplace Payer Prompt Payment Electronic ,R176,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for payer to prompt pay paper claims to the provider per State Marketplace agreement (INSERT NUMBER) ?,Timeline State Marketplace Payer Prompt Payment Paper ,R174,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PREPAY -What is timeline for provider timely filing of claims submitted to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Claim Timely Filing ,R170,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for provider to file a corrected claim with the payer per the State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Corrected Claim Filing ,R172,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY -What is timeline for provider to submit an overpayment appeal to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Overpayment Appeal,R188,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment appeal to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Payment Appeal,R180,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment dispute to the payer per State Marketplace agreement (INSERT NUMBER) ?,Timeline State Marketplace Provider Payment Dispute,R182,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -What is timeline for provider to submit a payment reconsideration request to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Payment Reconsideration,R184,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS -INVOICING" -Does the contract include a carve out for Transplant (Yes/No)?,Transplant Carve Out (Y/N)?,TRANSPLANT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Transplant, list the applicable codes or code ranges ",Transplant Codes or Code Range ,TRANSPLANT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Transplant, describe how these codes are reimbursed",Transplant Reimbursement Methodology,TRANSPLANT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Trauma (Yes/No)?,Trauma Carve Out (Y/N)?,TRAUMA_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Trauma, list the applicable codes or code ranges ",Trauma Codes or Code Range ,TRAUMA_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Trauma, describe how these codes are reimbursed",Trauma Reimbursement Methodology,TRAUMA_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"Is the contract related to a Professional, Institutional or Ancillary provider?",Type of Contract,CONTRACT_TYPE,VARCHAR,A,ACTIVE,Yes,AArete Derived from Title or Preamble ,LOB/Provider Type Specific,Always Required ,UNIQUE KEY -"If the contract is based on type of provider, identify each provider type for each line of business. Often the provider type will be found next to the word ""services.""",Type of Provider,PROV_TYPE,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,UNIQUE KEY -"If the contract includes a carve out for Unlisted codes, describe how these codes are reimbursed",Unlisted Code Reimbursement Methodology ,UNLISTED_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -Does the contract include a carve out for Unlisted codes (Yes/No)?,Unlisted Codes Carve Out (Y/N)?,UNLISTED_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -"If the contract includes a carve out for Unlisted codes, list the applicable codes or code ranges ",Unlisted Codes or Code Range,UNLISTED_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY -INTELLIGENT EDITS " -What is the title of the contract? (Page #),,CONTRACT_TITLE_PG,NUMERIC,C,ACTIVE,,,,, -What type of contract or agreement is the document? (Page #),,CONTRACT_HEADER_PG,NUMERIC,A,ACTIVE,,,,, -"If the contract is numbered, which number is it (e.g., if contract is titled Amendment #1, then enter ""1"")? (Page #)",,CONTRACT_NUM_PG,NUMERIC,A,ACTIVE,,,,, -"If this agreement is not the base contract, then what is the title of the associated base contract? (Page#) ",,CONTRACT_BASE_TITLE_PG,NUMERIC,C,ACTIVE,,,,, -"If this agreement is not the base contract, then what is the effective date of the associated base contract? (Page#) ",,CONTRACT_BASE_EFFECTIVE_DT_PG,NUMERIC,C,ACTIVE,,,,, -Is the contract the final version of the contract as evidenced by whether all signature lines in the signatory section of the agreement are signed? (Page#) ,,CONTRACT_SIGNATORY_IND_PG,NUMERIC,A,ACTIVE,,,,, -What is the name of the payer that is a party to the contract as stated in the Preamble? (Page#) ,,PAYER_NAME_PG,NUMERIC,A,ACTIVE,,,,, -What is the name of the Group provider that is a party to the contract as stated in the Preamble? (Page#) ,,PROV_GROUP_NAME_PG,NUMERIC,A,ACTIVE,,,,, -What is the Group provider's taxpayer identification number stated in the Preamble? (Page#) ,,PROV_GROUP_TIN_PG,NUMERIC,A,ACTIVE,,,,, -What is the name of the Group provider that is a party to the contract as stated in the Signatory Section? (Page#) ,,PROV_GROUP_NAME_SIGNATORY_PG,NUMERIC,A,ACTIVE,,,,, -What is the group provider's taxpayer identification number stated in the Signatory Section? (Page#) ,,PROV_GROUP_TIN_SIGNATORY_PG,NUMERIC,A,ACTIVE,,,,, -What is the group provider's national provider identifier number? (Page#) ,,PROV_GROUP_NPI_PG,NUMERIC,A,ACTIVE,,,,, -What is the contact information of the Group provider named in this contract? (Page#) ,,PROV_GROUP_PG,NUMERIC,D,ACTIVE,,,,, -What are the group providers identification numbers other than TIN and NPI? (Page#) ,,PROV_GROUP_NUM_PG,NUMERIC,D,ACTIVE,,,,, -What are the names of other providers associated with this agreement? (Note that amendments are needed to capture TINs added through acquisition/merger) (Page#) ,,PROV_OTHER_PG,NUMERIC,A,ACTIVE,,,,, -What are the provider taxpayer identification numbers for each of the other providers associated with this agreement? (Page#) ,,PROV_TIN_OTHER_PG,NUMERIC,A,ACTIVE,,,,, -What are the provider national provider identifier numbers for each of the other providers associated with this agreement? (Page#) ,,PROV_NPI_OTHER_PG,NUMERIC,A,ACTIVE,,,,, -What is the contact information for each of the other providers associated with this agreement? (Page#) ,,PROV_OTHER_PG,NUMERIC,D,TRANSFORMED,,,,, -What are the individual providers identification numbers other than TIN and NPI? (Page#) ,,PROV_OTHER_NUM_PG,NUMERIC,D,ACTIVE,,,,, -What is individual provider specialty per contract? (Page#) ,,PROV_SPECIALTY_PG,NUMERIC,B,ACTIVE,,,,, -What is individual provider specialty as mapped by AArete? (Page#) ,,,,,INACTIVE,,,,, -What is the contract effective date as stated in Preamble of the agreement? (Page#) ,,CONTRACT_EFFECTIVE_DT_PG,NUMERIC,A,ACTIVE,,,,, -What is the contract effective date as stated in the signatory section of the agreement? (Page#) ,,CONTRACT_EFFECTIVE_DT_SIGNATORY_PG,NUMERIC,A,ACTIVE,,,,, -Are the contract effective dates in the Preamble and the final signatory section consistent? (Page#) ,,R100,,,INACTIVE,,,,, -What is the contract termination date? (Page#) ,,CONTRACT_TERMINATION_DT_PG,NUMERIC,,ACTIVE,,,,, -Does the contract automatically renew (Yes/No)? (Page#) ,,CONTRACT_AUTO_RENEWAL_IND_PG,NUMERIC,,ACTIVE,,,,, -"If contract automatically renews, then what is the length of the renewal term? (Page#) ",,CONTRACT_AUTO_RENEWAL_TERM_LENGTH_PG,NUMERIC,A,ACTIVE,,,,, -"If contract automatically renews, then then what is the adjusted contract termination date? (Page#) ",,R101,,,INACTIVE,,,,, What is timeline for payer to give notice of policy changes to provider per base agreement? (INSERT UNIT OF MEASURE),,R103,,,INACTIVE,,,,, Concat - What is timeline for payer to give notice of policy changes to provider per base agreement? (INSERT NUMBER),,PAYER_POLICY_CHANGE_NOTICE_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for payer to give notice of policy changes to provider per base agreement? (INSERT TRIGGER ""FROM"" or ""BEFORE"")",,PAYER_POLICY_CHANGE_NOTICE_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for payer to give notice of policy changes to provider per base agreement? (Page#),,PAYER_POLICY_CHANGE_NOTICE_INFO_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for provider timely filing of claims submitted to the payer per base agreement (INSERT NUMEBER)?,Timeline Provider Claim Timely Filing ,R104,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS" What is timeline for provider timely filing of claims submitted to the payer per base agreement (INSERT UNIT OF MEASURE)?,,R105,,,INACTIVE,,,,, Concat - What is timeline for provider timely filing of claims submitted to the payer per base agreement (INSERT NUMEBER)?,,PROV_CLAIM_TIMELY_FILING_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for provider timely filing of claims submitted to the payer per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CLAIM_TIMELY_FILING_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for provider timely filing of claims submitted to the payer per base agreement (Page#)?,,PROV_CLAIM_TIMELY_FILING_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for provider to file a corrected claim with the payer per the base agreement (INSERT NUMBER)?,Timeline Provider Corrected Claim Filing ,R106,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for provider to file a corrected claim with the payer per the base agreement (INSERT UNIT OF MEASURE)?,,R107,,,INACTIVE,,,,, Concat - What is timeline for provider to file a corrected claim with the payer per the base agreement (INSERT NUMBER)?,,PROV_CORRECTED_CLAIM_FILING_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for provider to file a corrected claim with the payer per the base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CORRECTED_CLAIM_FILING_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for provider to file a corrected claim with the payer per the base agreement (Page#)?,,PROV_CORRECTED_CLAIM_FILING_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for payer to prompt pay paper claims to the provider per base agreement (INSERT NUMBER)?,Timeline Payer Prompt Payment Paper ,R108,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay paper claims to the provider per base agreement (INSERT UNIT OF MEASURE)?,,R109,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay paper claims to the provider per base agreement (INSERT NUMBER)?,,PAYER_PROMPT_PAY_PAPER_CLAIM_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for payer to prompt pay paper claims to the provider per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_PROMPT_PAY_PAPER_CLAIM_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for payer to prompt pay paper claims to the provider per base agreement (Page#)?,,PAYER_PROMPT_PAY_PAPER_CLAIM_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for payer to prompt pay electronic claims to the provider per base agreement (INSERT NUMBER)?,Timeline Payer Prompt Payment Electronic ,R110,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay electronic claims to the provider per base agreement (INSERT UNIT OF MEASURE)?,,R111,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay electronic claims to the provider per base agreement (INSERT NUMBER)?,,PAYER_PROMPT_PAY_ELECTRONIC_CLAIM_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for payer to prompt pay electronic claims to the provider per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_PROMPT_PAY_ELECTRONIC_CLAIM_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for payer to prompt pay electronic claims to the provider per base agreement (Page#)?,,PAYER_PROMPT_PAY_ELECTRONIC_CLAIM_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for payer to audit claims per base agreement (INSERT NUMBER)?,Timeline Payer Claim Audit ,R112,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to audit claims per base agreement (INSERT UNIT OF MEASURE)?,,R113,,,INACTIVE,,,,, Concat - What is timeline for payer to audit claims per base agreement (INSERT NUMBER)?,,PAYER_AUDIT_CLAIM_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for payer to audit claims per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_AUDIT_CLAIM_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for payer to audit claims per base agreement (Page#)?,,PAYER_AUDIT_CLAIM_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for provider to submit a payment appeal to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Payment Appeal,R114,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment appeal to the payer per base agreement (INSERT UNIT OF MEASURE)?,,R115,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment appeal to the payer per base agreement (INSERT NUMBER)?,,PROV_SUBMIT_PAYMENT_APPEAL_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for provider to submit a payment appeal to the payer per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_SUBMIT_PAYMENT_APPEAL_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for provider to submit a payment appeal to the payer per base agreement (Page#)?,,PROV_SUBMIT_PAYMENT_APPEAL_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for provider to submit a payment dispute to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Payment Dispute,R116,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment dispute to the payer per base agreement (INSERT UNIT OF MEASURE)?,,R117,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment dispute to the payer per base agreement (INSERT NUMBER)?,,PROV_SUBMIT_PAYMENT_DISPUTE_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for provider to submit a payment dispute to the payer per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_SUBMIT_PAYMENT_DISPUTE_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for provider to submit a payment dispute to the payer per base agreement (Page#)?,,PROV_SUBMIT_PAYMENT_DISPUTE_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for provider to submit a payment reconsideration request to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Payment Reconsideration,R118,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment reconsideration request to the payer per base agreement (INSERT UNIT OF MEASURE)?,,R119,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment reconsideration request to the payer per base agreement (INSERT NUMBER)?,,PROV_SUBMIT_PAYMENT_RECONSIDERATION_TIMELINE,VARCHAR,,ACTIVE,,,,, "What is timeline for provider to submit a payment reconsideration request to the payer per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_SUBMIT_PAYMENT_RECONSIDERATION_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for provider to submit a payment reconsideration request to the payer per base agreement (Page#)?,,PROV_SUBMIT_PAYMENT_RECONSIDERATION_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for payer to identify overpayments in paid claims per base agreement (INSERT NUMBER)?,Timeline Payer Overpayment Identification,R120,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to identify overpayments in paid claims per base agreement (INSERT UNIT OF MEASURE)?,,R121,,,INACTIVE,,,,, Concat - What is timeline for payer to identify overpayments in paid claims per base agreement (INSERT NUMBER)?,,PAYER_IDENTIFY_OVERPAYMENT_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for payer to identify overpayments in paid claims per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_IDENTIFY_OVERPAYMENT_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for payer to identify overpayments in paid claims per base agreement (Page#)?,,PAYER_IDENTIFY_OVERPAYMENT_PG,NUMERIC,E,ACTIVE,,,,, +What is timeline for provider to submit an overpayment appeal to the payer per base agreement (INSERT NUMBER)?,Timeline Provider Overpayment Appeal,R122,,,INACTIVE,No,Base Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit an overpayment appeal to the payer per base agreement (INSERT UNIT OF MEASURE)?,,R123,,,INACTIVE,,,,, Concat - What is timeline for provider to submit an overpayment appeal to the payer per base agreement (INSERT NUMBER)?,,PROV_SUBMIT_OVERPAYMENT_APPEAL_TIMELINE,VARCHAR,E,ACTIVE,,,,, "What is timeline for provider to submit an overpayment appeal to the payer per base agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_SUBMIT_OVERPAYMENT_APPEAL_INFO,VARCHAR,E,ACTIVE,,,,, What is timeline for provider to submit an overpayment appeal to the payer per base agreement (Page#)?,,PROV_SUBMIT_OVERPAYMENT_APPEAL_PG,NUMERIC,E,ACTIVE,,,,, +,,,,,,,,,, +What is timeline for payer to give notice of policy changes to provider per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Policy Change Notice ,R124,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY +COST AVOIDANCE" What is timeline for payer to give notice of policy changes to provider per Medicare agreement (INSERT UNIT OF MEASURE)?,,R125,,,INACTIVE,,,,, Concat - What is timeline for payer to give notice of policy changes to provider per Medicare agreement (INSERT NUMBER)?,,PAYER_NOTICE_POLICY_CHANGE_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to give notice of policy changes to provider per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_NOTICE_POLICY_CHANGE_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to give notice of policy changes to provider per Medicare agreement (Page#)?,,PAYER_NOTICE_POLICY_CHANGE_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider timely filing of claims submitted to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Claim Timely Filing ,R126,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for provider timely filing of claims submitted to the payer per Medicare agreement (INSERT UNIT OF MEASURE)?,,R127,,,INACTIVE,,,,, Concat - What is timeline for provider timely filing of claims submitted to the payer per Medicare agreement (INSERT NUMBER)?,,PROV_CLAIM_TIMELY_FILING_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider timely filing of claims submitted to the payer per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CLAIM_TIMELY_FILING_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider timely filing of claims submitted to the payer per Medicare agreement (Page#)?,,PROV_CLAIM_TIMELY_FILING_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to file a corrected claim with the payer per the Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Corrected Claim Filing ,R128,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for provider to file a corrected claim with the payer per the Medicare agreement (INSERT UNIT OF MEASURE)?,,R129,,,INACTIVE,,,,, Concat - What is timeline for provider to file a corrected claim with the payer per the Medicare agreement (INSERT NUMBER)?,,PROV_CORRECTED_CLAIM_FILING_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to file a corrected claim with the payer per the Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CORRECTED_CLAIM_FILING_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to file a corrected claim with the payer per the Medicare agreement (Page#)?,,PROV_CORRECTED_CLAIM_FILING_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to prompt pay paper claims to the provider per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Prompt Payment Paper ,R130,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay paper claims to the provider per Medicare agreement (INSERT UNIT OF MEASURE)?,,R131,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay paper claims to the provider per Medicare agreement (INSERT NUMBER)?,,PROV_PROMPT_PAY_PAPER_CLAIM_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to prompt pay paper claims to the provider per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PROMPT_PAY_PAPER_CLAIM_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to prompt pay paper claims to the provider per Medicare agreement (Page#?,,PROV_PROMPT_PAY_PAPER_CLAIM_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to prompt pay electronic claims to the provider per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Prompt Payment Electronic ,R132,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay electronic claims to the provider per Medicare agreement (INSERT UNIT OF MEASURE)?,,R133,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay electronic claims to the provider per Medicare agreement (INSERT NUMBER)?,,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to prompt pay electronic claims to the provider per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to prompt pay electronic claims to the provider per Medicare agreement (Page#)?,,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to audit claims per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Claim Audit ,R134,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to audit claims per Medicare agreement (INSERT UNIT OF MEASURE)?,,R135,,,INACTIVE,,,,, Concat - What is timeline for payer to audit claims per Medicare agreement (INSERT NUMBER)?,,PAYER_CLAIM_AUDIT_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to audit claims per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_CLAIM_AUDIT_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to audit claims per Medicare agreement? (Page#) ,,PAYER_CLAIM_AUDIT_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment appeal to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Payment Appeal,R136,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment appeal to the payer per Medicare agreement (INSERT UNIT OF MEASURE)?,,R137,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment appeal to the payer per Medicare agreement (INSERT NUMBER)?,,PROV_SUBMIT_PAYMENT_APPEAL_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment appeal to the payer per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_SUBMIT_PAYMENT_APPEAL_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment appeal to the payer per Medicare agreement (INSERT NUMBER)? (Page#) ,,PROV_SUBMIT_PAYMENT_APPEAL_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment dispute to the payer per Medicare agreement (INSERT NUMBER) ?,Timeline Medicare Provider Payment Dispute,R138,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment dispute to the payer per Medicare agreement (INSERT UNIT OF MEASURE) ?,,R139,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment dispute to the payer per Medicare agreement (INSERT NUMBER) ?,,PROV_SUBMIT_PAYMENT_DISPUTE_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment dispute to the payer per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"") ?",,PROV_SUBMIT_PAYMENT_DISPUTE_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment dispute to the payer per Medicare agreement ? (Page#) ,,PROV_SUBMIT_PAYMENT_DISPUTE_MEDICARE_P,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment reconsideration request to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Payment Reconsideration,R140,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment reconsideration request to the payer per Medicare agreement (INSERT UNIT OF MEASURE)?,,R141,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment reconsideration request to the payer per Medicare agreement (INSERT NUMBER)?,,PROV_SUBMIT_PAYMENT_RECONSIDERATION_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment reconsideration request to the payer per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_SUBMIT_PAYMENT_RECONSIDERATION_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment reconsideration request to the payer per Medicare agreement? (Page#) ,,PROV_SUBMIT_PAYMENT_RECONSIDERATION_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to identify overpayments in paid claims per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Payer Overpayment Identification,R142,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to identify overpayments in paid claims per Medicare agreement (INSERT UNIT OF MEASURE)?,,R143,,,INACTIVE,,,,, Concat - What is timeline for payer to identify overpayments in paid claims per Medicare agreement (INSERT NUMBER)?,,PROV_OVERPAYMENT_IDENTIFICATION_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to identify overpayments in paid claims per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_OVERPAYMENT_IDENTIFICATION_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to identify overpayments in paid claims per Medicare agreement? (Page#) ,,PROV_OVERPAYMENT_IDENTIFICATION_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit an overpayment appeal to the payer per Medicare agreement (INSERT NUMBER)?,Timeline Medicare Provider Overpayment Appeal,R144,,,INACTIVE,No,Medicare Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit an overpayment appeal to the payer per Medicare agreement (INSERT UNIT OF MEASURE)?,,R145,,,INACTIVE,,,,, Concat - What is timeline for provider to submit an overpayment appeal to the payer per Medicare agreement (INSERT NUMBER)?,,PROV_OVERPAYMENT_APPEAL_MEDICARE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit an overpayment appeal to the payer per Medicare agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_OVERPAYMENT_APPEAL_MEDICARE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit an overpayment appeal to the payer per Medicare agreement? (Page#) ,,PROV_OVERPAYMENT_APPEAL_MEDICARE_PG,NUMERIC,,INACTIVE,,,,, +Does Medicare agreement allow offshore (Yes/No)?,Medicare Offshore (Y/N)? ,MEDICARE_ALLOW_OFSHORE,VARCHAR,E,ACTIVE,No,Medicare Agreement ,,Required Only If Available , Does Medicare agreement allow offshore (Yes/No)? (Page#) ,,MEDICARE_ALLOW_OFFSHORE_PG,NUMERIC,E,ACTIVE,,,,, +,,,,,,,,,, +What is timeline for payer to give notice of policy changes to provider per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Policy Change Notice ,R146,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY +COST AVOIDANCE" What is timeline for payer to give notice of policy changes to provider per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R147,,,INACTIVE,,,,, Concat - What is timeline for payer to give notice of policy changes to provider per Medicaid agreement (INSERT NUMBER)?,,PAYER_NOTICE_POLICY_CHANGE_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to give notice of policy changes to provider per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_NOTICE_POLICY_CHANGE_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to give notice of policy changes to provider per Medicaid agreement? (Page#) ,,PAYER_NOTICE_POLICY_CHANGE_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider timely filing of claims submitted to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Claim Timely Filing ,R148,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for provider timely filing of claims submitted to the payer per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R149,,,INACTIVE,,,,, Concat - What is timeline for provider timely filing of claims submitted to the payer per Medicaid agreement (INSERT NUMBER)?,,PROV_CLAIM_TIMELY_FILING_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider timely filing of claims submitted to the payer per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CLAIM_TIMELY_FILING_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider timely filing of claims submitted to the payer per Medicaid agreement? (Page#) ,,PROV_CLAIM_TIMELY_FILING_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to file a corrected claim with the payer per the Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Corrected Claim Filing ,R150,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for provider to file a corrected claim with the payer per the Medicaid agreement (INSERT UNIT OF MEASURE)?,,R151,,,INACTIVE,,,,, Concat - What is timeline for provider to file a corrected claim with the payer per the Medicaid agreement (INSERT NUMBER)?,,PROV_CORRECTED_CLAIM_FILING_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to file a corrected claim with the payer per the Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CORRECTED_CLAIM_FILING_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to file a corrected claim with the payer per the Medicaid agreement? (Page#) ,,PROV_CORRECTED_CLAIM_FILING_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to prompt pay paper claims to the provider per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Prompt Payment Paper ,R152,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay paper claims to the provider per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R153,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay paper claims to the provider per Medicaid agreement (INSERT NUMBER)?,,PROV_PROMPT_PAY_PAPER_CLAIM_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to prompt pay paper claims to the provider per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PROMPT_PAY_PAPER_CLAIM_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to prompt pay paper claims to the provider per Medicaid agreement? (Page#) ,,PROV_PROMPT_PAY_PAPER_CLAIM_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to prompt pay electronic claims to the provider per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Prompt Payment Electronic ,R154,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay electronic claims to the provider per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R155,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay electronic claims to the provider per Medicaid agreement (INSERT NUMBER)?,,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to prompt pay electronic claims to the provider per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to prompt pay electronic claims to the provider per Medicaid agreement? (Page#) ,,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to audit claims per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Claim Audit ,R156,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to audit claims per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R157,,,INACTIVE,,,,, Concat - What is timeline for payer to audit claims per Medicaid agreement (INSERT NUMBER)?,,PROV_CLAIM_AUDIT_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to audit claims per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CLAIM_AUDIT_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to audit claims per Medicaid agreement? (Page#) ,,PROV_CLAIM_AUDIT_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment appeal to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Payment Appeal,R158,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment appeal to the payer per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R159,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment appeal to the payer per Medicaid agreement (INSERT NUMBER)?,,PROV_PAYMENT_APPEAL_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment appeal to the payer per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PAYMENT_APPEAL_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment appeal to the payer per Medicaid agreement? (Page#) ,,PROV_PAYMENT_APPEAL_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment dispute to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Payment Dispute,R160,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment dispute to the payer per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R161,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment dispute to the payer per Medicaid agreement (INSERT NUMBER)?,,PROV_SUBMIT_PAYMENT_DISPUTE_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment dispute to the payer per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_SUBMIT_PAYMENT_DISPUTE_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment dispute to the payer per Medicaid agreement ? (Page#) ,,PROV_SUBMIT_PAYMENT_DISPUTE_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment reconsideration request to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Payment Reconsideration,R162,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment reconsideration request to the payer per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R163,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment reconsideration request to the payer per Medicaid agreement (INSERT NUMBER)?,,PROV_PAYMENT_RECONSIDERATION_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment reconsideration request to the payer per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PAYMENT_RECONSIDERATION_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment reconsideration request to the payer per Medicaid agreement? (Page#) ,,PROV_PAYMENT_RECONSIDERATION_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to identify overpayments in paid claims per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Payer Overpayment Identification,R164,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to identify overpayments in paid claims per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R165,,,INACTIVE,,,,, Concat - What is timeline for payer to identify overpayments in paid claims per Medicaid agreement (INSERT NUMBER)?,,PROV_IDENTIFY_OVERPAYMENTS_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to identify overpayments in paid claims per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_IDENTIFY_OVERPAYMENTS_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to identify overpayments in paid claims per Medicaid agreement? (Page#) ,,PROV_IDENTIFY_OVERPAYMENTS_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit an overpayment appeal to the payer per Medicaid agreement (INSERT NUMBER)?,Timeline Medicaid Provider Overpayment Appeal,R166,,,INACTIVE,No,Medicaid Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit an overpayment appeal to the payer per Medicaid agreement (INSERT UNIT OF MEASURE)?,,R167,,,INACTIVE,,,,, Concat - What is timeline for provider to submit an overpayment appeal to the payer per Medicaid agreement (INSERT NUMBER)?,,PROV_OVERPAYMENT_APPEAL_MEDICAID_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit an overpayment appeal to the payer per Medicaid agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_OVERPAYMENT_APPEAL_MEDICAID_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit an overpayment appeal to the payer per Medicaid agreement? (Page#) ,,PROV_OVERPAYMENT_APPEAL_MEDICAID_PG,NUMERIC,,INACTIVE,,,,, +Does Medicaid agreement allow offshore (Yes/No)?,Medicaid Offshore (Y/N)? ,MEDICAID_ALLOW_OFFSHORE,VARCHAR,,INACTIVE,No,Medicaid Agreement ,,Required Only If Available , Does Medicaid agreement allow offshore (Yes/No)? (Page#) ,,MEDICAID_ALLOW_OFFSHORE_PG,NUMERIC,,INACTIVE,,,,, +,,,,,,,,,, +What is timeline for payer to give notice of policy changes to provider per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Payer Policy Change Notice ,R168,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"PAYMENT ACCURACY +COST AVOIDANCE" What is timeline for payer to give notice of policy changes to provider per State Marketplace agreement (INSERT UNIT OF MEASURE)?,,R169,,,INACTIVE,,,,, Concat - What is timeline for payer to give notice of policy changes to provider per State Marketplace agreement (INSERT NUMBER)?,,PAYER_NOTICE_POLICY_CHANGE_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to give notice of policy changes to provider per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PAYER_NOTICE_POLICY_CHANGE_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to give notice of policy changes to provider per State Marketplace agreement? (Page#) ,,PAYER_NOTICE_POLICY_CHANGE_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider timely filing of claims submitted to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Claim Timely Filing ,R170,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for provider timely filing of claims submitted to the payer per State Marketplace agreement (INSERT UNIT OF MEASURE)?,,R171,,,INACTIVE,,,,, Concat - What is timeline for provider timely filing of claims submitted to the payer per State Marketplace agreement (INSERT NUMBER)?,,PROV_CLAIM_TIMELY_FILING_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider timely filing of claims submitted to the payer per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CLAIM_TIMELY_FILING_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider timely filing of claims submitted to the payer per State Marketplace agreement? (Page#) ,,PROV_CLAIM_TIMELY_FILING_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to file a corrected claim with the payer per the State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Corrected Claim Filing ,R172,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for provider to file a corrected claim with the payer per the State Marketplace agreement (INSERT UNIT OF MEASURE)?,,R173,,,INACTIVE,,,,, Concat - What is timeline for provider to file a corrected claim with the payer per the State Marketplace agreement (INSERT NUMBER)?,,PROV_CORRECTED_CLAIM_FILING_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to file a corrected claim with the payer per the State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CORRECTED_CLAIM_FILING_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to file a corrected claim with the payer per the State Marketplace agreement? (Page#) ,,PROV_CORRECTED_CLAIM_FILING_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to prompt pay paper claims to the provider per State Marketplace agreement (INSERT NUMBER) ?,Timeline State Marketplace Payer Prompt Payment Paper ,R174,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay paper claims to the provider per State Marketplace agreement (INSERT UNIT OF MEASURE) ?,,R175,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay paper claims to the provider per State Marketplace agreement (INSERT NUMBER) ?,,PROV_PROMPT_PAY_PAPER_CLAIM_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to prompt pay paper claims to the provider per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"") ?",,PROV_PROMPT_PAY_PAPER_CLAIM_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to prompt pay paper claims to the provider per State Marketplace agreement? (Page#) ,,PROV_PROMPT_PAY_PAPER_CLAIM_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to prompt pay electronic claims to the provider per State Marketplace agreement (INSERT NUMBER) ?,Timeline State Marketplace Payer Prompt Payment Electronic ,R176,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PREPAY What is timeline for payer to prompt pay electronic claims to the provider per State Marketplace agreement (INSERT UNIT OF MEASURE) ?,,R177,,,INACTIVE,,,,, Concat - What is timeline for payer to prompt pay electronic claims to the provider per State Marketplace agreement (INSERT NUMBER) ?,,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to prompt pay electronic claims to the provider per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"") ?",,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to prompt pay electronic claims to the provider per State Marketplace agreement? (Page#) ,,PROV_PROMPT_PAY_ELECTRONIC_CLAIM_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to audit claims per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Payer Claim Audit ,R178,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to audit claims per State Marketplace agreement (INSERT UNIT OF MEASURE)?,,R179,,,INACTIVE,,,,, Concat - What is timeline for payer to audit claims per State Marketplace agreement (INSERT NUMBER)?,,PROV_CLAIM_AUDIT_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to audit claims per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_CLAIM_AUDIT_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to audit claims per State Marketplace agreement? (Page#) ,,PROV_CLAIM_AUDIT_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment appeal to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Payment Appeal,R180,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment appeal to the payer per State Marketplace agreement (INSERT UNIT OF MEASURE)?,,R181,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment appeal to the payer per State Marketplace agreement (INSERT NUMBER)?,,PROV_PAYMENT_APPEAL_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment appeal to the payer per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PAYMENT_APPEAL_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment appeal to the payer per State Marketplace agreement? (Page#) ,,PROV_PAYMENT_APPEAL_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment dispute to the payer per State Marketplace agreement (INSERT NUMBER) ?,Timeline State Marketplace Provider Payment Dispute,R182,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment dispute to the payer per State Marketplace agreement (INSERT UNIT OF MEASURE) ?,,R183,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment dispute to the payer per State Marketplace agreement (INSERT NUMBER) ?,,PROV_PAYMENT_DISPUTE_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment dispute to the payer per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"") ?",,PROV_PAYMENT_DISPUTE_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment dispute to the payer per State Marketplace agreement ? (Page#) ,,PROV_PAYMENT_DISPUTE_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit a payment reconsideration request to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Payment Reconsideration,R184,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit a payment reconsideration request to the payer per State Marketplace agreement (INSERT UNIT OF MEASURE)?,,R185,,,INACTIVE,,,,, Concat - What is timeline for provider to submit a payment reconsideration request to the payer per State Marketplace agreement (INSERT NUMBER)?,,PROV_PAYMENT_RECONSIDERATION_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit a payment reconsideration request to the payer per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_PAYMENT_RECONSIDERATION_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit a payment reconsideration request to the payer per State Marketplace agreement? (Page#) ,,PROV_PAYMENT_RECONSIDERATION_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for payer to identify overpayments in paid claims per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Payer Overpayment Identification,R186,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,PAYMENT ACCURACY What is timeline for payer to identify overpayments in paid claims per State Marketplace agreement (INSERT UNIT OF MEASURE)?,,R187,,,INACTIVE,,,,, Concat - What is timeline for payer to identify overpayments in paid claims per State Marketplace agreement (INSERT NUMBER)?,,PROV_IDENTIFY_OVERPAYMENT_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for payer to identify overpayments in paid claims per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"")?",,PROV_IDENTIFY_OVERPAYMENT_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for payer to identify overpayments in paid claims per State Marketplace agreement? (Page#) ,,PROV_IDENTIFY_OVERPAYMENT_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +What is timeline for provider to submit an overpayment appeal to the payer per State Marketplace agreement (INSERT NUMBER)?,Timeline State Marketplace Provider Overpayment Appeal,R188,,,INACTIVE,No,State Marketplace Agreement ,Key Dates,Required Only If Available ,"APPEALS +INVOICING" What is timeline for provider to submit an overpayment appeal to the payer per State Marketplace agreement (INSERT UNIT OF MEASURE )?,,R189,,,INACTIVE,,,,, Concat - What is timeline for provider to submit an overpayment appeal to the payer per State Marketplace agreement (INSERT NUMBER)?,,PROV_OVERPAYMENT_APPEAL_MARKETPLACE_TIMELINE,VARCHAR,,INACTIVE,,,,, "What is timeline for provider to submit an overpayment appeal to the payer per State Marketplace agreement (INSERT TRIGGER ""FROM"" OR ""BEFORE"" )?",,PROV_OVERPAYMENT_APPEAL_MARKETPLACE_INFO,VARCHAR,,INACTIVE,,,,, What is timeline for provider to submit an overpayment appeal to the payer per State Marketplace agreement? (Page#) ,,PROV_OVERPAYMENT_APPEAL_MARKETPLACE_PG,NUMERIC,,INACTIVE,,,,, +Does State Marketplace agreement allow offshore (Yes/No)?,State Marketplace Offshore (Y/N)? ,MARKETPLACE_ALLOW_OFFSHORE,VARCHAR,,INACTIVE,No,State Marketplace Agreement ,,Required Only If Available , Does State Marketplace agreement allow offshore (Yes/No)? (Page#) ,,MARKETPLACE_ALLOW_OFSHORE_PG,NUMERIC,,INACTIVE,,,,, +,,,,,,,,,, +What is start date of line of business specific compensation exhibit?,Effective Date of Pricing Terms,LOB_PRICING_TERMS_EFFECTIVE_DT,D,A,ACTIVE,No (but please use GDP date format throughout),"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,PAYMENT ACCURACY UNIQUE KEY What is start date of line of business specific compensation exhibit? (Page#) ,,LOB_PRICING_TERMS_EFFECTIVE_DT_PG,NUMERIC,A,ACTIVE,,,,, +What is termination date of line of business specific compensation exhibit?,Termination Date of Pricing Terms,LOB_PRICING_TERMS_TERMINATION_DT,D,A,ACTIVE,No (but please use GDP date format throughout),"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,"GREEN LIGHT - IF DATE IS LESS THAN TODAY'S DATE THEN STOP, DO NOT REVIEW CONTRACT CONFIGURATION UNLESS THERE IS AN EFFECTIVE AMENDMENT UNIQUE KEY" What is termination date of line of business specific compensation exhibit? (Page#) ,,LOB_PRICING_TERMS_TERMINATION_DT_PG,NUMERIC,A,ACTIVE,,,,, +"Is the contract related to a Professional, Institutional or Ancillary provider?",Type of Contract,CONTRACT_TYPE,VARCHAR,A,ACTIVE,Yes,AArete Derived from Title or Preamble ,LOB/Provider Type Specific,Always Required ,UNIQUE KEY "Is the contract related to a Professional, Institutional or Ancillary provider? (Page#) ",,CONTRACT_TYPE_PG,NUMERIC,A,ACTIVE,,,,, +"If the contract is based on line of business, then create one row for each line of business",Line of Business,CONTRACT_LOB,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,UNIQUE KEY "If the contract is based on line of business, then create one row for each line of business (Page#) ",,CONTRACT_LOB_PG,NUMERIC,A,ACTIVE,,,,, +"If the contract is based on network type, then create one row within each impacted line of business for each specifically listed network",Network,CONTRACT_NETWORK,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY "If the contract is based on network type, then create one row within each impacted line of business for each specifically listed network (Page#) ",,CONTRACT_NETWORK_PG,NUMERIC,A,ACTIVE,,,,, +"If the contract if for Marketplace line of business, then create one row within the Marketplace line of business for each specifically listed metal level",Plan - Metal Level,CONTRACT_MARKETPLACE_METAL_LEVEL,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY "If the contract if for Marketplace line of business, then create one row within the Marketplace line of business for each specifically listed metal level (Page#) ",,CONTRACT_MARKETPLACE_METAL_LEVEL_PG,NUMERIC,A,ACTIVE,,,,, +"If the contract is based on service areas, then create one row within each impacted line of business for each specifically listed area, county, ZIP, etc. ",Plan- Service Area,CONTRACT_SERVICE_AREA,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY "If the contract is based on service areas, then create one row within each impacted line of business for each specifically listed area, county, ZIP, etc. (Page#) ",,CONTRACT_SERVICE_AREA_PG,VARCHAR,A,ACTIVE,,,,, +"If the contract is for Medicare or Medicaid line of business, then create one row within each impacted Medicare/Medicaid line of business for each specifically listed program",Program,MEDICARE_MEDICAID_LOB,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY "If the contract is for Medicare or Medicaid line of business, then create one row within each impacted Medicare/Medicaid line of business for each specifically listed program (Page#) ",,MEDICARE_MEDICAID_LOB_PG,NUMERIC,A,ACTIVE,,,,, +"If the contract is based on type of provider, then create one row within each impacted line of business for each specifically listed provider type of place of service",Type of Provider,PROV_TYPE,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Always Required ,UNIQUE KEY "If the contract is based on type of provider, then create one row within each impacted line of business for each specifically listed provider type of place of service (Page#) ",,PROV_TYPE_PG,NUMERIC,A,ACTIVE,,,,, +"If the contract is limited to certain Professional specialties, then create one row within each line of business for each specifically listed specialty",Provider Specialty,PROV_SPECIALTYTY,VARCHAR,A,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",LOB/Provider Type Specific,Required Only If Available ,UNIQUE KEY "If the contract is limited to certain Professional specialties, then create one row within each line of business for each specifically listed specialty (Page#) ",,PROV_SPECIALTYTY_PG,NUMERIC,A,ACTIVE,,,,, +"Is the provider contracted to participate in the line of business, network, plan, program for the given provider type?",Participation Status,PROV_PARTICIPATION_STATUS,VARCHAR,A,ACTIVE,Yes,"Derived From Combination of LOB, Network, Metal Level, Service Area, Program and/or Type of Provider Fields ",LOB/Provider Type Specific,Always Required ,UNIQUE KEY "Is the provider contracted to participate in the line of business, network, plan, program for the given provider type? (Page#) ",,PROV_PARTICIPATION_STATUS_PG,NUMERIC,A,ACTIVE,,,,, +,,,,,,,,,, +"If contract automatically renews, then does the contract include annual rate escalators for year-over-year rate increases (Yes/No)?",Rate Escalators (Y/N)?,RATE_ESCALATOR_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK PRICING" "If contract automatically renews, then does the contract include annual rate escalators for year-over-year rate increases (Yes/No)? (Page#) ",,RATE_ESCALATOR_IND_PG,NUMERIC,B,ACTIVE,,,,, +"If contract includes annual rate escalators, on what are they based?",Rate Escalator Basis,RATE_ESCALATOR_BASIS,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK PRICING" "If contract includes annual rate escalators, on what are they based? (Page#) ",,RATE_ESCALATOR_BASIS_PG,NUMERIC,B,ACTIVE,,,,, +"If contract includes annual rate escalators based on % rate increase, then what is the yearly percentage increase? ",Rate Escalator %,RATE_ESCALATOR_YEARLY_PERCENT_INCREASE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If contract includes annual rate escalators based on % rate increase, then what is the yearly percentage increase? (Page#) ",,RATE_ESCALATOR_YEARLY_PERCENT_INCREASE_PG,NUMERIC,B,ACTIVE,,,,, +Does contract include terms for discounts applied to total claim (Yes/No)?,Claim Discount (Y/N),CLAIM_DISCOUNT_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Does contract include terms for discounts applied to total claim (Yes/No)? (Page#) ,,CLAIM_DISCOUNT_IND_PG,NUMERIC,B,ACTIVE,,,,, +What is claim discount rate?,Claim Discount Rate,CLM_DISC_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim discount rate? (Page#) ,,CLAIM_DISCOUNT_RATE_PG,NUMERIC,B,ACTIVE,,,,, +What is claim discount start date?,Claim Discount Start Date,CLAIM_DISCOUNT_START_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim discount start date? (Page#) ,,CLAIM_DISCOUNT_START_DT_PG,NUMERIC,B,ACTIVE,,,,, +What is claim discount termination date?,Claim Discount Termination Date,CLAIM_DISCOUNT_TERMINATION_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim discount termination date? (Page#) ,,CLAIM_DISCOUNT_TERMINATION_DT_PG,NUMERIC,B,ACTIVE,,,,, +Does contract include terms for premiums applied to total claim (Yes/No)?,Claim Premium (Y/N),CLAIM_PREMIUM_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Does contract include terms for premiums applied to total claim (Yes/No)? (Page#) ,,CLAIM_PREMIUM_IND_PG,NUMERIC,B,ACTIVE,,,,, +What is claim premium rate?,Claim Premium Rate,CLAIM_PREMIUM_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim premium rate? (Page#) ,,CLAIM_PREMIUM_RATE_PG,NUMERIC,B,ACTIVE,,,,, +What is claim premium start date?,Claim Premium Start Date,CLAIM_PREMIUM_START_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim premium start date? (Page#) ,,CLAIM_PREMIUM_START_DT_PG,NUMERIC,B,ACTIVE,,,,, +What is claim premium termination date?,Claim Premium Termination Date,CLAIM_PREMIUM_TERMINATION_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim premium termination date? (Page#) ,,CLAIM_PREMIUM_TERMINATION_DT_PG,NUMERIC,B,ACTIVE,,,,, +Does contract include terms for sequestration amounts applied to total claim (Yes/No)?,Claim Sequestration (Y/N),CLAIM_SEQUESTRATION_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Does contract include terms for sequestration amounts applied to total claim (Yes/No)? (Page#) ,,CLAIM_SEQUESTRATION_IND_PG,NUMERIC,B,ACTIVE,,,,, +What is claim sequestration rate?,Claim Sequestration Rate,CLAIM_SEQUESTRATION_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim sequestration rate? (Page#) ,,CLAIM_SEQUESTRATION_RATE_PG,NUMERIC,B,ACTIVE,,,,, +What is claim sequestration start date?,Claim Sequestration Start Date,CLAIM_SEQUESTRATION_START_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim sequestration start date? (Page#) ,,CLAIM_SEQUESTRATION_START_DT_PG,NUMERIC,B,ACTIVE,,,,, +What is claim sequestration termination date?,Claim Sequestration Termination Date,CLAIM_SEQUESTRATION_TERMINATION_DT,D,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is claim sequestration termination date? (Page#) ,,CLAIM_SEQUESTRATION_TERMINATION_DT_PG,NUMERIC,B,ACTIVE,,,,, +Does the contract include terms for penalties and interest (Yes/No)?,Penalties & Interest (Y/N)?,PENALTIES_INTEREST_IND,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Does the contract include terms for penalties and interest (Yes/No)? (Page#) ,,PENALTIES_INTEREST_IND_PG,NUMERIC,B,ACTIVE,,,,, +What triggers computation of penalties and interest?,Penalties & Interest Trigger,PENALTIES_INTEREST_TRIGGER,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What triggers computation of penalties and interest? (Page#) ,,PENALTIES_INTEREST_TRIGGER_PG,NUMERIC,B,ACTIVE,,,,, +What is rate charged for penalties and interest?,Penalties & Interest Rate,PENALTIES_INTEREST_RATE,VARCHAR,B,ACTIVE,No,"From Base Contract or from LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider","Discounts, Premiums, Sequestration, Penalties, Interest",Required Only If Available ,"PAYMENT ACCURACY +NETWORK" What is rate charged for penalties and interest? (Page#) ,,PENALTIES_INTEREST_RATE_PG,NUMERIC,B,ACTIVE,,,,, What is contract's Chargemaster protection language?,,CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE,VARCHAR,B,ACTIVE,,,,, What is contract's Chargemaster protection language? (Page#) ,,CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE_PG,NUMERIC,B,ACTIVE,,,,, +,,,,,,,,,, +Does the Reimbursement methodology include lesser of language (Yes/No)?,Lesser Of Language (Y/N)?,LESSER_OF_LANGUAGE_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Always Required ,"PAYMENT ACCURACY +NETWORK" Does the Reimbursement methodology include lesser of language (Yes/No)? (Page#) ,,LESSER_OF_LANGUAGE_IND_PG,NUMERIC,B,ACTIVE,,,,, +Does the Reimbursement methodology include greater of language (Yes/No)?,Greater Of Language (Y/N)?,GREATER_OF_LANGUAGE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Always Required ,"PAYMENT ACCURACY +NETWORK" Does the Reimbursement methodology include greater of language (Yes/No)? (Page#) ,,GREATER_OF_LANGUAGE_PG,NUMERIC,B,ACTIVE,,,,, +What is the primary Reimbursement methodology?,Reimbursement Methodology - Primary,PRIMARY_REIMBURSEMENT_METHODOLOGY,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Always Required ,"PAYMENT ACCURACY +NETWORK" What is the primary Reimbursement methodology? (Page#) ,,PRIMARY_REIMBURSEMENT_METHODOLOGY_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges",Applicable Procedure Codes - Primary,PRIMARY_REIMBURSEMENT_PROC_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges (Page#) ",,PRIMARY_REIMBURSEMENT_PROC_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges",Applicable Revenue Codes - Primary,PRIMARY_REIMBURSEMENT_REVENUE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges (Page#) ",,PRIMARY_REIMBURSEMENT_REVENUE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations",Applicable Revenue /Procedure Code Combinations - Primary,PRIMARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations (Page#) ",,PRIMARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges",Applicable Diagnosis Codes - Primary,PRIMARY_REIMBURSEMENT_DIAG_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges (Page#) ",,PRIMARY_REIMBURSEMENT_DIAG_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges",Applicable Grouper Codes - Primary,PRIMARY_REIMBURSEMENT_GROUPER_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges (Page#) ",,PRIMARY_REIMBURSEMENT_GROUPER_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges",Applicable Place of Service Codes - Primary,PRIMARY_REIMBURSEMENT_PLACEOFSERVICE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges (Page#) ",,PRIMARY_REIMBURSEMENT_PLACEOFSERVICE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges",Applicable Admit Type Codes - Primary,PRIMARY_REIMBURSEMENT_ADMITTYPE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges (Page#) ",,PRIMARY_REIMBURSEMENT_ADMITTYPE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges",Applicable Status Indicator Codes - Primary,PRIMARY_REIMBURSEMENT_STATUS_INDICATOR_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges (Page#) ",,PRIMARY_REIMBURSEMENT_STATUS_INDICATOR_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the primary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based?",Fee Schedule - Primary,PRIMARY_REIMBURSEMENT_FEE_SCHEDULE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the primary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based? (Page#) ",,PRIMARY_REIMBURSEMENT_FEE_SCHEDULE_PG,NUMERIC,B,ACTIVE,,,,, +"If the primary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based?",Fee Schedule Version - Primary,PRIMARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the primary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based? (Page#) ",,PRIMARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION_PG,NUMERIC,B,ACTIVE,,,,, +"If the primary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage?",Reimbursement % Rate - Primary,PRIMARY_REIMBURSEMENT_RATE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the primary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage? (Page#) ",,PRIMARY_REIMBURSEMENT_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the primary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount?",Reimbursement $ Rate - Primary,PRIMARY_REIMBURSEMENT_FLAT_FEE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the primary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount? (Page#) ",,PRIMARY_REIMBURSEMENT_FLAT_FEE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate?",Medicare $ Rate - Primary,PRIMARY_REIMBURSEMENT_CMS_MEDICARE_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate? (Page#) ",,PRIMARY_REIMBURSEMENT_CMS_MEDICARE_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Primary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate?",Medicaid $ Rate - Primary,PRIMARY_REIMBURSEMENT_MEDICAID_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Primary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate? (Page#) ",,PRIMARY_REIMBURSEMENT_MEDICAID_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the primary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology?",Reimbursement Grouper - Primary ,PRIMARY_REIMBURSEMENT_GROUPER,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the primary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology? (Page#) ",,PRIMARY_REIMBURSEMENT_GROUPER_PG,NUMERIC,B,ACTIVE,,,,, "Deprecated - See columns PD, PE, PF +Are there any carve outs or exceptions to the primary reimbursement methodology?",Reimbursement Exceptions - Primary ,PRIMARY_REIMBURSEMENT_EXCEPTION_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" +"Deprecated - See columns PD, PE, PF + Are there any carve outs or exceptions to the primary reimbursement methodology? (Page#) ",,PRIMARY_REIMBURSEMENT_EXCEPTION_IND_PG,NUMERIC,B,ACTIVE,,,,, Are there any carve outs?,,PRIMARY_REIMBURSEMENT_CARVEOUT_IND,VARCHAR,B,ACTIVE,,,,, "If there are any exceptions to Primary Reimbursement Methodology, describe exceptions?",,PRIMARY_REIMBURSEMENT_DESCRIBE_EXCEPTION,VARCHAR,B,ACTIVE,,,,, "If there are any exceptions to Primary Reimbursement Methodology, describe exceptions? ( Page #)",,PRIMARY_REIMBURSEMENT_DESCRIBE_EXCEPTION_PG,NUMERIC,B,ACTIVE,,,,, +,,,,,,,,,, +"If the contract includes lesser of or greater of language, what is the secondary Reimbursement methodology?",Reimbursement Methodology -Secondary,SECONDARY_REIMBURSEMENT_METHODOLOGY,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the contract includes lesser of or greater of language, what is the secondary Reimbursement methodology? (Page#) ",,SECONDARY_REIMBURSEMENT_METHODOLOGY_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges",Applicable Procedure Codes - Secondary,SECONDARY_REIMBURSEMENT_PROC_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges (Page#) ",,SECONDARY_REIMBURSEMENT_PROC_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges",Applicable Revenue Codes - Secondary,SECONDARY_REIMBURSEMENT_REVENUE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges (Page#) ",,SECONDARY_REIMBURSEMENT_REVENUE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations",Applicable Revenue /Procedure Code Combinations - Secondary,SECONDARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations (Page#) ",,SECONDARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges",Applicable Diagnosis Codes - Secondary,SECONDARY_REIMBURSEMENT_DIAG_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges (Page#) ",,SECONDARY_REIMBURSEMENT_DIAG_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges",Applicable Grouper Codes - Secondary,SECONDARY_REIMBURSEMENT_GROUPER_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges (Page#) ",,SECONDARY_REIMBURSEMENT_GROUPER_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges",Applicable Place of Service Codes - Secondary,SECONDARY_REIMBURSEMENT_PLACEOFSERVICE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges (Page#) ",,SECONDARY_REIMBURSEMENT_PLACEOFSERVICE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges",Applicable Admit Type Codes - Secondary,SECONDARY_REIMBURSEMENT_ADMITTYPE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges (Page#) ",,SECONDARY_REIMBURSEMENT_ADMITTYPE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges",Applicable Status Indicator Codes - Secondary,SECONDARY_REIMBURSEMENT_STATUS_INDICATOR_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges (Page#) ",,SECONDARY_REIMBURSEMENT_STATUS_INDICATOR_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the secondary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based?",Fee Schedule - Secondary,SECONDARY_REIMBURSEMENT_FEE_SCHEDULE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the secondary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based? (Page#) ",,SECONDARY_REIMBURSEMENT_FEE_SCHEDULE_PG,NUMERIC,B,ACTIVE,,,,, +"If the secondary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based?",Fee Schedule Version - Secondary,SECONDARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the secondary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based? (Page#) ",,SECONDARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage?",Reimbursement % Rate - Secondary,SECONDARY_REIMBURSEMENT_RATE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage? (Page#) ",,SECONDARY_REIMBURSEMENT_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount?",Reimbursement $ Rate - Secondary,SECONDARY_REIMBURSEMENT_FLAT_FEE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount? (Page#) ",,SECONDARY_REIMBURSEMENT_FLAT_FEE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate?",Medicare $ Rate - Secondary,SECONDARY_REIMBURSEMENT_CMS_MEDICARE_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate? (Page#) ",,SECONDARY_REIMBURSEMENT_CMS_MEDICARE_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate?",Medicaid $ Rate - Secondary,SECONDARY_REIMBURSEMENT_MEDICAID_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate? (Page#) ",,SECONDARY_REIMBURSEMENT_MEDICAID_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Secondary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology?",Reimbursement Grouper - Secondary,SECONDARY_REIMBURSEMENT_GROUPER,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Secondary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology? (Page#) ",,SECONDARY_REIMBURSEMENT_GROUPER_PG,NUMERIC,B,ACTIVE,,,,, +Are there any exceptions to the Secondary reimbursement methodology?,Reimbursement Exceptions - Secondary ,SECONDARY_REIMBURSEMENT_EXCEPTION_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Are there any exceptions to the Secondary reimbursement methodology? (Page#) ,,SECONDARY_REIMBURSEMENT_EXCEPTION_IND_PG,NUMERIC,B,ACTIVE,,,,, +,,,,,,,,,, +"If the contract includes lesser of or greater of language, what is the tertiary Reimbursement methodology (if any)?",Reimbursement Methodology - Tertiary,TERTIARY_REIMBURSEMENT_METHODOLOGY,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the contract includes lesser of or greater of language, what is the tertiary Reimbursement methodology (if any)? (Page#) ",,TERTIARY_REIMBURSEMENT_METHODOLOGY_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges",Applicable Procedure Codes - Tertiary,TERTIARY_REIMBURSEMENT_PROC_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Procedure Codes, then list the applicable codes or code ranges (Page#) ",,TERTIARY_REIMBURSEMENT_PROC_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges",Applicable Revenue Codes - Tertiary,TERTIARY_REIMBURSEMENT_REVENUE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Revenue Codes, then list the applicable codes or code ranges (Page#) ",,TERTIARY_REIMBURSEMENT_REVENUE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations",Applicable Revenue /Procedure Code Combinations - Tertiary,TERTIARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Revenue/ Procedure code combinations, then list the applicable code combinations (Page#) ",,TERTIARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges",Applicable Diagnosis Codes - Tertiary,TERTIARY_REIMBURSEMENT_DIAG_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Diagnosis Codes, then list the applicable codes or code ranges (Page#) ",,TERTIARY_REIMBURSEMENT_DIAG_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges",Applicable Grouper Codes - Tertiary,TERTIARY_REIMBURSEMENT_GROUPER_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Grouper Codes, then list the applicable codes or code ranges (Page#) ",,TERTIARY_REIMBURSEMENT_GROUPER_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges",Applicable Place of Service Codes - Tertiary,TERTIARY_REIMBURSEMENT_PLACEOFSERVICE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Place of Service Codes, then list the applicable codes or code ranges (Page#) ",,TERTIARY_REIMBURSEMENT_PLACEOFSERVICE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges",Applicable Admit Type Codes - Tertiary,TERTIARY_REIMBURSEMENT_ADMITTYPE_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Admit Type codes, then list the applicable codes or code ranges (Page#) ",,TERTIARY_REIMBURSEMENT_ADMITTYPE_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges",Applicable Status Indicator Codes - Tertiary,TERTIARY_REIMBURSEMENT_STATUS_INDICATOR_CODES,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary Reimbursement methodology is based on Status Indicator codes, then list the applicable codes or code ranges (Page#) ",,TERTIARY_REIMBURSEMENT_STATUS_INDICATOR_CODES_PG,NUMERIC,B,ACTIVE,,,,, +"If the tertiary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based?",Fee Schedule - Tertiary,TERTIARY_REIMBURSEMENT_FEE_SCHEDULE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the tertiary reimbursement methodology is based on a Fee Schedule, what is the name of the fee schedule on which it is based? (Page#) ",,TERTIARY_REIMBURSEMENT_FEE_SCHEDULE_PG,NUMERIC,B,ACTIVE,,,,, +"If the tertiary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based?",Fee Schedule Version - Tertiary,TERTIARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the tertiary reimbursement methodology is based on a Fee Schedule, on which fee schedule VERSION is it based? (Page#) ",,TERTIARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage?",Reimbursement % Rate - Tertiary,TERTIARY_REIMBURSEMENT_RATE,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary reimbursement methodology is based on Billed Charges, Fee Schedule, Cost Plus, AWP, or other percentage rate, what is the reimbursed percentage? (Page#) ",,TERTIARY_REIMBURSEMENT_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount?",Reimbursement $ Rate - Tertiary,TERTIARY_REIMBURSEMENT_FLAT_FEE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary reimbursement methodology is based on a fee for service, flat rate, all-inclusive rate, episode of care rate, case rate, per diem rate, or other dollar rate, what is the reimbursed dollar amount? (Page#) ",,TERTIARY_REIMBURSEMENT_FLAT_FEE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate?",Medicare $ Rate - Tertiary,TERTIARY_REIMBURSEMENT_CMS_MEDICARE_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary reimbursement is based on codes listed on the CMS fee schedule, what is the comparable Medicare fee schedule rate? (Page#) ",,TERTIARY_REIMBURSEMENT_CMS_MEDICARE_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate?",Medicaid $ Rate - Tertiary,TERTIARY_REIMBURSEMENT_MEDICAID_RATE,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary reimbursement is based on codes listed on the the State Medicaid fee schedule, what is the comparable Medicaid fee schedule rate? (Page#) ",,TERTIARY_REIMBURSEMENT_MEDICAID_RATE_PG,NUMERIC,B,ACTIVE,,,,, +"If the Tertiary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology?",Reimbursement Grouper - Tertiary,TERTIARY_REIMBURSEMENT_GROUPER,VARCHAR,B,ACTIVE,Yes,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the Tertiary reimbursement methodology is based on a grouper rate, what is the applicable grouper methodology? (Page#) ",,TERTIARY_REIMBURSEMENT_GROUPER_PG,NUMERIC,B,ACTIVE,,,,, +Are there any exceptions to the Tertiary reimbursement methodology?,Reimbursement Exceptions - Tertiary ,TERTIARY_REIMBURSEMENT_EXCEPTION_IND,VARCHAR,B,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Reimbursement Methodology,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Are there any exceptions to the Tertiary reimbursement methodology? (Page#) ,,TERTIARY_REIMBURSEMENT_EXCEPTION_IND_PG,NUMERIC,B,ACTIVE,,,,, +,,,,,,,,,, +Does the contract include a carve out for timeline for payer to implement changes in regulations per LOB Specific agreement?,Timeline State Marketplace Payer Policy Change Notice ,CARVEOUT_IND_IMPLEMENT_POLICY_CHANGE,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Key Dates,Required Only If Available ,"PAYMENT ACCURACY +COST AVOIDANCE" Does the contract include a carve out for timeline for payer to implement changes in regulations per LOB Specific agreement? (Page#) ,,CARVEOUT_IND_IMPLEMENT_POLICY_CHANGE_PG,NUMERIC,F,ACTIVE,,,,, +Does the contract include a carve out for Emergency Department (Yes/No)?,Emergency Carve Out (Y/N)?,EMERGENCY_DEPARTMENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Emergency Department (Yes/No)? (Page#) ,,EMERGENCY_DEPARTMENT_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Emergency Department, list the applicable codes or code ranges ",Emergency Codes or Code Range ,EMERGENCY_DEPARTMENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Emergency Department, describe how these codes are reimbursed",Emergency Reimbursement Methodology,EMERGENCY_DEPARTMENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Emergency Department, describe schedule name",,EMERGENCY_DEPARTMENT_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Emergency Department, describe reference year or version",,EMERGENCY_DEPARTMENT_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Emergency Department, describe describe reimbursement rate",,EMERGENCY_DEPARTMENT_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, Does the contract include a carve out for Observation Codes(Yes/No)?,,OBSERVATION_CAREVEOUT_IND,VARCHAR,F,ACTIVE,,,,, Does the contract include a carve out for Observation Codes(Yes/No)? (Page#) ,,OBSERVATION_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Observation, list the applicable codes or code ranges ",Observation Codes or Code Range ,OBSERVATION_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Observation, describe how these codes are reimbursed",Observation Reimbursement Methodology,OBSERVATION_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Observation, describe schedule name",,OBSERVATION_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Observation, describe schedule reference year or version",,OBSERVATION_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Observation, describe reimbursement rate",,OBSERVATION_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Ambulatory Surgery (Yes/No)?,Ambulatory Surgery Carve Out (Y/N)?,AMBULATORY_SURGERY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Ambulatory Surgery (Yes/No)? (Page#) ,,AMBULATORY_SURGERY_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Ambulatory Surgery, list the applicable codes or code ranges ",Ambulatory Surgery Codes or Code Range ,AMBULATORY_SURGERY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Ambulatory Surgery, describe how these codes are reimbursed",Ambulatory Surgery Reimbursement Methodology,AMBULATORY_SURGERY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Ambulatory Surgery, describe schedule name",,AMBULATORY_SURGERY_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Ambulatory Surgery, describe schedule reference year or version",,AMBULATORY_SURGERY_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Ambulatory Surgery, describe reimbursement rate",,AMBULATORY_SURGERY_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Intensive Care Unit (Yes/No)?,Intensive Care Carve Out (Y/N)?,INTENSIVE_CARE_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Intensive Care Unit (Yes/No)? (Page#) ,,INTENSIVE_CARE_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Intensive Care Unit, list the applicable codes or code ranges ",Intensive Care Codes or Code Range ,INTENSIVE_CARE_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Intensive Care Unit, describe how these codes are reimbursed",Intensive Care Reimbursement Methodology,INTENSIVE_CARE_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Intensive Care Unit, describe schedule name",,INTENSIVE_CARE_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Intensive Care Unit, describe schedule reference year or version",,INTENSIVE_CARE_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Intensive Care Unit, describe reimbursement rate",,INTENSIVE_CARE_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Trauma (Yes/No)?,Trauma Carve Out (Y/N)?,TRAUMA_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Trauma (Yes/No)? (Page#) ,,TRAUMA_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Trauma, list the applicable codes or code ranges ",Trauma Codes or Code Range ,TRAUMA_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Trauma, describe how these codes are reimbursed",Trauma Reimbursement Methodology,TRAUMA_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Trauma, describe schedule name",,TRAUMA_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Trauma, describe schedule reference year or version",,TRAUMA_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Trauma, describe reimbursement rate",,TRAUMA_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Cancer (Yes/No)?,Cancer Carve Out (Y/N)?,CANCER_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Cancer (Yes/No)? (Page#) ,,CANCER_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Cancer, list the applicable codes or code ranges ",Cancer Codes or Code Range ,CANCER_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Cancer, describe how these codes are reimbursed",Cancer Reimbursement Methodology,CANCER_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Cancer, describe schedule name",,CANCER_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Cancer, describe schedule reference year or version",,CANCER_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Cancer, describe reimbursement rate",,CANCER_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for HIV (Yes/No)?,HIV Carve Out (Y/N)?,HIV_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for HIV (Yes/No)? (Page#) ,,HIV_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for HIV, list the applicable codes or code ranges ",HIV Codes or Code Range ,HIV_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for HIV, describe how these codes are reimbursed",HIV Reimbursement Methodology,HIV_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for HIV, describe schedule name",,HIV_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for HIV, describe schedule reference year or version",,HIV_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for HIV, describe reimbursement rate",,HIV_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Major Joint Replacement (Yes/No)?,Joint Replacement Carve Out (Y/N)?,JOINT_REPLACE_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Major Joint Replacement (Yes/No)? (Page#) ,,JOINT_REPLACE_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Major Joint Replacement, list the applicable codes or code ranges ",Joint Replacement Codes or Code Range ,JOINT_REPLACE_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Major Joint Replacement, describe how these codes are reimbursed",Joint Replacement Reimbursement Methodology,JOINT_REPLACE_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Major Joint Replacement, describe schedule name",,JOINT_REPLACE_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Major Joint Replacement, describe schedule reference year or version",,JOINT_REPLACE_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Major Joint Replacement, describe reimbursement rate",,JOINT_REPLACE_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Transplant (Yes/No)?,Transplant Carve Out (Y/N)?,TRANSPLANT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Transplant (Yes/No)? (Page#) ,,TRANSPLANT_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Transplant, list the applicable codes or code ranges ",Transplant Codes or Code Range ,TRANSPLANT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Transplant, describe how these codes are reimbursed",Transplant Reimbursement Methodology,TRANSPLANT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Transplant, describe schedule name",,TRANSPLANT_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Transplant, describe schedule reference year or version",,TRANSPLANT_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Transplant, describe reimbursement rate",,TRANSPLANT_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for OB/GYN Services (Yes/No)?,OB/GYN Carve Out (Y/N)?,OBGYN_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for OB/GYN Services (Yes/No)? (Page#) ,,OBGYN_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for OB/GYN Services, list the applicable codes or code ranges ",OB/GYN Codes or Code Range ,OBGYN_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for OB/GYN Services, describe how these codes are reimbursed",OB/GYN Reimbursement Methodology,OBGYN_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for OB/GYN Services, describe schedule name",,OBGYN_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for OB/GYN Services, describe schedule reference year or version",,OBGYN_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for OB/GYN Services, describe reimbursement rate",,OBGYN_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for OB/GYN Services, is there a lesser of billed charges clause? (Yes/No)",,OBGYN_CARVEOUT_LESSER_OF_BILLED_IND,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for OB/GYN Services, describe billed charges reimbursement rate",,OBGYN_BILLED_CHARGE_REIMBURSEMENT_RATE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for OB/GYN, describe exceptions",,OBGYN_CARVEOUT_DESCRIBE_EXCEPTIONS,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Neonatal Services (Yes/No)?,Neonatal Carve Out (Y/N)?,NEONATAL_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Neonatal Services (Yes/No)? (Page#) ,,NEONATAL_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Neonatal Services, list the applicable codes or code ranges ",Neonatal Codes or Code Range ,NEONATAL_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Neonatal Services, describe how these codes are reimbursed",Neonatal Reimbursement Methodology,NEONATAL_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Neonatal Services, describe schedule name",,NEONATAL_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Neonatal Services, describe schedule reference year or version",,NEONATAL_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Neonatal Services, describe reimbursement rate",,NEONATAL_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Behavioral Health & Substance Abuse Services (Yes/No)?,Behavioral Health & Substance Abuse Carve Out (Y/N)?,BEH_HEALTH_SUB_ABUSE_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Behavioral Health & Substance Abuse Services (Yes/No)? (Page#) ,,BEH_HEALTH_SUB_ABUSE_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Behavioral Health & Substance Abuse Services, list the applicable codes or code ranges ",Behavioral Health & Substance Abuse Codes or Code Range ,BEH_HEALTH_SUB_ABUSE_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Behavioral Health & Substance Abuse Services, describe how these codes are reimbursed",Behavioral Health & Substance Abuse Reimbursement Methodology,BEH_HEALTH_SUB_ABUSE_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Behavioral Health & Substance Abuse Services, describe schedule name",,BEH_HEALTH_SUB_ABUSE_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Behavioral Health & Substance Abuse Services, describe schedule reference year or version",,BEH_HEALTH_SUB_ABUSE_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Behavioral Health & Substance Abuse Services, describe reimbursement rate",,BEH_HEALTH_SUB_ABUSE_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Ophthalmology & Vision Services (Yes/No)?,Ophthalmology & Vision Services Carve Out (Y/N)?,OPHTHAMOLOGY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Ophthalmology & Vision Services (Yes/No)? (Page#) ,,OPHTHAMOLOGY_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Ophthalmology & Vision Services, list the applicable codes or code ranges ",Ophthalmology & Vision Services Codes or Code Range ,OPHTHAMOLOGY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Ophthalmology & Vision Services, describe how these codes are reimbursed",Ophthalmology & Vision Services Reimbursement Methodology,OPHTHAMOLOGY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Ophthalmology & Vision Services, describe schedule name",,OPHTHAMOLOGY_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Ophthalmology & Vision Services, describe schedule reference year or version",,OPHTHAMOLOGY_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Ophthalmology & Vision Services, describe reimbursement rate",,OPHTHAMOLOGY_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for never events (Yes/No)?,Never Event Carve Out (Y/N)?,NEVER_EVENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for never events (Yes/No)? (Page#) ,,NEVER_EVENT_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for never events, list the applicable codes or code ranges ",Never Event Codes or Code Range,NEVER_EVENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for never events, describe how these codes are reimbursed",Never Event Reimbursement Methodology ,NEVER_EVENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for never events, describe schedule name",,NEVER_EVENT_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for never events, describe schedule reference year or version",,NEVER_EVENT_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for never events, describe reimbursement rate",,NEVER_EVENT_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for procedures that are not medically necessary (Yes/No)?,Not Medically Necessary Procedures Carve Out (Y/N)?,NOT_MED_NECESSARY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for procedures that are not medically necessary (Yes/No)? (Page#) ,,NOT_MED_NECESSARY_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for procedures that are not medically necessary, list the applicable codes or code ranges ",Not Medically Necessary Codes or Code Range,NOT_MED_NECESSARY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for procedures that are not medically necessary, describe how these codes are reimbursed",Not Medically Necessary Reimbursement Methodology ,NOT_MED_NECESSARY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for procedures that are not medically necessary, describe schedule name",,NOT_MED_NECESSARY_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for procedures that are not medically necessary, describe schedule reference year or version",,NOT_MED_NECESSARY_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for procedures that are not medically necessary, describe reimbursement rate",,NOT_MED_NECESSARY_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for experimental procedures (Yes/No)?,Experimental Procedures Carve Out (Y/N)?,EXPERIMENTAL_PROCEDURES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for experimental procedures (Yes/No)? (Page#) ,,EXPERIMENTAL_PROCEDURES_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for experimental procedures, list the applicable codes or code ranges ",Experimental Codes or Code Range,EXPERIMENTAL_PROCEDURES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for experimental procedures, describe how these codes are reimbursed",Experimental Reimbursement Methodology ,EXPERIMENTAL_PROCEDURES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for experimental procedures, describe schedule name",,EXPERIMENTAL_PROCEDURES_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for experimental procedures, describe schedule reference year or version",,EXPERIMENTAL_PROCEDURES_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for experimental procedures, describe reimbursement rate",,EXPERIMENTAL_PROCEDURES_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for investigational procedures (Yes/No)?,Investigational Procedures Carve Out (Y/N)?,INVESTIGATIONAL_PROCEDURES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for investigational procedures (Yes/No)? (Page#) ,,INVESTIGATIONAL_PROCEDURES_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for investigational procedures, list the applicable codes or code ranges ",Investigational Codes or Code Range,INVESTIGATIONAL_PROCEDURES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for investigational procedures, describe how these codes are reimbursed",Investigational Reimbursement Methodology ,INVESTIGATIONAL_PROCEDURES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for investigational procedures, describe schedule name",,INVESTIGATIONAL_PROCEDURES_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for investigational procedures, describe schedule reference year or version",,INVESTIGATIONAL_PROCEDURES_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for investigational procedures, describe reimbursement rate",,INVESTIGATIONAL_PROCEDURES_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Unlisted codes (Yes/No)?,Unlisted Codes Carve Out (Y/N)?,UNLISTED_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Unlisted codes (Yes/No)? (Page#) ,,UNLISTED_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Unlisted codes, list the applicable codes or code ranges ",Unlisted Codes or Code Range,UNLISTED_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Unlisted codes, describe how these codes are reimbursed",Unlisted Code Reimbursement Methodology ,UNLISTED_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Unlisted codes, describe schedule name",,UNLISTED_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Unlisted codes, describe schedule reference year or version",,UNLISTED_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Unlisted codes, describe reimbursement rate",,UNLISTED_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Unlisted Codes, describe exceptions",,UNLISTED_CARVEOUT_DESCRIBE_EXCEPTIONS,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for invalid codes (Yes/No)?,Invalid Codes Carve Out (Y/N)?,INVALID_CODES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for invalid codes (Yes/No)? (Page#) ,,INVALID_CODES_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for invalid codes, list the applicable codes or code ranges ",Invalid Codes or Code Range,INVALID_CODES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for invalid codes, describe how these codes are reimbursed",Invalid Code Reimbursement Methodology ,INVALID_CODES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for invalid codes, describe schedule name",,INVALID_CODES_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for invalid codes, describe schedule reference year or version",,INVALID_CODES_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for invalid codes, describe reimbursement rate",,INVALID_CODES_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Durable Medical Equipment (Yes/No)?,Durable Medical Equipment Carve Out (Y/N)?,DME_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Durable Medical Equipment (Yes/No)? (Page#) ,,DME_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Durable Medical Equipment, list the applicable codes or code ranges ",Durable Medical Equipment Codes or Code Range,DME_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Durable Medical Equipment, describe how these codes are reimbursed",Durable Medical Equipment Reimbursement Methodology ,DME_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Durable Medical Equipment, describe schedule name",,DME_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Durable Medical Equipment, describe schedule reference year or version",,DME_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Durable Medical Equipment, describe reimbursement rate",,DME_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Durable Medical Equipment, describe exceptions",,DME_CARVEOUT_DESCRIBE_EXCEPTIONS,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for prosthetics (Yes/No)?,Prosthetics Carve Out (Y/N)?,PROSTHETICS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for prosthetics (Yes/No)? (Page#) ,,PROSTHETICS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for prosthetics, list the applicable codes or code ranges ",Prosthetics Codes or Code Range,PROSTHETICS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for prosthetics, describe how these codes are reimbursed",Prosthetics Reimbursement Methodology ,PROSTHETICS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for prosthetics, describe schedule name",,PROSTHETICS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for prosthetics, describe schedule reference year or version",,PROSTHETICS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for prosthetics, describe reimbursement rate",,PROSTHETICS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for implants (Yes/No)?,Implants Carve Out (Y/N)?,IMPLANTS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for implants (Yes/No)? (Page#) ,,IMPLANTS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for implants, list the applicable codes or code ranges ",Implants Codes or Code Range,IMPLANTS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for implants, describe how these codes are reimbursed",Implants Reimbursement Methodology ,IMPLANTS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for implants, describe schedule name",,IMPLANTS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for implants, describe schedule reference year or version",,IMPLANTS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for implants, describe reimbursement rate",,IMPLANTS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for implants, describe exceptions",,IMPLANTS_CARVEOUT_DESCRIBE_EXCEPTIONS,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Hearing Aids & Hearing Services (Yes/No)?,Hearing Aids & Hearing Services Carve Out (Y/N)?,HEARING_AID_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Hearing Aids & Hearing Services (Yes/No)? (Page#) ,,HEARING_AID_SVCS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Hearing Aids & Hearing Services, list the applicable codes or code ranges ",Hearing Aids & Hearing Services Codes or Code Range,HEARING_AID_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Hearing Aids & Hearing Services, describe how these codes are reimbursed",Hearing Aids & Hearing Services Reimbursement Methodology ,HEARING_AID_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Hearing Aids & Hearing Services, describe schedule name",,HEARING_AID_SVCS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Hearing Aids & Hearing Services, describe schedule reference year or version",,HEARING_AID_SVCS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Hearing Aids & Hearing Services, describe reimbursement rate",,HEARING_AID_SVCS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for anesthesia (Yes/No)?,Anesthesia Carve Out (Y/N)?,ANESTHESIA_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for anesthesia (Yes/No)? (Page#) ,,ANESTHESIA_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for anesthesia, list the applicable codes or code ranges ",Anesthesia Codes or Code Range,ANESTHESIA_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for anesthesia, describe how these codes are reimbursed",Anesthesia Reimbursement Methodology ,ANESTHESIA_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for anesthesia, describe schedule name",,ANESTHESIA_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for anesthesia, describe schedule reference year or version",,ANESTHESIA_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for anesthesia, describe reimbursement rate",,ANESTHESIA_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for anesthesia, is there a lesser of billed charges clause? (Yes/No)",,ANESTHESIA_CARVEOUT_LESSER_OF_BILLED_IND,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for anesthesia, describe billed charges reimbursement rate",,ANESTHESIA_BILLED_CHARGE_REIMBURSEMENT_RATE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for medical pharmacy and/or physician administered drugs (Yes/No)?,Medical Pharmacy Carve Out (Y/N)?,ADMINISTERED_DRUGS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for medical pharmacy and/or physician administered drugs (Yes/No)? (Page#) ,,ADMINISTERED_DRUGS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for medical pharmacy and/or physician administered drugs, list the applicable codes or code ranges ",Medical Pharmacy Codes or Code Range,ADMINISTERED_DRUGS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for medical pharmacy and/or physician administered drugs, describe how these codes are reimbursed",Medical Reimbursement Methodology ,ADMINISTERED_DRUGS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for medical pharmacy and/or physician administered drugs, describe schedule name",,ADMINISTERED_DRUGS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for medical pharmacy and/or physician administered drugs, describe schedule reference year or version",,ADMINISTERED_DRUGS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for medical pharmacy and/or physician administered drugs, describe reimbursement rate",,ADMINISTERED_DRUGS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for medical pharmacy and/or physician administered drugs, describe exceptions",,ADMINISTERED_DRUGS_CARVEOUT_DESCRIBE_EXCEPTIONS,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for medical pharmacy and/or physician administered drugs, is there a lesser of billed charges clause? (Yes/No)",,ADMINISTERED_DRUGS_CARVEOUT_LESSER_OF_BILLED_IND,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for medical pharmacy and/or physician administered drugs, describe billed charges reimbursement rate",,ADMINISTERED_DRUGS_BILLED_CHARGE_REIMBURSEMENT_RATE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for global services (Yes/No)?,Global Services Carve Out (Y/N)?,GLOBAL_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for global services (Yes/No)? (Page#) ,,GLOBAL_SVCS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for global services, list the applicable codes or code ranges ",Global Services Codes or Code Range,GLOBAL_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for global services, describe how these codes are reimbursed",Global Services Reimbursement Methodology ,GLOBAL_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for global services, describe schedule name",,GLOBAL_SVCS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for global services, describe schedule reference year or version",,GLOBAL_SVCS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for global services, describe reimbursement rate",,GLOBAL_SVCS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +"Does the contract include a carve out for bundled or unbundled codes (e.g., bundling, unbundling) (Yes/No)?",Bundled Services Carve Out (Y/N)?,BUNDLED_UNBUNDLED_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "Does the contract include a carve out for bundled or unbundled codes (e.g., bundling, unbundling) (Yes/No)? (Page#) ",,BUNDLED_UNBUNDLED_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for bundling or unbundling, list the applicable codes or code ranges ",Bundled Services Codes or Code Range,BUNDLED_UNBUNDLED_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for bundling or unbundling, describe how these codes are reimbursed",Bundled Services Reimbursement Methodology ,BUNDLED_UNBUNDLED_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for bundling or unbundling, describe schedule name",,BUNDLED_UNBUNDLED_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for bundling or unbundling, describe schedule reference year or version",,BUNDLED_UNBUNDLED_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for bundling or unbundling, describe reimbursement rate",,BUNDLED_UNBUNDLED_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +"Does the contract include a carve out for Multiple Procedure Reductions (i.e., discounted procedures) (Yes/No)?",Reductions Carve Out (Y/N)?,MULTIPLE_PROCEDURE_REDUCTIONS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "Does the contract include a carve out for Multiple Procedure Reductions (i.e., discounted procedures) (Yes/No)? (Page#) ",,MULTIPLE_PROCEDURE_REDUCTIONS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Multiple Procedure Reductions, which types of reductions apply?",Reduced Services Codes or Code Range,MULTIPLE_PROCEDURE_REDUCTIONS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract address Multiple Procedure Reductions, for each type of reduction, what reimbursement methodology applies?",Reduced Services Reimbursement Methodology ,MULTIPLE_PROCEDURE_REDUCTIONS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Multiple Procedure Reductions, describe schedule name",,MULTIPLE_PROCEDURE_REDUCTIONS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract address Multiple Procedure Reductions, describe schedule reference year or version",,MULTIPLE_PROCEDURE_REDUCTIONS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Multiple Procedure Reductions, describe reimbursement rate",,MULTIPLE_PROCEDURE_REDUCTIONS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for second surgeries and/or procedures (Yes/No)?,Second Surgery/Procedure Carve Out (Y/N)?,SECOND_SURGERIES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for second surgeries and/or procedures (Yes/No)? (Page#) ,,SECOND_SURGERIES_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for second surgeries and/or procedures, list the applicable codes or code ranges ",Second Surgery/Procedure Codes or Code Range,SECOND_SURGERIES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for second surgeries and/or procedures, describe how these codes are reimbursed",Second Surgery/Procedure Reimbursement Methodology ,SECOND_SURGERIES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for second surgeries and/or procedures, describe schedule name",,SECOND_SURGERIES_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for second surgeries and/or procedures, describe schedule reference year or version",,SECOND_SURGERIES_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for second surgeries and/or procedures, describe reimbursement rate",,SECOND_SURGERIES_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for subsequent surgeries and/or procedures (Yes/No)?,Subsequent Surgery/Procedure Carve Out (Y/N)?,SUBSEQUENT_SURGERIES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for subsequent surgeries and/or procedures (Yes/No)? (Page#) ,,SUBSEQUENT_SURGERIES_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for subsequent surgeries and/or procedures, list the applicable codes or code ranges ",Subsequent Surgery/Procedure Codes or Code Range,SUBSEQUENT_SURGERIES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for subsequent surgeries and/or procedures, describe how these codes are reimbursed",Subsequent Surgery/Procedure Reimbursement Methodology ,SUBSEQUENT_SURGERIES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for subsequent surgeries and/or procedures, describe schedule name",,SUBSEQUENT_SURGERIES_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for subsequent surgeries and/or procedures, describe schedule reference year or version",,SUBSEQUENT_SURGERIES_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for subsequent surgeries and/or procedures, describe reimbursement rate",,SUBSEQUENT_SURGERIES_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Mid-Level Professionals (Yes/No)? ,Mid-Level Carve Out (Y/N)?,MID_LEVEL_PROFESSIONAL_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Mid-Level Professionals (Yes/No)? (Page#) ,,MID_LEVEL_PROFESSIONAL_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Mid-Level Professionals, list the applicable codes or code ranges ",Mid-Level Codes or Code Range,MID_LEVEL_PROFESSIONAL_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Mid-Level Professionals, describe how these codes are reimbursed",Mid-Level Reimbursement Methodology ,MID_LEVEL_PROFESSIONAL_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Mid-Level Professionals, describe schedule name",,MID_LEVEL_PROFESSIONAL_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Mid-Level Professionals, describe schedule reference year or version",,MID_LEVEL_PROFESSIONAL_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Mid-Level Professionals, describe reimbursement rate",,MID_LEVEL_PROFESSIONAL_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Technical Component (Yes/No)? ,Technical Component Carve Out (Y/N)?,TECHNICAL_COMPONENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Technical Component (Yes/No)? (Page#) ,,TECHNICAL_COMPONENT_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Technical Component, list the applicable codes or code ranges ",Technical Component Codes or Code Range,TECHNICAL_COMPONENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Technical Component, describe how these codes are reimbursed",Technical Component Reimbursement Methodology ,TECHNICAL_COMPONENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Technical Component, describe schedule name",,TECHNICAL_COMPONENT_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Technical Component, describe schedule reference year or version",,TECHNICAL_COMPONENT_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Technical Component, describe reimbursement rate",,TECHNICAL_COMPONENT_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Professional Component (Yes/No)? ,Professional Component Carve Out (Y/N)?,PROFESSIONAL_COMPONENT_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Professional Component (Yes/No)? (Page#) ,,PROFESSIONAL_COMPONENT_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Professional Component, list the applicable codes or code ranges ",Professional Component Codes or Code Range,PROFESSIONAL_COMPONENT_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Professional Component, describe how these codes are reimbursed",Professional Component Reimbursement Methodology ,PROFESSIONAL_COMPONENT_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Professional Component, describe schedule name",,PROFESSIONAL_COMPONENT_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Professional Component, describe schedule reference year or version",,PROFESSIONAL_COMPONENT_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Professional Component, describe reimbursement rate",,PROFESSIONAL_COMPONENT_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Laboratory / Pathology (Yes/No)?,Laboratory / Pathology Carve Out (Y/N)?,LAB_PATHOLOGY_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Laboratory / Pathology (Yes/No)? (Page#) ,,LAB_PATHOLOGY_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Laboratory / Pathology , list the applicable codes or code ranges ",Laboratory / Pathology Codes or Code Range,LAB_PATHOLOGY_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Laboratory / Pathology , describe how these codes are reimbursed",Laboratory / Pathology Reimbursement Methodology ,LAB_PATHOLOGY_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Laboratory / Pathology , describe schedule name",,LAB_PATHOLOGY_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Laboratory / Pathology , describe schedule reference year or version",,LAB_PATHOLOGY_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Laboratory / Pathology , describe reimbursement rate",,LAB_PATHOLOGY_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Laboratory / Pathology , is there a lesser of billed charges clause? (Yes/No)",,LAB_PATHOLOGY_CARVEOUT_LESSER_OF_BILLED_IND,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Laboratory / Pathology , describe billed charges reimbursement rate",,LAB_PATHOLOGY_BILLED_CHARGE_REIMBURSEMENT_RATE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Laboratory / Pathology , describe exceptions",,LAB_PATHOLOGY_CARVEOUT_DESCRIBE_EXCEPTIONS,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for Radiology/Imaging Services (Yes/No)?,Radiology/Imaging Carve Out (Y/N)?,RADIOLOGY_IMAGING_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for Radiology/Imaging Services (Yes/No)? (Page#) ,,RADIOLOGY_IMAGING_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for Radiology/Imaging Services, list the applicable codes or code ranges ",Radiology/Imaging Codes or Code Range,RADIOLOGY_IMAGING_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for Radiology/Imaging Services, describe how these codes are reimbursed",Radiology/Imaging Reimbursement Methodology ,RADIOLOGY_IMAGING_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for Radiology/Imaging Services, describe schedule name",,RADIOLOGY_IMAGING_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Radiology/Imaging Services, describe schedule reference year or version",,RADIOLOGY_IMAGING_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Radiology/Imaging Services, describe reimbursement rate",,RADIOLOGY_IMAGING_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Radiology / Imaging , describe exceptions",,RADIOLOGY_IMAGING_CARVEOUT_DESCRIBE_EXCEPTIONS,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for diagnostic services (Yes/No)?,Diagnostic Services Carve Out (Y/N)?,DIAGNOSTIC_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for diagnostic services (Yes/No)? (Page#) ,,DIAGNOSTIC_SVCS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for diagnostic services, list the applicable codes or code ranges ",Diagnostic Services Codes or Code Range,DIAGNOSTIC_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for diagnostic services, describe how these codes are reimbursed",Diagnostic Services Reimbursement Methodology ,DIAGNOSTIC_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for diagnostic services, describe schedule name",,DIAGNOSTIC_SVCS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for diagnostic services, describe schedule reference year or version",,DIAGNOSTIC_SVCS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for diagnostic services, describe reimbursement rate",,DIAGNOSTIC_SVCS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for pre-admission procedures (Yes/No)? ,Pre-Admission Procedures Carve Out (Y/N)?,PREADMISSION_PROC_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for pre-admission procedures (Yes/No)? (Page#) ,,PREADMISSION_PROC_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for pre-admission procedures, list the applicable codes or code ranges ",Pre-Admission Services Codes or Code Range,PREADMISSION_PROC_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for pre-admission procedures, describe how these codes are reimbursed",Pre-Admission Services Reimbursement Methodology ,PREADMISSION_PROC_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for pre-admissions procedures, how long is the pre-admission window?",Pre-Admission Window,PREADMISSION_PROC_CAREVEOUT_WINDOW,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for pre-admission procedures, describe schedule name",,PREADMISSION_PROC_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for pre-admissions procedures, describe schedule reference year or version",,PREADMISSION_PROC_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for pre-admission procedures, describe reimbursement rate",,PREADMISSION_PROC_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for post-discharge procedures (Yes/No)?,Post-Discharge Procedures Carve Out (Y/N)?,POSTDISCHARGE_PROC_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for post-discharge procedures (Yes/No)? (Page#) ,,POSTDISCHARGE_PROC_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for post-discharge procedures, list the applicable codes or code ranges",Post-Discharge Services Codes or Code Range,POSTDISCHARGE_PROC_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for post-discharge procedures, describe how these codes are reimbursed",Post-Discharge Services Reimbursement Methodology ,POSTDISCHARGE_PROC_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for post-discharge procedures, how long is the post-discharge window?",Post-Discharge Window,POSTDISCHARGE_PROC_CARVEOUT_WINDOW,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for post-discharge procedures, describe schedule name",,POSTDISCHARGE_PROC_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for post-discharge procedures, describe schedule reference year or version",,POSTDISCHARGE_PROC_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for post-discharge procedures, describe reimbursement rate",,POSTDISCHARGE_PROC_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for readmissions (Yes/No)?,Readmissions Carve Out (Y/N)?,READMISSIONS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for readmissions (Yes/No)? (Page#) ,,READMISSIONS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for readmissions, list the applicable codes or code ranges ",Readmissions Codes or Code Range,READMISSIONS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for readmissions, describe how these codes are reimbursed",Readmissions Reimbursement Methodology ,READMISSIONS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for readmissions, how long is the readmission window?",Readmissions Window,READMISSIONS_CAREVEOUT_WINDOW,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for readmissions, describe schedule name",,READMISSIONS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for readmissions, describe schedule reference year or version",,READMISSIONS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for readmissions, describe reimbursement rate",,READMISSIONS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for certain Status Indicators (Yes/No)?,Status Indicator Carve Out (Y/N)?,STATUS_INDICATORS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include a carve out for certain Status Indicators (Yes/No)? (Page#) ,,STATUS_INDICATORS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for certain Status Indicators, list the applicable codes or code ranges ",Status Indicator Codes or Code Range,STATUS_INDICATORS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes a carve out for certain Status Indicators, describe how these codes are reimbursed",Status Indicator Reimbursement Methodology ,STATUS_INDICATORS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes a carve out for certain Status Indicators, describe schedule name",,STATUS_INDICATORS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for certain Status Indicators, describe schedule reference year or version",,STATUS_INDICATORS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for certain Status Indicators, describe reimbursement rate",,STATUS_INDICATORS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include a carve out for outlier provisions (Yes/No)?,Outlier Provisions (Y/N)?,OUTLIER_PROVISIONS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Does the contract include a carve out for outlier provisions (Yes/No)? (Page#) ,,OUTLIER_PROVISIONS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for outlier provisions, what is the outlier threshold?",Outlier Threshold,OUTLIER_PROVISIONS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" +"If the contract includes a carve out for outlier provisions, what is the reimbursement method?",Outlier Allowed Amount,OUTLIER_PROVISIONS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the contract includes a carve out for outlier provisions, describe schedule name",,OUTLIER_PROVISIONS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for outlier provisions, describe schedule reference year or version",,OUTLIER_PROVISIONS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for outlier provisions, describe reimbursement rate",,OUTLIER_PROVISIONS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, @@ -1099,47 +1048,107 @@ Does the contract include a carve out for outlier provisions (Yes/No)? (Page#) , OUTLIER FIELDS TO BE POPULATED ,,,VARCHAR,,,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY NETWORK" OUTLIER FIELDS TO BE POPULATED (Page#) ,,,VARCHAR,,,,,,, +Does the contact include a carve out for stop loss (Yes/No)?,Stop Loss (Y/N)?,STOP_LOSS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" Does the contact include a carve out for stop loss (Yes/No)? (Page#) ,,STOP_LOSS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes a carve out for stop loss, what is the stop loss threshold?",Stop Loss Threshold,STOP_LOSS_CAREVOUT_THRESHOLD,VARCHAR,F,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" +"If the contract includes a carve out for stop loss, what is the percent allowed above the stop loss threshold?",Stop Loss Allowed Amount,STOP_LOSS_CARVEOUT_PERCENT_ALLOWED,VARCHAR,G,ACTIVE,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +NETWORK" "If the contract includes a carve out for stop loss, what are the EMS Trauma codes?",,STOP_LOSS_CARVEOUT_EMS_TRAUMA_CODES,VARIANT,G,ACTIVE,,,,, "If the contract includes a carve out for stop loss, what are the EMS Trauma rates?",,STOP_LOSS_CARVEOUT_EMS_TRAUMA_RATES,VARIANT,G,ACTIVE,,,,, STOP LOSS FIELDS TO BE POPULATED ,,,VARCHAR,,,No,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY NETWORK" STOP LOSS FIELDS TO BE POPULATED (Page#) ,,,VARCHAR,,,,,,, +Does the contract include other Vaccine for Children carve outs (Yes/No)?,Client-Specific Carve Out #1 (Y/N),VACCINE_CHILDREN_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include other Vaccine for Children carve outs (Yes/No)? (Page#) ,,VACCINE_CHILDREN_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Vaccine for Children carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #1 Codes or Code Range,VACCINE_CHILDREN_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes Vaccine for Children client-specific carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #1 Reimbursement Methodology,VACCINE_CHILDREN_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes Vaccine for Children carve outs, describe schedule name",,VACCINE_CHILDREN_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes Vaccine for Children client-specific carve outs, describe schedule reference year or version",,VACCINE_CHILDREN_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes Vaccine for Children carve outs, describe reimbursement rate",,VACCINE_CHILDREN_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include Surgical Assist/Assistant carve outs (Yes/No)?,Client-Specific Carve Out #2 (Y/N),SURGICAL_ASSIST_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include Surgical Assist/Assistant carve outs (Yes/No)? (Page#) ,,SURGICAL_ASSIST_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Surgical Assist/Assistant carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #2 Codes or Code Range,SURGICAL_ASSIST_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes Surgical Assist/Assistant carve outs, describe how these codes are reimbursed",,SURGICAL_ASSIST_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,,,,, "If the contract includes Surgical Assist/Assistant carve outs, describe schedule name",,SURGICAL_ASSIST_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes Surgical Assist/Assistant carve outs, describe schedule reference year or version",,SURGICAL_ASSIST_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes Surgical Assist/Assistant carve outs, describe reimbursement rate",,SURGICAL_ASSIST_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +"If the contract includes other client-specific carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #2 Reimbursement Methodology,,VARCHAR,,INACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes other client-specific carve outs, describe how these codes are reimbursed (Page#) ",,,VARCHAR,,INACTIVE,,,,, +"Does the contract include Physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs (Yes/No)?",Client-Specific Carve Out #3 (Y/N),PHY_CLINICAL_PSYCHOLOGIST_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "Does the contract include Physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs (Yes/No)? (Page#) ",,PHY_CLINICAL_PSYCHOLOGIST_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #3 Codes or Code Range,PHY_CLINICAL_PSYCHOLOGIST_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #3 Reimbursement Methodology,PHY_CLINICAL_PSYCHOLOGIST_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs, describe schedule name",,PHY_CLINICAL_PSYCHOLOGIST_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs, describe schedule reference year or version",,PHY_CLINICAL_PSYCHOLOGIST_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes physicians/Clinical Psychologists (MD, DO, PhD, DPN) carve outs, describe reimbursement rate",,PHY_CLINICAL_PSYCHOLOGIST_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +"Does the contract include Audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs)carve outs (Yes/No)?",Client-Specific Carve Out #4-25 (Y/N),AUDIO_CHIRO_DIETICIAN_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "Does the contract include Audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs)carve outs (Yes/No)? (Page#) ",,AUDIO_CHIRO_DIETICIAN_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,AUDIO_CHIRO_DIETICIAN_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs), describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,AUDIO_CHIRO_DIETICIAN_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs), describe schedule name",,AUDIO_CHIRO_DIETICIAN_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs), describe schedule reference year or version",,AUDIO_CHIRO_DIETICIAN_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes audiologists, Chiropractors, Registered Dieticians (AUDs, DCs, RDs), describe reimbursement rate",,AUDIO_CHIRO_DIETICIAN_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include Board Certified Behavioral Analyst (BCBA) carve outs (Yes/No)?,Client-Specific Carve Out #4-25 (Y/N),CERT_BH_ANALYST_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include Board Certified Behavioral Analyst (BCBA) carve outs (Yes/No)? (Page#) ,,CERT_BH_ANALYST_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Board Certified Behavioral Analyst (BCBA) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,CERT_BH_ANALYST_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes Board Certified Behavioral Analyst (BCBA) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,CERT_BH_ANALYST_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes Board Certified Behavioral Analyst (BCBA) carve outs, describe schedule name",,CERT_BH_ANALYST_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes Board Certified Behavioral Analyst (BCBA) carve outs, describe schedule reference year or version",,CERT_BH_ANALYST_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes Board Certified Behavioral Analyst (BCBA) carve outs, describe reimbursement rate",,CERT_BH_ANALYST_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +"Does the contract include Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs (Yes/No)?",Client-Specific Carve Out #4-25 (Y/N),INDEPENDENT_LICENSURES_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "Does the contract include Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs (Yes/No)? (Page#) ",,INDEPENDENT_LICENSURES_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,INDEPENDENT_LICENSURES_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,INDEPENDENT_LICENSURES_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs, describe schedule name",,INDEPENDENT_LICENSURES_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs, describe schedule reference year or version",,INDEPENDENT_LICENSURES_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes Independent Licensures (LPC, LMFT, LISAC, LCSW) carve outs, describe reimbursement rate",,INDEPENDENT_LICENSURES_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include Behavioral Health Outpatient Clinics/Integrated Clinics carve outs (Yes/No)?,Client-Specific Carve Out #4-25 (Y/N),BH_OP_CLINICS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include Behavioral Health Outpatient Clinics/Integrated Clinics carve outs (Yes/No)? (Page#) ,,BH_OP_CLINICS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Behavioral Health Outpatient Clinics/Integrated Clinics carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,BH_OP_CLINICS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes Behavioral Health Outpatient Clinics/Integrated Clinics carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,BH_OP_CLINICS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes Behavioral Health Outpatient Clinics/Integrated Clinics carve outs, describe schedule name",,BH_OP_CLINICS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes Behavioral Health Outpatient Clinics/Integrated Clinics carve outs, describe schedule reference year or version",,BH_OP_CLINICS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes Behavioral Health Outpatient Clinics/Integrated Clinics carve outs, describe reimbursement rate",,BH_OP_CLINICS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +"Does the contract include Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs (Yes/No)?",Client-Specific Carve Out #4-25 (Y/N),POS_THERAPISTS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "Does the contract include Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs (Yes/No)? (Page#) ",,POS_THERAPISTS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,POS_THERAPISTS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,POS_THERAPISTS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs, describe schedule name",,POS_THERAPISTS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs, describe schedule reference year or version",,POS_THERAPISTS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes Physical, Occupational, Speech Therapists (PTs/OTs/STs) carve outs, describe reimbursement rate",,POS_THERAPISTS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +Does the contract include Transportation Services carve outs (Yes/No)?,Client-Specific Carve Out #4-25 (Y/N),TRANSPORTATION_SVCS_CAREVEOUT_IND,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " Does the contract include Transportation Services carve outs (Yes/No)? (Page#) ,,TRANSPORTATION_SVCS_CAREVEOUT_IND_PG,NUMERIC,F,ACTIVE,,,,, +"If the contract includes Transportation Services carve outs, list the applicable codes or code ranges ",Client-Specific Carve Out #4-25 Codes or Code Range,TRANSPORTATION_SVCS_CAREVOUT_CODES,VARCHAR,F,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " +"If the contract includes Transportation Services carve outs, describe how these codes are reimbursed",Client-Specific Carve Out #4-25 Reimbursement Methodology,TRANSPORTATION_SVCS_CARVEOUT_REIMBURSEMENT_METHODOLOGY,VARCHAR,G,ACTIVE,TBD,"From LOB Specific Exhibit, Attachment, Schedule or Amendment, Addendum, Rider",Carve Outs,Required Only If Available ,"PAYMENT ACCURACY +INTELLIGENT EDITS " "If the contract includes Transportation Services carve outs, describe schedule name",,TRANSPORTATION_SVCS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes Transportation Services carve outs, describe schedule reference year or version",,TRANSPORTATION_SVCS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes Transportation Services carve outs, describe reimbursement rate",,TRANSPORTATION_SVCS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, @@ -1475,6 +1484,8 @@ Does the contract include a carve out for Clinic Visits (Yes/No)? (Page#) ,,CLIN "If the contract includes a carve out for Clinic Visits, describe schedule name",,CLINIC_VISITS_CARVEOUT_SCHEDULE_NAME,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Clinic Visits, describe reference year or version",,CLINIC_VISITS_CAREVEOUT_SCHEDULE_VERSION,VARCHAR,G,ACTIVE,,,,, "If the contract includes a carve out for Clinic Visits, describe reimbursement rate",,CLINIC_VISITS_CARVEOUT_DESCRIBE,VARCHAR,G,ACTIVE,,,,, +,,,,,,,,,, +,,,,,,,,,, Does the contract include reimbursement language for members who have exhausted Medicare benefits and Medicaid provides benefits?,,REIMBURSEMENT_EXHAUST_MEDI_BENEFITS_IND,VARCHAR,B,ACTIVE,,,,, Does the contract include reimbursement language for members who have exhausted Medicare benefits and Medicaid provides benefits? (Page#) ,,REIMBURSEMENT_EXHAUST_MEDI_BENEFITS_IND_PG,NUMERIC,B,ACTIVE,,,,, "If the contract includes reimbursement language for members who have exhausted Medicare benefits and Medicaid provides benefits, is there lesser of language?",,REIMBURSEMENT_EXHAUST_MEDI_BENEFITS_IS_LESSER_OF,VARCHAR,B,ACTIVE,,,,, diff --git a/streamlit/results.csv b/streamlit/results.csv index 14e29f9..0f3509c 100644 --- a/streamlit/results.csv +++ b/streamlit/results.csv @@ -1,15 +1,6448 @@ Contract Name,Contract ID,Field Name,SF_DB_COL_NAME,Actual Value Stored,New Extracted value,Confidence Level,Snippet,Original Page Number,New Page Number,Revised Prompt,Result -Boilerplate_AMEND - BAYLOR MEDCARE - 74-1613878 - 46-2714379,training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_AMEND - BAYLOR MEDCARE - 74-1613878 - 46-2714379 MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"See ""MOHTX26BaylorProvRoster"" tab","['Baylor Medcare (Orthopedic Surgery)', 'BMC Physicians of San Antonio']", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -ICMProviderAgreement_AvenueMedicalAssociatesPA_212330_5,training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AvenueMedicalAssociatesPA_212330_5.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,Avenue Medical Associates PA,I do not see any other provider names listed in the agreement. The agreement is between Granite State Health Inc. d/b/a Delaware First Health and Avenue Medical Associates PA., , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -"Molina Healthcare of Texas, Inc. Amendment 4 - HIX ACA__EFF 01012016","training-data/contract-text-file/0. Professional Boilerplate/Molina Healthcare of Texas, Inc. Amendment 4 - HIX ACA__EFF 01012016_MU.txt",Associated Provider Full Names,PROV_DOING_BUSINESS_AS,Dallas County Hospital District dba Parkland Health & Hospital System,"I do not see any other provider names or TINs listed in the context provided. +"2017 01 01 Raul A. Rivera & Associates, P.A. (Master)PHY Executed","training-data/contract-text-file/0. Professional Boilerplate/2017 01 01 Raul A. Rivera & Associates, P.A. (Master)PHY Executed MU.txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,760528768,7605-28768, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +2023 10 26_Pediatrix Medical Group of T...ment CHIP_STAR_Removed HIM_executed,training-data/contract-text-file/0. Professional Boilerplate/2023 10 26_Pediatrix Medical Group of T...ment CHIP_STAR_Removed HIM_executed MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,65-0578395,65-0578395, ," dba Pediatrix +Community Health Choice, Inc +Medical Group of Texas +2636 South Loop West, Suite 125 +1301 Concord Terrace, Sunrise, FL 33323 +Houston, TX 77054 +Attn: AVP, Managed Care +Phone: 713-295-2294 +Phone: 800-243-3839 +Email: +payorcontracting@pediatrix com +and +Facsimile: 713-295-7058 +legalnotice@pediatrix com +Ryan Sorrell +DanGer +Daniel Corcoran (Oct 19, 2023 13:23 EDT) +Community Signature: +Authorized Signature: +Ryan Sorrell +Daniel Corcoran +Printed Name: +Printed Name +VP, Network Management Operations +SVP, Administration and Managed Care +Title +Title +10/26/2023 +Oct 19, 2023 +Date +Date + 65-0578395 +TIN +TO BE COMPLETED BY COMMUNITY +1649377359 +ONLY: +NPI +Effective Date: 10/26/2023 +1/1/2020 CHC_Hospital-Based Physician Agreement +Page 19 of 43 -", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923,training-data/contract-text-file/1. Professional Custom/Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923 MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,Advanced Gastroenterology of Texas PLC,"I do not see any other provider names listed in the agreement. The agreement is between Molina Healthcare of Texas, Inc. and Advanced Gastroenterology of Texas PLLC.", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -Laboratory Corporation of America Holdings_2023.06.16.Fifth Amendment_OH MCD Comp Chg and TINs add,training-data/contract-text-file/3. Ancillary Custom/Laboratory Corporation of America Holdings_2023.06.16.Fifth Amendment_OH MCD Comp Chg and TINs add_MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"See ""CSNP11 - Lab Corp Provider Roster""","['Laboratory Corporation of America Holdings', 'Laboratory Corporation of America', 'Dianon Systems, Inc.', 'Esoterix Genetic Laboratories, LLC', 'Esoterix Genetic Counseling, LLC', 'Accupath Diagnostic Laboratories, Inc.', 'Esoterix, Inc.', 'National Genetics Institute', 'Monogram Biosciences, Inc.', 'Litholink Corporation', 'MedTox Laboratories, Inc.', 'Sequenom Center for Molecular Medicine, LLC', 'Center for Disease Detection, LLC', 'LabCorp Indiana, Inc.']", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -2021-07-15 COMM Agmt FE - Samaritan Health Services,training-data/contract-text-file/5. Multiple Custom/2021-07-15 COMM Agmt FE - Samaritan Health Services MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"See ""ModaSamaritanCareveouts"" tab","""Samaritan Lebanon Community Hospital"",""93-0396847""},{""Samaritan North Lincoln Hospital"",""93-1305493""},{""Samaritan Pacific Communities Hospital"",""93-1329784""},{""Albany General Hospital"",""93-0110095""},{""Samaritan Medical Supplies"",""46-5619962""},{""Samaritan Endoscopy Center LLC"",""202860067""},{""Good Samaritan Home Health"",""930391573""},{""Good Samaritan Home Infusion Services"",""930391573""},{""Samaritan Evergreen Hospice, Albany, Corvallis"",""930110095""},{""North Lincoln Home Health"",""931305493""},{""Pacific Communities Home Health"",""931329784""},{""Corvallis MRI"",""93-0949704""},{""East Linn MRI"",""320229399""", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -2021-07-15 COMM Agmt FE - Samaritan Health Services,training-data/contract-text-file/5. Multiple Custom/2021-07-15 COMM Agmt FE - Samaritan Health Services MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"See ""ModaSamaritanCareveouts"" tab","""Samaritan Lebanon Community Hospital"",""93-0396847""},{""Samaritan North Lincoln Hospital"",""93-1305493""},{""Samaritan Pacific Communities Hospital"",""93-1329784""},{""Albany General Hospital"",""93-0110095""},{""Samaritan Medical Supplies"",""46-5619962""},{""Samaritan Endoscopy Center LLC"",""202860067""},{""Good Samaritan Home Health"",""930391573""},{""Good Samaritan Home Infusion Services"",""930391573""},{""Samaritan Evergreen Hospice, Albany, Corvallis"",""930110095""},{""North Lincoln Home Health"",""931305493""},{""Pacific Communities Home Health"",""931329784""},{""Corvallis MRI"",""93-0949704""},{""East Linn MRI"",""320229399""", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -2021-07-15 COMM Agmt FE - Samaritan Health Services,training-data/contract-text-file/5. Multiple Custom/2021-07-15 COMM Agmt FE - Samaritan Health Services MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"See ""ModaSamaritanCareveouts"" tab","""Samaritan Lebanon Community Hospital"",""93-0396847""},{""Samaritan North Lincoln Hospital"",""93-1305493""},{""Samaritan Pacific Communities Hospital"",""93-1329784""},{""Albany General Hospital"",""93-0110095""},{""Samaritan Medical Supplies"",""46-5619962""},{""Samaritan Endoscopy Center LLC"",""202860067""},{""Good Samaritan Home Health"",""930391573""},{""Good Samaritan Home Infusion Services"",""930391573""},{""Samaritan Evergreen Hospice, Albany, Corvallis"",""930110095""},{""North Lincoln Home Health"",""931305493""},{""Pacific Communities Home Health"",""931329784""},{""Corvallis MRI"",""93-0949704""},{""East Linn MRI"",""320229399""", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -2021-07-15 COMM Agmt FE - Samaritan Health Services,training-data/contract-text-file/5. Multiple Custom/2021-07-15 COMM Agmt FE - Samaritan Health Services MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"See ""ModaSamaritanCareveouts"" tab","""Samaritan Lebanon Community Hospital"",""93-0396847""},{""Samaritan North Lincoln Hospital"",""93-1305493""},{""Samaritan Pacific Communities Hospital"",""93-1329784""},{""Albany General Hospital"",""93-0110095""},{""Samaritan Medical Supplies"",""46-5619962""},{""Samaritan Endoscopy Center LLC"",""202860067""},{""Good Samaritan Home Health"",""930391573""},{""Good Samaritan Home Infusion Services"",""930391573""},{""Samaritan Evergreen Hospice, Albany, Corvallis"",""930110095""},{""North Lincoln Home Health"",""931305493""},{""Pacific Communities Home Health"",""931329784""},{""Corvallis MRI"",""93-0949704""},{""East Linn MRI"",""320229399""", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -"Custom_Parkview Health Systems-OH MP, IN MP-ID C15656222AA","training-data/contract-text-file/CareSource -Professional/Custom_Parkview Health Systems-OH MP, IN MP-ID C15656222AA MU.txt",Associated Provider Full Names,PROV_DOING_BUSINESS_AS,Midwest Community Health Associates,"['Midwest Community Health Associates', 'Parkview Physicians Group']", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -Custom_TriHealth_Group Practice_Sixth Amendment_20140101,training-data/contract-text-file/CareSource -Professional/Custom_TriHealth_Group Practice_Sixth Amendment_20140101 MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"TriHealth OS, LLC","['Dirk Pruis', 'David Taylor', 'Lisa Vickers', 'Joseph Thomas', 'Paul Gangl', 'Arnold Penix', 'Emily Dixon', 'David Doyle', 'Monty Backus', 'Connie Chiu', 'Susan Segerman', 'Julie Novotny', 'Dianne Otten', 'Carmen Palascak', 'Richard Okragly', 'Walter Zancan', 'Kevin Reilly', 'Joel Sorger', 'Mark Snyder', 'Christopher Ruhnke', 'James Leonard', 'Robert Raines', 'Kristi White', 'Jessica Spears', 'Tina Mckinney', 'Erin Voss', 'Kyle Danemayer', 'Jeffery Riesenbeck', 'Mary Lutz', 'Steven Wurzelbacher', 'Steven Kinzer', 'Shaun White', 'Nicole Overbeck-Lynch', 'Sean Lynch', 'Mary Pfiester', 'Keene Bryant', 'Todd Heidrick', 'John McDonough', 'Thomas Kiefhaber', 'Daniel Reilly', 'Andrew Markiewitz', 'Paul Fassler', 'Andrew Cross', 'Benjamin Kleinhenz', 'Peter Stern', 'T. Gregory Sommerkamp', 'Paul Fassier', 'Brian Crellin']", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False -Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt,Associated Provider Full Names,PROV_DOING_BUSINESS_AS,"Barnet Dulaney Surgery Centers, LLC","['Barnet Dulaney Perkins Eye Center, PLLC', 'Barnet Dulaney Surgery Centers, LLC']", , , ,,"What are the names of other providers associated with this agreement? The names can be found across multiple pages after the signature page. These names can be found in a roster and can be a list of provider names or TINs. Do not provide any context or explanation, simply state the names.",False +Start of Page No = 20 +EXHIBIT A +HOSPITAL-BASED PROVIDER DEMOGRAPHICS +This Exhibit may be updated at any time without the need of a signed amendment by both parties However, +Provider must comply with notification requirements under this Agreement and any guidelines or protocols located +in the Provider Manual, as well as Community's credentialing policies. +Legal Business Name +Pediatrix Medical Group of Texas Billing, Inc. +Business Name (dba) +Pediatrix Medical Group of Texas +Website +Tax Identification Number +65-0578395 +Group NPI Number +1649377359 +Group TPI +Group THSteps TPI, if applicable +Remit Address +Address: +PO BOX 840384 +City/State/ZIP: +Dallas, TX 75284-0384 +Phone: +(972) 437-5099 +Fax: +(972) 479-9588 +Specialty / Type of +Service +Name of Hospital(s) or +Physician or Mid-Level +Surgery Center(s) +Medicare +Practitioner +**If more than one +where Hospital-Based +CAQH +Individual +Medicaid +Physician or Mid-Level +Number +NPI Number +Participation +Last Name, First Name, MI +specialty, create a +Number +Number +and Degree +new record for +Practitioner renders +each specialty/type +services +of service +1/1/2020 CHC_Hospital-Based Physician Agreement +Page 20 of 43 + +-------TABLE Start----- +Legal Business Name +Pediatrix Medical Group of Texas Billing, Inc. +Business Name (dba) +Pediatrix Medical Group of Texas +Website +Tax Identification Number +65-0578395 +Group NPI Number +1649377359 +Group TPI +Group THSteps TPI, if applicable +Remit Address +Address: +PO BOX 840384 +City/State/ZIP: +Dallas, TX 75284-0384 +Phone: +(972) 437-5099 +Fax: +(972) 479-9588 +-------TABLE End----- + +-------TABLE Start----- +Specialty / Type of +Service +Name of Hospital(s) or +Physician or Mid-Level +Surgery Center(s) +Medicare +Practitioner +**If more than one +where Hospital-Based +CAQH +Individual +Medicaid +Physician or Mid-Level +Number +NPI Number +Participation +Last Name, First Name, MI +specialty, create a +Number +Number +and Degree +new record for +Practitioner renders +each specialty/type +services +of service +-------TABLE End----- + +Start of Page No = 21 +EXHIBIT B-1 +COMPENSATION +CHIP +Does not participate in CHIP +Applicable Benefit +CHIP Perinatal +Does not participate in CHIP/P +Plan(s): +STAR +Does not participate in STAR +STAR+PLUS +Does not participate in STAR+PLUS +Primary Care Physician +Hospital-Based PCP or OB/Gyn +Provider Type: +OB/Gyn +Other: Mid-Level/Physician Extender +Services: +Professional Services +Physician/Provider agrees to participate in the Benefit Plan/Program described in this Exhibit and authorizes, through its signature below, +the transfer of all payment/reimbursement terms and obligations under the Agreement to Payors as set forth in this Agreement. +Subject to allowed reductions that Community may apply as a result of Physician/Provider's non-compliance with any applicable +credentialing, billing, Prior Authorization, Referral, or Utilization Management guidelines, or other Community Protocols referenced in this +Agreement, Physician/Provider shall accept as payment in full for Covered Services and all other services rendered to Members under +this Agreement, the lesser of Physician/Provider's Billed Charges or the agreed compensation set forth in this Exhibit, less any applicable +Member Expense: +All Covered Services: one hundred and ten percent (110%) of the then current Texas Medicaid Fee Schedule, except: +Vaginal delivery only, after previous cesarean delivery (Current Procedural Coding (CPT) 59612): four hundred and dollars +($400.00) above the then current reimbursement for CPT R code 59514 (Cesarean delivery only). +Radiology services (CPT codes 70000 through 76505): eighty (80%) of the Texas Medicaid Fee Schedule. +Ultrasound services (CPT R) codes 76506 through 79999): one hundred and ten (110%) of the Texas Medicaid Fee +Schedule. +Clinical Laboratory services (CPT® codes 80000 through 87999): sixty percent (60%) of the Texas Medicaid Clinical Laboratory +Fee Schedule. +Drugs dispensed and administered by Physician/Provider: one hundred percent (100%) of the Texas Medicaid reimbursement, +except: +Rho (D) immune globulin billed with Healthcare Common Procedure Code System (HCPCS) codes defined herein shall be +reimbursed at one hundred and twenty percent (120%) of the Texas Medicaid Fee Schedule: +J2788 - injection, Rho (D) immune globulin, human, mini dose, 50 mcg (250 IU) +J2790 - injection, Rho (D) immune globulin, human, full dose, 300 mcg (1500 IU) +J2791 - injection, Rho (D) immune globulin (human), (Rhophylac), intramuscular or intravenous, 100 IU +J2792 - injection, Rho (D) immune globulin, intravenous, human, solvent detergent, 100 IU +Compensation Notes: +Community shall process Clean Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and +according to Texas Medicaid reimbursement methodology. +Physician/Provider agrees to only bill for and Community shall be obligated to only pay for clinical laboratory services for which +Physician/Provider holds a valid CLIA certification. +If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods listed above, Community +shall compensate Physician/Provider according to thirty percent (30%) of Physician/Provider's Billed Charges. +In the event a service is not specifically mentioned above, the intent of reimbursement will follow Texas Medicaid Methodology. +Govt +Oct 19, 2023 +Provider Signature: Daniel Corcoran (Oct 19, 2023 13:23 EDT) +Date: +1/1/2020 CHC_Hospital-Based Physician Agreement +Page 21 of 43 + +-------TABLE Start----- +CHIP +Does not participate in CHIP +Applicable Benefit +CHIP Perinatal +Does not participate in CHIP/P +Plan(s): +STAR +Does not participate in STAR +STAR+PLUS +Does not participate in STAR+PLUS +Primary Care Physician +Hospital-Based PCP or OB/Gyn +Provider Type: +OB/Gyn +Other: Mid-Level/Physician Extender +Services: +Professional Services +-------TABLE End----- + +Start of Page No = 22 +EXHIBIT B-1 +COMPENSATION +CHIP +Does not participate in CHIP +Applicable +CHIP Perinatal +Does not participate in CHIP/P +Benefit Plan(s): +STAR +Does not participate in STAR +STAR+PLUS +Does not participate in STAR+PLUS +Hospital-Based Specialist +Provider Type: +Specialist +Other: Mid-Level/Physician Extender +Services: +Professional Services +Physician/Provider agrees to participate in the Benefit Plan/Program described in this Exhibit and authorizes, +through its signature below, the transfer of all payment/reimbursement terms and obligations under the +Agreement to Payors as set forth in this Agreement. +Subject to allowed reductions that Community may apply as a result of Physician/Provider's non-compliance with +any applicable credentialing, billing, Prior Authorization, Referral, or Utilization Management guidelines, or other +Community Protocols referenced in this Agreement, Physician/Provider shall accept as payment in full for +Covered Services and all other services rendered to Members under this Agreement, the lesser of +Physician/Provider's Billed Charges or the agreed compensation set forth in this Exhibit, less any applicable +Member Expense: +All Covered Services: one hundred ten percent (110%) of the then current Texas Medicaid Fee Schedule, except: +Radiology services (CPT ) codes 70000 through 79999): eighty (80%) of the Texas Medicaid Fee +Schedule. +Clinical Laboratory services (CPT6 codes 80000 through 87999): sixty percent (60%) of the Texas +Medicaid Clinical Laboratory Fee Schedule. +Durable Medical Equipment, Prosthetics/Orthotics, and Supplies: eighty (80%) of the then current +Medicaid Fee Schedule. +Drugs dispensed and administered by Physician/Provider: one hundred percent (100%) of the Texas +Medicaid Fee Schedule. +Compensation Notes: +Community shall process Clean Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and +according to Texas Medicaid reimbursement methodology. +Physician/Provider agrees to only bill for and Community shall be obligated to only pay for clinical laboratory services for which +Physician/Provider holds a valid CLIA certification. +If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods listed above, Community +shall compensate Physician/Provider according to thirty percent (30%) of Physician/Provider's Billed Charges. +Gov +Physician/Provider Signature: +Daniel Corcoran (Oct 19, 2023 13:23 EDT) +Date: +Oct 19,2023 +1/1/2020 CHC_Hospital-Based Physician Agreement +Page 22 of 43 + +-------TABLE Start----- +CHIP +Does not participate in CHIP +Applicable +CHIP Perinatal +Does not participate in CHIP/P +Benefit Plan(s): +STAR +Does not participate in STAR +STAR+PLUS +Does not participate in STAR+PLUS +Hospital-Based Specialist +Provider Type: +Specialist +Other: Mid-Level/Physician Extender +Services: +Professional Services +-------TABLE End----- + +Start of Page No", ,19,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Boilerplate_Benjamin Bieber MD - Amendment 5.30.16,training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Benjamin Bieber MD - Amendment 5.30.16_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,15-2487027,15-2487027, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Boilerplate_Benjamin Bieber,training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Benjamin Bieber_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,15-2487027,15-2487027, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +"Boilerplate_Bethpage Medical, PLLC - Agreement","training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Bethpage Medical, PLLC - Agreement_MU.txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,26-3847741,26-3847741, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +"Boilerplate_Bethpage Medical, PLLC - Amendment 9.23.13","training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Bethpage Medical, PLLC - Amendment 9.23.13_MU.txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,26-3847741,26-3847741, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Boilerplate_Prof_Premier Health Specialists Inc Third Amendment_A.4_20160101,training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Prof_Premier Health Specialists Inc Third Amendment_A.4_20160101_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,06-1744704,06-1744704, ," +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", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_AlisonUnitisLPCMH_227710_5,training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AlisonUnitisLPCMH_227710_5.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,47-2541674,47-2541674, ," = 13 +THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION +THAT MAY BE ENFORCED BY THE PARTIES +IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Delaware First Health, Inc +Alison Unitis, LPCMH +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Alison Unitis +Aaron Brace (Aug 16, 2022 08:28 EDT) +Alison Unitis (Aug 15, 2022 16:50 EDT) +Print Name: Aaron Brace +Print Name: Alison Unitis +Title: Regional Vice President, New Business Network +Title: LPCMH +Development +Signature Date: Aug 16, 2022 +Signature Date: Aug 15, 2022 +ICM #: ICMProviderAgreement_227710 +Tax Identification Number: 47-2541674 +To be completed by Health Plan only: +National Provider Identifier: 1154468593 +Effective Date: Sep 14, 2022 +Medicare Number: + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_AmyRiceMA_223388_5,training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AmyRiceMA_223388_5.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-1235543,86-1235543, ," = 13 +THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION +THAT MAY BE ENFORCED BY THE PARTIES +IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Delaware First Health, Inc +Amy Rice MA +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Amy Rice LPCMH +Aaron Brace (Aug 16, 2022 15:22 EDT) +Amy Rice LPCMH (Aug 16, 2022 10:14 PDT) +Print Name: Aaron Brace +Print Name: Amy Rice LPCMH +Title: Regional Vice President, New Business Network +Title: provider +Development +Signature Date: Aug 16, 2022 +Signature Date: Aug 16, 2022 +ICM #: ICMProviderAgreement_223388 +Tax Identification Number: 86-1235543 +To be completed by Health Plan only: +National Provider Identifier: 1023691201 +Effective Date: Sep 15, 2022 +Medicare Number: + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_AnnEWhite-TheCenterForHealingConversations_227589_4,training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AnnEWhite-TheCenterForHealingConversations_227589_4.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,83-3773736,83-3773736, ," +Ann E White DBA The Center for Healing +Conversations, LLC +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Ann E White +Aaron Brace (Sep 15, 2022 13:42 EDT) +Ann E White (Sep 14, 2022 12:45 EDT) +Print Name: Aaron Brace +Print Name: Ann E White +Title: Regional Vice President, New Business Network +Title: Psychotherapist/Owner +Development +Signature Date: Sep 15, 2022 +Signature Date: Sep 14, 2022 +ICM #: (CMProviderAgreement_227589 +Tax Identification Number: 83-3773736 +To be completed by Health Plan only: +National Provider Identifier: 1700405727 +Effective Date: Oct 14, 2022 +Medicare Number: + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_AvenueMedicalAssociatesPA_212330_5,training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AvenueMedicalAssociatesPA_212330_5.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,01-0927020,01-0927020, ," = 13 +THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION +THAT MAY BE ENFORCED BY THE PARTIES +IN +WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Granite State Health Inc d/b/a Delaware First Health +Avenue Medical Associates PA +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Avani Virani MD +Aaron Brace (Aug 9, 2022 11:23 EDT) +Avani Virani MD (Aug 8, 2022 18:31 EDT) +Print Name: Aaron Brace +Print Name: Avani Virani +Title: Regional Vice President, New Business Network +Title: President +Development +Signature Date: Aug 9, 2022 +Signature Date: Aug 8, 2022 +ICM #: ICMProviderAgreement_212330 +Tax Identification Number: 01-0927020 +To be completed by Health Plan only: +National Provider Identifier: +Effective Date: Sep 07, 2022 +Medicare Number: + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_BalancedMindCounselingCenter_217525_6,training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_BalancedMindCounselingCenter_217525_6.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,47-4931000,47-4931000, ," = 13 +THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION +THAT MAY BE ENFORCED BY THE PARTIES +IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Delaware First Health, Inc +BALANCED MIND COUNSELING CENTER LLC +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Jennifer Ewald, LCSW +Aaron Brace (Aug 11, 2022 13:02 EDT) +Jennifer Ewald, LCSW (Aug 11, 2022 10:16 EDT) +Print Name: Aaron Brace +Print Name: Jennifer Ewald, LCSW +Title: Corporate Vice President, National Contracting +Title: Owner/Clinician +Officer +Signature Date: Aug 11, 2022 +Signature Date: Aug 11, 2022 +ICM #: ICMProviderAgreement_217525 +Tax Identification Number: 47-4931000 +To be completed by Health Plan only: +National Provider Identifier: 1518335876 +Effective Date: Sep 10, 2022 +Medicare Number: + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomProf_Behavior Analysit Professional Services PLLC - Amendment Provider Signed 1.1.19,training-data/contract-text-file/1. Professional Custom/CustomProf_Behavior Analysit Professional Services PLLC - Amendment Provider Signed 1.1.19_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,81-3535131,813535131, ," = 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", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923,training-data/contract-text-file/1. Professional Custom/Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,464543923,47-4543923, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed,training-data/contract-text-file/1. Professional Custom/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,263143681,263-143681, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed,training-data/contract-text-file/1. Professional Custom/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,263143681,263-143681, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC,training-data/contract-text-file/1. Professional Custom/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0290033,86-0290033, ,", (hereinafter ""PROVIDER"") +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +PLAN +PROVIDER +By: Scott Cummings 9-27-2018 Date Signature of to CPA +State Plan President +Michael Fett, CPA +Printed Name +Title Chief Financial officer +Southwest Behavioral Health Services, Inc +Address for Plan Notices: +Contracting Entity/Group Name + 86-0290033 +CareIst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Network Management +9/25/2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Care1st Provider Agreement +Page 2 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No = 3 +RECITALS +R.1 +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible through a +program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +R.2 +WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care +Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general +practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist +Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership +organized and in good standing under the laws of the State of Arizona, which professional corporation or +partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) +and independent contractors. +R.3 +WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract +with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- +For-Service (""FFS"") basis, to AHCCCS Members enrolled with Plan (hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable +consideration the receipt of which is hereby acknowledged, the parties agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Active Labor"" means a labor at a time at which either of the following would occur: (1) there is +inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a +threat to the health and safety of the patient or the unborn child. +1.2 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.3 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and treatment +of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical +equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency +Services and other services customarily deemed ancillary. +1.4 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. +§ 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement +through which health care services are provided to a member. +1.5 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +Care1st Provider Agreement +Page 3 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC,training-data/contract-text-file/1. Professional Custom/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0290033,86-0290033, ,", (hereinafter ""PROVIDER"") +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +PLAN +PROVIDER +By: Scott Cummings 9-27-2018 Date Signature of to CPA +State Plan President +Michael Fett, CPA +Printed Name +Title Chief Financial officer +Southwest Behavioral Health Services, Inc +Address for Plan Notices: +Contracting Entity/Group Name + 86-0290033 +CareIst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Network Management +9/25/2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Care1st Provider Agreement +Page 2 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No = 3 +RECITALS +R.1 +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible through a +program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +R.2 +WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care +Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general +practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist +Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership +organized and in good standing under the laws of the State of Arizona, which professional corporation or +partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) +and independent contractors. +R.3 +WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract +with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- +For-Service (""FFS"") basis, to AHCCCS Members enrolled with Plan (hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable +consideration the receipt of which is hereby acknowledged, the parties agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Active Labor"" means a labor at a time at which either of the following would occur: (1) there is +inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a +threat to the health and safety of the patient or the unborn child. +1.2 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.3 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and treatment +of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical +equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency +Services and other services customarily deemed ancillary. +1.4 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. +§ 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement +through which health care services are provided to a member. +1.5 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +Care1st Provider Agreement +Page 3 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +BoilerplateAnc_Bentley Medical PLLC - Amendment 8.1.14,training-data/contract-text-file/2. Ancillary Boilerplate/BoilerplateAnc_Bentley Medical PLLC - Amendment 8.1.14_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,26-2637727,26-2637727, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +BoilerplateAnc_Boro Park Obstetrics & Gynecology PC - Amendment 11.2.12,training-data/contract-text-file/2. Ancillary Boilerplate/BoilerplateAnc_Boro Park Obstetrics & Gynecology PC - Amendment 11.2.12_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,11-2799543,112799543, ," = 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", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +"Boilerplate_Anc_Better Living Now, Inc. - Agreement","training-data/contract-text-file/2. Ancillary Boilerplate/Boilerplate_Anc_Better Living Now, Inc. - Agreement_MU.txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,13-3683081,13-3683081, ," +BETTER LIVING NOW, 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 +185 oser Ave +By: David P Thomas +Address +Hauppauge +NY 11788 +Its: Senior Vice President & Chief Administrative Officer +City, State, Zip Code +Entity Tax ID#: 13-3683081 +Date: +1/26/10 +Entity +NPI#: 109 3711 996 +WOR +Signature: +Name: DaniEL S POPE +(Please Print) +Title: PRESIDENT/CEO +Date: +1/11/2010 +Signature: QUAD +Fidelis Care New York TM +19 +THIS AGREEMENT IS SUBJECT TO THE APPROVAL +Standard Ancillary 6.2007 +OF THE NEW YORK STATE DEPARTMENT OF HEALTH +BetterLivingNow.SASA.JC.12.23.2009 + +Start of Page No = 22 +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: +DME +Fidelis Care New YorkTM +20 +THIS AGREEMENT IS SUBJECT TO THE APPROVAL +Standard Ancillary 6.2007 +OF THE NEW YORK STATE DEPARTMENT OF HEALTH +BetterLivingNow.SASA.JC.12.23.2009 + +Start of Page No = 23 +SCHEDULE 1.14 +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., the +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. +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. +Fidelis Care New YorkTM +21 +THIS AGREEMENT IS SUBJECT TO THE APPROVAL +Standard Ancillary 6.2007 +OF THE NEW YORK STATE DEPARTMENT OF HEALTH +BetterLivingNow.SASA.JC.12.23.2009 + +Start of Page No", ,21,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Boilerplate_Anc_Bio Reference Laboratories Inc - Amendment 8.1.17,training-data/contract-text-file/2. Ancillary Boilerplate/Boilerplate_Anc_Bio Reference Laboratories Inc - Amendment 8.1.17_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,222405059,222-405059, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Boilerplate_Anc_Borbas Surgical Supply Inc - Amendment 7.15.12,training-data/contract-text-file/2. Ancillary Boilerplate/Boilerplate_Anc_Borbas Surgical Supply Inc - Amendment 7.15.12_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,11-3568895,113568895, ," +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", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc10_040121 Nationwide Vision Center Care 1st Amendment,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0560663,86-0560663, ," 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, the parties have executed this Amendment to the Agreement in duplicate by their +respective officers duly authorized to do so +PLAN +PROVIDER +By: +6/3/21 +Scott Cummings +Date +Signature Vincent Hayes +Chief Administrative Officer +Printed Name +Vincent Hayes +Title Vice President Managed Care +NAtion wide Vision Center INC +Address for Plan Notices: +Contracting Entity/Group Name + 86-0560663 +Carels Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +5-6-2021 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +220 N McKemy Ave +Chandler, Az 85226 +Carelst +Revised 050817 + +Start of Page No = 2 +ATTACHMENT A +ANCILLARY COMPENSATION AND COVERED SERVICES +Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members +shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any +applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds +PROVIDER's billed charges. +Routine Vision Care +Effective +Contracted Rates +HCIF Rates* +Frames +$39.00 +$47.51 +Single Vision Lenses +$38.00 +$46.30 +Bifocal Lenses** +$59.00 +$71.88 +Trifocal Lenses** +$69.00 +$84.06 +Contact Lenses +95% of the current AHCCCS +95% of the current AHCCCS +Fee Schedule +Fee Schedule +* Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are +required by AHCCCS", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc10_040121 Nationwide Vision Center Care 1st Amendment,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0560663,86-0560663, ," 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, the parties have executed this Amendment to the Agreement in duplicate by their +respective officers duly authorized to do so +PLAN +PROVIDER +By: +6/3/21 +Scott Cummings +Date +Signature Vincent Hayes +Chief Administrative Officer +Printed Name +Vincent Hayes +Title Vice President Managed Care +NAtion wide Vision Center INC +Address for Plan Notices: +Contracting Entity/Group Name + 86-0560663 +Carels Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +5-6-2021 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +220 N McKemy Ave +Chandler, Az 85226 +Carelst +Revised 050817 + +Start of Page No = 2 +ATTACHMENT A +ANCILLARY COMPENSATION AND COVERED SERVICES +Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members +shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any +applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds +PROVIDER's billed charges. +Routine Vision Care +Effective +Contracted Rates +HCIF Rates* +Frames +$39.00 +$47.51 +Single Vision Lenses +$38.00 +$46.30 +Bifocal Lenses** +$59.00 +$71.88 +Trifocal Lenses** +$69.00 +$84.06 +Contact Lenses +95% of the current AHCCCS +95% of the current AHCCCS +Fee Schedule +Fee Schedule +* Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are +required by AHCCCS", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,56-2589722,86-0713148, ," +By: 6 8 2017 +Soldiering +Scott Cummings +Date +Signature +Chief Administrative Officer +MARK R osenberg +Printed Name +CEO +Title +Barnet Dulaney Perkins Eye Center, PLLC +Address for Plan Notices: +Barnet Dulaney Surgery Centers, LLC +Contracting Entity/Group Name +Care1st Health Plan Arizona, Inc +Attention: Director, Provider Network Operations +56-2589722/ 86-0713148 +2355 E Camelback Road, #300 +Contracting Entity/Group Tax I.D. +Phoenix, Arizona 85016 +4-12-2017 +Date +Address for Provider Notices: +4800 N, 22nd Street +PhoeNix , AZ 85016 +artn: Contrating +Carelst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may +file a grievance, or (2) an action such as a denial of authorization from which a Member can file an +appeal and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,56-2589722,86-0713148, ," +By: 6 8 2017 +Soldiering +Scott Cummings +Date +Signature +Chief Administrative Officer +MARK R osenberg +Printed Name +CEO +Title +Barnet Dulaney Perkins Eye Center, PLLC +Address for Plan Notices: +Barnet Dulaney Surgery Centers, LLC +Contracting Entity/Group Name +Care1st Health Plan Arizona, Inc +Attention: Director, Provider Network Operations +56-2589722/ 86-0713148 +2355 E Camelback Road, #300 +Contracting Entity/Group Tax I.D. +Phoenix, Arizona 85016 +4-12-2017 +Date +Address for Provider Notices: +4800 N, 22nd Street +PhoeNix , AZ 85016 +artn: Contrating +Carelst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may +file a grievance, or (2) an action such as a denial of authorization from which a Member can file an +appeal and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc4_White Mountain Phys Contract,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0460643,86-0460643, ," +Michael L Johnson PT +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +Scott +By: Gummings 10-23-2018 Date +Sellbury +Signature +Dechange +Chief Administrative Officer +Printed Name +Michael L Johnson PT +PT, TIN owner +Title +White Mountain Physical therapy, +Address for Plan Notices: +Contracting Entity/Group Name +LTD + 86-0460643 +Carel 1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +05-03-2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +PO Box 1420 +Show Low, AZ 85902-1420 +CareIst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc4_White Mountain Phys Contract,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0460643,86-0460643, ," +Michael L Johnson PT +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +Scott +By: Gummings 10-23-2018 Date +Sellbury +Signature +Dechange +Chief Administrative Officer +Printed Name +Michael L Johnson PT +PT, TIN owner +Title +White Mountain Physical therapy, +Address for Plan Notices: +Contracting Entity/Group Name +LTD + 86-0460643 +Carel 1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +05-03-2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +PO Box 1420 +Show Low, AZ 85902-1420 +CareIst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc5_Tipton,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc5_Tipton MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,30487744,030497744, ," +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +By: Cummings 10 18 2018 Date +Anita Phelps +Scott +Signature +Chief Administrative Officer +Anita Phelps +Printed Name +Contracts/Medical Biller +Title +Tipton Physical Therapy, LLC +Address for Plan Notices: +Contracting Entity/Group Name + 030497744 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +2/2/2017 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Tipton Physical Therapy, LLC +8400 E Florentine Road +Prescott Valley, AZ 86314-8653 + +Start of Page No = 3 +RECITALS +A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1,3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc5_Tipton,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc5_Tipton MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,30487744,030497744, ," +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +By: Cummings 10 18 2018 Date +Anita Phelps +Scott +Signature +Chief Administrative Officer +Anita Phelps +Printed Name +Contracts/Medical Biller +Title +Tipton Physical Therapy, LLC +Address for Plan Notices: +Contracting Entity/Group Name + 030497744 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +2/2/2017 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Tipton Physical Therapy, LLC +8400 E Florentine Road +Prescott Valley, AZ 86314-8653 + +Start of Page No = 3 +RECITALS +A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1,3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0872873,86-0872873, ," +PLAN +PROVIDER +Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life +Chief Administrative Officer +DAVID A DEXTER +Printed Name +CEO +Title +Address for Plan Notices: +Contracting Entity/Group Name + 86-0872873 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +8/21/2019 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +1255 W Washington SI. +Tempe, Az +85281 +Page 1 of 1 + +Start of Page No = 2 +ATTACHMENT C +LABORATORY SERVICES COMPENSATION +Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider +to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the +AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- +Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory +services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at +fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. +For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule +will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the +effective date of the new AHCCCS Fee Schedule", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st,training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0872873,86-0872873, ," +PLAN +PROVIDER +Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life +Chief Administrative Officer +DAVID A DEXTER +Printed Name +CEO +Title +Address for Plan Notices: +Contracting Entity/Group Name + 86-0872873 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +8/21/2019 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +1255 W Washington SI. +Tempe, Az +85281 +Page 1 of 1 + +Start of Page No = 2 +ATTACHMENT C +LABORATORY SERVICES COMPENSATION +Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider +to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the +AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- +Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory +services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at +fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. +For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule +will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the +effective date of the new AHCCCS Fee Schedule", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +2.2000_OptionalCare.INC_ServicesAgreement,training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/2.2000_OptionalCare.INC_ServicesAgreement MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,75-2496435,75-2496435, ," reboran +too +Ancillary Provider: +By: +L Deborah Strane, CPA, MBA +Slenda By: +Executive Director, PCHP +Title: +Title: V P +Date: +MAY 01 2000 +Date: Mark , 2000 +Tax ID: 75-2496435 +Ancillary Agreement +2 +02/22/00 +12:47 PM + +Start of Page No = 30 + + +Start of Page No = 31 +PARKLAND COMMUNITY HEALTH PLAN, INC. +A PROGRAM OF DALLAS COUNT HOSPITAL DISTRICT +PARTICIPATING ANCILLARY SERVICES PROVIDER AGREEMENT +Attachment B +SECTION 1 - PCHP MEDICAID STAR HMO SERVICES +Participating Ancillary Services Provider shall be reimbursed for medically necessary Covered +Services provided to HEALTHfirst Members as follows: +1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for +the State of Texas or the Participating Ancillary Services Provider's usual and customary +charge, whichever is less. +SECTION 2 PCHP CHIP HMO SERVICES +Participating Ancillary Services Provider shall be reimbursed for Covered Services provided to +KIDSfirst Members as follows: +1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for +the State of Texas or the Participating Ancillary Services Provider's usual and customary +charge, whichever is less. +Ancillary Agreement +3 +02/22/00 +12:47 PM + +Start of Page No", ,29,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +5.2000_Rehab Designs of America_VendorAgreement,training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/5.2000_Rehab Designs of America_VendorAgreement MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,48-1165993,48-1165993, ," +IN WITNESS WHEREOF, PCHP and Ancillary Provider have entered into this +Agreement as of the Effective Date +Parkland Community Health Plan +Ancillary Provider: Rehab Designs +U Debonah StRane +Ar +of America +By: +L Deborah Strane, CPA, MBA +By: Jult/Sirley +Executive Director, PCHP +Title: +Title: U-P, Business +Develop next +MAY 01 2000 +Date: +Date: +3-16-00 +Tax ID: 48-1165993 +Ancillary Agreement +2 +02/22/00 +12:47 PM + +Start of Page No = 31 +PARKLAND COMMUNITY HEALTH PLAN, INC. +A PROGRAM OF DALLAS COUNT HOSPITAL DISTRICT +PARTICIPATING ANCILLARY SERVICES PROVIDER AGREEMENT +Attachment B +SECTION 1 - PCHP MEDICAID STAR HMO SERVICES +Participating Ancillary Services Provider shall be reimbursed for medically necessary Covered +Services provided to HEALTHfirst Members as follows: +1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for +the State of Texas or the Participating Ancillary Services Provider's usual and customary +charge, whichever is less. +SECTION 2 PCHP CHIP HMO SERVICES +Participating Ancillary Services Provider shall be reimbursed for Covered Services provided to +KIDSfirst Members as follows: +1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for +the State of Texas or the Participating Ancillary Services Provider's usual and customary +charge, whichever is less. +Ancillary Agreement +3 +02/22/00 +12:47 PM + +Start of Page No = 32 +", ,30,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +6.2000_Omni Transport Systems_ServicesAgreement,training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/6.2000_Omni Transport Systems_ServicesAgreement MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,75-2809999,75-2809994, ," Any notice given by telecopy +or +personal delivery shall be deemed received on the date of transmission or delivery, as the +case may be +IN WITNESS WHEREOF, PCHP and Ancillary Provider have entered into this +Agreement as of the Effective Date +Parkland +Ancillary Provider: North Tx LifeStar,L +By: +By: +L Deborah Strane, CPA, MBA +Executive Director, PCHP +Title: +Title: QUALCED +JUN 12 2000 +Date: +Date: March 8, 2000 +Tax ID: 75-2809994 +Ancillary Agreement +2 +02/22/00 +12:47 PM + +Start of Page No = 17 +PARKLAND COMMUNITY HEALTH PLAN, INC. +A PROGRAM OF DALLAS COUNT HOSPITAL DISTRICT +PARTICIPATING ANCILLARY SERVICES PROVIDER AGREEMENT +Attachment B +SECTION 1 - PCHP MEDICAID STAR HMO SERVICES +Participating Ancillary Services Provider shall be reimbursed for medically necessary Covered +Services provided to HEALTHfirst Members as follows: +1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for +the State of Texas or the Participating Ancillary Services Provider's usual and customary +charge, whichever is less. +SECTION 2 PCHP CHIP HMO SERVICES +Participating Ancillary Services Provider shall be reimbursed for Covered Services provided to +KIDSfirst Members as follows: +1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for +the State of Texas or the Participating Ancillary Services Provider's usual and customary +charge, whichever is less. +Ancillary Agreement +3 +02/22/00 +12:47 PM + +Start of Page No = 18 +PARKLAND COMMUNITY HEALTH PLAN, INC., +A PROGRAM OF DALLAS COUNTY HOSPITAL DISTRICT +STAR Medicaid Managed Care Program +Provider Information Form +Please Note: This information is requested in order to demonstrate to the Texas Department of Health that V +will have an adequate network with sufficient capacity to care for Medicaid patients. +PROVIDER NAME +OMNI TRANSPORT SYSTEMS, LLC, DALLAS +PROVIDER D.B.A +NORTH TEXAS LIFESTAR, LLC, DALLAS +PROVIDER TYPE +HELICOPTER Ambulance +TYPE OF SERVICES PROVIDED (LIST FULL SCOPE OF SERVICES) +Air Ambulance Services for Trauma and cutical care. +ARE YOU LICENSED BY THE STATE OF TEXAS? +LICENSE TYPE (IF APPLICABLE) +(IMPORTANT: Please attach copy of state license) +MICU +N/A +YES +NO +LICENCE NO# 300241 +ADDRESS 1 +ADDRESS 2 +4650 Airport Parkway +CITY +STATE +ZIP +CITY +STATE. +ZIP +Addison +Tx +75001 +NOTE: If you have additional addresses attach a separate page +BILLING ADDRESS +ARE YOU A HISTORICALLY UNDERUTILIZED BUSINESS (HUB)? +MEDBILL RESOURCES CORP. +YES +NO +1890 W", ,16,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Advanced Respiratory Inc. - signed,training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/Advanced Respiratory Inc. - signed MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,41-1419350,41-1419350, ," Smith +By: kari Roehrich (Feb 9,2023 15:26 CST) +By: Nicholas J Smith (Feb 9, 2023 15:48 CST) +Printed Name: Kari Roehrich +Printed Name: Nicholas Smith +Title: Authorized Signer +Title: VP, Network Development & Provider Relations +Contract Effective Date: 3/1/2023 +(TO BE COMPLETED BY HEALTH PLAN) +REIMBURSEMENT ADDRESS: 1020 County Road F W Saint Paul, MN 55126-2910 +MAIN TELEPHONE NUMBER: 1-800-426-4224 +CHIEF EXECUTIVE OFFICER: +N/A +CHIEF FINANCIAL OFFICER: +N/A +BUSINESS OFFICE MANAGER: N/A +FEDERAL TAX I D NUMBER : 41-1419350 +NPI NUMBER: 1053357905 +As required by Section 10.8 (""Notices"") of this Agreement, notices shall be sent to each Party at the following +addresses: +To Provider at: Advanced Respiratory Inc, +Address: 1020 County Road F W Saint Paul, MN 55126-2910 +To Parkland at: Community Health Plan, Inc. +1341 West Mockingbird Lane +Dallas, Texas 75247 +Attention: Nicholas Smith +Email: NICHOLAS.SMITH@phhs.org +23 + +Start of Page No = 24 +Exhibit 1 +Electronic Claims Submission +The following are requirements for the submission of claims electronically to Payors: +1 In transmitting EDI, Provider will transmit such claims edited and formatted according to the +specifications indicated within the most current Provider User Guide or the ANSI X12 837 +Implementation Guide Provider understands that Payors shall be the final authority in resolving any +disputes about how electronic data shall be submitted. +2. +Provider agrees and understands that all claims submitted via EDI, for all legal and other purposes will +be considered signed by Provider or Provider's authorized representative and Provider attests as to the +accuracy and truthfulness of such claims. +3. +Provider acknowledges that Payors shall have no obligation with respect to the content of the +information in claims either to verify, check or otherwise inspect the information supplied by Provider, +except to reformat the claim data to the specification required by Payors Provider further +acknowledges that Payors will determine whether a claim qualifies as a Clean Claim, including, but not +limited to, whether Provider has submitted enough information in the EDI claims in order to determine +the completeness, accuracy and validity of the information and claims and that source documents for +claims data are the responsibility of Provider. +24 + +Start of Page No", ,23,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_2015-08-01 COMM Amend FE - Slocum Surgery Center,training-data/contract-text-file/3. Ancillary Custom/Custom_2015-08-01 COMM Amend FE - Slocum Surgery Center MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,77-0590285,77-0590285, ," Johnson, MD, MBA +michelle yuva +(Print Name) +(Print Name) +President, Moda Health +Sr Vice President, Moda Inc +Administrator +(Title) +(Title) +7/27/2015 +6/16/15 +(Date) +(Date) + 77-0590285 +(Tax ID Number) +Prepared by: Darren Dromgoole (6/12/2015) +Moda Health Participating Provider Amendment +Slocum Surgery Center +3 of 8 + +Start of Page No = 4 +02:27:04p.m.06-15-2015 +, +541 743 2517 +Jun 16 2015 2:30PM Slocum 541 743 2517 +No 0262 +P. +5 +EXHIBIT A +PRACTICE INFORMATION +Tax ID#: +77-90285 +NPI: +1679696157 +Claims Remittance / Billing Location +Remittance/Billing Address* +55 Coberg Rd +Eugene OR 97401 +Telephone Number +(544)743-2500 +Fax Number: +(541) 743-2517 +Office Contact: +Shelley yuva +Email address (if applicable): +Payments will be made to Group/Clinic unless otherwise requested +*Remittance address listed must match information provided in box 33 on CMS 1500 or equivalent form, +or box 2 on a UB-04 or equivalent form. +Practice Location(s) +Physical Address (Primary): +as above +Telephone Numbers +Fax Number: +Physical Address 2 (if applicable): +N/A +Telephone Number: +Fax Number: +Please attach a separate locations listing, as necessary. +Moda Health Participating Provider Amendment +Slocum Surgery Center +4 of 8 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +"Custom_2017-09-15 COMM Agmt FE - Plaza Ambulatory Surgery Center, LLC","training-data/contract-text-file/3. Ancillary Custom/Custom_2017-09-15 COMM Agmt FE - Plaza Ambulatory Surgery Center, LLC MU.txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,35-2480914,35-2480914, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +"Custom_2018-09-15 COMM Amend FE Plaza Ambulatory Surgery Center, LLC","training-data/contract-text-file/3. Ancillary Custom/Custom_2018-09-15 COMM Amend FE Plaza Ambulatory Surgery Center, LLC MU.txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,35-2480914,35-2480914, ," +Plaza Ambulatory Surgery Center, LLC +601 SW Second Avenue +5050 NE Hoyt Street, Suite 156 +Portland, OR 97204 +Portland, OR 97213 +mys +pawn +(Signature) +IIAM JOHNSON +(Signature) +William E Johnson, MD, MBA +Daniel Weber +(Print Name) +(Print Name) +President, Moda Health +Sr Vice President, Moda, Inc +Administrator +(Title) +(Title) +9/17/2018 +8/21/2018 +(Date) +(Date) + 35-2480914 +(Tax ID Number) +2016 Moda Health PPO-POS Provider Amendment +Plaza Ambulatory Surgery Center, LLC +Page 2 + +Start of Page No = 3 +EXHIBIT A +PROVIDER INFORMATION +Tax ID#: +35-2480914 +Location(s) +Physical Address (Primary): +5050 we Hoyt St STE # 156 +City: +State: +Zip: +PORtland +OR +97203 +Phone #: +Fax #: +971-229-8100 +971-229-8101 +NPI: +1891127981 +Physical Address 2 (if applicable): +City: +State: +Zip: +Phone #: +Fax #: +NPI: +(Attach any additional locations on a separate sheet) +Claims Remittance / Billing Location +Remittance / Billing Address*: +Plaza Ambulatory # I +P.O Box 84201 +City: +State: +Zip: +Seattle +WA +98124 5501 +Phone #: +Fax #: +971-229-8100 +971-229-8101 +Office Contact: +Daniel weber +Contract Administrator email address (if applicable): +A woodell@Regard Surgical health.com +Payments will be made to Group/Clinic unless otherwise requested +*Remittance address listed must match information provided in box 33 on CMS 1500 or equivalent form, or box 2 on +a UB-04 or equivalent +2016 Moda Health PPO-POS Provider Amendment +Plaza Ambulatory Surgery Center, LLC +Page 3 + +-------TABLE Start----- +Physical Address 2 (if applicable): +City: +State: +Zip: +Phone #: +Fax #: +NPI: +-------TABLE End----- + +Start of Page No", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_Anc_Better Living Now Inc - Amendment Provider Signed 4.29.19,training-data/contract-text-file/3. Ancillary Custom/Custom_Anc_Better Living Now Inc - Amendment Provider Signed 4.29.19_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,13-3683081,133-683081, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_Bestcare Inc - Amendment 7.1.14,training-data/contract-text-file/3. Ancillary Custom/Custom_Bestcare Inc - Amendment 7.1.14_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,13-3121904,133-121904, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +BoilerplateFac_Bertrand Chaffee Hospital - Amendment 4.17.15,training-data/contract-text-file/4. Facility Boilerplate/BoilerplateFac_Bertrand Chaffee Hospital - Amendment 4.17.15 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,160743921,160-743921, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14,training-data/contract-text-file/4. Facility Boilerplate/Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,"13-1974191, 132707945",13-1974191, ," = 4 +IN WITNESS WHEREOF, the parties here have signed this AMENDMENT to become +effective on the date referenced above +Bronx Lebanon Hospital +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 +1650 Grand Concourse +By: David P Thomas +Address +Its: Executive Vice President & Chief Operating +Bronx, NY 10457 +Officer +City, State, Zip Code +Entity Tax ID#: 13-1974191 +Date: +6/24/13 +Entity NPI#: 1417027558 +Signature: Duna +Name: Victor Dellarco +(Please Print) +Title SUP Chief FINANCIAL Officer +Date: +6/12/13 +Signature: +4 +BronxLebanonHospital.HEX.Amend.04.09.13 + +Start of Page No = 5 +IN WITNESS WHEREOF, the parties here have signed this AMENDMENT to become +effective on the date referenced above. +Dr Martin Luther King Jr Health Center +NEW YORK STATE CATHOLIC HEALTH +Provider (Please Print) +PLAN, INC", ,4,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Boilerplate_HSA_EFF03012012_Children's Medical Center,training-data/contract-text-file/4. Facility Boilerplate/Boilerplate_HSA_EFF03012012_Children's Medical Center MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,75-0800628,75-0800628, ," Box 844007 +Email Address +Dallas, TX 75284-4007 +Tax I D No + 75-0800628 +License No. +000143 +Physical Address (if di fferent than above): +Texas Provider Identification +1389108-07 +Number (TPIN) +NPI (or UPIN if NPI not yet +NPI: 1194743013 +designated) +UPIN: +DEA No. +AC2260242 +(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) +Signatory Title +(Printed): +Signature Date: +Mirr HSA 02/10/10 +Page 26 of 40 +Provider or authorized +representatives intinis +Run + +-------TABLE Start----- +Provider Name +Children's Medical Center of Dallas +Billing Address: +Telephone No. +214-456-7000 +Facsimile No. +P.O Box 844007 +Email Address +Dallas, TX 75284-4007 +Tax I.D No. +75-0800628 +License No. +000143 +Physical Address (if di fferent than above): +Texas Provider Identification +1389108-07 +Number (TPIN) +NPI (or UPIN if NPI not yet +NPI: 1194743013 +designated) +UPIN: +DEA No. +AC2260242 +-------TABLE End----- + +-------TABLE Start----- +Provider +Signature: +Signatory Name +(Printed) +Signatory Title +(Printed): +Signature Date: +-------TABLE End----- + +Start of Page No = 27 +ATTACHMENT A +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 +Children's Dallas Ambulatory +Billing Address: +Care Pavilion +Telephone No. +214-730-KIDS (5437) +P.O Box 844007 +Facsimile No. +Dallas, TX75284-4007 +Email Address +Taxl.D", ,26,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/4. Facility Boilerplate/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, ," 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 +El Paso County Hospital District, DBA, +Molina Healthcare of Texas, Inc , +University Medical Center of El Paso +- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Pres / CEO +Signatory Title +Title (Printed): +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: + 74-6000756 +Effective Date: +3/1/2012 +Amendment to +Page I of 3 +Provider or authorized gar +HSA - UMC El Paso 03122012 +representative's initials: + +-------TABLE Start----- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Title (Printed): +Pres / CEO +Signatory Title +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: +74-6000756 +Effective Date: +3/1/2012 +-------TABLE End----- + +Start of Page No = 2 +ATTACHMENT D +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. +In addition to the above listed compensation rates, payment for the following services for all Health +Plan products & programs shall be reimbursed according to the table below: +Outpatient Services +Revenue Codes +Negotiated Payment +Implants/Prosthetics/Pacemakers +274,275,276,278 +70% of Billed Charges equal +paid when any one single item is +to Provider's Acquisition Cost +over $500 +plus five percent (5%) +High Cost Drugs - paid when any +634,636 +70% of Billed Charges equal +one single item is over $500 +to Provider's Acquisition Cost +plus five percent (5%) +Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one +hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider +shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) +of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are +made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written +notification At any time Health Plan may request a copy of an invoice from Provider to validate +Provider's Acquisition Cost", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/4. Facility Boilerplate/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, ," 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 +El Paso County Hospital District, DBA, +Molina Healthcare of Texas, Inc , +University Medical Center of El Paso +- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Pres / CEO +Signatory Title +Title (Printed): +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: + 74-6000756 +Effective Date: +3/1/2012 +Amendment to +Page I of 3 +Provider or authorized gar +HSA - UMC El Paso 03122012 +representative's initials: + +-------TABLE Start----- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Title (Printed): +Pres / CEO +Signatory Title +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: +74-6000756 +Effective Date: +3/1/2012 +-------TABLE End----- + +Start of Page No = 2 +ATTACHMENT D +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. +In addition to the above listed compensation rates, payment for the following services for all Health +Plan products & programs shall be reimbursed according to the table below: +Outpatient Services +Revenue Codes +Negotiated Payment +Implants/Prosthetics/Pacemakers +274,275,276,278 +70% of Billed Charges equal +paid when any one single item is +to Provider's Acquisition Cost +over $500 +plus five percent (5%) +High Cost Drugs - paid when any +634,636 +70% of Billed Charges equal +one single item is over $500 +to Provider's Acquisition Cost +plus five percent (5%) +Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one +hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider +shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) +of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are +made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written +notification At any time Health Plan may request a copy of an invoice from Provider to validate +Provider's Acquisition Cost", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/4. Facility Boilerplate/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, ," 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 +El Paso County Hospital District, DBA, +Molina Healthcare of Texas, Inc , +University Medical Center of El Paso +- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Pres / CEO +Signatory Title +Title (Printed): +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: + 74-6000756 +Effective Date: +3/1/2012 +Amendment to +Page I of 3 +Provider or authorized gar +HSA - UMC El Paso 03122012 +representative's initials: + +-------TABLE Start----- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Title (Printed): +Pres / CEO +Signatory Title +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: +74-6000756 +Effective Date: +3/1/2012 +-------TABLE End----- + +Start of Page No = 2 +ATTACHMENT D +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. +In addition to the above listed compensation rates, payment for the following services for all Health +Plan products & programs shall be reimbursed according to the table below: +Outpatient Services +Revenue Codes +Negotiated Payment +Implants/Prosthetics/Pacemakers +274,275,276,278 +70% of Billed Charges equal +paid when any one single item is +to Provider's Acquisition Cost +over $500 +plus five percent (5%) +High Cost Drugs - paid when any +634,636 +70% of Billed Charges equal +one single item is over $500 +to Provider's Acquisition Cost +plus five percent (5%) +Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one +hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider +shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) +of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are +made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written +notification At any time Health Plan may request a copy of an invoice from Provider to validate +Provider's Acquisition Cost", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Fac1_Bullhead City_Western Arizona Med Center - 860982071,training-data/contract-text-file/4. Facility Boilerplate/Fac1_Bullhead City_Western Arizona Med Center - 860982071 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-1027746,86-0982071, ," +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written +PLAN +PROVIDER +By: +Scott Cummings +Efficiency 10-5-2018 Date +State Plan resident +Signature MICHAEL J STENGER +Printed Name: +INTERIM CEO +Title +Address for Plan Notices: +Contracting Entity/Group Name + 86-0982071 86-1027746 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Network Management +1/27/18 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Community Health Systems +Attn: Managed Care Departmetn +4000 Meridian Blvd +Franklin, TN37067 +Careist Hospital Services Agreement +120114 +Page 1 of23 + +Start of Page No = 4 +RECITALS +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible through a program +administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +WHEREAS, Plan desires to enter into contracts with licensed and experienced Health Care +Professionals, hospitals and other providers to provide or arrange for the provision of certain health care services to Plan +Members; +WHEREAS, Hospital is licensed and experienced to provide or arrange for the provision of certain +hospital and other services and supplies; and +WHEREAS, Plan and Hospital desire to enter into this Agreement for Hospital to provide or arrange +for the provision of certain hospital and other services and supplies to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and +valuable consideration, the receipt of which is hereby acknowledged, the parties mutually agree as follows: +I, +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Active Labor"" means a labor at a time at which either of the following would occur: (1) There is +inadequate time to effect safe transfer to another hospital prior to delivery, (2) A transfer may pose a threat to the health +and safety of the patient or the unborn child. +1.2 +""Acts and Regulations"" means the Federal and Arizona codes and regulations that govern the services +to be provided under this Agreement which are more fully described in Article VII. +1,3 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical +equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services and other +services customarily deemed ancillary. +1,4 +""AHCCCS"" "" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care +services are provided to a member. +Carelst Hospital Services Agreement +120114 +Page 2 of 23 + +Start of Page No = 5 +1.5 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Fac3_Phoenix Children Hosp_2,training-data/contract-text-file/4. Facility Boilerplate/Fac3_Phoenix Children Hosp_2 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0422559,86-0422559, ," +PLAN +HOSPITAL +By: +Scott +Cummings Selfining 10 24 2014 Date +Robert bleyn +Signature +Chief Administrative Officer +Robert L Meyer +Printed Name +President & Chief Executive Officer +Title +Phoenix Children's Hospital +Address for Plan Notices: +Contracting Entity/Group Name + 86-0422559 +Carelst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +10/16/14 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Phoenix Children's Hospital, Inc. +ATTN: Managed Care +1919 E Thomas Road, Bldg 2108, #101 +Phoenix, AZ 85016 +CC: Address for Provider Notices: +Phoenix Children's Hospital, Inc. +ATTN: Office of General Counsel +1919 E Thomas Road +Phoenix, AZ 85016 +Page 3 of 5 + +Start of Page No = 4 +ATTACHMENT C +HOSPITAL COMPENSATION +Hospital is responsible for providing all necessary Covered Health Care Services to Plan Members deemed to +be necessary by the Plan Medical Director or AHCCCS, whether Member presents for emergency services or +is admitted by Plan Provider upon authorization from Plan, consistent with the standards and limitations of +Hospital's licensure and the AHCCCS statutes, regulations and policies and payment methodology, and +consistent with Federal regulations. +Plan shall pay to Hospital for those services properly billed (see Article IV of Agreement) which are +Medically Necessary Covered Health Care Services and which are compliant with all AHCCCS and Plan +policies, including notification and authorization policies as follows: +1 Payment conditions for Services rendered from date of contract. +Hospital shall bill Plan for Services rendered within six months of discharge of Member. +Plan shall adjudicate the bills and inform Hospital of the results of the adjudication within +AHCCCS claims payment timeliness guidelines of bills correctly submitted under this +Agreement and that constitute ""clean claims"" under the AHCCCS Requirements", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +HSA_EFF TBD_PrimeHealthcare_MissionRegionalMedicalCenter,training-data/contract-text-file/4. Facility Boilerplate/HSA_EFF TBD_PrimeHealthcare_MissionRegionalMedicalCenter MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-2206635,74-2206635, ," III +09/06/2022 +Telephone Number: +Fax Number - Official Correspondence: +956-323-9000 +956-323-9102 +Mailing Address - Official Correspondence: +Payment Address - If different than Mailing Address: +900 S Bryan Rd, Mission, TX 78572 +P O Box 674059, Dallas, TX 75267-4059 +Email Address - Official Correspondence: +Tax ID Number - As listed on corresponding tax form: +healthplanops@primehealthcare com + 74-2206635 +NPI - That corresponds to the above Tax ID Number: +Notice Address: 3480 E Guasti Rd., Ontario, CA 91761 +1205833985 +Health Plan Signature and Information: +Molina Healthcare of Texas, Inc., a Texas Corporation (""Health Plan"") +Authorized Representative's Signature: +Authorized Representative's Name - Printed: +Chris Coffey +Authorized Representative's Title: +Authorized Representative's Countersignature Date: +Plan President +Mailing Address - Official Correspondence: +Email Address - Official Correspondence: +1660 North Westridge Circle, Irving, TX 785038 +MHTContract@MolinaHealthcare.com +Molina Texas HSA (FFS) +Page 1 of 48 +MHTHSA030218 + +-------TABLE Start----- +Provider's Legal Name (""Provider"") - as listed on applicable tax form (i.e W-9): +Mission Hospital, Inc. +Authorized Representative's Signature: +Authorized Representative's Name - Printed: +Harsha Upadhyay +Authorized Representative's Title: +Authorized Representative's Signature Date: +Regional Chief Executive Officer, Reg III +09/06/2022 +Telephone Number: +Fax Number - Official Correspondence: +956-323-9000 +956-323-9102 +Mailing Address - Official Correspondence: +Payment Address - If different than Mailing Address: +900 S Bryan Rd, Mission, TX 78572 +P.O Box 674059, Dallas, TX 75267-4059 +Email Address - Official Correspondence: +Tax ID Number - As listed on corresponding tax form: +healthplanops@primehealthcare.com +74-2206635 +NPI - That corresponds to the above Tax ID Number: +Notice Address: 3480 E", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreementAmendment_ICMProviderAgreementAmendment_169834_6 - Hope Community,training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreementAmendment_ICMProviderAgreementAmendment_169834_6 - Hope Community MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,73-1098634,73-1098634, ," = 2 +IN WITNESS WHEREOF, the Parties hereto have executed and delivered this Amendment as of the date above +Health Plan: +PROVIDER: +Oklahoma Complete Health, Inc +Hope Community Services, Inc +Authorized Signature +Authorized Signature +Clayton Franklin +Jeanette L Moore, CEO +Clayton Franklin (Oct 20, 2023 10:06 CDT) +Jeanette L Moore, CEO (Oct 13, 2023 10:03 CDT) +Printed Name: Clayton Franklin +Printed Name: Jeanette Moore +Title: President & CEO +Title: CEO +Date: Oct 20, 2023 +Date: Oct 13, 2023 +ICM #: ICMProviderAgreementAmendment_16983 +Tax ID Number: 73-1098634 +State Medicaid Number: +NPI: +ICMProviderAgreementAmendment_169834 +Page 2 of 28 + +Start of Page No = 3 +Attachment A: Medicaid +PRODUCT ATTACHMENT +OKLAHOMA MEDICAID PRODUCT (SOONERSELECT) +(INCLUDING REGULATORY REQUIREMENTS) +THIS PRODUCT ATTACHMENT (this ""Attachment"") is made and entered between Oklahoma Complete +Health, Inc (""Health Plan"") and Hope Community Services, Inc (""Provider""). +WHEREAS, Health Plan and Provider entered into that certain provider agreement, as the same may have +been amended and supplemented from time to time (the ""Agreement""), pursuant to which Provider and its Contracted +Providers participate in certain Products offered by or available from or through a Company; +WHEREAS, pursuant to the provisions of the Agreement, Contracted Providers will be designated and +participate as ""Participating Providers"" in the Product described in this Attachment; and +WHEREAS, Health Plan has contracted with the Oklahoma Health Care Authority (""OHCA"") to be a State +Medicaid Care Management Organization to provide Covered Services to Covered Persons in the State's Medicaid +program known as SoonerSelect, and such other programs (hereafter referred to as ""Medicaid Product"") as may be +awarded to Health Plan by OHCA. +WHEREAS, the Agreement is modified or supplemented as hereafter provided. +NOW THEREFORE, in consideration of the recitals, the mutual promises herein stated, the parties hereby +agree to the provisions set forth below. +1. +Defined Terms All capitalized terms not specifically defined in this Attachment will have the +meanings given to such terms in the Agreement", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_ChampionsForChildrensMentalHealth_219129_5,training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreement_ChampionsForChildrensMentalHealth_219129_5.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,81-3580335,81-3580335, ," = 13 +THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION +THAT MAY BE ENFORCED BY THE PARTIES +IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Delaware First Health, Inc +CHAMPIONS FOR CHILDREN'S MENTAL +HEALTH +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Barbara Messick +Aaron Brace (Aug 30, 2022 10:49 EDT) +Barbara Messick (Aug 22, 2022 14:17 EDT) +Print Name: Aaron Brace +Print Name: Barbara Messick +Title: Corporate Vice President, National Contracting +Title: Executive Director +Officer +Signature Date: Aug 30, 2022 +Signature Date: Aug 22, 2022 +ICM #: ICMProviderAgreement_219129 +Tax Identification Number: 81-3580335 +To be completed by Health Plan only: +National Provider Identifier: 1750809729 +Effective Date: Sep 21, 2022 +Medicare Number: + +-------TABLE Start----- +Delaware First Health, Inc. +CHAMPIONS FOR CHILDREN'S MENTAL +HEALTH +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Barbara Messick +Aaron Brace (Aug 30, 2022 10:49 EDT) +Barbara Messick (Aug 22, 2022 14:17 EDT) +Print Name: Aaron Brace +Print Name: Barbara Messick +Title: Corporate Vice President, National Contracting +Title: Executive Director +Officer +Signature Date: Aug 30, 2022 +Signature Date: Aug 22, 2022 +ICM #: ICMProviderAgreement_219129 +Tax Identification Number: 81-3580335 +To be completed by Health Plan only: +National Provider Identifier: 1750809729 +Effective Date: Sep 21, 2022 +Medicare Number: +-------TABLE End----- + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_ICMProviderAgreement_49186_5 - Hope Community,training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreement_ICMProviderAgreement_49186_5 - Hope Community MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,73-1098634,73-1098634, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_RecoveryInnovations_223416_5,training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreement_RecoveryInnovations_223416_5.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,71-1018775,71-1018775, ," +IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Delaware First Health, Inc +Recovery Innovations, Inc +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Aaron Brace +Paul Galdys +Aaron Brace (Oct 3, 2022 14:33 EDT) +Paul Galdys (Sep 28, 2022 10:02 PDT) +Print Name: Aaron Brace +Print Name: Paul Galdys +Title: Regional Vice President, New Business Network +Title: Deputy CEO +Development +Signature Date: Oct 3,2022 +Signature Date: Sep 28, 2022 +ICM #: ICMProviderAgreement_223416 +Tax Identification Number: 71-1018775 +To be completed by Health Plan only: +National Provider Identifier: 1912381344 +Effective Date: Oct 28, 2022 +Medicare Number: + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +St. Joseph_Fac2_MEDICAID 22-1487602 Amendment_121367,training-data/contract-text-file/4. Facility Boilerplate/St. Joseph_Fac2_MEDICAID 22-1487602 Amendment_121367 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,22-1487602,22-1487602, ," = 2 +IN WITNESS WHEREOF, the Parties hereto have executed and delivered this Amendment as of the date above +HEALTH PLAN: +CONTRACTED PROVIDER: +WellCare Health Plans of New Jersey, Inc +St Joseph's Regional Medical Center +Authorized Signature +Authorized Signature +Kevin Slavin +DIGITALLY +SIGNED +John g Kirchner +Printed Name: John Kirchner +Printed Name: {{*Name_es_:Signer1 +Title: Plan President & CEO +Title: {{*Ttll_es_:Signer1:title +}} +12/18/22 +Date: {{$IntDate +}} +Date: { {$ExtDate +}} 12/14/2022 +09:15 AM EST +ICM #: (CMProviderAgreementAmendment_121637 +Tax ID Number: 22-1487602 +State Medicaid Number: +NPI: +{ {#ExtDate=ExtSignDate_es_:signer1:date +}} +{ +{#IntDate=IntSignDate_es_:signer2:date +}} +ICMProviderAgreementAmendment_121637 +Page 2 of 3 + +-------TABLE Start----- +Authorized Signature +Kevin Slavin +DIGITALLY +SIGNED +Printed Name: {{*Name_es_:Signer1 +Title: {{*Ttll_es_:Signer1:title +}} +Date: { {$ExtDate +}} 12/14/2022 +09:15 AM EST +-------TABLE End----- + +Start of Page No = 3 +ATTACHMENT C-2 +NEW JERSEY MEDICAID/FAMILYCARE +COMPENSATION SCHEDULE +HOSPITAL SERVICES +[St Joseph's Regional Medical Center] +This compensation schedule (""Compensation Schedule"") sets forth the maximum reimbursement amounts for +Covered Services provided by Providers to Members enrolled in a Medicaid Program Where the Provider's tax +identification number (""TIN"") has been designated by the Health Plan as subject to this Compensation Schedule, +Health Plan shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Provider +according to the terms of, and subject to the requirements set forth in, the Agreement and this Compensation Schedule. +Payment under this Compensation Schedule shall consist of the Allowed Amount as set forth herein less all applicable +Member Expenses All capitalized terms used in this Compensation Schedule shall have the meanings set forth in the +Agreement, the applicable Program Attachment, or the Definitions section set forth at the end of this Compensation +Schedule. +The maximum compensation for hospital Covered Services rendered to a Member shall be the ""Allowed Amount."" +Except as otherwise provided in this Compensation Schedule, the Allowed Amount for hospital Covered Services is +the lesser of: (i) Allowable Charges; or (ii) the rates set forth in Table 1 below. +Table 1 +Covered Services +Rates +107 percent of the applicable New Jersey +Medicaid/FamilyCare inpatient prospective payment +Inpatient Covered Services +system rates of Diagnosis Related Groups (DRG) +published on DMAHS's website, or otherwise provided +by DMAHS, on the date of the Member's discharge. +107 percent of the New Jersey Medicaid/FamilyCare +outpatient fee schedule or hospital specific payment +Outpatient Covered Services +amount for outpatient services published on DMAHS's +website, or as otherwise provided by DMAHS, on the +date the Covered Services are rendered. +Definitions: +1. +Allowed Amount means the amount designated in this Compensation Schedule as the maximum amount payable +to a Provider for any particular Covered Service provided to any particular Member, pursuant to this Agreement +or its Attachments. +2. +Allowable Charges means a Provider's billed charges for services that qualify as Covered Services. +ICMProviderAgreementAmendment_121637 +Page 3 of 3 + +-------TABLE Start----- +Covered Services +Rates +107 percent of the applicable New Jersey +Medicaid/FamilyCare inpatient prospective payment +Inpatient Covered Services +system rates of Diagnosis Related Groups (DRG) +published on DMAHS's website, or otherwise provided +by DMAHS, on the date of the Member's discharge. +107 percent of the New Jersey Medicaid/FamilyCare +outpatient fee schedule or hospital specific payment +Outpatient Covered Services +amount for outpatient services published on DMAHS's +website, or as otherwise provided by DMAHS, on the +date the Covered Services are rendered. +-------TABLE End-----", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +2017-07-01 St. Agnes Medical Center AMD,training-data/contract-text-file/4. Facility Custom/2017-07-01 St. Agnes Medical Center AMD MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,94-1437713,94-1437713, ,"07 12 09:36:42 -07'00' +Signature +Signature +NANCY HOLLINGSWORTH +Thomas Hamilton +Print Name +Regional Health Plan Officer +CEO +Title +7-6-17 +Date +Date +Saint Agnes Medical Center +3 +July 1, 2017 Amendment + +Start of Page No = 4 +Provider/Facility Name, +State +Federal Tax +Medicare +National +Medi-Cal +Other +Drug +Address, Telephone and +License +Identification +Provider +Specialty +Provider +Contract +Language( +Enforcement +Facsimile Phone +Number +Number +Number +Number +Identifier +s) +Agency Number +Saint Agnes Medical Center +1303 East Herndon Ave +General +040000173 + 94-1437713 +05-0093 +1205845567 +HSC00093F +Fresno, CA 93720 +Acute +559-450-3000 +Care +559-450-2143 +Hospital +Additional Location(s): +040000173 +94-1437713 +05-0093 +1205845567 +HSC00093F +Outpatient Services - Bone +Density Services at Hologic +Discovery SL Bone Density +Unit +7202 N Millbrook Ave #206 +Fresno, CA 93720 +Outpatient Services - Breast +Center +1105 E Spruce, Ste 102 +Fresno, CA 93720 +Outpatient Services +- +Mammography at Outpatient +Mammography +7202 N Millbrook, Ste", ,4,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_2017-01-01 Amendment & Addendum A & B Bayfront Health St Pete,training-data/contract-text-file/4. Facility Custom/Custom_2017-01-01 Amendment & Addendum A & B Bayfront Health St Pete MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,300759177,30-0759177, ," +The effective date of this Amendment shall be January 1, 2017 +IN WITNESS THEREOF, the parties, through their duly authorized representatives, hereby execute this +Amendment and agree to be bound by its terms +Hospital +By: +H +Date: +1/4/17 +Name: +Eric Smith +Title: +CFO, Bayfront St Pete +Tax ID: + 30-0759177 +Provider #: +363518 +AvMed, Inc. +By: +am 0 with +Date: 2/6/17 +Ann O Wehr, MD +SVP, Chief Medical Officer +AvMed, Inc. +1800 Pembrook Drive, Suite 190 +Orlando, FL 32810 +Dr + +Start of Page No = 10 +AvMED, INC. +REIMBURSEMENT SCHEDULE +ADDENDUM A [Commercial] +BAYFRONT HMA MEDICAL CENTER, LLCDBA +BAYFRONT HEALTH ST PETERSBURG +Effective: 01/01/17 through 9/30/18 +Service Description +Reimbursement Description +COMMERCIAL (INPATIENT): +All Commercial Inpatient Services +$7,928 Conversion Factor* +Multiplied by current CMS Medicare Relative Weights +as published by CMS and amended as updated by CMS +from time to time. +*The reimbursement for Normal Newborns (MS-DRG +795) is included in mother's reimbursement Non- +weighted DRGs will be reimbursed at 35% of billed +charges. +Transferring Members Per diem +$1,736 Per day for any AvMed member who is +(Per diem is in lieu of DRG payment). +transferred to another acute facility", ,9,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_2017-04-05 Lee Memorial Amendment Exhibits A-B,training-data/contract-text-file/4. Facility Custom/Custom_2017-04-05 Lee Memorial Amendment Exhibits A-B MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,"See "" Lee Memorial Providers"" tab",65-0319983, ,"Document Index +AVMED, INC 1AMENDMENT TO THE 1PHYSICIAN-HOSPITAL ORGANIZATION SERVICES AGREEMENT 1 +The effective date of this Amendment shall be July 1, 2017 4 +EXHIBIT A 5PRODUCT AND COMPENSATION SCHEDULE 5[Commercial] 5 +COMMERCIAL (OUTPATIENT/ANCILLARY SERVICES): 5 +EXHIBIT A 6PRODUCT AND COMPENSATION SCHEDULE 6[Commercial] 6 +Charge Master Price Protection 6 +Calculation Example 6 +EXHIBIT A 7PRODUCT AND COMPENSATION SCHEDULE 7[Commercial] 7 +REIMBURSEMENT SCHEDULE 8EXHIBIT B [Commercial] 8 +Health Park Care and Rehabilitation Center 8TIN 65-0319983, NPI 1699786061 8 +Effective: July 1, 2017 8 +REIMBURSEMENT SCHEDULE 9EXHIBIT B [Commercial] 9 +Health Park Care and Rehabilitation Center 9TIN 65-0319983, NPI 1699786061 9 +Charge Master Price Protection 9 +Calculation Example 9 +REIMBURSEMENT SCHEDULE 10EXHIBIT B [Commercial] 10 +Health Park Care and Rehabilitation Center 10TIN 65-0319983, NPI 1699786061 10 + + + +Start of Page No = 1 +AVMED, INC. +AMENDMENT TO THE +PHYSICIAN-HOSPITAL ORGANIZATION SERVICES AGREEMENT +THIS AMENDMENT TO THE PHYSICIAN-HOSPITAL ORGANIZATION SERVICES +AGREEMENT (the ""Amendment"") is by and between AvMed, Inc., a State Certified Health +Maintenance Organization (""Company"") and Lee Physicians Hospital Organization, a sub-agency of Lee +Memorial Health System, which operates a physician-hospital organization duly established in +accordance with the laws of the State of Florida (""PHO""). +WHEREAS, Company and PHO entered into that certain Physician-Hospital Organization Services +Agreement effective as of June 29, 2001, as amended previously by the parties (hereinafter referred to +collectively as the ""Agreement""); +NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions contained in the +Agreement and herein, the parties hereto agree as follows: +1. +Lee Physicians Hospital Organization is removed as a party to the Agreement and is +replaced by Lee Memorial Health System (hereinafter ""LMHS"") LMHS through its +execution of this Amendment, agrees to replace Physicians Hospital Organization and +be the party to the Agreement bound by all of the terms and conditions in the +Agreement. +2. +All references in the Agreement to PHO shall be deleted and replaced with ""LMHS."" +All references in the Agreement, including in the title, to ""PHYSICIAN-HOSPITAL +ORGANIZATION AGREEMENT"" are replaced with ""HOSPITAL +ORGANIZATION AGREEMENT."" +3. +EXHIBIT A PRODUCT AND COMPENSATION SCHEDULE attached to the +Agreement is deleted in its entirety and replaced with the new EXHIBIT A PRODUCT +AND COMPENSATION SCHEDULE [Commercial], attached hereto and made a part +hereof. +4. +REIMBURSEMENT SCHEDULE EXHIBIT B [Commercial] attached hereto and +made a part hereof is hereby added to the Agreement. +5. +The definition of ""Ancillary Provider"" in Section 1.1 of the Agreement is deleted in its +entirety and all references in the Agreement to ""Ancillary Provider"" are deleted from +the Agreement. +6. +The definition of ""PHO Hospital"" in Section 1.12 of the Agreement is deleted in its +entirety and all references in the Agreement to ""PHO Hospital"" are deleted and +replaced with ""LMHS Provider"". +7. +The definition of ""PHO Physician"" in Section 1.13 of the Agreement is deleted in its +entirety and all references in the Agreement to ""PHO Physician"" are deleted and +replaced with ""LMHS Provider."" +8. +The definition of ""PHO Provider"" in Section 1.14 of the Agreement is deleted in its +entirety and replaced with the following definition: +""LMHS Provider"" shall mean only the hospitals or skilled nursing facilities that are +listed in the Facility Listing Exhibit I [Commercial] attached to this Amendment to the +Agreement, which have agreed to furnish such Covered Services to Covered Persons +Page 1 of 4 + +Start of Page No = 2 +pursuant to an agreement with LMHSO No hospitals or skilled nursing facilities will +be added to or removed from this Agreement and/or Exhibit I, unless specifically +agreed to by both parties and a proper written amendment to the Agreement is +executed by both parties. +9. +The language in Section 2.1 ""General Representation"" of the Agreement is deleted in +its entirety and replaced with the following: +General Representation", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_2020-01-01 Com Affinity Amend FE - St Charles Health System,training-data/contract-text-file/4. Facility Custom/Custom_2020-01-01 Com Affinity Amend FE - St Charles Health System MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,93-0602940,93-0602940, ," Vice President, Moda, Inc +(Title) +(Title) +1 1 2020 +March 27, 2019 +(Date) +(Date) + 93-0602940 +(Tax ID Number) +Prepared by: T Metzler +Moda Health Provider Amendment-Affinity 2020 +2 +St Charles Health System Inc. + +Start of Page No = 3 +DocuSign Envelope ID: F7EB71C9-869B-4A09-8DA1-6E60E3ADB0CC +EXHIBIT -1b +HOSPITAL REIMBURSEMENT +ST", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_2023-01-01 COMM (CMI-Compression) Amend FE - Samaritan Health Services,training-data/contract-text-file/4. Facility Custom/Custom_2023-01-01 COMM (CMI-Compression) Amend FE - Samaritan Health Services MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,"930391573, 930110095, 930396847, 931305493, 931329784",930-391573, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +ICMProviderAgreement_CorasWellnessAndBehavioralHealth_212482_8,training-data/contract-text-file/4. Facility Custom/ICMProviderAgreement_CorasWellnessAndBehavioralHealth_212482_8.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,87-0846562,I do not see a taxpayer identification number stated on the signatory page. The document does not contain that information, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +ICMProviderAgreement_ICMProviderAgreement_143342_10_Landmark of Midwest City Rehab and Nursing Center,training-data/contract-text-file/4. Facility Custom/ICMProviderAgreement_ICMProviderAgreement_143342_10_Landmark of Midwest City Rehab and Nursing Center.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,82-1580561,82-1580561, ," = 12 +THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION +THAT MAY BE ENFORCED BY THE PARTIES +IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Oklahoma Complete Health, Inc +LANDMARK +OF +MIDWEST +CITY +REHABILITATION AND NURSING CENTER, LLC +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +Clayton Franklin +the +Clayton Franklin (Mar 31, 2022 09:13 CDT) +Angela Jackson (Mar 30, 2022 14:20 CDT) +Print Name: Clayton Franklin +Print Name: Angela Jackson +Title: President & CEO +Title: Administrator +Signature Date: Mar 31, 2022 +Signature Date: Mar 30, 2022 +ICM #: ICMProviderAgreement_143342 +Tax Identification Number: 82-1580561 +To be completed by Health Plan only: +National Provider Identifier: 1902323694 +Effective Date: Apr 29, 2022 +Medicare Number: +Page 12 of 56 + +Start of Page No = 13 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following +provisions apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to +Covered Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,12,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_ICMProviderAgreement_34251_10_Summit Medical Center,training-data/contract-text-file/4. Facility Custom/ICMProviderAgreement_ICMProviderAgreement_34251_10_Summit Medical Center MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,27-0826862,"27-0826862 + +Question: What is the name of the provider organization stated on the signatory page?", , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/4. Facility Custom/Molina/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, ," 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 +El Paso County Hospital District, DBA, +Molina Healthcare of Texas, Inc , +University Medical Center of El Paso +- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Pres / CEO +Signatory Title +Title (Printed): +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: + 74-6000756 +Effective Date: +3/1/2012 +Amendment to +Page I of 3 +Provider or authorized gar +HSA - UMC El Paso 03122012 +representative's initials: + +-------TABLE Start----- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Title (Printed): +Pres / CEO +Signatory Title +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: +74-6000756 +Effective Date: +3/1/2012 +-------TABLE End----- + +Start of Page No = 2 +ATTACHMENT D +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. +In addition to the above listed compensation rates, payment for the following services for all Health +Plan products & programs shall be reimbursed according to the table below: +Outpatient Services +Revenue Codes +Negotiated Payment +Implants/Prosthetics/Pacemakers +274,275,276,278 +70% of Billed Charges equal +paid when any one single item is +to Provider's Acquisition Cost +over $500 +plus five percent (5%) +High Cost Drugs - paid when any +634,636 +70% of Billed Charges equal +one single item is over $500 +to Provider's Acquisition Cost +plus five percent (5%) +Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one +hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider +shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) +of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are +made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written +notification At any time Health Plan may request a copy of an invoice from Provider to validate +Provider's Acquisition Cost", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/4. Facility Custom/Molina/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, ," 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 +El Paso County Hospital District, DBA, +Molina Healthcare of Texas, Inc , +University Medical Center of El Paso +- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Pres / CEO +Signatory Title +Title (Printed): +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: + 74-6000756 +Effective Date: +3/1/2012 +Amendment to +Page I of 3 +Provider or authorized gar +HSA - UMC El Paso 03122012 +representative's initials: + +-------TABLE Start----- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Title (Printed): +Pres / CEO +Signatory Title +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: +74-6000756 +Effective Date: +3/1/2012 +-------TABLE End----- + +Start of Page No = 2 +ATTACHMENT D +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. +In addition to the above listed compensation rates, payment for the following services for all Health +Plan products & programs shall be reimbursed according to the table below: +Outpatient Services +Revenue Codes +Negotiated Payment +Implants/Prosthetics/Pacemakers +274,275,276,278 +70% of Billed Charges equal +paid when any one single item is +to Provider's Acquisition Cost +over $500 +plus five percent (5%) +High Cost Drugs - paid when any +634,636 +70% of Billed Charges equal +one single item is over $500 +to Provider's Acquisition Cost +plus five percent (5%) +Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one +hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider +shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) +of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are +made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written +notification At any time Health Plan may request a copy of an invoice from Provider to validate +Provider's Acquisition Cost", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/4. Facility Custom/Molina/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, ," 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 +El Paso County Hospital District, DBA, +Molina Healthcare of Texas, Inc , +University Medical Center of El Paso +- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Pres / CEO +Signatory Title +Title (Printed): +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: + 74-6000756 +Effective Date: +3/1/2012 +Amendment to +Page I of 3 +Provider or authorized gar +HSA - UMC El Paso 03122012 +representative's initials: + +-------TABLE Start----- +Provider Signature: +Molina Signature: +Signatory Name +Signatory Name +(Printed): +(Printed): +Stephanie Slaughts +Signatory +Title (Printed): +Pres / CEO +Signatory Title +(Printed): +Vr Operations +Signature Date: +5-7-12 +Signature Date: +5-17-2012 +(To be completed by Molina) +Tax ID: +74-6000756 +Effective Date: +3/1/2012 +-------TABLE End----- + +Start of Page No = 2 +ATTACHMENT D +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. +In addition to the above listed compensation rates, payment for the following services for all Health +Plan products & programs shall be reimbursed according to the table below: +Outpatient Services +Revenue Codes +Negotiated Payment +Implants/Prosthetics/Pacemakers +274,275,276,278 +70% of Billed Charges equal +paid when any one single item is +to Provider's Acquisition Cost +over $500 +plus five percent (5%) +High Cost Drugs - paid when any +634,636 +70% of Billed Charges equal +one single item is over $500 +to Provider's Acquisition Cost +plus five percent (5%) +Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one +hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider +shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) +of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are +made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written +notification At any time Health Plan may request a copy of an invoice from Provider to validate +Provider's Acquisition Cost", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_Dallas County Hospital Parkland 75-6004221 - Amendment 5,training-data/contract-text-file/4. Facility Custom/Molina/Custom_Dallas County Hospital Parkland 75-6004221 - Amendment 5 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,75-6004221,75-6004221, ," All +other services to be reimbursed at 16 8% of billed which is 105% of their OP Interim rate) +Request Date +8/18/17 +PAR +Yes +NON PAR +Provider Name +Parkland Health & Hospital System +Provider/Facility Type (Example: +HOSPITAL +Hospital, FQHC, Physician, etc ) +TIN Number + 75-6004221 +NPI Number +127295703 +Provider ID +QMP000003368804 that have more than one +Impact assessment +None +Desired Effective Date +9/1/17 +If non Standard Effective date +Reason: +1 John J McGuinness COO +Approval for non-Standard Effective +date/ Rates +3/21/17 +New, Existing or Correction to +Existing +Contract +(Provide contract for +existing/correction contract) +NOTE: Existing Contracts and +Corrections requires Contracting +Leadership approval prior to +submission +Line of Business +New MP Rate +Inpatient Services: +Covered Services shall be paid at One Hundred Thirty-Five (135%) of +Hospital's Standard Dollar Amount in accordance with the State of Texas +Medicaid DRG reimbursement methodology in effect on the date of service. +List any applicable details on how +Inpatient Service reimbursement will follow the terms and conditions that +the contract should be set up for +currently exist in Providers Hospital Service Agreement Professional +reimbursement +services are included in this case rate except Hospitalists as defined by Parkland +Exhibit A. + +-------TABLE Start----- +Request Date +8/18/17 +PAR +Yes +NON PAR +Provider Name +Parkland Health & Hospital System +Provider/Facility Type (Example: +HOSPITAL +Hospital, FQHC, Physician, etc.) +TIN Number +75-6004221 +NPI Number +127295703 +Provider ID +QMP000003368804 that have more than one +Impact assessment +None +Desired Effective Date +9/1/17 +If non Standard Effective date +Reason: +1 John J", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_HSA_AMD 1_EFF07152023_Children's Medical Center_Marketplace Agreement,training-data/contract-text-file/4. Facility Custom/Molina/Custom_HSA_AMD 1_EFF07152023_Children's Medical Center_Marketplace Agreement MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,75-0800628,75-0800628, ," +Provider's Legal Name (""Provider"") - Matching the applicable tax form (i e W-9, Line 1): +Children's Health System of Texas +Authorized Representative's Signature: +Authorized Representative's Name - Printed: +Rulfs +Robert Fries +Robert Fries (Jun 28, 2023 16:50 CDT) +Authorized Representative's Title: +Authorized Representative's Signature Date: +Executive Vice President, CFO +Mailing Address - Official Correspondence: +Payment Address - If different than Mailing Address: +1935 Medical District Drive +PO Box 844007 +Dallas, Texas 75235 +Dallas, Texas 75284-4007 +IRS 1099 Address - If different than Mailing Address: +Tax ID Number - As listed on corresponding tax form: + 75-0800628 +NPI - That corresponds to the above Tax ID Number: +1194743013 and 1720480627 +Health Plan Signature and Information. +Molina Healthcare of Texas, a Texas Corporation (""Health Plan"") +Authorized Representative's Signature: +Authorized Representative's Name - Printed: +Scott Albosta +Authorized Representative's Title: +Authorized Representative's Countersignature Date: +VP, Network Strategy & Services +July 7, 2023 +Mailing Address - Official Correspondence: +1660 North Westridge Circle Irving, TX 75038 +Effective Date of Agreement (""Effective Date"") July 15, 2023 +Page 1 of 7 +Molina Texas SCA - Marketplace +MHI v07192018r04222020 + +-------TABLE Start----- +Provider's Legal Name (""Provider"") - Matching the applicable tax form (i.e W-9, Line 1): +Children's Health System of Texas +Authorized Representative's Signature: +Authorized Representative's Name - Printed: +Rulfs. +Robert Fries +Robert Fries (Jun 28, 2023 16:50 CDT) +Authorized Representative's Title: +Authorized Representative's Signature Date: +Executive Vice President, CFO +Mailing Address - Official Correspondence: +Payment Address - If different than Mailing Address: +1935 Medical District Drive +PO Box 844007 +Dallas, Texas 75235 +Dallas, Texas 75284-4007 +IRS 1099 Address - If different than Mailing Address: +Tax ID Number - As listed on corresponding tax form: +75-0800628 +NPI - That corresponds to the above Tax ID Number: +1194743013 and 1720480627 +-------TABLE End----- + +-------TABLE Start----- +Molina Healthcare of Texas, a Texas Corporation (""Health Plan"") +Authorized Representative's Signature: +Authorized Representative's Name - Printed: +Scott Albosta +Authorized Representative's Title: +Authorized Representative's Countersignature Date: +VP, Network Strategy & Services +July 7, 2023 +Mailing Address - Official Correspondence: +1660 North Westridge Circle Irving, TX 75038 +Effective Date of Agreement (""Effective Date"") July 15, 2023 +-------TABLE End----- + +Start of Page No = 2 +LETTER OF AGREEMENT +Provider and Health Plan enter into this Agreement as of the Effective Date set forth on the Signature Page of this +Agreement The Provider and Health Plan each are referred to as a ""Party"" and collectively as the ""Parties"". +1.1 +Provision of Covered Services Provider agrees to provide medically necessary services and supplies covered +under the Health Plan's benefit plan (""Covered Services"") for individuals enrolled in Health Plan's Exchange plan +(""Members"")", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_HSA_EFF07012010_Driscoll Children's Hospital,training-data/contract-text-file/4. Facility Custom/Molina/Custom_HSA_EFF07012010_Driscoll Children's Hospital MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-2577746,74-2577746, ,"2089 +P O Box 926 +Email Address +San Antonio, TX 78294 +Tax I D No + 74-2577746 +License No. +000488 +Physical Address (if different than above): +Texas Provider Identification +1328122 +Driscoll Children's Hospital +Number (TPIN) +3533 S Alameda +NPI (or UPIN if NPI not yet +NPI: 1548286172 +Corpus Christi, TX 78411 +designated) +UPIN: +DEA No. +AD0894952 +(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: +E.An +Signatory Name +(Printed): +Eric Hamon +Signatory Title +(Printed): +Executive Vice President / CFO +Signature Date: +3/4/10 +Driscoll Children's Hospital (Final) 02-18-10.doc +Page 22 of 30 +Initials of authorized +representative of Provider + +-------TABLE Start----- +Provider Name +Driscoll Children's Hospital +Billing Address: +Telephone No. +361.694.5000 +Driscoll Children's Hospital +Facsimile No. +361.808.2089 +P O Box 926 +Email Address +San Antonio, TX 78294 +Tax I.D No. +74-2577746 +License No. +000488 +Physical Address (if different than above): +Texas Provider Identification +1328122 +Driscoll Children's Hospital +Number (TPIN) +3533 S Alameda +NPI (or UPIN if NPI not yet +NPI: 1548286172 +Corpus Christi, TX 78411 +designated) +UPIN: +DEA No. +AD0894952 +-------TABLE End----- + +-------TABLE Start----- +Provider +Signature: +E.An +Signatory Name +(Printed): +Eric Hamon +Signatory Title +(Printed): +Executive Vice President / CFO +Signature Date: +3/4/10 +-------TABLE End----- + +Start of Page No = 23 +ATTACHMENT B +Definitions +1. +Advance Directive is a Member's written instructions, recognized under state law, relating to the +provision of health care when the Member is not competent to make a health care decision as +determined under state law Examples of Advance Directives are living wills and durable powers of +attorney for health care. +2 Agreement means this Provider Services Agreement and all attachments +3", ,22,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Adena_First_Amendment_and_2022_Quality_Rewards_and_Shared_Savings_Duall Exec,training-data/contract-text-file/5. Multiple Custom/Adena_First_Amendment_and_2022_Quality_Rewards_and_Shared_Savings_Duall Exec.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,31-4379443,31-4379443, ," = 4 +DocuSign Envelope ID: 9E64A5DA-DF01-4DD7-BF52-204C86F7A04E +IN WITNESS WHEREOF, the parties have executed this Amendment as of the Effective Date: +July 1 2022 +CARESOURCE NETWORK PARTNERS +Adena Health System +LLC, on behalf of itself and its Affiliates +Provider Name +DocuSigned by: +By: +Matthew Barrett +By: James P JPM fameman McManus +John +3598A4BB47D64C8 +Matthew Barrett +James McManus +Title: VP, Network Strategy and Contracting +Title: Chief Financial Officer +Date: 7/21/2022 +Chief Financial Officer +Date: + 31-4379443 +Federal Tax ID + +Start of Page No = 5 +DocuSign Envelope ID: 19E64A5DA-DF01-4DD7-BF52-204C86F7A04E +Exhibit A.4 +COMPENSATION SCHEDULE +CareSource Marketplace - Ohio +Addendum to Agreement +For Medically Necessary Covered Services rendered to Covered Persons by Hospital in accordance with +the terms of this Agreement, Hospital shall accept as payment in full the lesser the amounts set forth +below under subsections (1) (2) and (3). +For purposes of this Attachment, the terms ""CMS Hospital Per Diem Rate"", ""CMS Part B % Rate"", and +""CMS Swing Bed Per Diem Rate"" shall mean the Hospital Per Diem, Part B %, and Swing Bed Per Diem +rates set forth in the Rate Review letter issued to Hospital by the fiscal intermediary acting on behalf of +the Centers for Medicare and Medicaid Services (""CMS"") and that are in effect on the date the service or +admission, as the case may be (""Rate Review Letter"") Hospital shall provide Plan with the most recent +Rate Review Letter prior to the effective date of the rates set forth in the Rate Review Letter and +whenever specifically requested by Plan. +For purposes of this Attachment, the term ""Medicare Allowed Amount"" shall mean the Medicare allowed +amount that is published annually in the Federal Register, is based on valid codes recognized by CMS and +is in effect on the date of service *or admission, as the case may be. +1. +Inpatient and Outpatient Hospital Services: the Plan shall pay the Hospital the lesser of billed +charges or the following: +Effective July 1, 2022 Inpatient / Outpatient Services: 190% of MCR +Effective July 1, 2023 Inpatient / Outpatient Services: 185% of MCR +Effective July 1, 2024 Inpatient / Outpatient Services: 180% of MCR +Effective July 1, 2025 Inpatient / Outpatient Services: 175% of MCR +2 Other Outpatient Services: the Plan shall pay Hospital the rate set forth below, as determined by the +type of Covered Services rendered: +a. +Laboratory: The lesser of 100% of Allowable Billed Charges or 100% of the Medicare +Allowed Amount +b Durable Medical Equipment: The lesser of 100% of Allowable Billed Charges or 100% of +the Medicare Allowed Amount +c", ,4,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Bon Secours Mercy Health_20190101_Base Contract,training-data/contract-text-file/5. Multiple Custom/Bon Secours Mercy Health_20190101_Base Contract.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,See tab: Bon Secours Base Carveouts,34-1105619, ," Main Street 23Dayton, OH 45402 23Attn: Ohio Market President 23 +SIGNATURES 25 +EXHIBIT A 26 +LEGAL NAMES OF AFFILIATES AND FEDERAL EMPLOYER IDENTIFICATION 26NUMBERS 26 +EXHIBIT B 45PROVISIONS APPLICABLE TO 45CARESOURCE MEDICARE PRODUCTS 45 +EXHBIT C - OHIO 47 +STATE SPECIFC PROVISIONS 47FOR OHIO 47 +Payment of Claims 47 +Governing Law and Venue 47 +Amendment 48 +EXHIBIT C - OHIO 49OHIO MEDICAID ADDENDUM 49 +ADDENDUM DEFINITIONS 49 +ADDENDUM PROVISIONS 49 +EXHIBIT C - OHIO 55 +PLAN COMPENSATION SCHEDULE 55 +MEDICAID PROVIDER REIMBURSEMENT AND COMPENSATION 55 +1 FACILITYREIMBURSEMENT 55 +St Rita's Medical Center Hospital TIN 34-1105619 56 +Mercy Regional Medical Center TIN 34-0714704 56Mercy Allen Hospital TIN 34-0864230 56 +Our Lady of Bellefonte Hospital 61-1356023 56 +Outliers: 56 +Transfer Policy: 56 +Outpatient Services: 56 +Outpatient Services are reimbursed as follows: 56 +2 OTHER SERVICES 57 +Skilled Nursing Facilities: St Rita's Medical Center Hospital TIN 34-1105619 62 +Outpatient Therapy Services: St Rita's Medical Center Hospital TIN 34-1105619 63 +3", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Bon_Secours_Mercy_Third_Amendment,training-data/contract-text-file/5. Multiple Custom/Bon_Secours_Mercy_Third_Amendment MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,"See ""Bon Secours Mercy Providers"" tab",31-1091597, ,"O Box 636500 +and Pediatrics fka Mercy +Avenue +OH 43078 +6157 +I Services +Cincinnati, OH 45263-6500 +Well Child Pediatrics +Mercy Health Physicians +31-1007881 +1205887023, +Varies +Varies +Varies +Professiona +P O Box 632110Cincinnati, OH +Cincinnati, LLC +1013974161, +I Services +45263-2110 +1154851178 +Mercy Health - Harrison + 31-1091597 +1366532301 +10450 New +Harrison, +513-367- +24-Hour +P.O Box 631774 +Medical Center (fka Mercy +Haven Road +OH 45030 +2222 +Emergency +Cincinnati, OH 45263-2244 +Medical Center Harrison) +Room; +Diagnostic +Svcs: CT +Scan, Lab & +X-Ray +Mercy Hospital West +31-1091597 +1740368851 +3300 Mercy +Cincinnati, +513-215- +IP Rehab +P.O Box 631774 +Hospital Rehab Unit +Health Blvd. +OH 45211 +5000 +Cincinnati, OH 45263-2244 +Queen City Medical +31-1091597 +1912007931 +3131 Queen +Cincinnati, +513-389- +24-Hour +P.O Box 631774 +Center (FKA Western Hills +City Avenue +OH 45238 +5000 +Emergency +Cincinnati, OH 45263-2244 +Medical Center) +Room; +Diagnostic +Svcs: CT +Scan, Lab & +X-Ray +Mercy Health West +31-1091597 +1912007931 +3300 Mercy +Cincinnati, +513-215- +Acute Care +P.O Box 631774 +Hospital LLC +Health Blvd. +OH 45211 +5000 +Hospital +Cincinnati, OH 45263-2244 +Outpatient Surgery at +31-1091597 +1912007931 +3300 Mercy +Cincinnati, +513-215- +Ambulatory/ +P.O", ,9,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +"CustomFac_Benedictine Hospital - Amendment 1.1.16 (HBX,HARP,EPP) (REVISED)","training-data/contract-text-file/5. Multiple Custom/CustomFac_Benedictine Hospital - Amendment 1.1.16 (HBX,HARP,EPP) (REVISED).txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,141338470,14-1338470, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_AncProf_Keith C Chang MD PLLC - Agreement Provider Signed 1.1.16,training-data/contract-text-file/5. Multiple Custom/Custom_AncProf_Keith C Chang MD PLLC - Agreement Provider Signed 1.1.16.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,208623734,20-8623734, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +MarionCounty_Caresource Exchange Hosp 110121 Partial_MP,training-data/contract-text-file/5. Multiple Custom/MarionCounty_Caresource Exchange Hosp 110121 Partial_MP.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,35-6005697,35-6005697, ,"20 13:55:32 -04'00 +Print +Name: +Christopher M Scott, PharmD +Title : +Chief Clinical & Revenue Officer +Date: +10 20 2021 +Provider Tax ID: 35-6005697 +Page 3 of 10 + +-------TABLE Start----- +By: +Print +Steve Smitherman +Name: +Title : +IN Market President +Date: +11/5/2021 +-------TABLE End----- + +-------TABLE Start----- +By: +Christopher M Scott, +CM Suith +PharmD, FCCM, FASHP, BCPS +2021.10.20 13:55:32 -04'00 +Print +Name: +Christopher M Scott, PharmD +Title : +Chief Clinical & Revenue Officer +Date: +10.20.2021 +-------TABLE End----- + +Start of Page No = 4 +EXHIBIT A +PROVIDER AFFILIATION ATTACHMENT +LEGAL IRS NAMES AND FEDERAL EMPLOYER IDENTIFICATION NUMBERS OF +PROVIDER AFFILIATES, ENTITIES, AND SUBSIDIARIES BILLING FOR COVERED +SERVICES AND/OR OPERATING UNDER THIS AGREEMENT: +Federal Tax ID +Legal IRS Name +35-6005697 +The Health and Hospital Corporation of Marion County +Page 4 of 10 + +Start of Page No = 5 +EXHIBIT C- INDIANA +PLAN COMPENSATION SCHEDULES +CARESOURCE INDIANA MARKETPLACE +HOSPITAL +For Medically Necessary Covered Services rendered to Covered Persons by Provider, in +accordance with the terms of this Agreement, Provider shall accept as payment in full the lesser +of: +(i) +Provider's billed charges; or +(ii) +The percentage, listed below, of the Hospital's current year Medicare Allowed +Amount applicable to Provider 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 (the ""Medicare Allowed Amount""). +Any Cost Share shall be offset against the Medicare Allowed Amount for Covered +Services, without regard to whether the Provider has collected such amounts. +Inpatient and Outpatient Facility Reimbursement Rate: 160% of the Medicare +Allowed Amount. +Home Health, Hospice and Dialysis Reimbursement Rate: 125% of the current +Medicare Allowed Amount", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +221487173_EnglewoodHospitalandMedicalCenter_ICMSupportingDocuments_566705,training-data/contract-text-file/6. Multiple - Boilerplate/221487173_EnglewoodHospitalandMedicalCenter_ICMSupportingDocuments_566705 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,22-1487173,22-1487173, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +ICMProviderAgreement_ICMProviderAgreement_295973_15,training-data/contract-text-file/6. Multiple - Boilerplate/ICMProviderAgreement_ICMProviderAgreement_295973_15.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,83-0410970,83-0410970, ," +IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments +noted on Schedule B, effective as of the date set forth beneath their respective signatures +HEALTH PLAN: +PROVIDER: +Oklahoma Complete Health, Inc +Fairfax Medical Facilities, Inc +(Legibly Print Name of Provider) +Authorized Signature: +Authorized Signature: +417 +Karen McConnell +Clayton Franklin (Oct 11, 2023 15:12 CDT) +Karen McConnell (Oct 10, 2023 13:36 CDT) +Print Name: Clayton Franklin +Print Name: Karen McConnell +Title: President & CEO +Title: Chief Executive Officer +Signature Date: Oct 11, 2023 +Signature Date: Oct 10, 2023 +ICM #: ICMProviderAgreement_295973 +Tax Identification Number: 83-0410970 +To be completed by Health Plan only: +National Provider Identifier: 1538183173 +Effective Date: Nov 09, 2023 +Medicare Number: +Page 13 of 46 + +Start of Page No = 14 +PARTICIPATING PROVIDER AGREEMENT +SCHEDULE A +CONTRACTED PROVIDER-SPECIFIC PROVISIONS +Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. +1. +Hospitals If Provider or a Contracted Provider is a hospital (""Hospital""), the following provisions +apply. +1.1 +24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered +Persons 24 hours per day, 7 days per week. +1.2 +Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in +accordance with Regulatory Requirements", ,13,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Mult6_VirtuaMemorialHospitalofBurlington_Amendment,training-data/contract-text-file/6. Multiple - Boilerplate/Mult6_VirtuaMemorialHospitalofBurlington_Amendment MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,210634562,21-0635001, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_KentuckyOne Group Practice Provider Agreement_20140806_Dually Executed (1),training-data/contract-text-file/CareSource -Professional/Custom_KentuckyOne Group Practice Provider Agreement_20140806_Dually Executed (1) MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,"See: ""CSNP21_CS KentuckyOne Roster""",61-1334601, ,"65 2014 +Page 24 of 67 +Bll + +Start of Page No = 25 +EXHIBIT A - GROUP PRACTICE SERVICE LOCATIONS +Page 25 of 67 +Bill + +Start of Page No = 26 +Medicare +Tax Id +Last Name +First Name +Specialty +PCP +Practice Name +Individual +Practice Address +City +Zip +Group NPI +Group # +NPI +(B)PartB +(A)Part A +Jeanetta +MD +Family +KentuckyOne Primary Care, +61-1029768 +Bosley +Y +Medicine +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +40108-1222 +1679632939 +1447312129 +8514 (B) +Hospital +183838 (A) +KentuckyOne Primary Care, +61-1029768 +Gibson +Kimberly +NP +Family +Y +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +Medicine +40108-1222 +1093931487 +1447312129 +8515 (B) +Hospital +183838 (A) +Robert +Family +KentuckyOne Primary Care, +61-1029768 +Smith +MD +Y +Medicine +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +40108-1222 +1457479396 +1447312129 +8516 (B) +Hospital +183838 (A) +Family +KentuckyOne Primary Care, +61-1029768 +Stegner +Sharron +NP +Y +Medicine +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +40108-1222 +1821157173 +1447312129 +8517 (B) +Hospital +183838 (A) + 61-1334601 +Abdeen +Anwar +MD +IM/Emergency +N +Med +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1821141763 +1720211774 +1254 +61-1334601 +Ahmed +Ali +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1144485822 +1164854675 +K095100 +61-1334601 +Ali +Amjad +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1598739617 +1164854675 +K095100 +61-1334601 +Ali +London Pediatric & +Muhammad +MD +Peds +Y +21 Middleground Way +London +KY +40741-8345 +Adolescent Medicine +1073587143 +1164854675 +183435 +61-1334601 +Aliu +Peter +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1205008703 +1164854675 +K095100 +61-1334601 +Almagdub +lhab +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1801050984 +1164854675 +K095100 +61-1334601 +Ammisetty +Vijaya +MD +FM +Y +Seton Family Health Center +11087 Main Street +Martin +KY +41649 +1164662508 +1184651994 +183440 +61-1334601 +Arekapudi +Aruna +MD +Hem/Onc +N +Saint Joseph Hematology +165 London Mountain +London +KY +40741-6601 +1811992852 +Oncology London +View Dr +1740550615 +K041590 +61-1334601 +Baeker +Thomas +Hem/Onc +Saint Joseph Hematology +165 London Mountain +MD +N +London +KY +40741-6601 +1992700926 +Oncology London +View Dr +1740550615 +K041590 +61-1334601 +Bhopatkar +Shailesh +MD +Anesthesiology +N +Anesthesia Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1407806318 +1164854675 +K095100 +61-1334601 +Browning +Ben +DO +FM +N +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1184685703 +1720211774 +1254 +61-1334601 +Burns +Patricia +APRN +NP +Y +Saint Joseph Berea Family +305 Estill St, 4th Floor +Berea +KY +40403-1742 +Medicine +1619232311 +1982955290 +pending +61-1334601 +Caddell +Joseph +PA +PA +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1588737621 +1164854675 +pending +Page 26 of 67 + +-------TABLE Start----- +Medicare +Tax Id +Last Name +First Name +Specialty +PCP +Practice Name +Individual +Practice Address +City +Zip +Group NPI +Group # +NPI +(B)PartB +(A)Part A +Jeanetta +MD +Family +KentuckyOne Primary Care, +61-1029768 +Bosley +Y +Medicine +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +40108-1222 +1679632939 +1447312129 +8514 (B) +Hospital +183838 (A) +KentuckyOne Primary Care, +61-1029768 +Gibson +Kimberly +NP +Family +Y +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +Medicine +40108-1222 +1093931487 +1447312129 +8515 (B) +Hospital +183838 (A) +Robert +Family +KentuckyOne Primary Care, +61-1029768 +Smith +MD +Y +Medicine +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +40108-1222 +1457479396 +1447312129 +8516 (B) +Hospital +183838 (A) +Family +KentuckyOne Primary Care, +61-1029768 +Stegner +Sharron +NP +Y +Medicine +a Department of Jewish +534 Hillcrest Drive +Brandenburg +KY +40108-1222 +1821157173 +1447312129 +8517 (B) +Hospital +183838 (A) +61-1334601 +Abdeen +Anwar +MD +IM/Emergency +N +Med +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1821141763 +1720211774 +1254 +61-1334601 +Ahmed +Ali +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1144485822 +1164854675 +K095100 +61-1334601 +Ali +Amjad +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1598739617 +1164854675 +K095100 +61-1334601 +Ali +London Pediatric & +Muhammad +MD +Peds +Y +21 Middleground Way +London +KY +40741-8345 +Adolescent Medicine +1073587143 +1164854675 +183435 +61-1334601 +Aliu +Peter +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1205008703 +1164854675 +K095100 +61-1334601 +Almagdub +lhab +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1801050984 +1164854675 +K095100 +61-1334601 +Ammisetty +Vijaya +MD +FM +Y +Seton Family Health Center +11087 Main Street +Martin +KY +41649 +1164662508 +1184651994 +183440 +61-1334601 +Arekapudi +Aruna +MD +Hem/Onc +N +Saint Joseph Hematology +165 London Mountain +London +KY +40741-6601 +1811992852 +Oncology London +View Dr +1740550615 +K041590 +61-1334601 +Baeker +Thomas +Hem/Onc +Saint Joseph Hematology +165 London Mountain +MD +N +London +KY +40741-6601 +1992700926 +Oncology London +View Dr +1740550615 +K041590 +61-1334601 +Bhopatkar +Shailesh +MD +Anesthesiology +N +Anesthesia Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1407806318 +1164854675 +K095100 +61-1334601 +Browning +Ben +DO +FM +N +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1184685703 +1720211774 +1254 +61-1334601 +Burns +Patricia +APRN +NP +Y +Saint Joseph Berea Family +305 Estill St, 4th Floor +Berea +KY +40403-1742 +Medicine +1619232311 +1982955290 +pending +61-1334601 +Caddell +Joseph +PA +PA +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1588737621 +1164854675 +pending +-------TABLE End----- + +Start of Page No = 27 +Medicare +Tax Id +Last Name +First Name +Specialty +PCP +Practice Name +Individual +Practice Address +City +Zip +Group NPI +Group # +NPI +(B)PartB +(A)Part A +61-1334601 +Caddell +Kevin +PA +PA +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1578838116 +1164854675 +pending +61-1334601 +Chang +Jake +CANA +CRNA +N +Saint Joseph Martin +11203 Main Street +Martin +KY +41649 +1700062726 +Physicians +1720211774 +pending +61-1334601 +Clark +Judy +APRN +NP +Y +Saint Joseph Berea Family +305 Estill St, 4th Floor +Berea +KY +Medicine +40403-1742 +1932404761 +1982955290 +pending +61-1334601 +Combs +Pamela +Saint Joseph East Sleep +160 N Eagle Creek Ste. +Lexington +KY +Wellness Center +40509-2124 +1225468275 +302 +P100027079 +61-1334601 +Compton +Ralph +MD +FM +Y +Saint Joseph Berea Family +Medicine +305 Estill St, 4th Floor +Berea +KY +40403-1742 +1538107826 +1982955290 +183473(B) +0016403(A) +61-1334601 +Croley +Jessica +MD +Hem/Onc +N +Saint Joseph Hematology +3470 Blazer Pkwy, Ste +150 +Lexington +KY +40509-1078 +1629231170 +1740550615 +Oncology +P100027079 +61-1334601 +Davenport- +Rachel +APRN +APRN +N +Campbell +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1710281399 +1164854675 +pending +61-1334601 +D'Costa +Gina +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1184653842 +1164854675 +K095100 +61-1334601 +Foster +Ben +CRNA +Anesthesia +N +Anesthesia Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1023241700 +1164854675 +K095100 +61-1334601 +Gardner +Jennie +APRN +NP-FM +Y +Bath Family Health Services +44 Water St +Owingsville +KY +40360-8944 +1790869071 +1720211774 +1254 +61-1334601 +Goodin +Donald +MD +Hem/Onc +N +Saint Joseph Hematology +3470 Blazer Pkwy, Ste +150 +Lexington +KY +40509-1078 +1922102391 +1740550615 +Oncology +P100027079 +61-1334601 +Grentz +Liesel +DO +FM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1821276130 +1164854675 +K095100 +61-1334601 +Griffin +Wendell +CRNA +CRNA +N +Anesthesia Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1518205269 +1164854675 +K095100 +61-1334601 +Hall +Maryann +PA +PA +Y +Martin Clinic +12579 Main St, Ste 101 +Martin +KY +41649 +1245238518 +1487689519 +183442 +61-1334601 +Hamilton +Ronald +MD +IM, EM +N +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1417971755 +1720211774 +1254 +London Pediatric & +61-1334601 +Hampton +Sheila +APRN +APAN +N +21 Middleground Way +London +KY +40741-8345 +1205890142 +Adolescent Medicine +1164854675 +pending +61-1334601 +Hardy +Donny +MD +IM +Y +Saint Joseph Berea Family +305 Estill St, 4th Floor +Berea +KY +40403-1742 +Medicine RHC +1811981533 +1982955290 +183473(B) +0016403(A) +61-1334601 +Hays +Jeremie +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1063611564 +1164854675 +K095100 +61-1334601 +Helwani +Hassan +MD +IM +N +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1477532422 +1720211774 +1254 +Page 27 of 67 + +-------TABLE Start----- +Medicare +Tax Id +Last Name +First Name +Specialty +PCP +Practice Name +Individual +Practice Address +City +Zip +Group NPI +Group # +NPI +(B)PartB +(A)Part A +61-1334601 +Caddell +Kevin +PA +PA +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1578838116 +1164854675 +pending +61-1334601 +Chang +Jake +CANA +CRNA +N +Saint Joseph Martin +11203 Main Street +Martin +KY +41649 +1700062726 +Physicians +1720211774 +pending +61-1334601 +Clark +Judy +APRN +NP +Y +Saint Joseph Berea Family +305 Estill St, 4th Floor +Berea +KY +Medicine +40403-1742 +1932404761 +1982955290 +pending +61-1334601 +Combs +Pamela +Saint Joseph East Sleep +160 N Eagle Creek Ste. +Lexington +KY +Wellness Center +40509-2124 +1225468275 +302 +P100027079 +61-1334601 +Compton +Ralph +MD +FM +Y +Saint Joseph Berea Family +Medicine +305 Estill St, 4th Floor +Berea +KY +40403-1742 +1538107826 +1982955290 +183473(B) +0016403(A) +61-1334601 +Croley +Jessica +MD +Hem/Onc +N +Saint Joseph Hematology +3470 Blazer Pkwy, Ste +150 +Lexington +KY +40509-1078 +1629231170 +1740550615 +Oncology +P100027079 +61-1334601 +Davenport- +Rachel +APRN +APRN +N +Campbell +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1710281399 +1164854675 +pending +61-1334601 +D'Costa +Gina +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1184653842 +1164854675 +K095100 +61-1334601 +Foster +Ben +CRNA +Anesthesia +N +Anesthesia Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1023241700 +1164854675 +K095100 +61-1334601 +Gardner +Jennie +APRN +NP-FM +Y +Bath Family Health Services +44 Water St +Owingsville +KY +40360-8944 +1790869071 +1720211774 +1254 +61-1334601 +Goodin +Donald +MD +Hem/Onc +N +Saint Joseph Hematology +3470 Blazer Pkwy, Ste +150 +Lexington +KY +40509-1078 +1922102391 +1740550615 +Oncology +P100027079 +61-1334601 +Grentz +Liesel +DO +FM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1821276130 +1164854675 +K095100 +61-1334601 +Griffin +Wendell +CRNA +CRNA +N +Anesthesia Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1518205269 +1164854675 +K095100 +61-1334601 +Hall +Maryann +PA +PA +Y +Martin Clinic +12579 Main St, Ste 101 +Martin +KY +41649 +1245238518 +1487689519 +183442 +61-1334601 +Hamilton +Ronald +MD +IM, EM +N +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1417971755 +1720211774 +1254 +London Pediatric & +61-1334601 +Hampton +Sheila +APRN +APAN +N +21 Middleground Way +London +KY +40741-8345 +1205890142 +Adolescent Medicine +1164854675 +pending +61-1334601 +Hardy +Donny +MD +IM +Y +Saint Joseph Berea Family +305 Estill St, 4th Floor +Berea +KY +40403-1742 +Medicine RHC +1811981533 +1982955290 +183473(B) +0016403(A) +61-1334601 +Hays +Jeremie +MD +IM +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1063611564 +1164854675 +K095100 +61-1334601 +Helwani +Hassan +MD +IM +N +Saint Joseph Martin ER +11203 Main Street +Martin +KY +41649 +1477532422 +1720211774 +1254 +-------TABLE End----- + +Start of Page No = 28 +Medicare +Tax Id +Last Name +First Name +Specialty +PCP +Practice Name +Individual +Practice Address +City +Zip +Group NPI +Group # +NPI +(B)PartB +(A)Part A +61-1334601 +Hensley +Edith +APAN +APRN +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1194045104 +1164854675 +pending +61-1334601 +Hickman +Kerrie +PA +PA +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1659518165 +1164854675 +pending +61-1334601 +Idrees +Muhammad +MD +Peds +Y +Seton Family Health Center +11087 Main Street +Martin +KY +41649 +1912960774 +1184651994 +183440 +61-1334601 +lqbal +Muhammad +MD +Pulm Dis +N +Hospitalist Program +1001 Saint Joseph Ln +London +KY +40741-8345 +1356547491 +1164854675 +K095100 +61-1334601 +Johnson +Dana +MD +Med Onc +N +Saint Joseph Hemalology +701 Bob-O-Link Dr, Ste +Lexington +KY +40504-3760 +1073512133 +1740550615 +Oncology +100 +P100027079 +Saint Joseph Hematology +Oncology London +61-1334601 +Kassem +165 London Mountain +Bachar +MD +Hem/Onc +N +manager Erin Wilcher +London +KY +40741-6601 +1548266844 +View Dr +1740550615 +K041590 +Andrea Sponcil does +credentialing +61-1334601 +Kern +Caroline +APRN +APRN +N +Saint Joseph East Sleep +160 N", ,26,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +"Custom_Parkview Health Systems-OH MP, IN MP-ID C15656222AA","training-data/contract-text-file/CareSource -Professional/Custom_Parkview Health Systems-OH MP, IN MP-ID C15656222AA MU.txt",Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,35-1972384,35-1972384, ,"3 do not apply if the delay caused +by such notices could result in imminent harm to a Covered Person, if the material +amendment is required by state or federal law, rule, or regulation, or if Provider +affirmatively accepts the material amendment in writing and agrees to an earlier +effective date than otherwise required by Ohio Revised Code section 3963 04 + +Start of Page No = 4 +EXHIBIT A - AFFILIATIONS ATTACHMENT +LEGAL NAMES OF AFFILIATES AND FEDERAL EMPLOYER IDENTIFICATION NUMBERS +Group(s) under the Agreement cover and all of its entities, subsidiaries and affiliates and facilities +billing for Covered Services and/or operating under the following federal tax identification +numbers: +Federal Tax ID +Legal IRS Name +34-1045870 +Midwest Community Health Associates + 35-1972384 +Parkview Physicians Group + +Start of Page No = 5 +Exhibit A.4 +OHIO +PLAN COMPENSATION SCHEDULES +CARESOURCE OHIO MARKETPLACE +For Medically Necessary Covered Services rendered to Covered Persons by Provider or by Group +Practice Providers, in accordance with the terms of this Agreement, Provider or Group Practice +Provider, as the case may be, shall accept as payment in full the lesser of: +(i) +Provider's or Group Practice Provider's billed charges; or +(ii) +The percentage listed below, of the current prevailing Medicare allowed amount +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 (the ""Medicare Allowed Amount"") Any co- +payment, deductible or coinsurance shall be offset against the Medicare Allowed +Amount for Covered Services, without regard to whether the Provider or Group +Practice Provider has collected such amounts. +Professional Services Reimbursement Rate: 110% of the Medicare Allowed +Amount for primary care physician services +Professional Services Reimbursement Rate: 120% of the Medicare Allowed +Amount for specialty physician services +(iii) For those services that do not have a Medicare Allowed Amount, Plan shall +reimbursement Provider Group 60% of billed charges. +Injectable medications will be paid according to 100% of the Medicare Allowed Amount, except +for those drugs that may be available through a specialty pharmacy benefits manager. +Medicare: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx +Parkview Health Systems d/b/a +CareSource Indiana, Inc. +Parkview Physician Group +By: BR +Provider Name +By: +Jeanne Wuckers +Jeanne' Wickens +Senior Vice President and +Title: Executive Donotor +Title: Chief Financial Officer +Date: +11/8/17 +Date: 10/25/17 + +Start of Page No = 6 +EXHIBIT C- INDIANA +PLAN COMPENSATION SCHEDULES +CARESOURCE INDIANA MARKETPLACE +For Medically Necessary Covered Services rendered to Covered Persons by Provider, in +accordance with the terms of this Agreement, Provider shall accept as payment in full the lesser +of: +(iv) +Provider's or Group Practice Provider's billed charges; or +(v) +The percentage listed below, of the current prevailing Medicare allowed amount +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 (the ""Medicare Allowed Amount"") Any co- +payment, deductible or coinsurance shall be offset against the Medicare Allowed +Amount for Covered Services, without regard to whether the Provider or Group +Practice Provider has collected such amounts. +Professional Services Reimbursement Rate: 110% of the Medicare Allowed +Amount for primary care physician services +Professional Services Reimbursement Rate: 120% of the Medicare Allowed +Amount for specialty physician services +(vi) For those services that do not have a Medicare Allowed Amount, Plan shall +reimbursement Provider Group 60% of billed charges. +Injectable medications will be paid according to 100% of the Medicare Allowed Amount, except +for those drugs that may be available through a specialty pharmacy benefits manager. +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 + +Start of Page No", ,4,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc10_040121 Nationwide Vision Center Care 1st Amendment,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0560663,86-0560663, ," 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, the parties have executed this Amendment to the Agreement in duplicate by their +respective officers duly authorized to do so +PLAN +PROVIDER +By: +6/3/21 +Scott Cummings +Date +Signature Vincent Hayes +Chief Administrative Officer +Printed Name +Vincent Hayes +Title Vice President Managed Care +NAtion wide Vision Center INC +Address for Plan Notices: +Contracting Entity/Group Name + 86-0560663 +Carelst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +5-6-2021 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +220 N McKemy Ave +Chandler, Az 85226 +Carelst +Revised 050817 + +Start of Page No = 2 +ATTACHMENT A +ANCILLARY COMPENSATION AND COVERED SERVICES +Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members +shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any +applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds +PROVIDER's billed charges. +Routine Vision Care +Effective +Contracted Rates +HCIF Rates* +Frames +$39.00 +$47.51 +Single Vision Lenses +$38.00 +$46.30 +Bifocal Lenses** +$59.00 +$71.88 +Trifocal Lenses** +$69.00 +$84.06 +Contact Lenses +95% of the current AHCCCS +95% of the current AHCCCS +Fee Schedule +Fee Schedule +* Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are +required by AHCCCS", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc10_040121 Nationwide Vision Center Care 1st Amendment,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0560663,86-0560663, ," 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, the parties have executed this Amendment to the Agreement in duplicate by their +respective officers duly authorized to do so +PLAN +PROVIDER +By: +6/3/21 +Scott Cummings +Date +Signature Vincent Hayes +Chief Administrative Officer +Printed Name +Vincent Hayes +Title Vice President Managed Care +NAtion wide Vision Center INC +Address for Plan Notices: +Contracting Entity/Group Name + 86-0560663 +Carelst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +5-6-2021 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +220 N McKemy Ave +Chandler, Az 85226 +Carelst +Revised 050817 + +Start of Page No = 2 +ATTACHMENT A +ANCILLARY COMPENSATION AND COVERED SERVICES +Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members +shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any +applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds +PROVIDER's billed charges. +Routine Vision Care +Effective +Contracted Rates +HCIF Rates* +Frames +$39.00 +$47.51 +Single Vision Lenses +$38.00 +$46.30 +Bifocal Lenses** +$59.00 +$71.88 +Trifocal Lenses** +$69.00 +$84.06 +Contact Lenses +95% of the current AHCCCS +95% of the current AHCCCS +Fee Schedule +Fee Schedule +* Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are +required by AHCCCS", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,56-2589722,86-0713148, ," +By: 6 8 2017 +Soldiering +Scott Cummings +Date +Signature +Chief Administrative Officer +MARK R osenberg +Printed Name +CEO +Title +Barnet Dulaney Perkins Eye Center, PLLC +Address for Plan Notices: +Barnet Dulaney Surgery Centers, LLC +Contracting Entity/Group Name +Care1st Health Plan Arizona, Inc +Attention: Director, Provider Network Operations +56-2589722/ 86-0713148 +2355 E Camelback Road, #300 +Contracting Entity/Group Tax I.D. +Phoenix, Arizona 85016 +4-12-2017 +Date +Address for Provider Notices: +4800 N, 22nd Street +PhoeNix , AZ 85016 +artn: Contrating +Carelst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may +file a grievance, or (2) an action such as a denial of authorization from which a Member can file an +appeal and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,56-2589722,86-0713148, ," +By: 6 8 2017 +Soldiering +Scott Cummings +Date +Signature +Chief Administrative Officer +MARK R osenberg +Printed Name +CEO +Title +Barnet Dulaney Perkins Eye Center, PLLC +Address for Plan Notices: +Barnet Dulaney Surgery Centers, LLC +Contracting Entity/Group Name +Care1st Health Plan Arizona, Inc +Attention: Director, Provider Network Operations +56-2589722/ 86-0713148 +2355 E Camelback Road, #300 +Contracting Entity/Group Tax I.D. +Phoenix, Arizona 85016 +4-12-2017 +Date +Address for Provider Notices: +4800 N, 22nd Street +PhoeNix , AZ 85016 +artn: Contrating +Carelst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may +file a grievance, or (2) an action such as a denial of authorization from which a Member can file an +appeal and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc4_White Mountain Phys Contract,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0460643,86-0460643, ," +Michael L Johnson PT +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +Scott +By: Gummings 10-23-2018 Date +Sellbury +Signature +Dechange +Chief Administrative Officer +Printed Name +Michael L Johnson PT +PT, TIN owner +Title +White Mountain Physical therapy, +Address for Plan Notices: +Contracting Entity/Group Name +LTD + 86-0460643 +Carel 1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +05-03-2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +PO Box 1420 +Show Low, AZ 85902-1420 +CareIst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc4_White Mountain Phys Contract,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0460643,86-0460643, ," +Michael L Johnson PT +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +Scott +By: Gummings 10-23-2018 Date +Sellbury +Signature +Dechange +Chief Administrative Officer +Printed Name +Michael L Johnson PT +PT, TIN owner +Title +White Mountain Physical therapy, +Address for Plan Notices: +Contracting Entity/Group Name +LTD + 86-0460643 +Carel 1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +05-03-2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +PO Box 1420 +Show Low, AZ 85902-1420 +CareIst Ancillary Services Agreement +120114 +Page 1 of 22 + +Start of Page No = 4 +RECITALS +A. +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D. +WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1.3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- +2901 et seq., which is composed of the Administration, contractors, and other arrangement through +which health care services are provided to a member. +1.4 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +1.5 +""Attachment(s)"" means the attachments, numbered A and B to this Agreement which are incorporated +herein as if set forth in full. +Carelst Ancillary Services Agreement +120114 +Page 2 of 22 + +Start of Page No", ,3,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc5_Tipton,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc5_Tipton MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,30487744,030497744, ," +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +By: Cummings 10 18 2018 Date +Anita Phelps +Scott +Signature +Chief Administrative Officer +Anita Phelps +Printed Name +Contracts/Medical Biller +Title +Tipton Physical Therapy, LLC +Address for Plan Notices: +Contracting Entity/Group Name + 030497744 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +2/2/2017 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Tipton Physical Therapy, LLC +8400 E Florentine Road +Prescott Valley, AZ 86314-8653 + +Start of Page No = 3 +RECITALS +A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1,3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc5_Tipton,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc5_Tipton MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,30487744,030497744, ," +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +By: Cummings 10 18 2018 Date +Anita Phelps +Scott +Signature +Chief Administrative Officer +Anita Phelps +Printed Name +Contracts/Medical Biller +Title +Tipton Physical Therapy, LLC +Address for Plan Notices: +Contracting Entity/Group Name + 030497744 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +2/2/2017 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Tipton Physical Therapy, LLC +8400 E Florentine Road +Prescott Valley, AZ 86314-8653 + +Start of Page No = 3 +RECITALS +A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +B. +WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to +provide or arrange for the provision of Covered Services to Plan Members; +C. +WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. +D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for +the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan +(hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the +receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.2 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and +treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent +care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging +services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and +enteral therapies, and other services customarily deemed ancillary. +1,3 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0872873,86-0872873, ," +PLAN +PROVIDER +Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life +Chief Administrative Officer +DAVID A DEXTER +Printed Name +CEO +Title +Address for Plan Notices: +Contracting Entity/Group Name + 86-0872873 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +8/21/2019 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +1255 W Washington SI. +Tempe, Az +85281 +Page 1 of 1 + +Start of Page No = 2 +ATTACHMENT C +LABORATORY SERVICES COMPENSATION +Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider +to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the +AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- +Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory +services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at +fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. +For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule +will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the +effective date of the new AHCCCS Fee Schedule", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st,training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0872873,86-0872873, ," +PLAN +PROVIDER +Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life +Chief Administrative Officer +DAVID A DEXTER +Printed Name +CEO +Title +Address for Plan Notices: +Contracting Entity/Group Name + 86-0872873 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +8/21/2019 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +1255 W Washington SI. +Tempe, Az +85281 +Page 1 of 1 + +Start of Page No = 2 +ATTACHMENT C +LABORATORY SERVICES COMPENSATION +Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider +to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the +AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- +Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory +services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at +fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. +For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule +will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the +effective date of the new AHCCCS Fee Schedule", ,1,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Anc8_Hanger Pros & Ortho West Contract,training-data/contract-text-file/Centene/Care1st/Anc8_Hanger Pros & Ortho West Contract.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,95-2667855,95-2667855, ," +PLAN +PROVIDER +By: Salt fining +Signature +ScottCummings +Chief Administrative Officer +Katie Burkholder +Printed Name +3 25 2011 +National Director, Contracts +Date +Title +Hanger Prosthetics & Orthotics, Inc +Address for Plan Notices: +Contracting Entity/Group Name + 95-2667855/52-1486235 +Care1st Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +February 18, 2011 +2355 E Camelback Rd, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +4155 E La Palma Ave B400 +Anaheim, CA 92807 +10910 Domain Drive Ste 300 +Austin, TX 78758 +Revised 04.21.08; 10.28.08; 2.17.09,11.10.10 +Page 21 of 21 + +Start of Page No = 24 +ATTACHMENT A +ANCILLARY COMPENSATION AND COVERED SERVICES +Payment for Covered Health Services (which are prior authorized, if required) provided by Provider to +Care1st Health Plan Arizona, Inc.(Plan) members shall be based on the lesser of 75% of the January 1, +2011 AHCCCS Fee for Service rates or Provider's charges less any applicable Co-Payments, Deductibles +and Coinsurance with the exception of those services listed below New HCPCS codes established after +January 1, 2011, shall be reimbursed at the lesser of 75% of the AHCCCS Fee for Service rates prevailing +as of the date of service or Provider's charges, less any applicable Co-Payments, Deductibles and +Coinsurance HCPC codes with no rates shall be reimbursed according to AHCCCS methodology until +rates are established At no time shall Plan pay an amount that exceeds Provider's billed charges. +Plan and Provider agree that the Metropolitan Phoenix Area as pertaining to this Agreement shall be a 30 +mile radius from the center of Phoenix in any direction", ,23,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC,training-data/contract-text-file/Centene/Care1st/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0290033,86-0290033, ,", (hereinafter ""PROVIDER"") +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +PLAN +PROVIDER +By: Scott Cummings 9-27-2018 Date Signature of to CPA +State Plan President +Michael Fett, CPA +Printed Name +Title Chief Financial officer +Southwest Behavioral Health Services, Inc +Address for Plan Notices: +Contracting Entity/Group Name + 86-0290033 +CareIst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Network Management +9/25/2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Care1st Provider Agreement +Page 2 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No = 3 +RECITALS +R.1 +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible through a +program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +R.2 +WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care +Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general +practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist +Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership +organized and in good standing under the laws of the State of Arizona, which professional corporation or +partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) +and independent contractors. +R.3 +WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract +with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- +For-Service (""FFS"") basis, to AHCCCS Members enrolled with Plan (hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable +consideration the receipt of which is hereby acknowledged, the parties agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Active Labor"" means a labor at a time at which either of the following would occur: (1) there is +inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a +threat to the health and safety of the patient or the unborn child. +1.2 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.3 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and treatment +of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical +equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency +Services and other services customarily deemed ancillary. +1.4 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. +§ 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement +through which health care services are provided to a member. +1.5 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +Care1st Provider Agreement +Page 3 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC,training-data/contract-text-file/Centene/Care1st/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0290033,86-0290033, ,", (hereinafter ""PROVIDER"") +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +PLAN +PROVIDER +By: Scott Cummings 9-27-2018 Date Signature of to CPA +State Plan President +Michael Fett, CPA +Printed Name +Title Chief Financial officer +Southwest Behavioral Health Services, Inc +Address for Plan Notices: +Contracting Entity/Group Name + 86-0290033 +CareIst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Network Management +9/25/2018 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Care1st Provider Agreement +Page 2 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No = 3 +RECITALS +R.1 +WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System +(hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Members eligible through a +program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +R.2 +WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care +Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general +practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist +Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership +organized and in good standing under the laws of the State of Arizona, which professional corporation or +partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) +and independent contractors. +R.3 +WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract +with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- +For-Service (""FFS"") basis, to AHCCCS Members enrolled with Plan (hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable +consideration the receipt of which is hereby acknowledged, the parties agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Active Labor"" means a labor at a time at which either of the following would occur: (1) there is +inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a +threat to the health and safety of the patient or the unborn child. +1.2 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal +and subsequent request for hearing. +1.3 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and treatment +of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical +equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency +Services and other services customarily deemed ancillary. +1.4 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. +§ 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement +through which health care services are provided to a member. +1.5 +""Appeal"" means a disagreement by a Member with a Plan action/adverse decision such as denial of +authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. +Care1st Provider Agreement +Page 3 of 23 +Southwest Behavioral Health Services, Inc.9.25.18 + +Start of Page No", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Mult1_Arizona Oncology_1 - 860938204,training-data/contract-text-file/Centene/Mult1_Arizona Oncology_1 - 860938204 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,86-0938204,86-0938204, ,", an Arizona Corporation, (hereinafter ""Plan"") and +Arizona Oncology Associates, PC (hereinafter ""PROVIDER"") +IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above +written +PLAN +PROVIDER +By: +Sale Guing +UCI 23 2013 +Sam Alber +Scott Cummings +Date +Signature +Chief Administrative Officer +Lanny I Hecker, MD, PhD +Printed Name +Practice President +Title +Arizona Oncology Associates, PC +Address for Plan Notices: +Contracting Entity/Group Name + 86-0938204 +Carelst Health Plan Arizona, Inc. +Contracting Entity/Group Tax I.D. +Attention: Director, Provider Network Operations +5/3/113 +2355 E Camelback Road, #300 +Date +Phoenix, Arizona 85016 +Address for Provider Notices: +Arizona Oncology Associates, PC +Attn: Managed Care +1760 E River Rd, Suite 350 +Tucson, AZ 85718 +Carelst Provider Agreement RFP14 072712 +Page 1 of 21 + +Start of Page No = 3 +RECITALS +R.1 +WHEREAS, Plan has or intends to enter into a Contract with the Arizona Health Care Cost Containment +System (hereinafter ""AHCCCS"") to provide or arrange for certain health care services to Plan Members eligible +through a program administered and/or regulated by AHCCCS (hereinafter ""AHCCCS Members""); +R.2 +WHEREAS, if Plan secures an AHCCCS contract in Provider's service area Plan intends to contract +directly with CMS to provide, arrange for or administer the provision of health care services to dual eligible +beneficiaries and Provider agrees to work with Plan to negotiate a contract to provide services to dual +eligible +beneficiaries enrolled with Plan; +R.3 +WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care +Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general +practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist +Physician practicing in a recognized specialty, or (iii) a professional corporation or medical group partnership +organized and in good standing under the laws of the State of Arizona, which professional corporation or +partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) +and independent contractors. +R.4 +WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract +with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- +For-Service (""FFS"") basis, to AHCCCS Members enrolled with Plan (hereinafter ""Plan Members""). +AGREEMENT +NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable +consideration the receipt of which is hereby acknowledged, the parties agree as follows: +ARTICLE I +DEFINITIONS +The following terms shall have the following meanings for purposes of this Agreement: +1.1 +""Active Labor"" means a labor at a time at which either of the following would occur: (1) there is +inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a +threat to the health and safety of the patient or the unborn child. +1.2 +""Adverse Action/Decision"" means (1) any action (such as a claim denial) from which a provider may file +a grievance, or (2) an action, such as a denial of authorization from which a Plan Member can file an +appeal and subsequent request for hearing. +1.3 +""Ancillary Services"" means those Covered Health Care Services necessary to the diagnosis and treatment +of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical +equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency +Services and other services customarily deemed ancillary. +1.4 +""AHCCCS"" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. +§ 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement +through which health care services are provided to a Plan Member. +Carelst Provider Agreement RFP14 072712 +Page 2 of 21 + +Start of Page No", ,2,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed,training-data/contract-text-file/To Be Reorganized Upon Completion/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,263143681,263-143681, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed,training-data/contract-text-file/To Be Reorganized Upon Completion/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,263143681,263-143681, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +Custom_ULP Inc_ULRF_20160311_Dually Executed KY J4M_MA-C13371728AA,training-data/contract-text-file/To Be Reorganized Upon Completion/Custom_ULP Inc_ULRF_20160311_Dually Executed KY J4M_MA-C13371728AA_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,27-3645560,27-3645560, ,", Suite 400 +Louisville, KY 40223 +By: Danea C Magin +Title: VP Health Partiver Services +Date: +3-11-16 +GROUP PRACTICE: +University of Louisville Physicians, Inc +Address: 300 E Market Street, Suite 400, Louisville, KY 40202 +By: +Title: CEO +Acting +Rabulaus +Date: +3/10/16 +Group Practice Tax ID: 27-3645560 +101-1029626 university of Louisville Research Franaction +Page 21 of 22 + +Start of Page No = 22 +EXIMBIT A - GROUP PRACTICE SERVICE LOCATIONS +with wood +Page 22 of 22 + +Start of Page No = 23 +CARESOURCE JUST4MET +PLAN COMPENSATION SCHEDULE +For Medically Necessary Covered Services rendered to Covered Persons by Provider or by Group Practice +Providers, in accordance with the terms of this Agreement, Provider or Group Practice Provider, as the case +may be, shall accept as payment in full the lesser of: +(i) +Provider's or Group Practice Provider's billed charges: or +(ii) +The percentage, listed below, of the Medicare allowed amount applicable lo 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 (the +""Medicare Allowed Amount"") Any co-payment, deductible or coinsurance shall be offset +against the Medicare Allowed Amount for Covered Services, without regard to whether +the Provider or Group Practice Provider has collected such amounts. +Professional Services Reimbursement Rate +Adult Primary Care Physicians: 115% of the Medicare Allowed +Amount +Adult Specialists: 140% of the Medicare Allowed Amount +Pediatric Primary Care Physicians: 200% of the Medicare Allowed +Amount +Pediatric Specialists: 225% of the Medicare Allowed Amount +Injectable medications will generally be paid at 105% of the Medicare Fce Schedule, as defined below, +except for those drugs that may be available through 8 specialty pharmacy benefits manager. +In the event there is no Medicare Allowed Amount Plan will price using the above percentages of the CMS +RVU values", ,21,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +2017-01-01 SJHS-St. Joseph Heritage Healthcare AMD,training-data/contract-text-file/To Be Reorganized Upon Completion/HealthFirst of Cali - Professional/2017-01-01 SJHS-St. Joseph Heritage Healthcare AMD_MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,33-0185031,33-0185031, ," c=US +Date: :2017 10 31 15:05:00-07'00 +Ginny Ripslinger +Signature +Interim Senior Vice President +Network Development and Contracting +Thomas D Hamilton +Print Name +10-26-17 +Date +Regional Health Plan Officer +Title + 33-0185031 +Federal Tax Identification Number +PPG +Provider Type +Date +St Joseph Heritage Healthcare +Amendment Effective 1/1/17 +Page 4", ,4,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +Custom_2018-09-15 COMM Agmt FE - Bandon Community Health Center dba Coast Community Health Center,training-data/contract-text-file/To Be Reorganized Upon Completion/Moda - Professional/Custom_2018-09-15 COMM Agmt FE - Bandon Community Health Center dba Coast Community Health Center.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,943455260,94-3455260, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",False +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/To Be Reorganized Upon Completion/Molina - Professional/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/To Be Reorganized Upon Completion/Molina - Professional/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True +CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756,training-data/contract-text-file/To Be Reorganized Upon Completion/Molina - Professional/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt,Group Provider Taxpayer Identification Number per Signatory ,PROV_GROUP_TIN_SIGNATORY,74-6000756,74-6000756, , , ,,"What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. ",True