doczyai-pipelines/streamlit/SOURCE_DOCUMENTS/2023 10 26_Pediatrix Medical Group of T...ment CHIP_STAR_Removed HIM_executed MU.txt

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COMMUNITY HEALTH CHOICE, INC.
HOSPITAL-BASED PHYSICIAN AGREEMENT
This Agreement is entered into and made effective as of the date shown on the signature page ("Effective
Date"), by and between Community Health Choice, Inc., a non-profit 501(c)(4) corporation licensed by the Texas
Department of Insurance ("TDI") as a health maintenance organization in the State of Texas, and its Affiliates
(collectively "Community"), and Pediatrix Medical Group of Texas Billing, Inc. dba Pediatrix Medical Group of
Texas_("Physician").
(Legal Name and DBA as it appears on W-9)
WITNESSETH:
WHEREAS, Community has its certificate of authority to operate as a health maintenance organization
under Chapter 843 of the Texas Insurance Code, as amended;
WHEREAS, Physician is an individual licensed to practice medicine in this state; a professional association
organized under the Texas Professional Association Act (Article 1528f, Vernon's Texas Civil Statutes); an approved
nonprofit health corporation certified under Chapter 162, Occupations Code; a medical school or medical and dental
unit, as defined or described by Section 61.003, 61.501, or 74.601, Education Code, that employs or contracts with
physicians to teach or provide medical services or employs physicians and contracts with physicians in a practice
plan; or another person wholly owned by physicians that is qualified to provide or arrange for the provision Primary
Care and/or Specialty Care professional services); and
WHEREAS, Community wishes to enter into an agreement with Physician to provide or arrange for the
provision of Covered Services to Members by Primary and Specialty Care Physicians, and Physician wishes to enter
into an agreement with Community to provide or arrange for the provision of such Covered Services to Members.
NOW, THEREFORE, for and in consideration of the premises and the mutual covenants and agreements
herein contained, it is understood and agreed by and between the parties hereto as follows:
SECTION 1 - DEFINITIONS
Many words and terms are capitalized throughout this Agreement to indicate that they are defined as set
forth in this Section I.
1.1
Accreditation Organization. Any organization, including but not limited to, URAC, the National
Committee for Quality Assurance ("NCQA") or the Joint Commission, engaged in accrediting or certifying
Community or any Participating Provider.
1.2
Affiliate. A corporation, partnership or other legal entity (including without limitation any Payor)
directly or indirectly owned or controlled by, or which owns or controls, or which is under common ownership or
control with Community.
1.3
Benefit Plan/Program/Program. A certificate of coverage, summary plan description, or other
document or program under which Community or other Payor undertakes to provide, arrange for, pay for, or
reimburse any part of the cost of health care services for eligible Members. Community may also enter into
administrative agreements with other Payors, governmental, public or private employers, or other entities to provide
administrative services related to providing, arranging for, paying for or reimbursing for the cost of health care
services, including self-funded employer sponsored plans. Benefit Plan/Program will include self-funded employee
benefit plans for which Community provides administrative services.
1.4
Billed Charges. The usual and customary fee charged by Physician that does not exceed the fee
Physician would ordinarily charge regardless of expected payment source.
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1.5
CMS. The federal agency, Center for Medicare & Medicaid Services, responsible for
administering the Medicare, Medicaid, and Children Health Insurance Programs.
1.6
Clean Claim. An electronic or paper claim for payment for services that meets the Texas and/or
federal statutory and regulatory requirements for a "clean claim."
1.7
Community Protocols. The rules, procedures, policies, protocols, and other conditions to be
followed by Participating Physicians, Providers and Members with respect to providing Covered Services under
a particular Benefit Plan/Program, generally defined in Community's Provider Manual.
1.8
Coinsurance. A component of Member Expense, generally reflected as a percentage, in an
amount identified in Member's Benefit Plan/Program, paid to a Provider or Physician for Covered Services by
Member.
1.9
Copayment. A component of Member Expense, generally reflected as a flat or fixed dollar amount
either per Covered Service or per encounter, identified in Member's Benefit Plan/Program, and collected by
Physician or Provider from the Member at the time Member receives Covered Services.
1.10
Coordination of Benefits. The allocation of financial responsibility between two or more Payors of
health care services, each with a legal duty to pay for or provide Covered Services to a Member at the same time.
1.11 Covered Services. The Medically Necessary health care services, products, or supplies for which a
Member is entitled to receive coverage from Community or other Payor, pursuant to the terms of the Member's
Benefit Plan/Program.
1.12
Deductible. A component of Member Expense, generally reflected as a fixed dollar amount during
a specific benefit period, typically one year, identified in a Member's Benefit Plan/Program; payable by a Member
prior to Community's or Payor's obligation to make payment for Covered Services. Deductibles may apply to a
Member or to a Member's eligible dependents.
1.13
Emergency Behavioral-Health Condition. Any condition, without regard to the nature or cause of the
condition, which requires immediate intervention and/or medical attention without which an individual would present
an immediate danger to himself/herself or others or which renders the individual incapable of controlling, knowing
or understanding the consequences of his/her actions.
1.14
Emergency Services. The health care services provided in a hospital emergency facility,
freestanding emergency medical care facility, or comparable facility to screen for emergency medical conditions
and/or to evaluate and stabilize medical conditions, including but not limited to severe pain, that would lead a prudent
layperson possessing an average knowledge of medicine in health to believe that the person's condition, sickness,
or injury is of such a nature that failure to get immediate medical care could result in: (1) placing the patient's health
in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part;
(4) serious disfigurement; (5) in the case of a pregnant woman, serious jeopardy to the health of the fetus; or (6) an
Emergency Behavioral Health Condition. In no event will "Emergency Services" be interpreted under this
Agreement so as to conflict with emergency service or emergency screening obligations under federal or State law.
1.15 Excluded Provider. A healthcare Provider that has been prohibited, debarred or excluded from
participation in a State or federal healthcare program by operation of law or an edict by a regulatory agency.
1.16
Excluded Services. Those health care services and supplies that are determined not to be Medically
Necessary or that otherwise are not Covered Services under a Member's Benefit Plan/Program.
1.17 Healthcare Professional. The Physicians, healthcare professionals, practitioners, and/or Providers
licensed and/or authorized under the laws of the State, who are employed by or contracted with Physician to provide
Covered Services under the terms of this Agreement.
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1.18 Medically Necessary/Medical Necessity. Those Covered Services that Community determines
under the applicable Utilization Management Program to be: (1) appropriate and necessary for the symptoms,
diagnosis, or treatment of a medical condition; (2) provided for the diagnosis or direct care and treatment of a medical
condition; (3) within standards of good medical practice within the organized medical community of the treating
provider; (4) not primarily for the custodial convenience of the Member or the treating provider; (5) consistent with
sound medical policy, the Utilization Management Program, the Quality Improvement Program, and the
requirements of the Benefit Plan/Program under which the Covered Services are rendered; and (6) an appropriate
and cost-effective service or supply consistent with generally accepted medical standards of care. For inpatient
stays, this means that acute care as an inpatient is necessary due to the kind of services the Member is receiving
or the severity of the Member's condition, and that safe, cost-effective, and adequate care cannot be received as an
outpatient or in a less acute, alternative medical setting.
1.19
Member. A person who is eligible for and enrolled in a covered Benefit Plan/Program.
1.20
Member Expense. The out-of-pocket expense or cost-sharing amounts, such as Copayments,
Coinsurance or Deductibles, a Member must pay to Physician or Provider for Covered Services, identified in
Member's Benefit Plan/Program.
1.21 Participating Physician. A Physician with a direct or indirect contractual relationship with
Community to provide certain Covered Services to Members.
1.22
Participating Provider. A Provider with a direct or indirect contractual relationship with Community
to provide certain Covered Services to Members.
1.23
Payor. Community, or any other public or private entity (including, but not limited to, the federal
government, the State, employers, insurance carriers, self-funded plans, associations, trust funds, and health
maintenance organizations), which provides, administers, funds, insures, or is responsible for paying Participating
Physician or Providers for Covered Services rendered to Members.
1.24 Physician. Physician is an individual licensed to practice medicine in the State; a professional
association organized under the Texas Professional Association Act (Article 1528f, Vernon's Texas Civil Statutes);
an approved nonprofit health corporation certified under Chapter 162, Occupations Code; a medical school or
medical and dental unit, as defined or described by Section 61.003, 61.501, or 74.601, Education Code, that
employs or contracts with Physicians to teach or provide medical services or employs physicians and contracts with
Physicians in a practice plan; or another person wholly owned by Physicians that is qualified to provide or arrange
for the provision primary care and/or specialty care professional services).
1.25 Prior Authorization. The written or confirmed electronic determination by Community, a Payor, or
other permitted person or entity that health care services proposed to be provided by a Physician or Provider
are medically necessary and appropriate before such services are provided.
1.26 Provider. A person or entity, other than a Physician, who is licensed or otherwise authorized to
provide a health care service in the State, including: (i) a chiropractor, registered nurse, pharmacist, optometrist,
registered optician, or acupuncturist; or (ii) a pharmacy, hospital, or other institution or organization; a person
who is wholly owned or controlled by a Provider or by a group of Providers who are licensed or otherwise
authorized to provide the same health care service; or a person who is wholly owned or controlled by one or
more hospitals and Physicians, including a Physician-hospital organization.
1.27 Provider Manual. The Community document, incorporated in its entirety by this reference,
containing administrative policies and procedures relating to issues such as credentialing, utilization
management, claims payment, provider complaints or appeals and quality improvement.
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1.28 Quality Improvement Program. The functions including, but not limited to, credentialing of Providers,
review and audit of medical and other records, clinical outcomes, peer review, and Provider appeals and grievance
procedures performed or required by Community, or any other permitted person or entity, to review the quality of
Covered Services rendered to Members.
1.29 Referral. Consultation for evaluation and/or treatment of a Member, requested by one Physician
or Provider to another Physician or Provider usually for a specified number of visits, treatments, or period of time.
1.30
Specialty Care Physician. A Physician who (i) is a Participating Physician; (ii) holds an unrestricted
license to practice allopathic or osteopathic medicine in the State of Texas; (iii) is engaged in a specialty medical
practice; (iv) accepts Referrals from primary care Physicians for the purpose of providing Covered Services to
Members in the Specialty Care Physician's designated specialty; and (v) is not a Specialty Care Physician who
meets the criteria of Section 1.25 above.
1.31
State. The State of Texas.
1.32
TDI. The Texas Department of Insurance.
1.33
Utilization Management Program. A system for prospective, concurrent, or retrospective review of
the medical necessity and appropriateness of health care services and a system for prospective, concurrent, or
retrospective review to determine the experimental or investigational nature of health care services. The term does
not include a review in response to an elective request for clarification of coverage or information regarding Member
eligibility.
SECTION 2 - OBLIGATIONS OF COMMUNITY
2.1
Marketing. Physician acknowledges that Community shall market or arrange for the marketing of its
Benefit Plans/Programs as well as Physician's and its Healthcare Professional's participation in such Benefit
Plans/Programs.
2.2
Identification Cards. For each Member, Community shall issue, or shall ensure the issuance, of a
Member identification card or similar item setting forth, at a minimum, the Member's name, the Member's unique
identification number, the first date on which the Member became enrolled or the toll-free number a Provider can
use to obtain the date, and the Member's primary care Physician or primary care Provider.
2.3
Regulatory Compliance. Community agrees that it shall comply with all applicable requirements of
State and federal authorities, all municipal ordinances and regulations, and all State and federal statutes and
regulations now or hereafter in force and effect which bear upon the subject matter of this Agreement.
SECTION 3 - OBLIGATIONS OF PHYSICIAN
3.1
Changes in Physician Information. Physician shall provide Community thirty (30) calendar days
advanced written notice of any of the following changes, as applicable to Physician's practice or any Healthcare
Professional rendering services under the terms of this Agreement:
a. termination of any Healthcare Professional from Physician's practice;
b. the addition of any Healthcare Professional to Physician's practice;
C. any change in address(es) or contact information where Healthcare Professional renders
Covered Services, including the addition or closure of a location;
d. any change in billing information, including but not limited to, a change in Physician's legal
structure, payment remit address, or change in Tax Identification Number;
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e. any change in other demographic or information necessary to ensure access and availability of
Covered Services to Member by Facility or that may be required for Community to meet
Community's obligations defined in Agreement.
Physician acknowledges that the addition of any Healthcare Professional to Physician's practice shall be
subject to Community's credentialing policies and payment guidelines defined herein.
Physician further acknowledges that if any fines or sanctions are levied against Community by applicable
State or federal agencies or fines are imposed by Community resulting from non-compliance by Physician of this
Section 3.1, Community shall have the right to withhold from future payments to Physician: (a) the entire amount of
such fine or sanction if Physician is the sole cause of such a fine or sanction levied or imposed; or (b) a pro rata
share of such fine or sanction amount if Physician is not the sole cause of the fine or sanction levied or imposed.
3.2
Authority. Physician attests that it has the authority to bind all Healthcare Professionals rendering
Covered Services under the terms of this Agreement to the obligations defined herein. Further, Physician represents
that the terms of this Agreement do not conflict with the terms of its agreements with Healthcare Professionals and
that the terms of this Agreement shall control and apply in any situation where there is an inconsistency or conflict
with the terms of such agreements or with respect to any matter that is not addressed in any such agreements.
Physician shall be responsible to Community for any such inconsistency or conflict in terms. This provision shall
supersede any similar provision in any agreement between Physician and Healthcare Professionals. Upon request,
Physician agrees to forward to Community: (1) a copy of any template contracts Physician maintains with Healthcare
Professionals, (2) a copy of any written policy and procedure pursuant to such agreements, (3) Physician's bylaws
and Articles of Incorporation, as well as any subsequent modifications thereto. Physician will notify Healthcare
Professionals of their rights and duties under this Agreement, and of all amendments, exhibits, and modifications
thereto. Physician is responsible for the compliance of its Healthcare Professionals of all the terms and conditions
in this Agreement. References to "Physician" also include Healthcare Professionals.
3.3
Physician Representations and Warranties. As applicable, Physician represents and warrants that
Physician and Healthcare Professionals: (1) hold/s a current and unrestricted license, certification or registration to
render Covered Services, according to the guidelines defined by the State of Texas, (2) hold/s current and
unrestricted DEA narcotic registration certificate and a current State of Texas narcotics license - unless approved
otherwise by Community, (3) render/s Covered Services consistent with Community Protocols established by
Community from time to time in its sole discretion (4) hold/s active staff privileges on the medical staff(s) of one or
more Participating Hospitals, unless otherwise approved in advance by Community, (5) maintain/s all continuing
education requirements necessary to retain Board certification or Board eligibility in Physician's or Healthcare
Professional's area(s) of practice; (6) maintain/s a professional relationship with each Member for whom such
Physician or Healthcare Professional renders Covered Services.
3.4
Services Rendered by Excluded Providers. Physician warrants that neither Physician nor any
Healthcare Professional is, or has ever been, an Excluded Provider. Physician agrees to assure that Physician
and its Healthcare Professionals shall refrain from the provision of any Covered Services to a Member if said
Physician or Healthcare Professional becomes an Excluded Provider. Notwithstanding any provision to the
contrary, Physician understands and agrees that Physician and/or its Healthcare Professionals shall not bill and
Payor shall not pay for any services or goods furnished under this Agreement by an Excluded Provider.
3.5
Provision of Services. Physician, for itself and on behalf of its Healthcare Professionals agrees to
render Covered Services to Members in accordance with: (1) the terms and conditions of this Agreement and the
applicable Benefit Plan/Program; (2) all laws, rules, and regulations applicable to Physician and its Healthcare
Professionals; (3) the Utilization Management Program, Quality Improvement Program, Community Protocols, and
grievance, appeals, and other policies and procedures of the particular Benefit Plan/Program under which the
Covered Services are rendered; (4) at least the minimum clinical quality of care and performance measurements
that are professionally recognized and/or adopted, accepted, or established by Community; (5) the customary rules
of ethics and conduct of applicable State and professional licensure boards and agencies; and (6) the prevailing
standards of care of similar providers in the same community.
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3.6
Non-Discrimination. Except as necessitated by Member's medical condition, Physician agrees not
to
differentiate or discriminate in the treatment of Members. Physician further agrees to provide Covered Services
to Members in accordance with the same standards and within the same time availability as provided to
Physician's other patients. Physician agrees not to discriminate against Members on the basis of race, color,
national origin, gender, sexual orientation, age, religion, marital status, health status or health insurance
coverage. Physician and/or Healthcare Professionals shall treat Members promptly, fairly, and courteously.
3.7
Subcontracting. Physician shall not subcontract for the performance of Covered Services under this
Agreement without the prior written consent of Community.
3.8
Certification and Regulatory Compliances. Physician and its Healthcare Professionals shall, at all
times during the term of this Agreement, satisfy all State and federal certifications, regulations, or licensure
requirements and shall render Covered Services under this Agreement in compliance with all applicable statutes,
regulations, standards, rules, and directives of State, federal, and other governmental and regulatory bodies having
jurisdiction over Physician. Evidence of such licensing, if applicable, shall be submitted to Community upon request.
Physician agrees to give immediate notice to Community in the case of a disciplinary action, modification, limitation,
suspension or revocation, or initiation of any proceeding that could result in a disciplinary action, modification,
limitation, suspension or revocation, of such licensure.
3.9
Non-Participating Provider. Physician agrees to notify Community within twenty-four (24) hours if
Physician has knowledge that a non-Participating Provider is rendering Covered Services to a Member in a situation
involving Emergency Services.
3.10
New or Additional Benefit Plan/Programs. Physician acknowledges that Community may administer
and/or offer new or additional Benefit Plan/Programs, if requested by Community, Physician agrees to negotiate
with Community in good faith to amend this Agreement to include such new or additional Benefit Plan/Programs.
3.11
Payment of Applicable Taxes. Subject to the provisions of Section 5.9 ("No Surcharges") hereof,
Physician shall be solely responsible for the payment of any sales, use, or other applicable taxes on the sale or
delivery of medical services.
3.12 Adherence to Community Protocols. Physician shall comply with all Community Protocols without
limitation (a) concurrent and retrospective review, and (b) Referral procedures, if applicable; provided, however, in
no event shall such policies and procedures be less than the standard of care for the provision of medical services
to patients in the geographic area where medical services are being provided by Physician hereunder. Nothing in
this Section 3.12, however, shall be construed to authorize Community or any of Community's officers or employees
to exercise any control over the practice of medicine by Physician or the manner in which Physicians provide medical
services. Physician acknowledges that Community may consider the failure of Physician or Healthcare
Professionals to abide by Benefit Plan/Program, Community Protocols, and/or Utilization Management Program
a
material breach of Agreement subject to termination as defined in Section 10.3.
3.13 Electronic Connectivity. Physician agrees to communicate with Community electronically
according to standard HIPAA transactions, including, but not limited to, verification of eligibility, claims status
check, electronic claims submission, electronic payment remittance advice, and electronic funds transfer. In the
event of a system(s) failure or a catastrophic event that substantially interferes with the Physician's business
operations, the Physician may submit paper claims to Community at the address in the signature block below
with "Attention to Technical Support Manager" for the days during which substantial interference with business
operations occurs as result of the catastrophic event or systems failure. Physician shall provide written notice of
the Physician's intent to submit non-electronic claims to Community within five (5 calendar days of the
catastrophic event or systems failure. Physician may request that Community waive this requirement to
communicate electronically under circumstances in which: no method is available for the submission of claims
in electronic form; the Physician is a small physician practice; there would be undue hardship, including fiscal or
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operational hardship; or any other special circumstance that would justify a waiver. Community in its sole
discretion will determine whether to agree to waive the requirement.
3.14
Credentialing of Physician and/or Healthcare Professional. Physician shall (a) be responsible for
completing the credentials application to the hospital in which Physician renders services (b) notify Community
immediately with regard to any change in the credentialing status with said hospital and, (c) submit credentialing
application directly to Community in any instance where Physician or Healthcare Professional is rendering services
at a location not covered by said hospital's credentialing program. If Physician or Healthcare Professional elects to
render services at any location not covered by said hospital's credentialing program, then in no event shall this
Agreement apply to Covered Services rendered at such location, nor will Physician or Healthcare Professional
render Covered Services to a Member at said location(s) until Physician's or Healthcare Professional's credential
application has been accepted and approved in writing by Community; provided, however, this Agreement may be
executed prior to acceptance by Community of all Healthcare Professional's credential applications.
3.15 Access to Premises. Physician agrees to permit Community and any Payor, or their designated
representatives, and the designated representatives of State and federal regulatory agencies having jurisdiction
over Community, Payor, or any Benefit Plan/Program, to conduct site evaluations and inspections of Physician's
offices and service locations as necessary under applicable laws, rules, or regulations or as may be needed to
assure quality of care rendered to Members. In the event the right of access is requested under this Section 3.15,
Physician shall, upon request, provide and make available its staff to assist in the audit or inspection effort, and
provide adequate space on the premises to reasonably accommodate the State or federal personnel conducting the
audit or inspection effort. All inspections or audits shall be conducted in a manner that will not unduly interfere with
the performance of Physician's and Healthcare Professionals' activities. All information obtained during such audit
or inspection shall be accorded confidential treatment as provided under applicable law.
3.16
Specialty Care Physician Follow Up. Each Specialty Care Physician rendering services shall, in a
timely manner, provide the referring primary care Physician with a record of all consultations and recommendations
for inclusion by the primary care Physician in the Member's medical records. Each Specialty Care Physician shall
promptly notify the referring Primary Care Physician regarding recommendations for hospitalization, further referrals,
or further specialized consultations. The referring Primary Care Physician shall have responsibility for, subject to
appropriate consultation with the Specialty Care Physician regarding hospitalization, further referrals, or specialized
consultations for Members.
3.17
Complaint Resolution Notice. Physician shall post a notice, in Physician's office or other location
reasonably certain to be seen by all Members, of the process for resolving complaints with Community, including
the Texas Department of Insurance's toll-free telephone number for filing complaints.
3.18 Provider Manual. Provider shall comply with all policies and procedures identified in the Provider
Manual. Community reserves the right to revise the Provider Manual in its sole discretion from time to time.
Community will use best efforts to inform Provider at least ninety (90) calendar days prior to the effective date of
changes that materially affect the rights or responsibilities of Provider under this Agreement. Revisions to the
Provider Manual shall not constitute amendments to this Agreement for purposes of Section 11.10.
SECTION 4 - MAINTENANCE, RELEASE, & ACCESS TO RECORDS
4.1
Administrative Records. Physician shall retain for a minimum of ten (10) years, or longer as
otherwise may be required by law, such financial, administrative, and other records as may be necessary for
compliance by Community and with other applicable local, State, and federal laws, rules, and regulations. Physician
shall make such records or documents available to Community, Payors and their authorized agents, and appropriate
representatives of any State and/or Federal regulatory agency during normal business hours for review, inspection,
and/or audit.
4.2
Medical Records. Physician shall maintain a complete medical record for each Member for which
Physician or Healthcare Professionals renders Covered Services hereunder. Such medical records shall include
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the recording of a Physician's services and such other records as may be required by law. Such records shall be
maintained in accordance with the requirements established in accordance with all applicable local, State, and
federal laws, rules, and regulations and shall be safeguarded against loss, destruction, and unauthorized use. All
medical records shall be treated as confidential so as to comply with all State and federal laws, rules, and regulations
regarding the confidentiality of patient records. Physician shall retain such medical records for a period of ten (10)
years following termination of this Agreement or longer as mandated by any applicable State or federal law.
4.3
Member Consent to Release of Medical Record Information. Physician will obtain Member
consent required in order to authorize Physician to provide access to the requested information or records as
contemplated in this Section 4 of Agreement, including copies of the Physician's medical records relating to the
care provided to Member.
4.4
Access to Records. The records referred to in Section 4.2 above shall be and remain the property
of Physician and shall not be removed or transferred from Physician except in accordance with applicable local,
State or federal laws, rules, and regulations. Subject to applicable State or federal confidentiality laws and pursuant
to written authorization by Members if required, Community or its designated representative and any Payor shall
have access to Physician's office during normal business hours on request, to inspect, review, and make copies of
such records. Physician shall provide, at Physician's expense, copies of such records to authorized representatives
of local, State, or federal regulatory agencies. In no event, shall Physician charge for records requested for payment
of a claim. Notwithstanding the foregoing, but subject to applicable local, State, or federal laws, rules, or regulations,
in the event of (i) termination of this Agreement, (ii) the selection by a Member of another Participating Provider in
accordance with Benefit Plan/Program procedures, or (iii) the approval by Community Protocols of Physician's
request to transfer a Member to another Participating Provider, Physician agrees to transfer copies of the Member's
medical records, x-rays, and/or other data to the Participating Provider when requested to do so by Community
or
Member, or at no charge to the Member or Community or transferee Participating Provider.
4.5
Continuing Obligation. The obligations of Physician under this Section 4 shall not be terminated
upon termination or rescission of this Agreement for any reason. After termination of this Agreement, Community
and the applicable Payor shall continue to have access to Physician's records as necessary to fulfill the requirements
of this Agreement and to comply with all applicable present and future laws, rules, and regulations.
SECTION 5 - COMPENSATION
If applicable, attached regulatory Addendum(s) may supersede certain requirements of this Section 5 -
Compensation.
5.1 Claims Submission. Physician shall submit Clean Claims to Payor within ninety-five (95) calendar
days of the provision of the Covered Services. Failure to submit a Clean Claim within this ninety-five (95) -day period
may result in non-payment. When submitting Claims, Physician shall: (a) use the most current coding
methodologies on all forms; (b) abide by all applicable coding rules and associated guidelines, including without
limitation inclusive code sets; and (c) in the event a code is formally retired or replaced, regardless of any
provision or term in the Agreement, discontinue use of such code and begin use of the new or replacement code
following the effective date published by the appropriate coding entity or government agency. Should Physician
submit claims using retired or replaced codes, Physician understands and agrees that Payor may deny such
claims until appropriately coded and resubmitted.
5.2
Adjudication of Claims. Payor shall adjudicate all Clean Claims submitted by Physician within forty-
five (45) calendar days for claims received by Payor via non-electronic submission, and within thirty (30) calendar
days for claims received by Payor via electronic submission. When adjudicating Physician's claim(s), Payor shall:
(1) pay the total amount of the claim in accordance with Exhibit B; (2) notify Physician in writing why the claim will
not be paid, or (3) pay the portion of the claim that is not in dispute and notify Physician in writing why the remaining
portion of the claim was not paid. Physician has one hundred and eighty (180) calendar days to appeal Payor's
adjudication of a claim. When medical information is requested to support payment, Physician shall have twenty-
one
(21) calendar days to provide information to Payor. Not later than fifteen (15) days following receipt of
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Physician's response to Payor's request for additional information, Payor shall make a final adjudication decision.
Payor will adjudicate all Clean Claims received in accordance with the terms and conditions of this Agreement,
Texas Insurance Code Section 843 and TDI rules promulgated thereto, governing claim payment for Covered
Services provided under a health maintenance organization's benefit plan, and federal laws, rules and
regulations related to ERISA claims payment for self-funded plans or for Medicare Advantage plans, regarding
timeliness of claims payments.
5.3
Claims Coding/Editing Determinations. Payor shall utilize CMS, state Medicaid and/or other
nationally recognized claims and payment processing policies, procedures, and guidelines, which may include
claim and code audit and edit determinations and other claims logic as may be implemented by Payor. Upon
request by Physician, Payor shall forward to Physician a description and copy of Payor's coding guidelines,
including any underlying bundling, recoding, or other payment process and fee schedules applicable to specific
Covered Services rendered by Physician. Payor shall forward such coding guidelines and fee schedules not
later than the thirtieth (30th) calendar day after receipt of Physician's request. Payor shall include the name,
edition, and model version of the software that Payor uses to determine bundling and unbundling of claims.
Further, Payor shall forward to Physician a notice of changes to Payor's coding guidelines and fee schedules
previously provided that will result in a change of payment to Physician. Such notice of changes will be provided
not later than the ninetieth (90th) calendar day before said changes take effect, unless required by CMS, TDI or
other regulatory entity, in which case Payor shall provide as much notice as reasonably possible. Payor shall
not make retroactive revisions to the coding guidelines and fee schedules. On or before the thirtieth (30th)
calendar day after the date after receipt of requested information and/or notice of future changes, Physician may
terminate this Agreement by providing written notice to Payor without penalty or discrimination in participation in
other health care products or plans. Physician shall use or disclose any information received by Payor solely
for the purpose of practice management, billing activities, and other business operations and shall disclose such
information only to a governmental agency involved in the regulation of health care or insurance.
5.4
Claims/Payment Disputes. Should Physician request reconsideration of or dispute payment or
payments made by Payor under this Agreement, Physician must notify Payor in writing of the dispute within one
hundred and eighty (180) calendar days of the date of the original claim adjudication. Physician acknowledges
that Payor may consider Physician's failure to submit such disputes within the above referenced time period as
Physician's waiver of any such dispute and Payor's original adjudication may be considered final without further
appeal options.
5.5
Correction of Claim Overpayments. In the event Payor determines that a claim was overpaid, Payor
may seek correction of the payment within one hundred and eighty (180) calendar days from the overpayment.
Physician may appeal the refund request within forty-five (45) calendar days of receipt of refund request. If after
appeal, the overpayment determination is maintained, Physician will repay Payor the overpayment amount within
ten (10) calendar days of notice of the outcome of the appeal. If Physician fails to refund overpayments, Physician
agrees that Payor may recover overpayments through offsets against future payments. Physician will report
promptly any credit balance that it maintains with regard to any claim overpayment under this Agreement, and will
return such overpayment to Payor within forty-five (45) calendar days after posting it as a credit balance. Physician
must refund an overpayment from an enrollee in the amount of the overpayment to the enrollee not later than the
30th day after the date the Physician determines that an overpayment has been made.
5.6
Payor Solely Responsible for Payment. Unless otherwise provided for in a Member's Benefit
Plan/Program, Physician shall collect Member Expenses for Covered Services directly from Members, and shall
not waive, discount or rebate any such Member Expenses. Physician understands and agrees that, except for
any applicable Member Expense, Payor has the sole responsibility for payment of Covered Services rendered by
Physician under this Agreement. In the event of the insolvency of Payor or cessation of operations by Payor,
provider's sole recourse shall be against Payor through the bankruptcy or receivership estate of Payor.
5.7
Benefit Plan/Program Participation and Compensation. The parties agree that Exhibit B shall outline:
(1) the Benefit Plan/Program (s) in which Physician and Healthcare Professionals participate; and (2) the applicable
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compensation to Physician for each program. Physician agrees to participation in such Benefit Plans/Programs and
agrees to receive compensation for Covered Services for such Benefit Plans/Programs as described in the
applicable Exhibit B. Physician acknowledges that Community may contract with Payors to provide access to
Community's rights and obligations under this Agreement and Physician authorizes Community to disclose the
information contained in the applicable Exhibit B to the applicable Payor(s). Physician may request information from
Community necessary to determine whether a specific Payor has been authorized access to Physician's services
and the compensation terms in Exhibit B under this Agreement.
For the term of this Agreement, Physician shall accept as payment in full for Covered Services and all other
services rendered to Members under this Agreement, the lesser of Physician's Billed Charges or the agreed
compensation set forth in Exhibit B, less any applicable Member Expense, attached hereto and incorporated by
reference into this Agreement.
5.8
Schedule of Benefits and Determination of Covered Services. Upon request, Payor will provide
or make available to Physician a summary of Covered Services for each applicable Benefit Plan/Program. Payor
shall be solely responsible for the determination of the extent of Member's coverage. Any action by Payor
pursuant to a Member's Benefit Plan/Program, or Community Protocols or Payor protocols or Utilization
Management Program in no way releases Physician or Healthcare Professional(s) of the responsibility to provide
appropriate care to Members.
5.9
Member Hold Harmless. Physician agrees that in no event, including but not limited to, non-payment
by Payor, the insolvency of Payor, or breach of this Agreement, shall Physician bill, charge, collect a deposit from,
seek compensation, remuneration, or reimbursement from, or have any other recourse against any Members or
persons other than Payor acting on the Member's behalf for Covered services provided under this Agreement. This
section shall not prohibit collection of Member Expense made in accordance with the terms of the applicable Benefit
Plan/Program. Physician further agrees that the terms of this section shall: (i) survive termination of this Agreement
regardless of the cause giving rise to termination and shall be construed to be for the benefit of Members; and (ii)
supersede any oral or written contrary agreement now existing or hereafter entered into between Physician or a
Healthcare Professional and Members or persons acting on their behalf. Any modification, addition, or deletion of
or to the provisions of this Section shall be effective on a date no earlier than fifteen (15) calendar days after the
Texas Commissioner of Insurance has received written notice of such proposed change.
5.10 No Surcharges. Physician shall not charge Member any fees or surcharges for provision of Covered
Services rendered pursuant to this Agreement, with the exception of any applicable Member Expense. In addition,
Physician shall not collect a sales tax, use, or other applicable tax from Members for the sale or delivery of medical
services. If Community receives notice of any additional charge for the provision of Covered Services, Physician
shall fully cooperate with Community to investigate such allegations, and shall promptly refund any payment deemed
improper by Community to the party who made the payment.
5.11
Member Payment of Excluded Services. Prior to the provision of any Excluded Service to a Member,
Physician shall obtain written confirmation with Member's signature indicating that: (a) Member has been informed
of the services to be provided; (b) the services to be provided are not covered under the Member's Benefit
Plan/Program; (c) Payor will not pay for or be liable for said services; (d) Member requests that Physician renders
the Excluded Services; and (e) Member will be financially liable for such services.
5.12
Coordination of Benefits. Payment for Covered Services provided to each Member may be subject
to subrogation and/or coordination with other benefits paid or payable to or on behalf of the Member, and to Payor's
right of recovery in other third party liability situations. Physician and Healthcare Professions shall retain in the
Member's records updated information concerning other health benefit plan coverage and agrees to provide such
information to Payor. Physician and Healthcare Professionals who submit a claim for particular health care services
to more than one Payor shall provide written notice on the claim submitted to each Payor of the identity of each
other Payor with which the same claim is being filed. Payor will coordinate payment for Covered Services
in
accordance with the terms of the Member's Benefit Plan/Program and applicable State and federal laws, rules, and
regulations. If a Member has coverage from more than one payment source, Payor will coordinate benefits with
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such other payment source in accordance with the Member's Benefit Plan/Program. Physician agrees to share
information obtained or documentation required by Payor to facilitate Payor's coordination of such other benefits. If
Physician has knowledge of an alternative primary Payor, Physician shall bill such other Payor(s) with the primary
liability based on such information prior to submitting claims for the same services to Payor. If Payor is a secondary
Payor and pays a portion of a claim that should have been paid by the primary Payor, Payor may recover the
overpayment only from the Payor that is primarily responsible for that amount. If the portion of the claim overpaid
by Payor was also paid by the primary payor, Community may recover the amount of the overpayment from
Physician or Healthcare Professional that received the payment. To the extent permitted by law, if Payor is not
Member's primary payor, payment for Covered Services from Payor shall be no more than the difference between
the amount paid by the primary Payor(s) and the applicable rate under this Agreement, less any applicable Member
Expense. Payor may share information with another Payor to the extent necessary to coordinate appropriate
payment obligations on a specific claim.
5.13 Services Locations/New Services. This Agreement applies to Covered Services rendered at
Physician's service locations set forth in Exhibit A. In the event Physician begins providing services at other
locations, new types of facilities, or under other tax identification number(s), (either by operating such locations
itself, or by acquiring, merging, or affiliating with an existing provider that was not already under contract as a
participant in Community's network of providers), such additional tax identification number(s), new types of
facilities, or locations, will be subject to this Agreement only upon written agreement between the parties.
SECTION 6 - UTILIZATION MANAGEMENT AND QUALITY IMPROVEMENT PROGRAMS
6.1
Utilization Management Program. Physician shall participate in, cooperate with, and comply with all
decisions rendered in connection with Community's Utilization Management Program. Physician shall (i) provide
such records and other information as may be required or requested under such Utilization Management Program,
and (ii) comply with all confidentiality requirements regarding a Utilization Management Program.
6.2
Quality Improvement Program. Physician shall be solely responsible for the quality of such Covered
Services rendered to Members. The quality of Covered Services rendered to Members shall be monitored under
the Quality Improvement Program applicable to the particular Benefit Plan/Program. Physician shall (i) participate
in, cooperate with, and comply with all decisions rendered by Community or the applicable Payor in connection with
a Quality Improvement Program, (ii) provide such medical records and such review data and other information as
may be required or requested under a Quality Improvement Program; and (iii) comply with all confidentiality
requirements regarding a Quality Improvement Program. In the event that the standard or quality of care furnished
by a Physician is found to be unacceptable under any Quality Improvement Program, Community shall give written
notice to Physician and/or Healthcare Professionals to correct the specified deficiencies within the time period
specified in the notice. Such Physician shall correct such deficiencies within that time period. Physician shall
perform such quality management in accordance with the performance standards and criteria of Community.
6.3
Limitation. In no event, however, shall the requirements of such Utilization Management Program
or Quality Improvement Program be less than the standard of care for the provision of medical services to patients
in the geographic area where medical services are being provided by Physicians under this Agreement. Further,
nothing in this Agreement shall be construed to authorize Community or any of Community's officers or employees
to exercise any control over the practice of medicine by Physicians or the manner in which Physicians provide
medical services.
SECTION 7 - INSURANCE, INDEMNIFICATION, & RELEASE
7.1
Professional and General Liability. Physician agrees to purchase and maintain during the term of
this Agreement, at its sole cost and expense, policies of general liability, professional liability, and other insurance
as shall be necessary to adequately insure Physician and Healthcare Professionals, agents, and employees against
any claim or claims for damage arising by reason of personal injury or death occasioned directly or indirectly in
connection with the performance of any procedure or service provided hereunder, the use of any property and
facilities provided by Physician, and activities performed by Physician and Healthcare Professionals in connection
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with this Agreement. Such policies shall provide coverage in the amounts acceptable to Community, but in no event
shall professional liability insurance be less than One Hundred Thousand Dollars ($100,000) for each person and
Three Hundred Thousand Dollars ($300,000) for each single occurrence for bodily injury or death and One Hundred
Thousand Dollars ($100,000) for each single occurrence for injury to or destruction of property, unless a lesser
amount is determined sufficient by Community in writing. Such professional liability coverage shall include "tail"
coverage of the same limits as stated above for any "claims-made" policy as necessary to continue coverage until
any applicable statute of limitations has expired. Physician shall require of Physician's professional liability insurance
carrier that Community be named as a party entitled to thirty (30) calendar days' prior written notice of an intent to
cancel or terminate such insurance. Upon execution of this Agreement, Physician shall provide to Community
written proof from Physician's carrier(s) of the coverage required under this Section.
7.2
Notice of Adverse Action. Physician shall notify Community in writing, within forty-eight (48) hours
or such lesser period of time as required by the applicable federal or State statute, of receiving any written or oral
notice of any adverse action, including without limitation, any malpractice suit or arbitration action, or other suit or
arbitration action naming or otherwise involving Physician, a Provider, Community, or any Payor, and of any other
event, occurrence, or situation that might materially interfere with, modify, or alter performance of any of Physician's
duties or obligations under this Agreement. Physician also shall notify Community promptly of any action against
any license or certification Physician or Healthcare Professional under Title XVIII or Title XIX or other applicable
statute of the Social Security Act or other State law, DEA narcotic registration certificate, State narcotics license, or
medical staff privileges, and of any material change in the ownership or business operations of Physician. Failure
to notify Community of any adverse action shall be a material breach of this Agreement and may include termination
under section 10.
7.3
Indemnification by Physician. Physician will at all times hereafter indemnify, defend, and hold
harmless Community and its representatives, officers, directors, employees, and agents individually and collectively
from any and all causes of action, liabilities, claims, or other expenses (including, without limitation, costs of suit and
attorney's fees, and mediation expenses) which might be asserted against Community and its representatives,
officers, directors, employees, and agents, individually and collectively arising from, or pertaining to, any acts or
omissions of Physician or Healthcare Professionals under this Agreement; provided, however, that to the extent
that any such causes of action, costs, or fees are compensated for by insurance purchased by Community,
Physician shall not be required to reimburse Community or insure for same.
Physician shall further indemnify, defend, and hold harmless Community, and as applicable any Payor, and
their representatives, officers, directors, employees, and agents individually and/or collectively from any and all
causes of action, liabilities, claims, or other expenses (including, without limitation, costs of suit, attorney's fees,
and/or mediation expenses) that might be asserted against Community and its representatives, officers, directors,
employees, and agents individually arising from, or pertaining to, the failure or refusal of Physician to pay its
subcontractors and/or the members of its provider network for services and/or goods and equipment provided to
Members. Physician agrees that all Healthcare Professionals' contracts related to the provision of services under
this agreements, will require that the Healthcare Professional providing such service hold harmless Community and
any Payor as applicable and their representatives, officers, director, employees, and agents in the event of Provider's
failure or refusal to make payment for any reason and whether due to Provider's insolvency or otherwise.
7.4
Release. Physician and Healthcare Professionals hereby release from liability Community, and its
affiliates, directors, committees, officers, employees, or agents, and agrees to waive all legal claims that Physician
or Healthcare Professionals may now or may hereafter have against such individuals or entities related to any and
all actions taken in good faith in connection with evaluating Physician's or Healthcare Professional's professional
qualifications. Physician hereby releases and shall cause Physician's Healthcare Professionals to further release
from liability any individual or entity that may have information bearing on Physician's or Healthcare Professional's
professional qualifications who discloses in good faith such information in connection with evaluation by the above
entities and individuals of Physician's or Healthcare Professional's professional qualifications. Physician and
Healthcare Professionals further agree/s that any act, communication, report, recommendation or disclosure made
in connection with the evaluation of professional qualifications, shall be privileged and confidential and shall not be
subject to discovery, subpoena, or other means of legal compulsion for their release.
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SECTION 8 - DISPUTE RESOLUTION
8.1
Dispute Resolution. The parties agree to meet promptly in good faith to resolve any controversy,
dispute or claim that may arise out of or relating to this Agreement that cannot be resolve informally. Neither party
shall unreasonably refuse or delay the other party's request for such meeting. If the parties are unsuccessful in
resolving such controversy or dispute, the dissatisfied party shall submit a written complaint (the "Complaint") to the
other party (the "Responding Party"), which complaint shall set forth with specificity the basis of the complaint and
the proposed resolution. The Responding Party shall respond in writing to the Complaint within thirty (30) calendar
days of receiving the Complaint. The Responding Party's written acceptance, rejection or modification of the
proposed resolution will constitute the Responding Party's final determination. If the parties are unable to resolve
the dispute within ten (10) calendar days from the date that the Responding Party responds to the Complaint, the
controversy or dispute may be submitted to non-binding mediation in Harris County, Texas, at the request of any
party, and the parties shall attempt to resolve the matter, in good faith, prior to the institution of any litigation or
other legal action. Each Party shall bear its own expenses pursuant to the dispute resolution process. The
parties agree to select an individual qualified under the requirements of Chapter 154, Texas Civil Practice and
Remedies Code, as amended, to serve as mediator. Failing agreement to name a mediator, the Parties agree
to have a mediator appointed by a court of competent jurisdiction. Nothing in this paragraph shall preclude either
party from seeking remedies in law or equity. Either Party may impose shortened time limits in this section if the
dispute is subject to the time limits in Section 843 of the Texas Insurance Code.
SECTION 9 - CONFIDENTIALITY
9.1
Member-Related Information. Community, Physician and/or Healthcare Professionals understand
and agree that all information and records related to Members are privileged and confidential. Any Member-related
information, records, or reports that may be disclosed to Community pursuant to the express terms of this Agreement
shall not be disclosed nor divulged by Community in whole or in part to any other third person, other than as allowed
by applicable law or as expressly provided for in this Agreement, without the prior written consent of the Member, if
required; except that information required for the Utilization Management Program, the Quality Improvement
Program, and claims adjudication will be released to Community or other appropriate Payor or designee without
Member consent as a healthcare operation.
9.2
Business Activities. Physician agrees to maintain the confidentiality of all information related to fees,
charges, expenses and utilization derived from, through, or provided by Community and/or a Payor. Except as
required by law and for the purposes of carrying out this Agreement, Physician agrees to keep confidential any
information regarding the other's business activities that is not otherwise available to the general public, unless prior
written consent for disclosure is obtained from the other party.
9.3
Proprietary Information. All information and materials provided by Community to Physician shall
remain proprietary to Community including, but not limited to, contracts, fee schedules, reimbursement rates and
methodology, handbooks, and any other operations manuals. Physician shall not disclose any of such information
or materials or use them except as may be required to perform Physician's obligations hereunder.
9.4
Survival of Obligations. The obligations of the parties under this Section 9 shall survive termination
of this Agreement.
9.5
HIPAA Provisions. Physician and Community are Covered Entities. Therefore, Community and
Physician agree to comply with the requirements of the Health Insurance Portability and Accountability Act of
1996, Pub. L. No. 104-191 (codified at 45 C.F.R. Parts 160 and 164), as amended ("HIPAA"); privacy and security
regulations promulgated by the United States Department of Health and Human Services ("DHHS"); Title XIII,
Subtitle D of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, as amended ("HITECH
Act"); provisions regarding Confidentiality of Alcohol and Drug Abuse Patient Records (codified at 42 C.F.R. Part
2), as amended; and TEX. HEALTH & SAFETY CODE ANN. §§ 81.046, as amended, 181.001 et seq., as
amended, 241.151 et seq., as amended, and 611.001 et seq., as amended (collectively referred to herein as the
"Privacy and Security Requirements").
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SECTION 10 - TERM AND TERMINATION
10.1
Term. Unless otherwise agreed upon by the parties, this Agreement shall commence on the
Effective Date as indicated on the signature page of this Agreement, shall continue for an initial term through a
period of one (1) year. The Agreement shall automatically renew for periods of one year, unless either party
terminates the Agreement as allowed in any of the following circumstances;
a. either party terminates the Agreement as allowed herein, or
b. the parties terminate this Agreement by mutual agreement in writing effective on a mutually agreed upon
date, subject to any applicable laws, rules and/or regulations.
Regardless of the Effective Date or any renewal date of this Agreement, Physician acknowledges that neither
Community nor a Member shall have any obligation to pay for Covered Services rendered by Physician or
Healthcare Professional, until such time as Physician completes Community's credentialing process and receives
approval from Community's credentialing body.
10.2
Termination Without Cause. Following the initial term as defined in Section 10.1, either party may
terminate this Agreement at any time, without cause, upon one-hundred eighty (180) calendar days' notice to the
other party.
10.3 Termination With Cause. Either party may terminate this Agreement for material breach of any of
the terms or provisions of this Agreement by providing the other party with at least ninety (90) calendar days'
advance written notice specifying the nature of the alleged material breach. During the first sixty (60) calendar days
of the above referenced notice period, if the breaching party cures the breach to the reasonable satisfaction of the
non-breaching party, in the non-breaching party's sole discretion, and upon mutual agreement between the Parties,
the Agreement shall not terminate at such time.
10.4
Immediate Termination. Community, at its sole election, may terminate this Agreement, and/or
participation of any Healthcare Professional rendering services under the terms of this Agreement, immediately
upon written notice to Physician in the event of any of the following; (a) suspension, revocation, condition, expiration,
or other restriction of Physician's or its Healthcare Professional's licensure, certification, and/or accreditation, (b)
failure to meet or maintain Community credentialing/re-credentialing standards, as determined by the Community in
its
sole discretion, (c) suspension, limitation or bar of Physician or its Healthcare Professional from participation in
any government healthcare program, (d) Physician's, its Healthcare Professionals, or its Healthcare Professional's
breach of Section 5.9 ("Member Hold Harmless"); (e) determination by a government agency or any judicial or
administrative review body that Physician or its Healthcare Professionals have engaged or is engaging in fraud, (f)
failure by Physician or its Healthcare Professionals to maintain the general and/or professional liability insurance
coverage requirements of this Agreement, (g) Community's reasonable determination that termination of Agreement
or Physician or its Healthcare Professional is necessary for health and safety of Member(s), or (h) any other
grounds that are not in bad faith.
10.5
Pre-Termination Review. Upon request of Physician, prior to terminating this Agreement or a
Healthcare Professional's participation hereunder, Community shall provide a written explanation to Physician of
the
reason or reasons for termination. On request and before the effective date of the termination, but within a
period not to exceed sixty (60) days, Physician shall be entitled to a review of Community's proposed termination by
an advisory review panel appointed by Community, except in a case in which there is imminent harm to patient
health, as determined solely by Community, or an action by a state medical or dental board, other medical or dental
licensing board, or other licensing board or other government agency, that effectively impairs Physician's ability to
practice medicine, dentistry, or another profession, or in a case of fraud or malfeasance, as determined solely by
Community. The advisory review panel shall be composed of physicians and providers, including at least one
representative in Physician's specialty or a similar specialty, if available, appointed to serve on the standing Quality
Improvement Committee or Utilization Review Committee of Community. The decision of the advisory review panel
must be considered but is not binding on Community. Community shall provide to Physician, on request, a copy of
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the recommendation of the advisory review panel and Community's determination. Physician shall be entitled, on
request, to an expedited review process by Community. Physician shall have no cause of action against any
member of the advisory review panel or against any person who supplies information to the advisory review panel.
10.6 Continuation of Care. If Physician renders Covered Services other than in a hospital setting,
Community shall give reasonable advance notice of the impending termination of Physician or a Healthcare
Professional to each Member receiving treatment from such Physician. Except for any Immediate Termination as
defined above, nothing herein shall be construed to release Community from the obligation to reimburse Physician
for the Covered Services of a Physician or a Healthcare Professional who is rendering ongoing Medically Necessary
treatment in accordance with the dictates of medical prudence to a Member of special circumstance at no less than
the compensation rate provided for under this Agreement in exchange for the ongoing treatment of the Member.
Special circumstance means a condition such that the treating Physician or the Healthcare Professional reasonably
believes that discontinuing care by the treating Physician or the Healthcare Professional could cause harm to the
patient, such as a person who has a disability, acute condition, life-threatening illness, or is past the twenty-fourth
(24th) week of pregnancy. Special circumstance shall be identified by the treating Physician or the Healthcare
Professional who must make a written request to Community asking that the Member be permitted to continue
treatment under the Physician's or the Healthcare Professional's care and Physician or Healthcare Professional
must agree not to seek payment from the Member of any amounts for which the Member would not be responsible
if the Physician or Healthcare Professional was still on the Community network. In the event Physician or
a
Healthcare Professional is deselected for a reason other than by a request from the Facility or a Healthcare
Professional, Community may not notify Members until the effective date of the deselection or Community's advisory
review panel makes a formal recommendation.
Any dispute between Community and Physician or Healthcare Professional with respect to coverage for
continued care to Members with special circumstance shall be resolved in accordance with the procedures set forth
in the Community provider manual or this Agreement, as it may be amended from time to time. This Section 10.6
does not extend the obligation of Community to reimburse Physician for ongoing treatment of a Member beyond
ninety (90) days from the effective date of termination or beyond nine (9) months in the case of a Member who at
the time of termination has been diagnosed with a terminal illness. However, the obligation of Community to
reimburse the terminated Physician for services rendered to a Member who at the time of termination is past the
twenty-fourth (24th) week of pregnancy, extends through delivery of the child, immediate postpartum care, and the
follow up checkup within the first six (6) weeks of delivery.
10.7
Post-Termination Continuation of Care. Upon termination of this Agreement for any reason,
Physician, upon Community's written request and at Community's sole discretion, shall continue to provide or
arrange for the provision of Covered Services to enrolled Members for a period not to exceed ninety (90) calendar
days following receipt of written notice of termination. Such extension of obligation shall not require Physician to
arrange for the provision of care for Members not enrolled as of the date of termination or cases where the Member
has not begun active treatment with Physician. Except as may be required by the obligation of Physician to continue
care in the event of special circumstances herein, Physician shall be compensated by Community for all Covered
Services provided to Members after the effective date of termination of this Agreement as follows: according to the
rates defined in this Agreement following the termination's effective date. Physician agrees to cooperate with
Community's efforts to arrange for the prompt, medically appropriate transfer of Members to Participating Providers
following termination notice of this Agreement.
10.8 Member Notification. If applicable, Community shall provide notification of the termination of
Physician or Healthcare Professional(s) to its Members receiving care from Physician or Healthcare
Professionals at least thirty (30) days before the effective date of the termination. Community may notify
Members at the time Community terminates Physician or a Healthcare Professional if such termination is
immediate as allowed in this Agreement. Upon a final determination of a date that Agreement will terminate,
Physician shall notify any Member attempting to schedule Covered Services, or any Member already scheduled,
beyond the termination date, that Physician or the Healthcare Professional will no longer be a Participating Provider
as
of
the termination date. Physician shall comply with Community's policy and procedures related to any Immediate
Termination of Agreement as referenced in Section 10.4, to include immediate cessation of scheduling further
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Members, prompt notification to all Members who with scheduled appointments, as well as immediate notification
to Community of any and all Members in active treatment or with scheduled procedures as well as identification and
prioritization of Members whose health may be in jeopardy without immediate transfer to another or other
Participating Provider.
10.9 Retaliation. Community shall not engage in any retaliatory action, including terminating or refusing
to renew this Agreement, against Physician because Physician has, on behalf of a Member, reasonably filed a
complaint against Community or appealed a decision of Community.
SECTION 11 - MISCELLANEOUS
11.1 Advance Directives. Physician acknowledges and agrees to comply with all federal and State laws
with respect to advance directives as defined in the Patient Self-Determination Act (P.L. 101-508), as amended).
An advance directive is, for example, a Directive to Physician (formerly known as a living will) or a Medical Power
of Attorney (formerly known as a durable power of attorney for health care) pursuant to TEX. HEALTH & SAFETY
CODE ANN. §§ 166.001 et seq., as amended, in which an individual makes decisions concerning medical care,
including the right to accept or refuse medical or surgical treatment or a Declaration for Mental Health Treatment
pursuant to TEX. Civ. PRAC. & REM. CODE ANN. §§ 137.001 et seq., as amended.
11.2 Independent Medical Judgment. Nothing contained in this Agreement shall be construed to require
a Physician to recommend or withhold any procedure or course of treatment that is not consistent with such
Physician's best medical judgment. Eligibility, Prior Authorization, case management, and Utilization Management
Program activities are performed for the purpose of clearly defining financial responsibility and encouraging efficient
use of resources and network services. A Physician is free to make independent medical recommendations and
Members are free to choose to accept or reject any treatment course.
11.3
Communications with Patients. Community shall not impose any restrictions upon Physician's free
communications with Members about a Member's medical conditions, treatment options, Community referral
policies, and other Community policies, including financial incentives or arrangements. Further, Community shall
not, as a condition of this Agreement with Physician, or in any other manner, prohibit, attempt to prohibit, or
discourage Physician from, or in any way penalize, terminate, or refuse to compensate Physician for Covered
Services for: (a) discussing with or communicating to a current, prospective or former patient, or a party designated
by a patient, information or opinions regarding the patient's health care, including, but not limited to, the patient's
medical condition or treatment options; or (b) discussing with or communicating in good faith to a current, prospective
or former patient, or a party designated by a patient, information or opinions regarding the provisions, terms,
requirements or services of the Benefit Plan/Program as they relate to the medical needs of the patient.
11.4 Non-Exclusivity. This Agreement shall not be an exclusive agreement between Community and
Physician. Nothing herein shall be construed to restrict the rights of Physician (and any Healthcare Professionals)
or Community to participate in other preferred provider plans, health maintenance organizations, or other managed
care systems.
11.5
Entire Agreement. This Agreement, the Community Protocols or protocols of a specific Payor,
Provider manual and the Exhibits constitute the sole and only agreement of the parties with respect to the subject
matter hereof and supersedes any and all prior agreements or understandings, either oral or in writing, between the
parties hereto with respect to the subject matter hereof, and no other agreement, statement, or promise relating to
the subject matter of this Agreement that is not contained or incorporated by reference herein shall be valid or
binding. Provided, however, the Covered Services provided hereunder must be provided in accordance with the
terms and conditions of the particular Benefit Plan/Program.
11.6 Assignment. Neither this Agreement nor the duties or obligations hereunder shall be assignable by
either party without the prior written consent of the other party hereto, except as may expressly be permitted under
this Agreement. Community shall have the right in its sole discretion to assign this Agreement to any affiliated entity,
parent or subsidiary of Community.
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11.7 Successors and Assigns. Subject to the provisions of Sections 5.14 ("Services Locations/New
Services") and 11.6 hereof ("Assignment"), this Agreement shall be binding on the heirs, executors, administrators,
legal representatives, successors, and assigns of the respective parties hereto.
11.8
Governing Law. The validity of any of the terms and provisions of this Agreement as well as the
rights and duties of the parties hereunder, shall be governed by the laws of the State of Texas, except to the extent
such laws conflict with or are preempted by any federal law, in which case such federal law shall govern. Federal
law shall also govern with respect to Benefit Plan/Programs of federal government Payors.
11.9 Venue. The sole venue for any dispute arising hereunder shall be in the court of appropriate
jurisdiction in Harris County, Texas, exclusively.
11.10 Amendment. This Agreement may be amended by the mutual agreement of the parties hereto in
writing or by Community upon written notice to Physician if necessary in order to comply with applicable law or
regulation. Mandatory modifications, additions or deletions required by any change in State or federal law or
regulation shall be effective immediately and shall not require mutual signature.
11.11 Severability. In case any one or more of the provisions contained in this Agreement shall for any
reason be held to be invalid, illegal, or unenforceable in any respect, such invalidity, illegality, or unenforceability
shall not affect any other provision hereof, and this Agreement shall be construed as if such invalid, illegal, or
unenforceable provision had never been contained herein.
11.12 Notices. Any notices to be given hereunder by either party to the other shall be in writing and may
be
effected by personal delivery or by registered or certified mail, postage prepaid, return receipt requested, to
Community at its principal place of business or to Physician at Physician's principal place of business according to
the address(es) provided on the signature page of this Agreement and as may be changed by written notice.
Notices are deemed received when personally delivered or three (3) days after being placed in the mail.
11.13 Waiver. The waiver by either party of a breach or violation of any provision of this Agreement shall
not operate as or be construed to be a waiver of any subsequent breach hereof. The failure of either party to insist
upon the strict observation or performance of any provision of this Agreement or to exercise any right or remedy
shall not impair or waive any such right or remedy. Every right and remedy given by this Agreement to the parties
may be exercised from time to time and as often as appropriate.
11.14 No Third-Party Beneficiary. Except as set forth in Section 5.9 hereof ("Member Hold Harmless"), or
as may be required by law, nothing in this Agreement is intended to, or shall be deemed or construed to, create any
rights or remedies in any third party, including a Member. Nothing contained herein shall operate (or be construed
to operate) in any manner whatsoever to increase the rights of any such Member or the duties or responsibilities of
Physician or Community with respect to such Members.
11.15 Regulations. Community is subject to the requirements of various local, State, and federal laws,
rules, and regulations. Any provision required to be in this Agreement by any of the above shall bind Physician,
Healthcare Professionals and Community whether or not provided herein.
11.16 Status as Independent Entities. None of the provisions of this Agreement are intended to create or
shall be deemed or construed to create any relationship between Physician and Community other than that of
independent entities contracting with each other solely for the purpose of effecting the provisions of this Agreement.
Neither Physician nor Community, nor any of their respective agents, employees, or representatives shall be
construed to be the agent, employee, or representative of the other.
11.17 Exhibits. Each Exhibit to this Agreement is made a part of this Agreement as though set forth fully
herein. Any provision of an Amendment that is in conflict with any provision of this Agreement and its Exhibit shall
take precedence and supersede the conflicting provision of this Agreement and Exhibit. Any provision of this
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Agreement that is in conflict with any provision of an Exhibit, other than an Amendment, or that is in conflict with any
provision of the Provider Manual shall take precedence and supersede the conflicting provision of the Exhibit or the
Provider Manual.
11.18 Headings. The headings contained in this Agreement are for the convenience of the parties only
and shall not be deemed to affect the meaning of the provisions hereof.
11.19 Authority. The provisions of this Agreement required to be approved by the governing board of
Community or Physician have been so approved and authorized.
11.20 Non-Assumption of Liabilities. Unless specifically provided by this Agreement, Physician does not
assume or become liable for any of the existing or future obligations, liabilities, or debts of Community, and
Community does not assume or become liable for any of the existing or future obligations, liabilities, or debts of
Physician.
11.21 Costs Associated with this Agreement. Except as otherwise provided herein, each party shall bear
the costs of its own legal, accounting, and other services necessary to comply with its duties and obligations under
this Agreement.
11.22 Impossibility of Performance. Neither Physician nor Community shall be deemed to be in default of
this Agreement if prevented from performing for reasons beyond its control including, without limitation,
governmental laws, rules and regulations, acts of God, war, and strikes. In such cases, the parties shall negotiate
in good faith with the goal and intent of preserving this Agreement and the respective rights and obligations of the
parties.
11.23 No Personal Liability. Nothing in this agreement is construed as creating any personal liability on
the part of any officer, director, employee, or agent or any public body that may be a party to this Agreement, and
the parties expressly agree that the execution of this Agreement does not create any personal liability on the part of
any officer, director, employee, or agent of Community.
11.24 Use of Name. Neither Community nor Physician shall use each other's trademarks, name, or
symbols without the prior written consent of the other; provided, however, Physician agrees that Community and
Benefit Plan/Programs may use Physician's and each Healthcare Professional's name, office address, telephone
number, and specialty, and a factual description of the practice in directories and other promotional materials.
[SIGNATURE PAGE TO FOLLOW]
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IN WITNESS WHEREOF, the parties have and caused this Agreement to be effective on the later day and
year written below by execution on behalf of Community Health Choice, Inc. by a duly authorized representative
of Community Health Choice, Inc., and by execution on behalf of Physician and all Healthcare Professionals by
a duly authorized representative of Physician, for itself and for all Healthcare Professional's.
Pediatrix Medical Services, Inc. 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
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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
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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:
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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
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EXHIBIT B-2
COMPENSATION
Applicable
Health Insurance Marketplace (HIM)
Does not participate in Marketplace
Benefit Plan(s):
Primary Care Physician
Hospital-Based Physician
Provider Type:
Specialist
Other: Mid-Level/Physician Extender
Services:
Professional Services
Physician/Provider does not participate in this program.
DanGov
Provider Signature: Daniel Corcoran (Oct 19, 2023 13:23 EDT)
Date:
Oct 19, 2023
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EXHIBIT B-3
COMPENSATION
Applicable Benefit
Dual Special Needs Plan (DSNP)
Does not participate in DSNP
Plan(s):
Primary Care Physician
Hospital-Based
Provider Type:
OB/Gyn
Other: Mid-Level/Physician Extender
Specialist
Services:
Medical/Professional
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:
A. Dual Special Needs Plan (DSNP)
Where Payor is the only Payor for Medicare Covered Services, Physician/Provider's maximum compensation shall be the
lesser of 1) Physician/Provider's Billed Charges or 2) one hundred percent (100%) of the Medicare payment in effect on the
date of service as primary coverage, not including Member Expense.
Compensation Notes:
Acute/Medical Services: Community shall process Clean Claims based on the then current Medicare or Medicaid Fee
Schedule as applicable to services rendered and according to Medicare reimbursement methodology, including the
geographic practice cost index (GPCI), or Medicaid reimbursement methodology as applicable.
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 either CMS Reimbursement
Methodology or Texas Medicaid Methodology.
Govt
Provider Signature:
Daniel Corcoran (Oct 19, 2023 13:23 EDT)
Date:
Oct 19, 2023
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TEXAS MEDICAID COMPLIANCE ADDENDUM - PROVIDER
This Texas Medicaid Provider Addendum ("Addendum") is incorporated by reference into the Agreement and applies to
Medicaid and CHIP products ("Medicaid Program(s)") and the eligible populations covered by the State Contract(s), between
Community Health Choice Texas, Inc. ("Community," "Company" or generally referred to in the State Contract as an MCO)
and the Texas Health & Human Services Commission ("HHSC"), which can be found at
https://hhs.texas.gov/services/health/medicaid-chip/provider-information/managed-care-contracts-manuals
This Addendum may be updated and amended unilaterally at any time in order to comply with any local, state, or federal
laws, rules, or regulations. If Community has delegated administrative functions to any Subcontractor under the Agreement,
Community shall notify Subcontractor and Subcontractor shall notify its Participating Providers regarding these changes as
soon as practicable after changes have been announced. If there is any conflict between the terms of this Addendum and
any of the other terms of the Agreement, the terms of this Addendum will govern and control; provided, however, if there is
any conflict between any of the terms of the Agreement, including this Addendum, and the State Contract (as defined below),
then the terms of the State Contract will govern and control.
SECTION 1 - DEFINITIONS
Many words and terms are capitalized throughout this Addendum to indicate that they are defined in Section I. Capitalized
terms used and not otherwise defined in this Addendum shall have the meanings set forth in the Agreement or, if not defined
in the Agreement, in the State Contract(s) or under Texas Law.
For purposes of this Addendum, the term "Provider" means Participating Provider as defined in the Agreement. As
applicable, the term "Community" includes any Subcontractor delegated administrative functions by Community under the
Agreement or otherwise providing or arranging for the provision of Covered Services.
1.1
Acute Care. Preventative care, primary care, and other medical care provided under the direction of a physician
for a condition having a relatively short duration.
1.2
Behavioral Health Services. Covered Services for the treatment of mental, emotional, or chemical dependency
disorders.
1.3
Covered Services. Health Care Services Community must arrange to provide to Members, including all services
required by the State Contract, state and federal law, and all value added services required under the State Contract.
1.4
Children's Health Insurance Program or "CHIP". The health insurance program authorized and funded pursuant
to
Title XXI, Social Security Act (42 U.S.C. §§ 1397aa-1397jj) and administered by Texas Health and Human Services
Commission ("HHSC").
1.5
CHIP Program. The State of Texas program in which HHSC contracts with managed care organizations to provide,
arrange for, and coordinate Covered Services for enrolled CHIP Members.
1.6
CHIP Perinatal Program. The State of Texas program in which HHSC contracts with managed care organizations
to provide, arrange for, and coordinate Covered Services for enrolled CHIP Perinate and CHIP Perinate Newborn Members.
Although the CHIP Perinatal Program is part of the CHIP Program, for administrative purposes, it is sometimes identified
independently in the State Contract.
1.7
Clean Claim. As set forth in subsection 4.2, a claim submitted by physician or provider for medical care or Health
Care Services rendered to a Member, with the data necessary for Community or subcontracted claims processors
to
adjudicate and accurately report the claim. A Clean Claim other than a nursing facility services clean claim must meet all
requirements for accurate and complete data as defined in the appropriate 837-(claim type) encounter guides as follows:
(1) 837 Professional Combined Implementation Guide; (2) 837 Institutional Combined Implementation Guide; (3) 837
Professional Companion Guide; (4) 837 Institutional Companion Guide; or (5) National Council for Prescription Drug
Programs (NCPDP) Companion Guide.
1.8
Health Care Services. Acute Care, Behavioral Health care, and health-related services that an enrolled population
might reasonably require in order to be maintained in good health.
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1.9
Material Subcontract." Any contract, Subcontract, or agreement between Community and another entity that meets
any of the following criteria:
(a) the other entity is an Affiliate of the MCO;
(b) the Subcontract is considered by HHSC to be for a key type of service or function, including Administrative
Services (including, but not limited to, third party administrator, Network administration, and claims processing);
delegated Networks (including, but not limited to, behavioral health, dental, pharmacy, and vision); management
services (including management agreements with parent); reinsurance; Disease Management; pharmacy
benefit management ("PBM") or pharmacy administrative services; call lines (including nurse and medical
consultation); or
(c) any other Subcontract that exceeds, or is reasonably expected to exceed, the lesser of:
a. $500,000 per year, or
b. 1% of Company's annual Revenues under the State Contract.
(d) Any Subcontracts between Company and a single entity that are split into separate agreements by time period,
Program, or SDA, etc., will be consolidated for the purpose of this definition. For the purposes of the Agreement,
Material Subcontracts do not include contracts with any non-Affiliates for any of the following, regardless of the
value of the contract: utilities (e.g., water, electricity, telephone, Internet, trash), mail/shipping, office space,
maintenance, security, or computer hardware.
1.10
Medicaid. The medical assistance entitlement program authorized and funded pursuant to Title XIX, Social Security
Act (42 U.S.C. § 1396, et seq.) and administered by HHSC.
1.11
Medical Home. A patient-centered medical home as described in Texas Government Code § 533.0029(a).
1.12
Primary Care Physician or Primary Care Provider ("PCP"). A physician or provider who has agreed with Community
to provide a Medical Home to Members and who is responsible for providing initial and primary care to patients, maintaining
the continuity of patient care, and initiating referral for care.
1.13
State Contract. The HHSC Uniform Managed Care Contract ("UMCC") for Medicaid, CHIP and STAR+PLUS
Contract(s) where applicable.
1.14
Subcontractor. Any entity with a Material Subcontract with Community.
1.15
Texas Health Steps or THSteps. The name adopted by the State of Texas for the federally mandated Early and
Periodic Screening, Diagnosis and Treatment ("EPSDT") program. It includes the State's Comprehensive Care Program
extension to EPSDT, which adds benefits to the federal EPSDT requirements contained in 42 U.S.C. § 1396® and defined
and codified at 42 C.F.R. §§ 440.40 and 441.56-62. HHSC's rules are contained in 25 T.A.C., Chapter 33 (relating to Early
and Periodic Screening, Diagnosis and Treatment).
SECTION 2 - OBLIGATIONS OF COMMUNITY
2.1
Community will initiate and maintain any action necessary to stop Provider or employee, agent, assign, trustee, or
successor-in-interest from maintaining an action against HHSC, an HHS Agency, or any Member to collect payment from
HHSC, an HHS Agency, or any Member, excluding payment for non-covered services. This provision does not restrict a
CHIP Provider from collecting allowable copayment and deductible amounts from CHIP Members. Additionally, this
provision does not restrict a CHIP Dental Network Provider from collecting payment for services that exceed a CHIP
Member's benefit cap.
SECTION 3 - OBLIGATIONS OF PROVIDER
3.1
Provider acknowledges that HHSC does not assume liability for the actions of, or judgments rendered against,
Community, its employees, agents or subcontractors or Subcontractors. Further, Provider understands and agrees that
there is no right of subrogation, contribution, or indemnification against HHSC for any duty owed to Provider by Community
or any judgment rendered against Community. HHSC's liability to Provider, if any, will be governed by the Texas Tort
Claims Act, as amended or modified (TEX. Civ. PRAC. & REM. CODE § 101.001, et seq.).
3.2
Pharmacy. If prior authorization for a medication is not immediately available, a 72-hour emergency supply may be
dispensed when the pharmacist on duty recommends it as clinically appropriate and when the medication is needed without
delay. Please consult the Vendor Drug Program Pharmacy Provider Procedures Manual, the Texas Medicaid Provider
Procedures Manual, and Community's Provider Manual (page 48) for information regarding reimbursement for 72-hour
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emergency supplies of prescription claims. It is important that pharmacies understand the 72-hour emergency supply policy
and procedure to assist Medicaid clients.
3.3
Access to Records.
a.
Provider agrees to provide at no cost to HHSC: all information required under Community's managed care
contract with HHSC, including, but not limited to, the reporting requirements and other information related to Provider's
performance of its obligations under that contract; and any information in its possession sufficient to permit HHSC to comply
with the federal Balanced Budget Act of 1997 or other federal or state laws, rules and regulations. All information must be
provided in accordance with the timelines, definitions, formats and instructions specified by HHSC.
b.
Provider agrees that upon receipt of a record review request from HHSC's Office of Inspector General
("OIG"), Special Investigative Units (SIUs) or another state or federal agency authorized to conduct compliance, regulatory,
or program integrity functions, Provider shall provide, at no cost to requesting agency, the records requested within 3
business days of the request. If the OIG, SIUs or another state or federal agency representative believes that the requested
records are about to be altered or destroyed or that the request may be completed at the time of the request and/or in less
than 24 hours, Provider shall provide the requested records at the time of the request and/or in less than 24 hours.
The request for records review may include, but is not limited to, clinical, medical or dental Member records, other records
pertaining to Member; any other records of services provided to Medicaid or other health and human services program
recipients and payments made for those services; documents related to diagnosis, treatment, service, lab results, charting,
billing records, invoices, documentation of delivery items, equipment, or supplies; radiographs and study models related to
orthodontia services; business and accounting records with backup support documentation; statistical documentation;
computer records and data; and/or contracts with providers and subcontractors.
Provider's failure to produce the records or make the records available for the purpose of reviewing, examining, and securing
custody of the records may result in the OIG imposing sanctions against Provider as described in 1 TEX. ADMIN. CODE,
Chapter 371, Subchapter G.
C.
Provider agrees to provide at no cost to the following entities or their designees with prompt, reasonable
and adequate access to this Agreement any records, books, documents, and papers that are related to this Agreement
and/or Provider's performance of its responsibilities under this Agreement:
(1) HHSC and MCO Program personnel from HHSC;
(2) U.S. Department of Health and Human Services;
(3) Office of Inspector General and/or the Texas Medicaid Fraud Control Unit;
(4) an independent verification and validation contractor or quality assurance contractor acting on behalf
of HHSC;
(5) state or federal law enforcement agency;
(6) special or general investigation committee of the Texas Legislature;
(7) the U.S. Comptroller General;
(8) the Office of the State Auditor of Texas; and
(9) any other state or federal entity identified by HHSC or any other entity engaged by HHSC.
Provider must provide access wherever it maintains such records, books, documents and papers. Provider must provide
such access in reasonable comfort and provide any furnishings, equipment and other conveniences deemed reasonably
necessary to fulfill the purposes described herein. Requests for access may be for, but are not limited to: examination,
audit, investigation, contract administration, the making of copies, excerpts or transcripts, or any other purpose HHSC
deems necessary for contract enforcement or to perform its regulatory functions.
d.
Provider understands and agrees that the acceptance of funds under this Agreement acts as acceptance
of the authority of the State Auditor's Office ("SAO"), or any successor agency, to conduct an investigation in connection
with those funds. Provider further agrees to cooperate fully with the SAO or its successor in the conduct of the audit or
investigation, including providing all records requested at no cost.
3.4
NPI and TPI. Providers serving Medicaid Members must enter into and maintain a Medicaid provider agreement
with HHSC or its agent to participate in the Medicaid Program, and must have a Texas Provider Identification Number
("TPI"). Provider shall have a National Provider Identifier ("NPI") in accordance with the timelines established in 45 C.F.R.
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Part 162, Subpart D. For purposes of this section, "national provider identifier" means the national provider identifier required
under Section 1128J(e), Social Security Act (42 U.S.C. Section 1320a-7k(e)).
3.5
Administrative Requirements. Provider must inform Community and HHSC's administrative services contractor of
any change to Provider's address, telephone number, group affiliation, etc.
3.6
Professional Conduct. While performing the services described in this Agreement, Provider agrees to comply with
applicable state laws, rules, and regulations and HHSC's requests regarding personal and professional conduct generally
applicable to the service locations; and otherwise conduct themselves in a businesslike and professional manner.
3.7
Quality Assessment and Performance and Improvement ("QAPI"). Provider agrees to comply with Community's
QAPI Program requirements.
3.8
Early Childhood Intervention ("ECI"). Provider must cooperate and coordinate with local ECI programs to comply
with federal and state requirements relating to the development, review and evaluation of Individual Family Service Plans
("IFSP"). Provider understands and agrees that any Medically Necessary Health and Behavioral Health Services contained
in an IFSP must be provided to the Member in the amount, duration, scope and setting established in the IFSP.
3.9
Women, Infants and Children ("WIC"). Provider must coordinate with the WIC Special Supplemental Nutrition
Program to provide medical information necessary for WIC eligibility determinations, such as height, weight, hematocrit
or
hemoglobin.
3.10
Tuberculosis ("TB"). Provider must coordinate with the local TB control program to ensure that all Members with
confirmed or suspected TB have a contact investigation and receive Directly Observed Therapy (DOT). The Network
Providers must report to the Texas Department of State Health Services (DSHS) or the local TB control program any
Member who is non-compliant, drug resistant, or who is or may be posing a public health threat.
3.11
Lead Screening. Provider agrees to (1) report all blood lead results to the Childhood Lead Poisoning Program (if
not performed at the DSHS state laboratory) and, (2) follow-up on suspected or confirmed cases of Childhood lead exposure
with the Childhood Lead Poisoning Prevention Program, and follow the Centers for Disease Control and Prevention
guidelines for testing children for lead and follow-up actions for children with elevated lead levels located at
http://www.dshs.state.tx.us/lead/pdff files/pb 109 physician reference.pdf
3.12
Waiting Times for Appointments. Provider must provide:
(a) Emergency Services upon Member presentation at the service delivery site, including at non-network and out-
of-area facilities;
(b) Treatment for an Urgent condition, including urgent specialty care, within 24 hours;
(c) Routine primary care within 14 days;
(d) Specialty routine care within 21 days;
(e) initial outpatient behavioral health visits within 14 days (this requirement does not apply to CHIP Perinate
Members);
(f) Non-urgent specialty care within 60 days (this requirement applies to STAR Health only);
(g)
Pre-natal care within 14 days, except for high-risk pregnancies or new Members in the third trimester, for whom
an appointment must be offered within 5 days, or immediately, if an emergency exists; and
(h)
Preventive health services including annual adult well checks for Members 21 years of age or older must be
offered within 90 Days
(i) Preventive health services for Members less than 6 month of age must be provided within 14 days. Preventive
health services for Members 6 months through age 20 must be provided within 60 Days. CHIP Members should
receive preventive care in accordance with the American Academy of Pediatrics (AAP) periodicity schedule.
Medicaid Members should receive preventive care in accordance with the Texas Health Steps periodicity
schedule.
In addition, PCPs must make referrals for specialty care on a timely basis, based on the urgency of the Member's medical
condition, but no later than 30 days.
3.13
Cancellation of Product Orders. Provider that offers delivery services for covered products, such as durable medical
equipment (DME), limited home health supplies (LHHS), or outpatient drugs or biological products must reduce, cancel, or
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stop delivery if the Member or the Member's authorized representative submits an oral or written request. Provider must
maintain records documenting the request.
SECTION 4 - COMPENSATION
4.1
Claims Payment. The method of payment applicable to this Agreement is described in the applicable Compensation
Addendum. If Provider is reimbursed based on the Texas Medicaid Fee Schedule, the rates are set by the State Medicaid
Program and are available at http://www.tmhp.com.
4.2
Claims Submission. Provider must file a Clean Claim with Community within 95 days from the date of service. The
required data elements for Medicaid claims must be present for a claim to be considered a Clean Claim and can be found
in the Section 8 "Managed Care" of the Texas Medicaid Provider Procedures Manual.
Community will notify Provider at least 90 days prior to implementing a change in the above-referenced claims guidelines,
unless the change is required by statute or regulation in a shorter timeframe.
Provider must submit claims for processing and/or adjudication to the following entity/entities or as set forth in the Provider
Manual:
Electronic submission
Payer ID 48145
Paper Claims
Community Health Choice
P.O. Box 301404
Houston, TX 77230-1404
Certified Mail
Community Health Choice
2636 South Loop West, Ste. 125
Houston, TX 77054
Provider may call 713-295-2295 for all claims inquiries.
Community will notify Provider in writing of any changes in the list of claims processing and adjudication entities at least 30
days prior to the effective date of change. If Community is unable to provide 30 days' notice, Community will give Provider
a 30-day extension on its claims filing deadline to ensure claims are routed to the correct processing center.
4.3
Corrected Claims. A Corrected Claim is a claim that has already been adjudicated, whether paid or denied. Provider
must submit a Corrected Claim if the original claim adjudicated needs to be changed. A Corrected Claim could be a result
of:
a) Errors were found involving diagnosis, procedure, date or modifier.
b)
Claims contained missing, incorrect, or incomplete data according to our claims submission requirements.
c) Services were missed in an original claim.
d) Original claim billed with incorrect number of units or billed amount.
When submitting a corrected claim on a CMS 1500, Provider must clearly mark the claim as "Corrected Claim" along with
the original claim number in box 22 form along with resubmission code of 7. When submitting a corrected claim on a UB
04, Provider must clearly mark the claim as "Corrected Claim" along with the third digit of Type of Bill indicated as Frequency
code 7.
Corrected Claims must be sent within 120 days of initial claim disposition. Failure to mark the claim as "corrected" could
result in a duplicate claim and be denied for exceeding the 95 days timely-filing deadline
4.4
Supervised Providers. If Provider, including a nurse practitioner or physician assistant, provides a referral for or
orders health care services for a recipient or enrollee, as applicable, at the direction or under the supervision of another
provider, and the referral or order is based on the supervised provider's evaluation of the recipient or enrollee, the names
and associated national provider identifier numbers of the supervised provider and the supervising provider must be included
on any claim for reimbursement submitted by a provider based on the referral or order as required by TEX. Gov. CODE
§
531.024161.
4.5
Adjudication of Claims. Community shall adjudicate (finalize as paid or denied adjudicated) Clean Claims for:
(a) healthcare services within 30 days from the date the claim is received by the MCO;
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(b) pharmacy services no later than 18 days of receipt if submitted electronically, or 21 days of receipt if submitted
non-electronically; and
(c) Community will pay Providers interest at a rate of 18% per annum on all clean claims that are not adjudicated
within 30 days.
Community must withhold all or part of payment for any claim submitted by a Provider for any of the following reasons:
a) excluded or suspended from the Medicare, Medicaid, or CHIP programs for Fraud, Abuse, or Waste;
b) on payment hold under the authority of HHSC or its authorized agent(s);
c) with debts, settlements, or pending payments due to HHSC, or the state or federal government;
d) for neonatal services provided on or after September 1, 2017, if submitted by a Hospital that does not have a
neonatal level of care designation from HHSC;
e) for maternal services provided on or after September 1, 2019, if submitted by a Hospital that does not have a
maternal level of care designation from HHSC.
In accordance with Texas Health and Safety Code § 241.186, the restrictions on payment identified in items (d) and (e)
above do not apply to emergency services that must be provided or reimbursed under state or federal law.
4.6
Claim Audits. With the following exceptions, Community must complete all audits of a Provider claim no later than
2 years after receipt of a Clean Claim, regardless of whether the Provider participates in the Community's network:
a) in cases of provider Fraud, Waste, or Abuse that Community did not discover within the 2-year period following
receipt of a claim;
b) when regulatory officials or entities conclude an examination, audit, or inspection of a Provider more than 2
years after Community received the claim;
c)
when HHSC has recovered a capitation from Community based on a Member's ineligibility.
If an exception to the 2-year limitation applies, then Community may recoup related payments from providers.
If an additional payment is due to Provider as a result of an audit, Community must make the payment no later than 30 days
after it completes the audit. If the audit indicates that Community is due a refund from Provider, except for retroactive
changes to a Member's Medicaid eligibility, Community must send Provider written notice of the basis and specific reasons
for the recovery no later than 30 days after it completes the audit. If the provider disagrees with Community's request,
Community must give Provider an opportunity to appeal, and may not attempt to recover the payment until the provider has
exhausted all appeal rights.
4.7
Co-payments and Deductibles. Co-payments are the only amounts that Provider may collect from CHIP Members,
except for costs associated with unauthorized non-emergency services provided to a Member by out-of-network providers
for non-covered services.
Provider is responsible for collecting at the time of service any applicable CHIP co-payments or deductibles in accordance
with CHIP cost-sharing limitations.
Providers shall not charge: (a) cost-sharing or deductibles to CHIP Members of Native American Tribes or Alaskan Natives;
(b) co-payments or deductibles to the CHIP Member with an ID card that indicates the Member has met his or her cost-
sharing obligation for the balance of their term of coverage; (c) co-payments for well-child or well-baby visits or
immunizations; or (d) co-payments for routine preventive and diagnostic dental services (CHIP Dental).
4.8
Liability for Payment of Services. Provider understands and agrees that HHSC is not liable or responsible for
payment for Covered Services rendered pursuant to the Agreement. In no event, including, but not limited to, nonpayment
by Community, Community's insolvency or breach of this Agreement, shall Provider bill, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any recourse against a Member or persons other than
Community acting on their behalf for Covered Services provided pursuant to this Agreement. Provider further understands
and agrees that Community's Members may not be held liable for Community's debts in the event of Community's
insolvency. This provision shall not prohibit collection from a Member for any non-covered service and/or Copayment
amounts in accordance with the terms of the applicable Member's health benefits and this Agreement. Provider further
agrees that: (1) this provision shall survive the termination of this Agreement regardless of the cause giving rise to
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termination and shall be construed to be for the benefit of the Member; and (2) this provision supersedes any oral or written
contrary agreement now existing or hereafter entered into between Provider and Member, or persons acting on their behalf.
In the event Community becomes insolvent or ceases operations, Provider understands and agrees that its sole recourse
against Community will be through the Community's bankruptcy, conservatorship, or receivership estate.
4.9
Third Party Recovery. Provider understands and agrees that it may not interfere with or place any liens upon the
State's right or Community's right, acting as the State's agent, to recovery from third-party resources.
After 120 days from the date of adjudication (on any claim, encounter, or other Medicaid related payment made by
Community, wherein the claim, encounter, or payment is subject to Third Party Recovery), HHSC may attempt recovery,
independent of any action by Community. HHSC will retain, in full, all funds received as a result of any state-initiated
recovery or subrogation action.
4.10
Costs of Non-Covered Services. Provider must inform Members of the cost for non-covered services prior to
rendering such services and must obtain a signed Private Pay form from such Member.
4.11
Claims Payment. Violations of the Medicaid program arising out of performance of the Agreement are subject to
administrative enforcement by the OIG as specified in 1 TEX. ADMIN. CODE, Chapter 371, Subchapter G.
4.12 Overpayments. An overpayment can be identified by the Provider or Community. If Provider identifies the
overpayment, Provider must submit a refund check all with an explanation of refund and/or Explanation of Payment (EOP)
to Community or call Provider Services at 713-295-2295 and approve a recoupment from any future payments to Provider.
If Community identifies the overpayment, a recovery letter will be sent to Provider, Provider has 45 days to submit a refund
check or appeal the refund request. If Provider does not respond within 45 days from the date of the recovery letter, then
Community will begin the recoupment on any future payments. In the event Members retroactively dis-enroll from
Community as a result of changes in their eligibility, Community reserves the right to automatically recover payments made
to Provider for services rendered to those Members.
SECTION 5 - DISPUTE RESOLUTION
5.1
Complaints and Appeals. Community's complaint and appeal processes applicable to Provider under the terms of
this Agreement are set forth in the Provider Manual. Specifically, a Provider may file a complaint at any time with
Community. Send Complaints to:
Community Health Choice
Attn: Services Improvement Team
2636 South Loop West, Ste. 125
Houston, TX 77054
Fax: 713.295.7033
Email:ServiceImprovement@CommunityHealthChoice.org
Complaints may also be submitted online at the Community Web site https://www.CommunityHealthChoice.org.0 Community
shall acknowledge all written complaints within five business days. If a Provider's complaint is oral, Community's
acknowledgement letter shall include a one-page Complaint Form. Community shall acknowledge, investigate and resolve
all complaints no later than the 30th calendar day after the date Community receives written complaint or one-page complaint
form from the complainant. Community will retain all Provider complaint documentation, including fax cover sheets, emails
to and from Community, and a telephone log of communication related to the complaint.
Provider understands and agrees that HHSC reserves the right and retains the authority to make reasonable inquiry and to
conduct investigations into Provider and Member complaints.
5.2
Claim Appeals. An appealed claim is a claim that has been previously adjudicated as a Clean Claim and the Provider
is appealing the disposition through written notification to Community. Provider must request Claim Appeals within 120
days from the date of remittance of the Explanation of Payment (EOP).
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SECTION 6 - CONFIDENTIALITY
6.1
Provider agrees to treat all information that is obtained through the performance of the services included in this
Agreement as confidential information to the extent that confidential treatment is provided under state and federal laws,
rules and regulations. This includes, but is not limited to, information relating to applicants or recipients of HHSC Programs.
6.2
Provider agrees it shall not use information obtained through the performance of this Agreement in any manner
except as is necessary for the proper discharge of obligations and securing of rights under this contract.
6.3
Provider agrees to protect the confidentiality of Member Protected Health Information ("PHI"), including patient
records. Provider must comply with all applicable federal and state laws, including the HIPAA Privacy and Security Rule
governing the use and disclosure of PHI.
SECTION 7 - FRAUD AND ABUSE
7.1 Provider acknowledges and agrees to the following:
(1) HHSC Office of Inspector General ("OIG") and/or the Texas Medicaid Fraud Control Unit must be allowed to
conduct private interviews of Network Providers and their employees, agents, contractors, and patients;
requests for information from such entities must be complied with, in the form and language requested;
Providers and their employees, agents, and contractors must cooperate fully with such entities in making
themselves available in person for interviews, consultation, grand jury proceedings, pre-trial conference,
hearings, trials at the Network Provider's own expense; and compliance with these requirements will be at the
Provider's own expense.
(2) Providers are subject to all state and federal laws and regulations relating to fraud, abuse or waste in health
care or dental care and the Medicaid and/or CHIP Programs, as applicable.
(3) Providers must cooperate and assist HHSC and any state or federal agency that is charged with the duty of
identifying, investigating, sanctioning or prosecuting suspected fraud, abuse or waste.
(4) Providers must provide originals and/or copies of any and all information as requested by HHSC or the state or
federal agency, allow access to premises, and provide records to the Office of Inspector General, HHSC, the
Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services, FBI,
TDI, the Texas Attorney General's Medicaid Fraud Control Unit or other unit of state or federal government,
upon request, and free-of-charge.
(5) If the Provider places required records in another legal entity's records, such as a hospital, the Network Provider
is responsible for obtaining a copy of these records for use by the above-named entities or their representatives.
(6) Network Providers must report any suspected fraud or abuse including any suspected fraud and abuse
committed by the MCO or a Member to the HHSC Office of Inspector General.
SECTION 8 - INSURANCE
8.1
Provider shall maintain, during the term of the Provider contract, Professional Liability Insurance of at least $100,000
per occurrence and $300,000 in the aggregate, or, where applicable, the limits required by the hospital at which Provider
has admitting privileges.
8.2
Subsection 8.1 does not apply if Provider is a state or federal unit of government, or a municipality, that is required
to comply with, and is subject to, the provisions of the Texas and/or Federal Tort Claims Act.
SECTION 9 - LAWS, RULES AND REGULATIONS
9.1
Liability for Violation of Applicable Laws. Provider understands and agrees that it is subject to all state and federal
laws, rules, regulations, waivers, policies and guidelines, and court-ordered consent decrees, settlement agreements or
other court orders that apply to this Agreement and Community's managed care contract with HHSC, the Community
Program, and all persons or entities receiving state and federal funds. Provider understands and agrees that any violation
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by a provider of a state or federal law relating to the delivery of services pursuant to this Provider Agreement, or any violation
of Community's contract with HHSC could result in liability for money damages, and/or civil or criminal penalties and
sanctions under state and/or federal law.
9.2
Applicable Laws. Provider further understands and agrees that the following laws that apply to the Agreement
include, but are not limited to, the following laws, rules, regulations and all amendments or modifications thereto, apply to
this Agreement:
a.
environmental protection laws:
(1)
Pro-Children Act of 1994 (20 U.S.C. § 6081, et seq.) regarding the provision of a smoke-free
workplace and promoting the non-use of all tobacco products;
(2)
National Environmental Policy Act of 1969 (42 U.S.C. § 4321, et seq.) and Executive Order 11514
("Protection and Enhancement of Environmental Quality") relating to the institution of environmental
quality control measures;
(3)
Clean Air Act and Water Pollution Control Act regulations (Executive Order 11738, "Providing for
Administration of the Clean Air Act and Federal Water Pollution Control Act with Respect to Federal
Contracts, Grants, and Loans");
(4)
State Clean Air Implementation Plan (42 U.S.C. § 740, et seq.) regarding conformity of federal
actions to State Implementation Plans under § 176(c) of the Clean Air Act; and
(5)
Safe Drinking Water Act of 1974 (21 U.S.C. § 349; 42 U.S.C. § 300f to 300j-9) relating to the
protection of underground sources of drinking water.
b.
state and federal anti-discrimination laws:
(1)
Title VI of the Civil Rights Act of 1964, (42 U.S.C. § 200d, et seq.) and as applicable 45 C.F.R. Part
80 or 7 C.F.R. Part 15;
(2)
Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794));
(3)
Americans with Disabilities Act of 1990 (42 U.S.C. § 12101, et seq.);
(4)
Age Discrimination Act of 1975 (42 U.S.C. §§ 1681-1688);
(5)
Title IX of the Education Amendments of 1972 (20 U.S.C. §§ 1681-1688);
(6)
Food Stamp Act of 1977 (7 U.S.C. § 1101, et seq.);
(7)
Executive Order 13279, and its implementing regulations at 45 C.F.R. Part 87 or 7 C.F.R. Part 16;
and
(8)
the HHS agency's administrative rules, as set forth in the Texas Administrative Code, to the extent
applicable to this Agreement.
C.
the Immigration Reform and Control Act of 1986 (8 U.S.C. § 1101, et seq.) and the Immigration Act of 1990
(8 U.S.C. § 1101, et seq.) regarding employment verification and retention of verification forms;
d.
the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191); and
e.
the Health Information Technology for Economic and Clinical Health Act (HITECH Act) at 42 U.S.C. §
17931, et seq.
9.3
Marketing. Provider agrees to comply with state and federal laws, rules and regulations governing marketing.
Provider agrees to comply with HHSC's marketing policies and procedures, as set forth in HHSC's Uniform Managed Care
Manual. Provider is prohibited from engaging in direct marketing to Members that is designed to increase enrollment in a
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particular health plan. The prohibition should not constrain Provider from engaging in permissible marketing activities
consistent with broad outreach objectives and application assistance.
9.4.
Member Protections. Provider must inform Community of any reports of abuse, neglect or exploitation made
regarding a Member. This includes self-reports and reports made by others that Provider becomes aware of.
SECTION 10 - MEMBER COMMUNICATIONS
10.1 Nothing contained in this Agreement is intended to interfere with or hinder communications between Provider and
Member regarding a patient's medical condition and/or treatment options; Community's referral policies, and other
Community policies, including financial incentives or arrangements and all managed care plans with whom the Provider
contracts.
SECTION 11 - PRIMARY CARE PHYSICIANS AND PRIMARY CARE PROVIDERS
11.1
Accessibility. If Provider is a PCP, it must be accessible to Members 24 hours per day, 7 days per week.
11.2
Preventative Care. If Provider is a PCP, it must provide preventative care to children under age 21 in accordance
with AAP recommendations for CHIP Members and CHIP Perinatal Newborns; the THSteps periodicity schedule published
in the THSteps Manual for Medicaid Members; and to adults in accordance with the U.S. Preventative Task Force
requirements.
11.3
Referral and Coordination of Care. If Provider is a PCP, it must assess the medical needs and behavioral health
needs of Members for referral to specialty care providers and provide referrals as needed; coordinate Members' care with
specialty care providers after referral; and serve as a Medical Home to Members.
SECTION 12 - TERMINATION
12.1
Termination. Community shall follow the procedures outlined in $843.306 of the Texas Insurance Code and 28
Tex. Admin. Code § 11.901 when terminating the Agreement with Provider.
In addition to the Termination section of the Agreement, the following provisions apply:
Community must notify HHSC within five Days after termination of (1) a Primary Care Provider (PCP) contract that impacts
more than 10 percent of its Members or (2) any Provider contract that impacts more than 10 percent of its Network for a
provider type by Service Area and Program. Community must make a good faith effort to give written notice of termination
of a Provider to each Member who receives his or her primary care, or who is seen on a regular basis by, the Provider as
follows:
(1) For involuntary terminations of a Provider (terminations initiated by Community), Community must provide notice to
the Member of the Provider's termination from the network within 15 Days of either expiration of the provider's
advance notice period or once the provider has exhausted rights to appeal. In cases of imminent harm to Member
health, the MCO must give the Member notice immediately that the Provider will be terminated even if a final
termination notice to the Provider has not been issued.
(2) For voluntary terminations of a Provider (terminations initiated by the Provider), Community must provide notice to
the Member 30 Days prior to the termination effective date. In the event that the Provider sends untimely notice of
termination to Community making it impossible for Community to send Member notice within the required timeframe,
Community must provide notice as soon as practical but no more than 15 days after Community receives notice to
terminate from the Provider. Community must send notice to: (1) all its Members in a PCP's panel, and (2) all its
Members who have had two or more visits with the Provider for home-based or office-based care in the past 12
months.
12.2
Termination for Gifts or Gratuities. Provider may not offer or give anything of value to an officer or employee of
HHSC or the State of Texas in violation of state law. A "thing of value" means any item of tangible or intangible property
that has a monetary value of more than $50.00 and includes, but is not limited to, cash, food, lodging, entertainment and
charitable contributions. The term does not include contributions to public office holders or candidates for public office that
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are paid and reported in accordance with state and/or federal law. Community may terminate this Provider contract at any
time for violation of this requirement.
SECTION 13 - BEHAVIORAL HEALTH
13.1
If Provider is a PCP, it must have screening and evaluation procedures for detection and treatment of, or referral
for, any known or suspected behavioral health problems and disorders.
13.2
Providers who provide inpatient psychiatric services to a Member must schedule the Member for outpatient follow-
up
and/or continuing treatment prior to discharge. The outpatient treatment must occur within 7 days from the date of
discharge. Behavioral Health providers must contact Members who have missed appointments within 24 hours to
reschedule appointments.
13.3
All behavioral and physical health providers (including PCPs, OB/GYNs, internists, and other relevant provider
types) must share amongst each other clinical information regarding Members with co-occurring behavioral and
physical health conditions, to the extent allowed by federal law.
ADDITIONAL PROVISIONS SPECIFIC TO MEDICAID
1.
Durable Medical Equipment. Please consult the Texas Medicaid Provider Procedures Manual, Durable Medical
Equipment (DME) and Comprehensive Care Program (CCP) sections, and Community's Provider Manual
(Pharmacy and Benefits sections) for information regarding the scope of coverage of durable medical equipment
(DME) and other products commonly found in a pharmacy. For qualified children, this includes medically necessary
over-the-counter drugs, diapers, disposable/expendable medical supplies, and some nutritional products. It also
includes medically necessary nebulizers, ostomy supplies or bed pans, and other supplies and equipment for all
qualified Members. Community encourages your pharmacy's participation in providing these items to Medicaid
clients.
2.
Family Planning. If a Member requests contraceptive services or family planning services, Provider must
provide
Member counseling and education about family planning and available family planning services. Provider shall not
require parental consent for Members who are minors to receive family planning services. Provider must comply
with state and federal laws and regulations governing Member confidentiality (including minors) when providing
information on family planning services to Members.
3.
THSteps. Provider must send all THSteps newborn screens to the Texas Department of State Health Services
("DSHS") or a DSHS-certified laboratory. Providers must include detailed identifying information for all screened
newborn Members and each Member's mother to allow HHSC to link the screens performed at hospitals with
screens performed at the 2-week follow-up visit.
PCPs must:
a. either be enrolled as THSteps providers or refer Members due for a THSteps check-up to a THSteps
provider;
b. refer Members for follow-up assessments or interventions clinically indicated as a result of the THSteps
check-up, including the developmental and behavioral components of the screening;
C. submit information from the THSteps forms and documents to the Health Passport.
4.
Provider Fraud and Abuse Policy. If Provider receives annual Medicaid payments of at least $5 million dollars
(cumulative, from all sources), Provider must:
a.
Establish written policies for all employees, managers, officers, contractors, subcontractors and agents of
Provider. The policies must provide detailed information about the False Claims Act, administrative
remedies for false claims and statements, any state laws about civil or criminal penalties for false claims,
and whistleblower protections under such laws, as described in Section 1902(a)(68)(A) of the Social
Security Act.
b.
Include as part of such written policies detailed provisions regarding Provider's policies and policies and
procedures for detecting and preventing fraud, waste and abuse.
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C.
Include in any employee handbook a specific discussion of the laws described in Section 1902(a)(68)(A) of
the Social Security Act, the rights of employees to be protected as whistleblowers, and Provider's policies
and procedures for detecting and preventing fraud, waste and abuse.
5.
Advance Directives. Provider must comply with requirements of state and federal laws, rules and regulations
relating to advance directives.
Referral and Coordination of Care. If Provider is a PCP, it must assess the medical needs and behavioral health
needs of Members for referral to specialty care providers and provide referrals as needed; coordinate Members'
care with specialty care providers after referral; and serve as a Medical Home to Members.
6.
Payment for Services. Provider is prohibited from billing or collecting from a Medicaid Member for health care
services provided pursuant to the Agreement. Federal and state laws provide severe penalties for any provider to
bill or collect any payment from a Medicaid recipient for a Covered Service.
7.
Mental Health. Provider must comply with 25 Tex. Adm. Code, Part 1, Chapter 415, Subchapter F, "Interventions
in Mental Health Services," when providing mental health rehabilitation services and mental health targeted case
management.
8.
Electronic Visit Verification. Network Providers using the EVV system must maintain compliance with HHSC
minimum standards detailed in UMCM, Chapter 8.7, Section IX.
9.
Service Coordination. All Home and Community Support Services Agency (HCSSA) providers, adult day care
providers, and residential care facility providers must notify the MCO if a Member experiences any of the following:
a) a significant change in the Member's physical or mental condition or environment; b) hospitalization; c) an
emergency room visit; or d) two or more missed appointments.
10.
Waiting Times for Appointments. In addition to the requirements in 3.12 of this Addendum, Community Long-Term
Services and Supports for Members must be initiated within 7 days from the start date on the Individual Service
Plan or the eligibility effective date for non-waiver LTSS unless the referring provider, Member, or STAR+PLUS
Handbook states otherwise.
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SECTION 14 - DELEGATED ACTIVITIES
Delegated Activities. In the event Community delegates to Provider any of Community's activities or responsibilities under
the Contract, Provider and Community agree to enter into a written agreement: (a) specifying the delegated activities and
reporting responsibilities; (b) providing for revocation of the delegation activities and reporting requirements or specifying other
remedies in instances where CMS, HHSC or Community determines that Provider has not performed satisfactorily; (c)
specifying that the performance of Provider is monitored by Community on an ongoing basis; (d) specifying that either (i) the
credentials of medical professionals affiliated with Provider will be either reviewed by Community, or (ii) the credentialing
process will be reviewed and approved by Community and Community must audit the credentialing process on an ongoing
basis; (e) in the event that Community delegates the selection of Providers, written arrangements must state that Community
retains the right to approve, suspend, or terminate such arrangement; (f) specifying that Provider must comply with all
applicable Medicaid and Medicare laws, regulations, including applicable sub-regulatory guidance and contract provisions,
and CMS instructions; (g) specifying that Provider agrees to perform the delegated activities and reporting responsibilities
specified in compliance with Community's contract obligations; and (h) specifying that Provider agrees to any required audit
provisions not otherwise covered under Section 4. [42 C.F.R. § 438.230; 42 C.F.R. § 422.504(i)].
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MEDICARE PRODUCT - CMS REGULATORY REQUIREMENTS ADDENDUM
The following provisions are mandated CMS contract requirements for Community Health Choice's (Community) agreement
with Participating Providers. The provisions contained in this Addendum shall supersede any conflicting provisions in the
Agreement in connection with Community's Medicare product membership. This Addendum may be unilaterally updated
and amended at any time in order to comply with any local, state or federal governmental laws, rules or regulations. Provider
will be notified regarding these changes as soon as practicable after changes have been announced.
For purposes of this Addendum:
The term "Medicare Product" refers to those programs and health benefit arrangements offered by Community or another
Payor in connection with one or more of the following Medicare product types that is administered, sponsored or regulated
by the federal government (or any agency, department or division thereof) on its own or jointly with a State that administers
or regulates such program or plan (each a "Medicare Product Type"); a non-Dual Eligible Special Needs Plan Medicare
Advantage Plan ("MA Plan"); a Medicare Advantage prescription drug plan ("MA-PD a Dual Eligible Special Needs
Plan ("DSNP Plan"); a Capitated Financial Alignment Demonstration ("MMP Plan") plan or program (e.g., a plan or program
adopted or established under the Affordable Care Act of 2010, to test new service delivery and payment models for people
dually eligible for Medicare and Medicaid, including any regulations or CMS pronouncements and any future Attachments);
or other Medicare Product types. The Medicare Product includes those coverage agreements entered into, issued or agreed
to by a Payor under which a company furnishes administrative services or other services in support of a Medicare Product.
The Medicare Product does not apply to any coverage agreements that are specifically covered by another compensation
exhibit to the Agreement. This Addendum applies only to the provision of health care services, supplies or accommodations
(including Covered Services) to Covered Persons enrolled in the Medicare Product. Provider acknowledges that it will
participate in each Medicare Product Type for which a Compensation Exhibit(s) is attached to this Addendum.
1.
DEFINITIONS. The following terms shall be defined as set forth below as used in this Addendum. Capitalized terms not
otherwise defined in this Addendum shall be defined as set forth in the Agreement or elsewhere in the Addendum.
1.1.
Clean Claim means a claim that has no defect, impropriety, lack of any required substantiating documentation-
including the substantiating documentation needed to meet the requirements for encounter data or particular
circumstance requiring special treatment that prevents timely payment; and a claim that otherwise conforms
to the Clean Claim requirements under original Medicare.
1.2.
CMS means the agency within the Department of Health and Human Services that administers the Medicare
program.
1.3.
CMS Contract means the contract between Community or a Payor and CMS, or among Community or a Payor,
CMS and the State, that governs the terms of Community's or Payor's participation in a Medicare Plan.
1.4.
Covered Persons means those individuals who are enrolled in a Medicare Plan.
1.5.
Covered Services means those services which are covered under a Medicare Plan.
1.6.
Downstream Entity means any party that enters into a written arrangement, acceptable to CMS, with person
or entities involved with the MA benefit, below the level of the arrangement between Community and a First
Tier Entity. These written arrangements continue down to the level of the ultimate provider of both health and
administrative services.
1.7.
First Tier Entity means any party that enters into a written arrangement, acceptable to CMS, with Community
to provide administrative services or health care services for a Medicare eligible individual under a Medicare
Plan.
1.8.
HHS means the United States Department of Health and Human Services.
1.9.
Related Entity means any entity that is related to Community by common ownership or control and (1) performs
some Community's management functions under contract or delegation; (2) furnishes services to Covered
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Persons under an oral or written agreement, or (3) leases real property or sells materials to Community at a
cost of more than $2,500 during a contract period.
1.10.
State means one or more applicable state governmental agencies of the State of Texas.
2.
COVERED SERVICES. Provider shall furnish Covered Services to Covered Persons as asset forth in the Agreement
and this Addendum.
3.
SUBCONTRACTOR OBLIGATIONS. To the extent that Provider engages any other person (excluding an employee)
or entity to perform services in connection with a Medicare Product, including any Downstream or Related Entity,
Provider agrees that such engagement shall be set forth in a written agreement that requires such other person or entity
to assume the same obligations that Provider assumes under this Addendum.
4.
GOVERNMENT RIGHT TO INSPECT
4.1. Provider agrees that HHS, the Comptroller General, or their designees have the right to audit, evaluate, collect,
and inspect any pertinent information for any particular contract period, including, but not limited to, any books,
contracts, computer or other electronic systems (including medical records and documentation of the first tier,
downstream, and entities related to CMS' contract with Community, (hereinafter, "MA organization") through 10
years from the final date of the final contract period of the contract entered into between CMS and the MA
organization or from the date of completion of any audit, whichever is later. 42 C.F.R. §422.504(i)(2)(i) and (iv) and
$423.505
4.2. Provider agrees that HHS, the Comptroller General or their designees have the right to audit, evaluate, collect, and
inspect any records under paragraph 1 of this amendment directly from any first tier, downstream, or related entity.
For records subject to review under paragraph 1, except in exceptional circumstances, CMS will provide notification
to the MA organization that a direct request for information has been initiated. 42 C.F.R. $422.504(i)(2)(ii) and (iii)
and 423.505
4.3. Provider further agrees that HHS, the Comptroller General or their designees have the right to audit, evaluate and
inspect any books, contracts, medical records, documents, papers, patient care documentation and other records
of the Provider, that pertain to any aspect of services performed, reconciliation of benefit liabilities, and
determination of amounts payable under this Addendum, or as the Secretary of HHS may deem necessary to
enforce the CMS Contract. Provider shall cooperate with and shall assist and provide such information and
documentation to such entities as requested. Provider shall retain, and agrees that this right to inspect, evaluate
and audit shall extend for a period of ten (10) years following the termination date of this Addendum or completion
of audit, whichever is later, unless (i) CMS determines that there is a special need to retain a particular record or
group of records for a longer period and notifies Payor at least 30 days before the normal disposition date; (ii) there
has been a termination, dispute, or allegation of fraud or similar fault by Payor, in which case the retention may be
extended to six (6) years from the date of any resulting final resolution of termination, dispute, fraud, or similar
fault; (iii) CMS determines that there is a reasonable possibility of fraud or similar fault, in which case CMS may
inspect, evaluate , and audit at any time. This provision shall survive termination of this Addendum. 42 C.F.R §
422.504 (e)(2)(3)(4)
5.
CONFIDENTIALITY AND ENROLLEE RECORD REQUIREMENTS. Provider shall comply with all confidentiality and
enrollee record accuracy requirements, including: (1) abiding by all federal and State laws regarding the confidentiality
and disclosure of medical records or other health and enrollment information (2) ensuring that medical information is
released only in accordance with applicable federal or State law, or pursuant to court orders or subpoena; (3)
maintaining the records and information in an accurate and timely manner; and (4) ensuring timely access by Covered
Persons to the records and information that pertains to them. 42 C.F.R §§ 422.504 (a)(13) and 422.118
6. HOLD HARMLESS
6.1. Provider herby agrees that Covered Persons shall not be held liable for payment of any fees that are the legal
obligation of Payor. 42 C.F.R. §§ 422.504(i)(3)(i), 422.504(g)(1)(i), and 423.505(i)(3)(i)
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6.2. Provider agrees that for all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for
Medicare Part A and B cost sharing when the State is responsible for paying such amounts. Providers will be
informed of Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid. Provider
may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the
individual under title XIX if the individual were not enrolled in such a plan. Providers will: (1) accept the MA plan
payment as payment in full, or (2) bill the appropriate State source. 42 C.F.R. §§ 422.504(i)(3)(i), 422.504(g)(1)(i),
423.505(i)(3)(i)
7. COMPLIANCE WITH CMS CONTRACT. Provider shall perform its obligations under this Addendum in a manner
consistent with and in compliance with Community's and Payor's contractual obligation under the CMS Contract. 42
C.F.R. $422.504(i)(3)(iii) and $423.505(i)(3)(iii)
8.
PROMPT PAYMENT. Payor shall pay, or arrange to pay, Provider for Covered Services rendered to Covered Persons
in accordance with Exhibit B-3 to this Addendum. Any Clean Claim, as defined in 42 C.F.R § 422.500, shall be paid
within thirty (30) days of receipt by Community, Payor or (if Provider contracts with Downstream Entities) Provider, as
applicable, as designated by Provider or such Downstream Entity, as applicable. 42 C.F.R § 422.520 (b)(1) and (2)
9.
COMPLIANCE WITH FEDERAL AND STATE LAWS. Community, Provider, Payor, and any Downstream or Related
Entity shall comply with all applicable laws including Medicare laws, regulations and CMS and/or State instructions. 42
C.F.R. $422.504(i)(4)(v) and $423.505(i)(4)(iv)
10. DELEGATION OF DUTIES. In the event that Community delegates to Provider any function or responsibility under
its contract with CMS are delegated to any first tier, downstream and related
entity:
10.1 The delegated activities and reporting responsibilities are specified in the Delegation Exhibit. 42 C.F.R.
$422.504(i)(4)(i) and $423.504(i)(4)(i)
10.2 CMS and Community reserve the right to revoke the delegation activities and reporting requirements or to specify
other remedies in instances where CMS or Community determine that such parties have not performed
satisfactorily. 42 C.F.R. $422.504(i)(4)(ii) and $423.505(i)(4)(ii)
10.3 Community will monitor the performance of the parties on an ongoing basis. 42 C.F.R. $422.504(i)(4)(iii) and
$423.505(i)(4)(iii)
10.4 The credentials of medical professionals affiliated with the party or parties will be either reviewed by Community
or the credentialing process will be reviewed and approved by Community and Community must audit the
credentialing process on an ongoing basis. 42 C.F.R. $422.504(i)(4)(iv) and 422.505(i)(5)
10.5 If the MA organization delegates the selection of providers, contractors, or subcontractor, the MA organization
retains the right to approve, suspend, or terminate any such arrangement. 42 C.F.R. 422.504(i)(5) and
423.505(i)(5)
11. NON-DISCRIMINATION BASED ON HEALTH OR OTHER STATUS. Provider shall not deny, limit, or condition
coverage or the furnishing of health care services or benefits to Covered Persons based on any factor related to health
status, including, but not limited to, medical condition (including mental as well as physical illness), claims experience,
receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of
acts of domestic violence), race, ethnicity, national origin, religion, sex, age, sexual orientation, source of payment and
mental and physical disability. 42 C.F.R § 422.110 (a)
12. SERVICE AVAILABILITY. Provider shall ensure that its hours of operation are convenient to Covered Persons and do
not discriminate against Covered Persons; and that Covered Services are available twenty-four (24) hours a day, seven
(7) days a week, when medically necessary. 42 C.F.R § 422.112(a)(7)
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13.
CULTURAL COMPETENCE. Provider must provide all services in a culturally competent manner to all Covered
Persons, including those with limited English proficiency or reading skills, and diverse cultural and ethnic backgrounds.
42 C.F.R § 422.112(a)(8)
14. FOLLOW-UP CARE. Provider shall ensure that Covered Persons are informed of specific health care needs that
require follow-up and receive, as appropriate, training in self-care and other measures they may take to promote their
own health. 42 C.F.R § 422.112(b)(5)
15. ADVANCE DIRECTIVES. Provider shall comply with Community's and Payor's policies and procedures concerning
advance directives. 42 C.F.R § 422.128(b)(1)(ii)(E)
16. PROFESSIONALLY RECOGNIZED STANDARDS OF CARE. Provider agrees to provide Covered Services under the
Agreement to Medicare beneficiaries in a manner consistent with professionally recognized standards of health care.
42 C.F.R § 422.504(a)(3)(iii)
17. CONTINUATION OF BENEFITS. Provider shall provide Covered Services as provided in the Agreement and this
Addendum: (a) for all Covered Persons, for the duration of the contract period for which CMS payments have been
made; and (b) for Covered Persons who are hospitalized on the date the CMS Contract terminates, or, in event of an
insolvency, through discharge. This continuation of benefits provision shall survive termination of this Addendum. 42
C.F.R §§ 422.504(g)(2)(i), 422.504(g)(2)(ii); (g) (3)
18.
PHYSICIAN INCENTIVE ARRANGEMENTS. If Provider is a physician or physician group, neither Payor nor
Community shall make any specific payment, directly or indirectly, to Provider as an inducement to reduce or limit
medically necessary services furnished to any particular Covered Person. Indirect payments may include offerings of
monetary value, (such as stock options or waivers of debt) measured in the present or future. Provider agrees that, if
Community or Payor has a physician incentive plan that places Provider at substantial financial risk (as determined
under 42 C.F.R. § 422.208(d)) for services that Provider does not furnish itself, Provider shall obtain and maintain either
aggregate or per-patient stop-loss protection in accordance with requirements at 42 C.F.R § 422.208(f). 42 C.F.R §
422.208
19. INFORMATION DISCLOSURE TO CMS. Provider shall cooperate with Community and Payor in providing any
information to CMS deemed necessary by CMS for the administration or evaluation of the Medicare Program. 42 C.F.R
§ 422.504(f)(2)
20. NOTICE OF PROVIDER TERMINATIONS. Community shall make good faith effort to provide written notice of
termination of a contracted provider at least 30 calendar days before termination effective date to all Covered Persons
who, are patients seen on a regular basis by the provider whose contract is terminating, irrespective of whether the
termination was for cause or without cause. If Provider is a primary care professional, all Covered Persons who are
patients of that primary care professional must be notified. 42 C.F.R § 422.111(e)
21.
RISK ADJUSTMENT DATA. Provider shall provide to Community risk adjustment data as required by CMS. 42 C.F.R
§§ 422.310(d)(3)(4). Upon Community's or CMS's request, Provider shall submit a sample of medical records for the
validation of risk adjustment data, as required by CMS. Provider acknowledges that penalties may apply for submission
of false data. Provider certifies based on best knowledge, information and belief that the data it submits under 42 C.F.R
§ 422.310 are accurate, complete and truthful. 42 C.F.R §§ 422.310(e) and 422.504(1)(3)
22. COMPLIANCE WITH COMMUNITY POLICIES AND PROCEDURES. Provider shall comply with Community's and
Payor's policies and procedures. In addition, if Provider is a physician or physician group, Provider shall, or shall require
the physician members of the group to, upon Community's request, consult with procedures and ensure that the
following standards are met: (a) practice guidelines and utilization management guidelines (i) are based ono reasonable
medical evidence or a consensus of health care professionals in the particular field; (ii) consider the needs of the
enrolled population; (iii) are developed in consultation with contracting physicians; and (iv) are reviewed and updated
periodically; (b) the guidelines are communicated to providers and, as appropriate, to Covered Persons; and (c)
decisions with respect to utilization management, Covered Person education, coverage of services, and other areas in
which the guidelines apply are consistent with the guidelines. 42 C.F.R § 422.202(b). Provider shall comply with
Community's quality assurance and performance improvement programs. 42 C.F.R § 422.504(a)(5)
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23. WRITTEN NOTICE FOR REASON FOR SUSPENSION AND TERMINATION. In the event Community suspends or
terminates tis Addendum with respect to Provider or any physicians employed or contracted with Provider Community
shall give Provider or such physician written notice of the following; (a) the reasons for the action, including, if relevant,
the standards and profiling data used to evaluate the affected physician, and the numbers and mix of physicians needed
by Community, and (b) the affected physician's right to appeal the action and the process and timing for requesting a
hearing. 42 C.F.R § 422.202(d)(1)
24. NOTICE OF WITHOUT CAUSE TERMINATION. Community and Provider must provide a minimum of sixty (60) days
written notice, or such longer period specified in this Agreement, to each other before terminating the Addendum without
cause. 42 C.F.R § 422.202(d)(4)
25. COMPLIANCE WITH FEDERAL LAWS AND REGULATIONS. Community and Providers agree to comply with (a)
federal laws and regulations designed to prevent or ameliorate fraud, waste, and abuse, including, but not limited to,
applicable provisions of federal criminal law, the False Claims Act (31 U.S.C 3729 et. Seq.) and the anti-kickback statue
(section 1128B(b)) of the Act); and (b) HIPPA administrative simplification rules at 45 C.F.R. parts 160, 162, and 164.
42 C.F.R § 422.504(h)(1)
26. FEDERAL FUNDS. Provider acknowledges that payments Provider receives from Community or Payor to pursuant to
this Addendum are, in whole or part, from federal funds. Therefore, Provider and any of its Downstream or Related
Entities are subject to certain laws that are applicable to individuals and entities receiving federal funds, which may
include, but is not limited to, Title VI of the Civil Rights Act of 1964 as implemented by 45 C.F.R. Part 84; the Age
Discrimination Act of 1975 and any other regulations applicable to recipients of federal funds. Medicare Managed Care
Manual, Ch. 11 § 120
27. EXCLUDED PERSONS/PROGRAM INTEGRITY. Provider warrants to Community and each Payor that it is not
excluded and shall not employ or contract for the provision of health care, utilization review, medical social work, or any
administrative services pursuant to this Agreement with any individual or entity (hereafter, "person") whom Provider
knows or reasonable should have known is excluded from participation in the Medicare and Medicaid program under
Section 1128 or 1128A of the Social Security Act. Provider hereby certifies that no such excluded person currently is
employed by or under contract with Provider. Provider shall review the Office of Inspector List of Excluded Individuals
and Entities and the System for Award Management exclusion list and verify on a monthly basis or as often as required
by CMS guidelines, that the persons it employs or contracts for the provision of such services pursuant to this Agreement
are in good standing. Provider shall promptly disclose to Community and Payor any exclusion, or other event that
makes a Provider employee or Downstream or Related Entity ineligible to perform work related to Medicare or Medicaid.
42 C.F.R § 422.752 (a)(8). Provider shall promptly notify Community and Payor in writing in the event that Provider is
criminally convicted or has a civil judgment entered against Provider for fraudulent activities or is sanctioned under any
federal program involving the provision of health care or prescription drug services. Provider agrees to be bound by
the provisions set forth at 2 C.F.R Part 376.
28. COMPLIANCE: TRAINING, EDUCATION, AND COMMUNICATION. Provider agrees it, its employees,
and
Downstream and Related Entities who provide services under this Addendum shall receive general compliance training
as well as fraud, waste, and abuse ("FWA") training, and that such training shall occur within ninety (90) days of initial
hiring and annually thereafter. Unless otherwise agreed to by Community or Payor in writing, such training shall be the
general compliance and FWA training modules located on the CMS Medicare Learning Network ("MLN") at:
https://learner.mlnlms.com/Default.aspx. Community and Payor shall accept the system-generated certificate of
completion as evidence of compliance with the training requirement. The FWA training requirement is not required for
providers or suppliers who have met the fraud, waste and abuse certification requirements through enrollment in Parts
A or B of the Medicare program or through accreditation as a supplier of DMEPOS. However, compliance with the
general training requirement is still required. Provider shall maintain records of Provider's and its employees' training.
42 C.F.R § 422.503(b)(4)(vi)(C)(3)
29. COMPLIANCE WITH GRIEVANCE AND APPEALS REQUIREMENTS. Provider shall cooperate and comply with all
applicable State, federal Community and Payor requirements regarding Covered Persons grievances and appeals, as
well as enrollment and disenrollment determinations, including the obligation to provide information (including medical
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records and other pertinent information) to Community and Payor within the time frame required by regulation or, if not
so required, reasonably required for such purpose.
30. OFFSHORE SUBCONTRACTORS. In addition to the applicable requirements of Section 10 of this Addendum and
pursuant to Community's contract with the State, Provider agrees that all work performed under this Agreement shall
be performed exclusively within the United States, and all information obtained by Provider under this Agreement shall
be maintained within the United States. No work or maintenance of any information relating or obtained pursuant to
this Agreement may occur outside the United States except as specifically authorized or approved by Community.
31. SCOPE AND CONFLICTS. Nothing in this Addendum shall be held to vary, alter, waive or extend any of the terms,
conditions, agreements or limitation of the Agreement, including the Provider Manual, except as stated in this
Addendum. In the event of any conflict between this Addendum and any provision of the Agreement, the provisions of
this Addendum shall govern. In the event that any provision of this Addendum conflicts with the provisions of any statute
or regulation applicable to Community, the provisions of the statute or regulation shall have full force and effect unless
such statute or regulation is preempted by federal law.
32. TERMINATION. This Addendum shall terminate upon the termination of the Agreement and under the same terms and
conditions specified in the Agreement. This Addendum may be further terminated Community immediately upon written
notice to Provider if CMS Contract is terminated, or if Provider is listed on the GSA List or SAM as excluded or is
otherwise suspended or excluded from participation in Medicare or Medicaid.
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