doczyai-pipelines/streamlit/SOURCE_DOCUMENTS/Alliance Physicians Inc_MU.txt

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Care Source
GROUP PRACTICE SERVICES AGREEMENT
THIS AGREEMENT (the "Agreement") is made and entered into as of the date set forth
on the signature page of this Agreement, by and between Dayton Area Health Plan, Inc.
d.b.a. CareSource ("Plan"), an Ohio not for profit corporation, and the undersigned
provider group, Alliance Physicians, Inc. (Group Practice").
RECITALS
WHEREAS, Plan contracts directly or indirectly with individuals, insurers, sponsors and
other payors to provide, insure, arrange for or administer the provision of health care
services; and
WHEREAS, Plan contracts with physicians, hospitals and other health care practitioners
health care services; and
and entities to provide, arrange for, or administer at predetermined rates, the delivery of
WHEREAS, Plan and Group Practice mutually desire for Group Practice to provide or
arrange for certain health care services to Covered Persons in accordance with the terms
and conditions of this Agreement.
NOW, THEREFORE, in consideration of the promises and mutual covenants set forth
herein, the parties hereto agree as follows:
ARTICLE I
DEFINITIONS
As used in this Agreement and in the Exhibits and Attachments and Addenda hereto, the
following terms shall have the meanings set forth below.
1.1
Contracted Services. Those Covered Services that are provided by Group Practice
consistent with provider's training, licensure and scope of practice as set forth in
applicable Attachments, Exhibits, or Addenda,
1.2
Covered Persons. Any individual, or eligible dependent of such individual, whether
referred to as "Insured," "Subscriber," "Member," "Participant," "Enrollee,"
"Dependent" or otherwise, who is eligible to receive Covered Services pursuant to a
Service Agreement.
1.3
Covered Services. Those Medically Necessary health care services or
supplies provided to a Covered Person in accordance with a Service
Agreement.
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1.4
Emergency Services. Emergency services are to cover inpatient and outpatient
services furnished by a qualified provider and are needed to evaluate or stabilize an
emergency medical condition. An emergency medical condition is one manifesting
itself by acute symptoms of sufficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate attention to result in :
placing the health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy;
serious impairment to bodily functions, or
serious dysfunction of a bodily organ or part.
1.5
Medical Director. A duly licensed physician or designee who has been designated
by Plan to monitor the provision of Covered Services to Members.
1,6
Medically Necessary. Age appropriate services reasonable and necessary to
diagnose and provide preventive, palliative, curative or restorative treatment for
physical or mental conditions in accordance with professionally recognized
standards of health care generally accepted at the time services are provided, and
in accordance with 42 C.F.R. § 440.230, including services for children authorized
under 42 U.S.C.-1396 (r).
The fact that a Group Practice orders, prescribes, recommends or approves a
service or supply does not, of itself, make the service or supply Medically
Necessary or a Covered Service,
1.7
Participating Provider. A health care professional or facility, including Group
Practice, and/or Group Practice Providers that Plan has entered into an agreement
with, to provide Covered Services to Members in accordance with Plan
requirements as set forth in the Plan Provider Manual. Each Group Practice
Provider at facility who requires credentialing shall be credentialed by Plan. No
Group Practice Provider who is not credentialed by Plan shall provide services to
any Member.
1,8
Participating Hospital. A hospital which has entered into an Agreement with Plan
as a hospital to which a Group Practice may admit Plan Members for Covered
Services in accordance with Plan requirements.
1.9
Payor. An individual or entity, including Plan, which, pursuant to a Service
Agreement, funds, administers, offers or insures Covered Services and which has
agreed to act as Payor in accordance with this Agreement.
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1.10 Primary Care Physician or PCP. An individual licensed physician (M.D. or D.O.),
generally, in the speciality of internal medicine, pediatrics, family medicine or
general practice who is contracted with Plan to provide or arrange for the provision
of all primary care Covered Services to Covered Persons, to initiate and manage
non-emergency referrals only to Participating Providers, including admissions to
Participating Hospitals, and to maintain the continuity of Covered Persons' care, as
required by the applicable Service Agreement. However, the Plan reserves the
right to designate other specialties as PCPs when appropriate.
1.11 Provider Manual. A manual developed by Plan and furnished to Group Practice for
the benefit of informing them of Plan procedures, policies, requirements, rules and
regulations which are amended or modified from time to time.
1.12
Quality Improvement Program. The processes established and operated by Plan or
its designee relating to the quality of Covered Services.
1.13 Service Agreement. Those agreements between Plan and an insurer, government
agency or other organization or entity, or an individual, that specify services to be
provided to, or arranged for or reimbursed to, or for the benefit of Covered Persons,
and the terms and conditions under which those services are to be provided or
reimbursed.
1.14
Utilization Management. The processes to review and determine whether certain
health care services provided or to be provided to Covered Persons are in
accordance with Plan policies and procedures.
1.15 Credentialing/Recredentialing. The process of gathering, verifying and evaluating
information for the purpose of determining whether applicable health care
practitioners including Group Practice Providers and facilities comply with Plan
participation standards. Credentialing will be repeated on a periodic basis
(Recredentialing). Credentials are collected by Plan, and evaluated by the Plan
Medical Director and designated quality improvement committees, unless otherwise
specified herein.
1.16 Group Practice. The entity which, through the execution of this Agreement, agrees
to provide or arrange for the provision of Contracted Services through Group
Practice Providers to Members who have selected or who have been referred or
assigned to Group Practice. Unless clearly inapplicable, all of the terms of this
Agreement shall apply to all Group Practice Providers and other health care
providers affiliated with, employed by or associated with Group Practice. It shall be
Group Practice's obligation to ensure compliance with such terms.
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1.17 Group Practice Provider. A provider employed by contracting with or associated
with Group Practice who has agreed to provide health services according to the
terms and conditions of this Agreement and who has been credentialed pursuant
to Plan's credentialing criteria to provide such services.
ARTICLE II
PARTIES OBLIGATIONS
2.1
Provision of Services. Group Practice and Group Practice Providers shall provide
medically necessary Contracted Services, as set forth in applicable Attachments
attached hereto, to Members through the last day this Agreement is in effect. In
providing Contracted Services to Covered Person, Group Practice agrees to (a) be
bound by and to abide by the terms of this Agreement, Exhibits, Attachments and
Addenda hereto, and Plan requirements as set forth in the Plan Provider Manual;
and (b) not allow non-credentialed Group Practice Providers employed by
contracted with or associated with Group Practice to serve Plan members and shall
hold Plan harmless should a non-credentialed Group Practice Provider serve a Plan
member.
2.2
Member Rights. Group Practice and Group Practice Providers shall not
discriminate in the treatment of Members on the basis of race, age within the scope
of Group Practice Provider's practice, marital status, disability, color, national origin,
ancestry, religion, sex, health status, sexual preference, Vietnam-era veteran's
status or presence of handicap, source of payment, or need for health services.
Group Practice will observe, protect and promote the rights of Members as patients.
2.3
Compliance with Laws and Regulations. Group Practice shall perform its duties,
and shall cause its employees, agents, Group Practice Providers and independent
contractors to perform their duties, in accordance with applicable federal, state, and
local standard of professional ethics, practices, laws, regulations and contractual
obligations of Plan. If Group Practice is a laboratory testing site or provides
laboratory services to Members, Group Practice must maintain a Clinical Laboratory
Improvement Amendment (CLIA) Certificate of Waiver, Certificate of Accreditation,
or a Certificate of Registration along with a CLIA identification number.
2.4
Professional Credentials: Licensure. Group Practice, Group Practice Providers
and all health care professionals employed by or under contract with Group
Practice to render Contracted Services hereunder on behalf of Group Practice
shall:
a.
be duly licensed, certified, or registered to perform such services under
applicable state and federal statutes and regulations;
b.
provide Contracted Services with the same standard of care, skill, and
diligence customarily used by similar providers in the community in which
such services are rendered; and
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C.
render Contracted Services in the same manner in accordance with the
same standards, and with the same availability as offered to individuals who
are not Covered Persons.
2.5
Service Locations. Group Practice shall provide or arrange for Contracted Services
at locations approved by Plan. Group Practice shall notify Plan of any changes or
eliminations to locations within ten (10) days of the changes. Verbal notification is
acceptable with written notification within the ten (10) day timeframe.
2.6
Accessibility and Continuity of Care. Group Practice, if inclusive of Primary Care
Physician(s), shall arrange for all applicable Contracted Services available twenty-
four (24) hours per day, seven (7) days per week, three hundred sixty-five (365)
days per year and in a manner that assures continuity of care. Group Practice shall
provide coverage arrangements with providers who are Participating Providers in
accordance with Plan policies and procedures unless otherwise approved in
advance by Plan.
2.7
Verification of Eligibility. Plan shall establish a verification system through which
Group Practice may verify whether (i) a person seeking service is a Covered
Person and (ii) whether a health care practitioner is a Participating Provider. If
Plan subsequently determines that the individual was not eligible for coverage for
the services rendered, those services shall not be eligible for payment. Group
Practice may then directly bill the individual for such service.
2.8
Communication. Plan shall communicate changes to Plan requirements to Group
Practice in a timely manner. Upon specific request by the Group Practice, Plan will
identify the Payor responsible for payment of Covered Services.
2.9
Referrals, Group Practice shall refer Covered Persons to Participating Providers
except: (i) in the case of emergency; (ii) as otherwise described in the Provider
Manual; (iii) as otherwise required by law; or (iv) as prior approved by Plan. Group
Practice Providers who are not Primary Care Physicians shall provide those
Contracted Services specifically authorized by a Member's Primary Care Physician
through Plan's referral system, unless a self-referred service as described in the
Provider manual.
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2.10
Quality Improvement, Credentialing and Utilization Management. Group Practice
agrees to cooperate with, participate in, and comply with the requirements of
Quality Improvement Program, Credentialing -Recredentialing and Utilization
Management programs. Group Practice shall notify Plan immediately after the
adverse outcome or the initiation of any complaint, inquiry, investigation, or review
with or by any licensing or regulatory authority, peer review organization, hospital
committee, or other committee, organization or body which reviews quality of
medical care which complaint, inquiry, investigation, or review directly or indirectly,
evaluates or focuses on the quality of care provided by Group Practice or a Group
Practice Provider either in any specific instance or in general.
2.11
Hospital Admissions. Each Group Practice Provider, if a physician, shall designate
one or more Participating Hospital(s) where Group Practice Provider will admit
Covered Persons under their care. Group Practice Provider shall admit Covered
Persons only to Participating Hospitals except: (i) in the case of emergency; (ii) as
otherwise described in the Provider Manual; (iii) as otherwise required by law; or (iv)
as prior approved by the Plan Medical Director or designee.
2.12 Liability Coverage. Throughout the term of this Agreement, Group Practice shall
maintain and provide proof of professional liability and comprehensive general
and/or umbrella liability insurance acceptable to Plan. Such insurance shall cover
Group Practice Group, Practice Providers and employees of Group Practice.
Group Practice shall notify Plan not more than ten (10) days after receipt of notice
of any reduction or cancellation of such coverage. Group Practice shall also give
Plan prompt written notice of all complaints filed with any court alleging misconduct
or unlawful discrimination on the part of Group Practice or a Group Practice
Provider and/or any health professional employed by, agent of or independent
contractor of Group Practice. Plan shall maintain insurance of the nature and in the
amounts as may be required by state law.
2.13 Records. Plan and Group Practice agree that clinical records of Covered Persons
shall be regarded as confidential and both shall comply with all applicable federal
and state laws regarding such records.
Provider shall be responsible for obtaining Covered Persons' consent for release of
medical record information by Group Practice for the purposes stated in this
section. Group Practice shall:
a.
maintain and furnish such records and documents as may be required by
applicable laws, regulations and Plan requirements. Group Practice shall
cooperate with Plan to facilitate the information and record exchanges
necessary for Quality Improvement Program, Credentialing -Recredentialing,
Utilization Management, peer review, transfer of records to a new provider or
other programs required for Plan operations.
b.
provide Plan or its designee with access during regular business hours and
upon reasonable notice to specified clinical and medical records of Covered
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Person maintained by Group Practice and Group Practice Providers, Plan
of this agreement.
shall have access for the period of at least six (6) years following termination
C.
provide Plan or its designee copies of such records at no cost as may be
by law or accreditation organization.
required by Plan or as may be requested for purposes of any audit required
2.14
Grievance System. Plan shall maintain and administer a grievance system for
Members. Complaints received by Plan concerning services rendered by Group
Practice Providers and/or Group Practice employees will be resolved in accordance
with the grievance procedure. Group Practice agrees to cooperate with Plan in the
Plan. resolution of Member complaints and comply with all final determinations made by
2.15 Ohio Department of Insurance (ODI) Designated Withholds. If requested to do so,
Plan has the right to withhold all or a portion of such payments as may be due
Group Practice for such period as ODI may direct.
2.16
Determination of Payment. Referrals, notifications and authorizations are not
determinations or representations that a patient is (or will continue to be) a
Member, that the Services requested are Covered Services for which benefits will
be payable or that Plan guarantees payment. An authorization is a determination
of whether a service is Medically Necessary only and is subject to re-determination
if the information submitted to Plan to obtain the authorization turns out to be
materially incomplete or inaccurate.
2.17
Provider Panel Closures. If Group Practice is a participating Provider, then
notwithstanding panel limitations agreed to in advance between Group Practice and
Plan, Group Practice agrees to notify Plan in writing of Group Practice's intent to
limit and/or close Panel and/or to treat current Plan members only in at least sixty
(60) consecutive days prior to the date Group Practice intends to change the panel.
Under no circumstances shall Group Practice close a panel that has less than the
maximum number of Plan Medicaid members as outlined in the Panel's Medicaid
Addendum. Should Group Practice neglect to notify Plan of a panel limitation or
closure, Group Practice will be required to reopen panel for a period of sixty (60)
consecutive days beginning from the date Plan learns of panel closure.
2.18 Provider Discussion with Members, Plan agrees not to prevent Group Practice
from discussing all medically necessary treatment options with Members.
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ARTICLE III
BILLING AND COMPENSATION
3.1
Group Practice, Group Practice shall:
Billing. With respect to all Contracted Services provided to Covered Persons by
a.
bill Plan in a format mutually agreed to at Group Practice's usual and
customary rates that are charged by Group Practice without regard to
whether a particular person has health care benefits;
b.
submit claims within one hundred eighty (180) days of the date Covered
Services are rendered. In no event, regardless of the cause or
circumstance, shall Plan or the Member be responsible or liable for any claim
submitted to Plan more than one hundred eighty (180) days after the date
Group Practice provided the Contracted Service.
C.
if applicable, submit encounter data in a form acceptable to Plan for each
member visit and/or service covered by capitation payments as defined in
applicable attachments, or capitation payments may be delayed.
d.
comply with any limitations on billing as set forth in applicable attachments.
If Plan's billing procedures are not followed, if the required information is not
present or if the billing form is not acceptable to Plan, Plan shall not be obligated to
make payment to Group Practice.
3.2
Payment of Contracted Services. For Medically Necessary Contracted Services
rendered to Covered Persons in accordance with the terms of this Agreement,
Group Practice shall be compensated as set forth in applicable Attachments
attached hereto.
3.3
Timing For Payment. Ninety (90) percent of clean claims for Covered Services
shall be paid to Group Practice within thirty (30) days and ninety-nine (99) percent
of clean claims for Covered Services shall be paid to Group Practice within ninety
(90) days following presentment of a completed claim or encounter form, unless
additional required information is requested or the claim involves medical necessity
review or coordination of benefits except as otherwise provided in applicable
Attachments.
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3.4
Payment. Group Practice agrees that in no event, including but not limited to
nonpayment by Plan, insolvency of Plan, or breach of this agreement, shall Group
Practice bill, charge, collect a deposit from, seek remuneration or reimbursement
from, or have any recourse against, a subscriber, enrollee, person to whom health
care services have been provided, or person acting on behalf of the covered
enrollee, for health care services provided pursuant to this agreement. This does
not prohibit Group Practice from collecting co-insurance or copayments as
specifically provided in the evidence of coverage, or fees for uncovered health care
services delivered on a fee-for-service basis to persons referenced above, nor from
any recourse against Plan or its successor,
In order to seek payment from a member for non-covered, non-medically necessary
services, Group Practice agrees, in advance of providing said services, to give
member written notice and to have a member acknowledge receipt in writing that
services are non-covered and/or non-medically necessary and that member will be
responsible for payment. Group Practice further agrees that (1) the hold harmless
provision and warranty herein survive the termination of this Agreement regardless
of the cause giving rise to the termination, and that (2) this hold harmless provision
and warranty supersedes any oral or written contract agreement heretofore entered
into between Group Practice, Plan and members or persons acting on their behalf.
3.5
Coordination of Benefits. The following provisions apply regarding coordination of
benefits:
a.
certain claims for services rendered to Covered Persons are claims for which
another payor may be primarily responsible under coordination of benefit
rules. Group Practice shall bill such claims to the primary payor when
information regarding such primary payor is available, or upon Plans request.
b.
when Plan is primary under applicable coordination of benefit rules, Plan
shall pay benefits as set forth in this Agreement without regard to the
obligations or any secondary payor.
C.
When Plan is determined to be secondary to any other payor including
Medicare, Plan will pay no greater amount than the difference between the
amount payable to Group Practice by the primary payor and the amount for
Covered Services owing under this Agreement. Plan shall not be liable for
any amount unless Plan has received Group Practice's claim for such
secondary payment within sixty (60) days of the date upon receipt of the
explanation of benefits.
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d.
If Group Practice has already been paid pursuant to this Agreement where
such duplicate coverage exists, Plan may, at its option, (I) elect to collect and
retain funds from the other plan or payor which would represent an
overpayment to Group Practice or (ii) if Group Practice is subsequently
reimbursed by another health care plan or payor, require Group Practice to
refund or credit to Member, as appropriate, the portion, if any, of such
payment which represents an overpayment to Group Practice.
3.6
Non-Covered Services. Services not included under the Service Agreement, not
deemed medically necessary or rendered to individuals who are no longer Covered
Persons are non-covered services and Plan has no obligation under this Agreement
to compensate Group Practice under these circumstances. Group Practice may bill
an individual directly for these services.
3,7
Claim Denial Appeals. Appeals of claims denied by Plan shall be submitted in
writing by Group Practice to Plan within ninety (90) days of receipt of the denial
notice. The Plan Medical Director or designee will render a decision within thirty
(30) days after receipt of the appeal notice. That decision shall be final and
binding.
3.8
Correction of Payments Made in Error. Group Practice shall reimburse Plan and
Plan shall reimburse Group Practice for payments made in error. The Plan reserves
the right to withhold or set-off overpayments against future claim payments to
Group Practice by Plan. Payments made in error may include, but not limited to,
Plan processing errors or Group Practice billing errors. This provision does not
apply to late submission of claims,
ARTICLE IV
TERM AND TERMINATION
4.1
Term of Agreement. This Agreement shall begin on the Effective Date and shall
continue from year to year on the anniversary of the effective date thereafter,
unless terminated as set forth below.
4.2
Termination for Cause. Either party to this Agreement may terminate this
Agreement for cause. In the event of termination of this Agreement for cause, this
Agreement shall terminate upon receipt of written notice from the terminating party.
Cause shall mean:
a.
failure of Plan to maintain license or certifications required to operate in
conformity with this Agreement;
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b.
habitual neglect or continued failure by either party to perform its duties
under this Agreement which affects the quality of care being delivered to the
Member;
C.
material breach of the terms of this Agreement by either Party provided that
such breaching party fails to cure such breach within thirty (30) days of
receipt of the notice of breach from the breaching party.
d.
failure by Group Practice or Group Practice Providers to maintain licenses
required to perform Group Practice's duties under this Agreement, or to
comply with applicable laws, regulations or Plan requirements;
e.
any material misrepresentation or falsification of any information submitted
by Group Practice or a Group Practice Provider to Plan including but not
limited to billing information or information set forth in Group Practice
Provider's Credentialing or Recredentialing application;
f.
commission or omission of any act or any misconduct or allegation of
misconduct for which Group Practice or Group Practice Provider's license or
certification may be subject to revocation or suspension whether or not
actually revoked or suspended, or if Group Practice or a Group Practice
Provider is otherwise disciplined by any licensing, regulatory, professional
entity or any professional organization with jurisdiction over Group Practice
or Group Practice Provider;
g.
the occurrence of or criminal indictment for any act or omission by Group
Practice or Group Practice Provider that is determined by Plan or Payor to
be detrimental to the reputation, operation or activities of Plan or Payor;
h.
failure of Group Practice or a Group Practice Provider to maintain required
liability coverage protection;
i.
commission or omission of any act or conduct by a Group Practice Provider,
Group Practice or its employees which is deemed by the Plan Medical
Director to be detrimental to Covered Person's health or safety;
j.
Plan activates the Ohio Department of Insurance (ODI) Designated Withhold
provision subject to Article 2.15.
k.
The occurrence of any act or omission by Group Practice or a Group
Practice Provider which involves dishonesty or moral turpitude whether or
not in a professional capacity.
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4.3
Termination Without Cause. Either party to this Agreement may terminate this
Agreement without cause upon ninety (90) days prior written notice by the
terminating party to the other party. In the event of such termination, Group
Practice acknowledges that Plan may determine that Group Practice is not
necessarily entitled to the payment of any of all withheld monies maintained in
reserve, if applicable.
4.4
Termination of Attachments and Amendments. Attachments and Amendments
may be terminated individually by Amendment as provided in Article 6.5 of this
Agreement. Termination of any individual Attachment or Amendment will not have
the effect of terminating the entire Agreement and all remaining Attachments and
Amendments of this Agreement will remain in full force.
4.5
Rights and Obligations Upon Termination. Upon termination of this Agreement for
any reason, the rights of each party hereunder shall terminate, except as provided
in any Amendment to this Agreement. Any such termination, however, shall not
release Group Practice or Plan from obligation under this Agreement prior to the
effective date of termination. Group Practice agrees to provide Contracted
Services to Covered Persons through the last day of this Agreement and accept
payment from Plan, pursuant to this Agreement, through the day of termination of
this Agreement. Upon termination of this Agreement for any reason, Plan shall
notify Covered Persons that Group Practice no longer provides services to Plan
Members. Group Practice, upon termination of this Agreement, shall promptly
supply all records necessary for the settlement of outstanding medical bills. Group
Practice agrees to transfer copies of Covered Persons' medical records to the new
Participating Provider within ten (10) days following notification being given to
Group Practice of new Participating Provider. This section shall survive the
termination of the Agreement.
4.6
Summary Suspension. The President and Chief Executive Officer of Plan, in
consultation with the Chief Medical Officer, shall have the absolute power to enter a
summary suspension, effective immediately, of any provider of Plan for good
cause. In the event of a summary suspension, Group Practice or the Group
Practice Provider shall have the rights under the Fair Hearing Plan.
4.7
Plan Insolvency or Discontinuance of Operations. Group Practice and Group
Practice Providers shall continue to provide Contracted Services to Members as
needed to complete any medically necessary services or procedures initiated but
not completed at the time of Plan's insolvency or discontinuance of operations.
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ARTICLE V
RELATIONSHIP OF PARTIES
5.1
Independent Contractor, This Agreement is not intended to create nor shall be
construed to create any relationship between Plan and Group Practice other than
that of independent entities contracting for the purpose of effecting provisions of
this Agreement. Neither party nor Group Practice Provider or any of their
representatives shall be construed to be the agent, employer, employee or
representatives of the other.
5.2
Medical Independence. Nothing in this Agreement, including Group Practice
Provider's participation in the Quality Improvement Program and Utilization
Management process shall be construed to interfere with or in any way effect
Group Practice Provider's obligation to exercise independent medical judgement in
rendering health care services to Covered Persons.
5.3
Notification. Group Practice shall notify Plan in writing within ten (10) days of any
suspension, revocation, condition, limitation, qualification or other restriction on a
Group Practice or Group Practice Providers professional license, certifications and
permits by any state in which Group Practice or Group Practice Provider is
authorized to provide health care services; and of any suspension, revocation,
condition, limitation, qualification or other restriction of a Group Practice Provider's
staff privileges at any licensed hospital or other facility at which Group Practice
Provider has staff privileges during the term of this Agreement.
5.4
Responsibility For Acts or Omissions. With respect to Contracted Services
provided to Members, Group Practice agrees to accept and be responsible for
Group Practice's own acts or omissions, as well as those acts of omissions of
Group Practice Providers employees, agents and independent contractors and
nothing in this Agreement shall be interpreted or construed to place any such
responsibility onto Plan. Plan similarly agrees to accept and be responsible for its
own acts or omissions, as well as those acts or omissions of its employees, agents,
independent contractors and nothing in this Agreement shall be interpreted or
construed to place any such responsibility onto the Group Practice.
5.5
Limitation of Liability. Neither party hereto shall be liable for defending or for the
expense of defending the other party, its agent, or employees, against any claim,
legal action, dispute resolution or administrative or regulatory proceeding arising out
of or related to such other party's actions or omissions under this Agreement.
Neither party hereto shall be liable for any liability of the other party, its agents, or
employees, whether resulting from judgement, settlement, award, fine or otherwise,
which arises out of such party's actions or omissions under this Agreement.
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ARTICLE VI
MISCELLANEOUS
6.1
Assignment. Neither Group Practice or Plan may assign or delegate rights, duties
or interest under this Agreement without the prior written consent of the other party.
6.2
Use of the Name. Group Practice agrees that Group Practice and Group Practice
Providers' names, office locations, office telephone numbers, addresses,
specialties, board certifications and hospital affiliations may be included in literature
distributed to existing or potential Covered Persons, Participating Providers, and
Payors. Group Practice's use of Plan name shall be upon prior written approval or
as the parties may agree. Any use of Group Practice's name and information other
than listed shall be upon prior written approval or as the parties may agree.
6.3
Governing Law: Interpretation. The validity, enforceability and interpretation of this
Agreement shall be governed by any applicable federal laws and by the applicable
laws of the State of Ohio.
6.4
Amendment. This Agreement and Attachments may not be modified or amended
except in writing as mutually agreed upon by the parties.
6.5
Entire Agreement. This Agreement, Attachments, Addenda, and Amendments
hereto contain all the terms and conditions agreed upon by the parties and
supersedes all other agreements, express or implied, regarding the subject matter
hereof. Any amendments hereto and the terms contained therein shall supersede
those of other parts of this Agreement in the event of a conflict.
6.6
Inspections. Upon reasonable notice and at reasonable hours, Plan or its agents
may inspect Group Practice's premises and operations to insure that such premises
and operations are appropriate to meet Covered Persons' needs and to comply with
Quality Assurance guidelines.
6.7
Representations. Plan does not make any representation or warranty regarding the
minimum number of Members that will be enrolled with Group Practice as a result
of this Agreement. Group Practice agrees to represent and warrant that only Group
Practice and Group Practice Providers will be allowed to provide Contracted
Services to Plan Members.
6.8
Enforceability and Waiver. The invalidity and non-enforceability of any term or
provision of this Agreement shall in no way affect the validity of enforceability of any
other term or provision. The waiver by either party of a breach of any provision of
this Agreement shall not operate as or be construed as a waiver of any subsequent
breach thereof.
6.9
Regulatory Approval. In the event that Plan has not received any applicable
regulatory approval for use of this Agreement prior to the execution of this
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Agreement, this Agreement shall be deemed to be a binding letter of intent. In
such event, the Agreement shall become effective on the date that such regulatory
approval is obtained. If Plan is unable to obtain such approval after due diligence,
Plan shall notify Group Practice and both parties shall be released from any liability
under this Agreement; provided however, that if such approval is obtained upon the
condition of Plan's amendment of this Agreement, then this Agreement shall
continue and Plan shall amend pursuant to Article 6.4.
6.10
Dispute Resolution. The parties shall resolve complaints or grievances arising
between the parties and Payor or the parties and Covered Persons in accordance
with the dispute resolution procedures described in the Provider Manual, Provider
Grievance/Fair Hearing Plan.
6.11 Release of Information. Group Practice consents to the release of information from
any person, institution, organization or entity which does or may maintain records of
additional information and/or information which will validate responses on the Plan
Provider Application Form. Group Practice agrees to hold harmless any person or
entity furnishing such information.
6.12 Notice. Any notice required hereunder by either party shall be in writing. All notices
and requests shall be deemed given when postmarked and mailed to Plan and/or
Group Practice at the addressees set forth on page 16 of this Agreement.
6.13 Conflict Between Documents. If there is any conflict between this Agreement
(including its Attachments) hereto and the Provider Manual or other manuals, this
Agreement shall control.
Eff. 07/01/2000
15

Start of Page No. = 16
In WITNESS WHEREOF, the parties hereto have executed and delivered this
Agreement as of the EFFECTIVE DATE. This Agreement may be executed in multiple
originals. Each party executing this Agreement represents that they are authorized to
execute this Agreement.
EFFECTIVE DATE:
Dayton Area Health Plan, Inc.
d.b.a. CareSource
Alliance Physicians, Inc.
One Dayton Centre, One South Main Street
Suite 440
Dayton, Ohio 45402
3490 Far Hills Ave. Suite 201
Kettering, Ohio 45429
By: Gormal Main
By:
Pete Hing
Pamela B. Morris
Peter King
Title: President and CEO
Title: President
Date: 9-27-01
Date:
9/17/01
31-1175717
Federal Tax I.D. Number
Medicaid Number
Medicare Group Practice Number
Eff. 07/01/2000
16

Start of Page No. = 17
ATTACHMENT A to GROUP AGREEMENT
COUNTIES OF COVERAGE
Group Provider agrees to provide services to Plan's Medicaid members in all counties of
service as approved by ODJFS.
BENEFIT PROGRAM
Group Provider agrees to provide services to Plan's Medicaid members in all products
Plan is approved for by ODJFS.
Dayton Area Health Plan, Inc
d.b.a. CareSource
Alliance Physicians, Inc.
By
Comelity
By
RetireMing
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9-27-01
9/17/01
Date
Date

Start of Page No. = 18
ATTACHMENT A.1
CONTRACTED SERVICES AND COMPENSATION
For Medically Necessary Covered Services rendered to Members by Group Practice
Providers in accordance with the terms of this Agreement, Group Practice and Group
Practice Providers shall accept as payment in full the lesser of:
(i)
Group Practice's billed charges, or
(ii)
CareSource's fee schedule for such services, which currently is the equivalent of
105% of the prevailing Ohio Medicaid fee schedule for physician services, and
100% of the current Ohio Medicaid fee schedule for non-physician Covered
Services. Such fee schedule may be changed from time to time by Plan at its
discretion upon sixty (60) days written notice to Group Practice.
H:\CONTRACTINGIATTACH A.1-GROUP.DOC
09/01/00

Start of Page No. = 19
Dayton Area Health Plan, Inc., d.b.a. CareSource
Medicaid Addendum
This Addendum will supplement the Agreement between Dayton Area Health Plan, Inc. d.b.a.
CareSource and Alliance Physicians, Inc. effective
and will run
concurrently with the terms of the Agreement. This Addendum is limited to the terms and
conditions governing the provision of and payment for health services provided to Covered
Families and Children (CFC) Medicaid members, including Healthy Start, who are covered
under CareSource's Medicaid benefit program as specified in Attachment A.
ADDENDUM DEFINITIONS
The following defines the population groups identified in this Addendum:
"Covered Families and Children Medicaid" (including Healthy Start) means a federal and
state financed grant-in-aid program administered by the state providing medical coverage to
low-income families, children and pregnant women who meet the eligibility criteria of Chapter
5101:1-39 and 5101:1-40 of the OAC.
"Healthy Start" is Ohio's name for the Covered Families and Children Medicaid eligibility
program which provides Medicaid services for pregnant women, infants, and children up to
specified ages and income limits.
"MCP" means managed care plan.
"Medicaid" means medical assistance provided under a state plan approved under Title XIX
of the Social Security Act.
"OAC" means the Ohio Administrative Code.
"ODJFS" means the Ohio Department of Job and Family Services.
ADDENDUM PROVISIONS
The provisions of this Medicaid Addendum supersede any language to the contrary, which may
appear elsewhere in the Agreement.
Participating providers providing health care services to CareSource's members enrolled
pursuant to a Medicaid Agreement agree to abide by all of the following specific terms:
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 20
1.
Provider shall not discriminate in the delivery of services based on the member's race,
color, religion, sex, sexual orientation, age, disability, national origin, veteran's status,
ancestry, health status or need for health services.
2.
Provider shall be bound by the same standards of confidentiality which apply to ODJFS
and the state of Ohio as described in OAC rule 5101:1-1-03.
3.
Provider agrees to comply with the provisions for record keeping and auditing in
accordance with OAC rule 5101:3-26.
4.
Provider agrees to allow the MCP access to all member medical records for a period of
not less than six years from the date of service and allow access to all record keeping,
audits, and medical records to ODJFS and the Medicaid Fraud and Control Unit (MFCU).
5.
Provider agrees that this Agreement and Addendum contain the same terms that are
applicable to the contracted service, is governed by, and is construed in accordance with
all laws, regulations, and contractual obligations of the MCP.
(A)
ODJFS will notify the MCP and the MCP shall notify the provider of any
changes in applicable state or federal law, regulations, waiver, or
contractual obligation of the MCP.
(B)
This addendum shall be automatically amended to conform to such
changes without the necessity for executing written amendments.
6.
Provider agrees not to charge the member or ODJFS any copayments for covered
services.
7.
Provider agrees to hold harmless both ODJFS and the member in the event that the
MCP cannot or will not pay for covered services performed by the provider pursuant to
the Agreement.
8.
Provider is duly licensed or certified under applicable state and federal statutes and
regulations to provide the health care services that are the subject of the Agreement.
9.
If the provider is currently a Medicaid provider, provider must meet the qualifications
specified in OAC rule 5101:3-26-05(E).
10.
Provider agrees to make available for transfer to new providers the medical records of
members at no cost to the member.
11.
Provider agrees to comply with the MCP's quality program.
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 21
12.
Provider agrees to comply with the ODJFS annual.review as described in OAC rule
5101:3-26-07.
13.
All laboratory testing sites providing services to members must have either a "Clinical
Laboratory Improvement Amendments (CLIA)" certificate of waiver, certificate of
accreditation or a certificate of registration with a CLIA identification number.
14.
Any home health agency used for members must be Medicare certified.
15.
The terms of the Agreement relating to the beginning and ending date, methods of
extension, renegotiations and termination apply to this Addendum.
16.
Subject to the provisions of items 17 and 18, if the Agreement is not automatically
renewed, the ending date of the Agreement will not precede the termination date of the
current Agreement between the MCP and ODJFS.
17.
Notwithstanding Item 15 of this Addendum, the MCP must give the provider at least sixty
days prior notice for the nonrenewal or termination of the Agreement except in cases
where an adverse finding by a regulatory agency or quality of care concerns dictate that
the Agreement be terminated sooner. If the MCP issues a notice to nonrenew or
terminate this Agreement due to an adverse finding by a regulatory agency or quality of
care concern, the MCP must notify ODJFS within one working day of issuing the notice.
18.
Notwithstanding item 15 of this addendum, the provider may nonrenew or terminate the
Agreement if:
(A)
The provider gives the MCP at least sixty days prior notice for the
nonrenewal or termination of the agreement and the effective date for the
nonrenewal or termination must be the last day of the month; or
(B)
ODJFS has proposed action in accordance with OAC rule 5101:3-26-10
(D), regardless of whether the action is appealed, or if a quality of care
concern dictates that the agreement be terminated sooner than sixty days,
the provider's nonrenewal or termination notice must be received by the
MCP within fifteen working days prior to the end of the month in which the
provider is proposing nonrenewal or termination. If the notice is not
received by this date, the provider must extend the nonrenewal or
termination date to the last day of the subsequent month.
19.
If the MCP receives the provider's notice to nonrenew or terminate this Agreement due
to an action proposed by ODJFS in accordance with OAC rule 5101:3-26-10 (D) or for
a quality of care concern, the MCP agrees to notify ODJFS within one working day of the
receipt of the provider's notice.
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 22
20.
Provider agrees to serve members through the last day the Agreement is in effect.
21.
In the event this Agreement is terminated, provider agrees to promptly supply all records
necessary for the settlement of outstanding medical claims.
22.
Except as exempted by ODJFS, if provider is a primary care physician (PCP), each
provider, individually or as part of a group, agrees to serve a minimum of 50 of the
MCP's Medicaid members at each practice site and the maximum number of MCP's
Medicaid members at each practice site as stated above the signature line on the
signature page of this Medicaid Addendum.
23.
If provider is a third party administrator (TPA), provider agrees to include all elements of
OAC rule 5101:3-26-05(D) in its sub-agreements and will ensure that its subcontractors
will forward information to ODJFS as requested.
24.
Any amendment to this Addendum related to the provisions of OAC rule 5101:3-26-05(D)
must be agreed to in writing by both parties.
25.
Provider agrees to provide services as enumerated in Attachment A of the Addendum
(within the provider's scope of practice).
26.
Provider shall be compensated pursuant to the method and in the amounts specified in
Attachment A. of the Agreement.
27.
If provider is a prenatal medical services provider for members in mandatory MCP
program counties, provider agrees to comply with the provision for the substance abuse
screening and reporting to MCP of pregnant women, as specified in Ohio Revised Code
section 5111.017(A) and OAC rule 5101:3-26-032.
28.
If provider is a hospital, the Agreement must include the ODJFS Hospital Services Form,
Attachment D, which specifies which services of the hospital are included in the
Agreement. If provider is a hospital system, the Agreement must include the ODJFS
Hospital Services Form for each hospital included in the system, or must specify on one
Hospital System Services Form, Attachment D, which services are provided by each of
the hospitals in the system.
29.
If
provider
is
an
FQHC
(federally
qualified
health
center),
MCP
agrees
to
reimburse
the
FQHC
on
either
a
capitated
basis
with
appropriate
adjustments
adverse
selection
factors,
or
on
a
cost
related
basis.
30.
MCP agrees not to prevent provider from discussing all medically necessary treatment
options with members.
31.
Provider agrees to inform members of the availability of, and if requested, provide the services
of sign language or bilingual language assistance in the primary language of the member.
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 23
32.
Provider agrees to mail or personally deliver notice of the member's right to request a
State hearing whenever the provider bills a member for a service due to denial of
payment by the MCP, utilizing the procedures and forms as specified in OAC rule
5101:6-2-35.
COMPLETE 1, 2, 3, 4 AND/OR 5, AS APPLICABLE
1) PRIMARY CARE PROVIDERS:
[For individual provider Agreements only:]
I agree to serve a maximum number of MCP's Medicaid members as follows:
at
(#)
Street Address
NOT APPLICABLE
City/State/Zip code
at
(#)
Street Address
City/State/Zip code
2) PRIMARY CARE PROVIDERS:
[For group or PHO provider Agreements only:]
Each provider at each of the practice sites agrees to serve a maximum number of MCP's
Medicaid members as shown on Attachment B of this Addendum. The name of the group or
PHO executing this Agreement is:
Alliance Physicians, Inc.
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 24
3) NON PRIMARY CARE PROVIDERS:
[For individual provider Agreements only:]
I agree to serve the MCP's Medicaid members at the following site(s):
At
Street Address
City/State/Zip code
NOT APPLICABLE
At
Street Address
City/State/Zip code
4) NON PRIMARY CARE PROVIDERS:
[For group or PHO provider Agreements only:]
The providers associated with the group practice that agree to serve the MCP's Medicaid
members are shown on Attachment C of this addendum. The name of the group or PHO
executing this agreement is:
Alliance Physicians, Inc.
5) If PROVIDER IS A HOSPITAL SYSTEM:
List all hospitals covered by this Agreement:
Not Applicable
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 25
The Ohio Department of Job and Family Services permits changes to Attachments A, B, C
and/or D by mutual written agreement of both parties and without renegotiation of the
Agreement or this Addendum.
IN WITNESS WHEREOF, the parties hereto have executed this Addendum to the
Agreement this
of
,
.
Dayton Area Health Plan, Inc.
Alliance Physicians, Inc.
d.b.a. CareSource
By
Reta Sling
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9-27-01
9/17/01
Date
Date
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 26
Attachment A
COUNTIES OF COVERAGE
Provider agrees to provide services to MCP's Medicaid members in the following counties:
Butler
Clark
Clermont
Cuyahoga
Franklin
Greene
Hamilton
Lorain
Montgomery
Pickaway
Summit
Stark
Warren
BENEFIT PROGRAM
The Medicaid MCP benefit programs under which members receive health care coverage are:
CFC
Healthy Start
Dayton Area Health Plan, Inc.
Alliance Physicians, Inc.
d.b.a. CareSource
Peter Sting
By
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9-26-01
9/17/01
Date
Date
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 27
Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
Northmont Family Medicine
Dettleff Olson, D.O.
100
d.b.a. Alliance Physicians, Inc.
16 West Wenger Rd.
Englewood, Ohio 45322
Farmersville Medical Center
John Kihm, M.D.
50
d.b.a. Alliance Physicians, Inc.
Lawrence Ratcliff, M.D.
50
49 East Center St.
Farmersville, Ohio 45325
Center for Family Medicine
Nathan Beebe, M.D.
50
d.b.a. Alliance Physicians, Inc.
Gary Bedel, M.D.
50
333 Conover Dr.
Dolores Crespo. M.D.
50
Franklin, Ohio 45005
Ron Klein, M.D.
50
Jewell Stevens, M.D.
50
Harold Stahl, D.O.
50
Germantown Medical Associaties
Bernard Berks, D.O.
125
d.b.a. Alliance Physicians, Inc.
Krisell Fedrizzi, D.O.
50
1265 W. Market St.
Germantown, Ohio 45327
Northeast Family Practice
Donald Turner, D.O.
250
d.b.a. Alliance Physicians, Inc.
Robert Hunter, D.O.
100
6255 Chambersburg Rd.
Huber Heights, Ohio 45424
Noel Watson, M.D.
Noel Watson, M.D.
61
d.b.a. Alliance Physicians, Inc.
1217 W. Market St.
Germantown, Ohio 453277
Dayton Area Health Plan, Inc.
d.b.a. CareSource
Alliance Physicians, Inc.
By
Famel Main
By
Peter thing
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9.26.07
9/17/01
Date
Date
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 28
Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
Suburban Family Practice Assoc.
Barbara Bennett, D.O.
d.b.a. Alliance Physicians, Inc.
1070
8701 Old Troy Pike
Huber Heights, Ohio 45424
Comprehensive Health Medical
Kurt A. Fleagle, M.D.
50
d.b.a. Alliance Physicians, Inc.
Nancy Liu, M.D.
5563 Far Hills Ave.
50
Kettering, Ohio 45429
Mad River Family Practice
Robert Gardner, D.O.
150
d.b.a. Alliance Physicians, Inc.
John Sefton, D.O.
2358 Lakeview Dr., Ste. E.
250
Beavercreek, Ohio 45431
Bellbrook Family Practice
John Murphy III, D.O.
50
d.b.a. Alliance Physicians, Inc.
Jeffrey McCutchen, D.O.
50
115 E. Franklin St.
Michelle Russell, D.O.
50
Bellbrook, Ohio 45305
Sugarcreek Family Medicine
James Foster, M.D.
100
d.b.a. Alliance Physicians, Inc.
Lisa Heinemeyer, M.D.
100
4403 St. Rt. 725, Suite D
Lori Sansone, M.D.
100
Bellbrook, Ohio 45305
Family Care Centers
Paul Martin, D.O.
50
d.b.a. Alliance Physicians, Inc.
Carl Hoyng, D.O.
75
100 Forest Park Dr.
Phillip Becker, D.O.
150
Dayton, Ohio 45405
Dayton Area Health Plan, Inc.
Alliance Physicians, Inc.
d.b.a. CareSource
By
Peter Illing
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9-26-81
9/17/01
Date
Date
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 29
Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
Family Practice Group
Eric Nordin, D.O.
50
d.b.a. Alliance Physicians, Inc.
5900 N. Main St.
Dayton, Ohio 45405
Dayton Family Practice
Joni Koren, D.O.
150
d.b.a. Alliance Physicians, Inc.
David Apple, D.O.
150
1320 Woodman Dr., Suite 100
Dayton, Ohio 45432
Kettering Family Practice
Charles Moody, M.D.
50
d.b.a. Alliance Physicians, Inc.
Mark Jeffries, D.O.
50
3716 Willmington Pike
Dayton, Ohio 45429
Greystone Family Care
Barry Fisher, M.D.
50
d.b.a. Alliance Physicians, Inc.
James M. Tytko, M.D.
50
2033 E. Stroop Rd.
Kettering, Ohio 45429
South Dayton Internists
Samuel Laneve, M.D.
50
d.b.a. Alliance Physicians, Inc.
Prashanth Kumar, M.D.
50
3533 Southern Blvd., Suite 3100
Kettering, Ohio 45492
Dayton Area Health Plan, Inc.
Alliance Physicians, Inc.
d.b.a. CareSource
Famel Main
By
Peter Thing
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9-26-01
9/17/01
Date
Date
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 30
Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
Medway Medical Clinic
Edward Hubach, D.O.
d.b.a. Alliance Physicians, Inc.
50
105 Sycamore St.
Medway, Ohio 45341
Crossroads Medical Center
Rich Gebhart, D.O.
d.b.a. Allliance Physicians, Inc.
50
58 Elva Court
Vandalia, Ohio 45377
Dayton Area Health Plan, Inc.
Alliance Physicians, Inc.
d.b.a. CareSource
By
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9-26-01
Date
9/17/01
Date
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 31
Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
1. Kettering Family Practice
Bradford Murphy DO
50
d.b.a. Alliance Physicians, Inc.
3716 Wilmington Pike
Dayton, Ohio 45429
2. South Dayton Internists
Rudy J. Bohinc, M.D.
50
d.b.a. Alliance Physicians, Inc.
3533 Southern Blvd., Suite 3100
Kettering, Ohio 45429
3. Preble County Family Practice
Robert A. Kominiarek, DO
50
& Assoc.
d.b.a. Alliance Physicians, Inc.
1845 Route 127 North
Eaton, Ohio 45320
4. Waynesville Health Care
Paul Opsahl, MD
100
d.b.a. Alliance Physicians, Inc.
Maryann P. Bhat, M.D.
100
4353 East St. Rte. 73
Waynesville, Ohio 45068
Dayton Area Health Plan Inc. d.b.a.
Alliance Physicians, Inc.
CareSource
By
By
Peter Study
Pamela B. Morris
Peter King
Printed Name
Printed Name
President & CEO
President
Title
Title
11-13-01
10/25/01
Date
Date

Start of Page No. = 32
Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
1. Lebanon Medical Group
Gary Hayes, M.D.
100
d.b.a. Alliance Physicians, Inc.
Candice Sieben, M.D.
100
1004 Oregonia Rd
Lebanon, Ohio 45036
SARWAl
2. Comprehensive Health Medical
Deepak Sarmina, M.D.
200
d.b.a. Alliance Physicians, Inc.
age 14 and older
5563 Far Hills Ave.
Kettering, Ohio 45429
3. Kettering Family Practice
Brad Murphy, D.O.
50
d.b.a. Alliance Physicians, Inc.
current patients only
3716 Wilmington Pike
Dayton, Ohio 45429
Dayton Area Health Plan Inc. d.b.a.
Alliance Physicians, Inc.
CareSource
Reter Ming
By
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President & CEO
President
Title
Title
11-21-01
11/15/01
Date
Date

Start of Page No. = 33
Attachment C
NON PCP GROUP PROVIDERS
Practice Site
Physician Name
Speciality
Contemporary OB/GYN
Liam Duggan, D.O.
OB/GYN
d.b.a. Alliance Physicians, Inc.
Caroline Peterson, D.O.
OB/GYN
8701 Old Troy Pike, Suite 30
Kimberly Warren, D.O.
OB/GYN
Huber Heights, Ohio 45424
Complete Women's Healthcare
Paul Pawlosky, D.O.
OB/GYN
d.b.a. Alliance Physicians, Inc.
Charles Watson, D.O.
OB/GYN
2358 Lakeview Dr., Suite A
Josette D'Amato, D.O.
OB/GYN
Beavercreek, Ohio 45431
Complete Women's Healthcare
Paul Pawlosky, D.O.
OB/GYN
d.b.a. Alliance Physicians, Inc.
Charles Watson, D.O.
OB/GYN
1989 Miamisburg Centerville Rd, Suite 204 Josette D'Amato, D.O.
OB/GYN
Centerville, Ohio 45458
Complete Women's Healthcare
Paul Pawlosky, D.O.
OB/GYN
d.b.a. Alliance Physicians, Inc.
Charles Watson, D.O.
OB/GYN
300 Forest Ave.
Josette D'Amato, D.O.
OB/GYN
Dayton, Ohio 45405
Max A. Clark, D.O.
Max A. Clark, D.O.
OB/GYN
d.b.a. Alliance Physicians, Inc.
1989 Miamisburg Centerville Rd., Suite 204
Centerville, Ohio 45458
Michael J. Clark, D.O.
Michael J. Clark, D.O.
OB/GYN
d.b.a. Alliance Physicians, Inc.
Daria Baker, C.N.M.
Nurse Midwife
900 S. Dixie Dr., Suite 40
Vandalia, Ohio 45377
Dayton Area Health Plan, Inc.
d.b.a. CareSource
Alliance Physicians, Inc.
Permit Main
Pete Illing
By
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President and CEO
President
Title
Title
9-26-01
9/17/01
Date
Date
Medicaid Addendum
Effective 7/1/2000

Start of Page No. = 34
13
-Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
1. Mark Striebel, D.O.
Mark Striebel, D.O.
75
d.b.a. Alliance Physicians
7391 Brandt Pike, Suite A
Huber Heights, Ohio 45424
Dayton Area Health Plan, Inc. d.b.a.
Alliance Physicians, Inc.
CareSource
Peter Mung
By
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President & CEO
President
Title
Title
5-2-02
3/22/02
Date
Date

Start of Page No. = 35
13
-Attachment B
CAPACITY ATTESTATION
Practice Site
Physician Name
Capacity Max.
1. Mark Striebel, D.O.
Mark Striebel, D.O.
75
d.b.a. Alliance Physicians
7391 Brandt Pike, Suite A
Huber Heights, Ohio 45424
Dayton Area Health Plan, Inc. d.b.a.
Alliance Physicians, Inc.
CareSource
Johnson
Returning
By
By
Pamela B. Morris
Peter King
Printed Name
Printed Name
President & CEO
President
Title
Title
5-2-02
3/22/02
Date
Date

Start of Page No. = 36
Form
W-9
Request for Taxpayer
Give form to the
(Rev. December 1996)
Identification Number and Certification
requester. Do NOT
Department of the Treasury
send to the IRS.
Internal Revenue Service
Name (If a joint account or you changed your name, see Specific Instructions on page 2.)
Business name, if different from above. (See Specific Instructions on page 2.)
alliance Onc Mark H. Strubal ,DD
Check appropriate box:
Individual/Sole
Corporation
Partnership
Other
Address (number, street, and apt. or suite no.)
Requester's name and address (optional)
P.O. Box 71-1808
City, state, and ZIP code
Columbus
Part I
Taxpayer Identification Number (TIN)
List account number(s) here (optional)
Enter your TIN in the appropriate box. For
individuals, this is your social security number
Social security number
(SSN). However, if you are a resident alien OR a
sole proprietor, see the instructions on page 2.
For other entities, it is your employer
Part II
identification number (EIN). If you do not have a
OR
For Payees Exempt From Backup
number, see How To Get a TIN on page 2.
Withholding (See the instructions
Employer identification number
Note: If the account is in more than one name,
on page 2.)
see the chart on page 2 for guidelines on whose
311175717
number to enter.
Part III
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am'waiting for a number to be issued to me), and
2.
I
am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that 1 am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding.
Certification Instructions.-You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 2.)
Sign
Here
Signature
Debocah K. McCain
Date
12/01/01
Purpose of Form.-A person who is
include interest, dividends, broker and
5. You do not certify your TIN when
required to file an information return with
barter exchange transactions, rents,
required. See the Part III instructions on.
the IRS must get your correct taxpayer
royalties, nonemployee pay, and certain
page 2 for details.
identification number (TIN) to report, for
payments from fishing boat operators. Real
Certain payees and payments are
example, income paid to you, real estate
estate transactions are not subject to
exempt from backup withholding. See the
transactions, mortgage interest you paid,
backup withholding.
Part II instructions and the separate
acquisition or abandonment of secured
If you give the requester your correct
Instructions for the Requester of Form
property, cancellation of debt, or
TIN, make the proper certifications, and
W-9.
contributions you made to an IRA.
report all your taxable interest and
Use Form W-9 to give your correct TIN
dividends on your tax return, payments
Penalties
to the person requesting it (the requester)
you receive will not be subject to backup
and, when applicable, to:
withholding. Payments you receive will be
Failure To Furnish TIN.-If you fail to
subject to backup withholding if:
furnish your correct TIN to a requester, you
1. Certify the TIN you are giving is
are subject to a penalty of $50 for each
correct (or you are waiting for a number to
1. You do not furnish your TIN to the
such failure unless your failure is due to
be issued),
requester, or
reasonable cause and not to willful neglect.
2. Certify you are not subject to backup
2. The IRS tells the requester that you
Civil Penalty for False Information With
withholding, or
furnished an incorrect TIN, or
Respect to Withholding.- you make a
3. Claim exemption from backup
3. The IRS tells you that you are subject
false statement with no reasonable basis
withholding if you are an exempt payee.
to backup withholding because you did not
that results in. no backup withholding, you
Note: If a requester gives you a form other
report all your interest and dividends on
are subject to a $500 penalty.
than a W-9 to request your TIN, you must
your tax return (for reportable interest and
Criminal Penalty for Falsifying
use the requester's form if it is substantially
dividends only), or
Information.- Willfully falsifying
similar to this Form W-9.
4. You do not certify to the requester
certifications or affirmations may subject
What Is Backup Withholding?-Persons
that you are not subject to backup
you to criminal penalties including fines
making certain payments to you must
withholding under 3 above (for reportable
and/or imprisonment.
withhold and pay to the IRS 31% of such
interest and dividend accounts opened
Misuse of TINs.-I the requester
payments under certain conditions. This is
after 1983 only), or
discloses or uses TINs in violation of
called "backup withholding." Payments
Federal law, the requester may be subject
that may be subject to backup withholding
to civil and criminal penalties.
Cat. No. 10231X
Form
W-9
(Rev. 12-96)