doczyai-pipelines/archive/streamlit/contract_field_values.csv at ddefa2ff30fb246d379274a10f84346e2bbc970d

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T

Katon Minhas afb6d5185d Merged in feature/lesser-table-caching-refactor-hybrid (pull request #847 )

Feature/lesser table caching refactor hybrid

* chore: Remove unused duplicate main.py from shared pipeline

* fix: Correct crosswalk paths in aarete_derived.py

* chore: Remove unused documentation files from fieldExtraction

* docs: Add documentation files to documentation folder

* docs: Update README with uv setup, expanded project structure, and branching conventions

* docs: Add uv installation steps with Ubuntu/WSL emphasis

* Enable prompt caching for all remaining LLM calls

- Add _INSTRUCTION() functions for: EXHIBIT_HEADER, EXHIBIT_LINKAGE,
  EXHIBIT_TITLE_MATCH, DATE_FIX, DERIVED_TERM_DATE, CHECK_PROVIDER_NAME_MATCH,
  SPECIAL_CASE_ASSIGNMENT
- Update all invoke_claude() calls in saas and clover pipelines to use
  cache=True with corresponding _INSTRUCTION() functions
- Add new instructions to get_cacheable_instructions() for cache warming
- Update tests for new instruction functions

Functions now using caching:
- prompt_exhibit_level
- prompt_exhibit_lesser (EXHIBIT_LEVEL_LESSER_OF)
- prompt_fee_schedule_breakout
- prompt_grouper_breakout
- prompt_special_case_assignment
- prompt_exhibit_linkage
- prompt_exhibit_header
- prompt_smart_chunked (ONE_TO_ONE templates)
- prompt_date_fix
- prompt_derived_term_date
- prompt_exhibit_title_match
- provider_name_match_check

🤖 Generated with [Claude Code](https://claude.com/claude-code)

Co-Authored-By: Claude Opus 4.5 <noreply@anthropic.com>

* Reorder

* feat: Add bcbs_promise client pipeline with OFFSET_TERM extraction

- Add new bcbs_promise client with HSC-based OFFSET_TERM field extraction
- Extract full paragraph text of offset/recoupment provisions from contracts
- Derive OFFSET_INDICATOR (Y/N) from OFFSET_TERM presence
- Fix reorder_columns to preserve extra columns not in COLUMN_ORDER
- Update QC/QA output path to outputs/qc_qa/

* fix: Update dev deps and test assertions for QC/QA output path

- Add pytest/pytest-mock to dev dependencies for mypy type checking
- Update test assertions to expect outputs/qc_qa instead of qa_qc_output

* style: Apply black formatting to prompt_templates.py

* Merge main, move scripts

* Archive some scripts

* update py version

* remove .py version file

* Remove ASCII characters

* Restore testbed code

* restore tracking

* Update testbed metrics

* Enable prompt caching for CODE_LAST_CHECK, FILL_BILL_TYPE, DUAL_LOB_CHECK, and GROUPER_BREAKOUT

- Add CODE_LAST_CHECK_INSTRUCTION() for service specificity classification
- Add FILL_BILL_TYPE_INSTRUCTION() for bill type code determination
- Add DUAL_LOB_CHECK_INSTRUCTION() for Medicare/Medicaid classification
- Update code_funcs.py to use caching for CODE_LAST_CHECK, FILL_BILL_TYPE, GROUPER_BREAKOUT
- Update postprocessing_funcs.py to use caching for DUAL_LOB_CHECK
- Add new instructions to get_cacheable_instructions() for cache warming
- Add unit tests for new instruction functions

🤖 Generated with [Claude Code](https://claude.com/claude-code)

Co-Authored-By: Claude Opus 4.5 <noreply@anthropic.com>

* Fix postprocessing_funcs to remove invalid columns

* Merge branch 'main' into feature/lesser-table-caching-refactor-hybrid

* Revert prompt caching changes from aed1b73c

* update formatting

* Update imports


Approved-by: Sha Brown
Approved-by: Praneel Panchigar

2026-01-26 16:52:55 +00:00

3.8 MiB

Raw Blame History

1	(internal) ID	Trimmed ID	IsNumber Check	(Internal) Carveout ID	(internal) AAR Owner	QC Status	(internal) Client	(internal) Document Name	(Internal) formula doc name	Contract Type	Action Required	CONTRACT_TITLE	CONTRACT_TITLE_PG	CONTRACT_HEADER	CONTRACT_HEADER_PG	CONTRACT_NUM	CONTRACT_NUM_PG	CONTRACT_BASE_TITLE	CONTRACT_BASE_TITLE_PG	CONTRACT_BASE_EFFECTIVE_DT	CONTRACT_BASE_EFFECTIVE_DT_PG	CONTRACT_SIGNATORY_IND	CONTRACT_SIGNATORY_IND_PG	PAYER_NAME	PAYER_NAME_PG	PROV_GROUP_NAME	PROV_GROUP_NAME_PG	PROV_GROUP_TIN	PROV_GROUP_TIN_PG	PROV_GROUP_NAME_SIGNATORY	PROV_GROUP_NAME_SIGNATORY_PG	PROV_GROUP_TIN_SIGNATORY	PROV_GROUP_TIN_SIGNATORY_PG	PROV_GROUP_NPI	PROV_GROUP_NPI_PG	PROV_GROUP_ADDRESS_LINE1	PROV_GROUP_ADDRESS_LINE2	PROV_GROUP_CITY	PROV_GROUP_STATE_CD	PROV_GROUP_POSTAL_CD	PROV_GROUP_PHONE_NUM	PROV_GROUP_FAX_NUM	PROV_GROUP_PG	PROV_GROUP_MEDICAID_NUM	PROV_GROUP_MEDICARE_NUM	PROV_GROUP_OTHER_NUM	PROV_GROUP_NUM_PG	PROV_DOING_BUSINESS_AS	PROV_OTHER_PG	PROV_TIN_OTHER	PROV_TIN_OTHER_PG	PROV_NPI_OTHER	PROV_NPI_OTHER_PG	PROV_OTHER_ADDRESS_LINE1	PROV_OTHER_ADDRESS_LINE2	PROV_OTHER_CITY	PROV_OTHER_STATE_CD	PROV_OTHER_POSTAL_CD	PROV_OTHER_PHONE_NUM	PROV_OTHER_FAX_NUM	PROV_OTHER_PG	PROV_OTHER_CAQH_NUM	PROV_OTHER_MEDICAID_NUM	PROV_OTHER_MEDICARE_NUM	PROV_OTHER_NUM	PROV_OTHER_NUM_PG	PROV_SPECIALTY	PROV_SPECIALTY_PG	CONTRACT_EFFECTIVE_DT	CONTRACT_EFFECTIVE_DT_PG	CONTRACT_EFFECTIVE_DT_SIGNATORY	CONTRACT_EFFECTIVE_DT_SIGNATORY_PG	AAR_IS_EFFECTIVE_DT_CONSISTENT_IND	R100	CONTRACT_TERMINATION_DT	CONTRACT_TERMINATION_DT_PG	CONTRACT_AUTO_RENEWAL_IND	CONTRACT_AUTO_RENEWAL_IND_PG	CONTRACT_AUTO_RENEWAL_TERM_LENGTH	CONTRACT_AUTO_RENEWAL_TERM_LENGTH_PG	PAYER_POLICY_CHANGE_NOTICE_TIMELINE	PAYER_POLICY_CHANGE_NOTICE_INFO	PAYER_POLICY_CHANGE_NOTICE_INFO_PG	PROV_CLAIM_TIMELY_FILING_TIMELINE	PROV_CLAIM_TIMELY_FILING_INFO	PROV_CLAIM_TIMELY_FILING_PG	PROV_CORRECTED_CLAIM_FILING_TIMELINE	PROV_CORRECTED_CLAIM_FILING_INFO	PROV_CORRECTED_CLAIM_FILING_PG	PAYER_PROMPT_PAY_PAPER_CLAIM_TIMELINE	PAYER_PROMPT_PAY_PAPER_CLAIM_INFO	PAYER_PROMPT_PAY_PAPER_CLAIM_PG	PAYER_PROMPT_PAY_ELECTRONIC_CLAIM_TIMELINE	PAYER_PROMPT_PAY_ELECTRONIC_CLAIM_INFO	PAYER_PROMPT_PAY_ELECTRONIC_CLAIM_PG	PAYER_AUDIT_CLAIM_TIMELINE	PAYER_AUDIT_CLAIM_INFO	PAYER_AUDIT_CLAIM_PG	PROV_SUBMIT_PAYMENT_APPEAL_TIMELINE	PROV_SUBMIT_PAYMENT_APPEAL_INFO	PROV_SUBMIT_PAYMENT_APPEAL_PG	PROV_SUBMIT_PAYMENT_DISPUTE_TIMELINE	PROV_SUBMIT_PAYMENT_DISPUTE_INFO	PROV_SUBMIT_PAYMENT_DISPUTE_PG	PROV_SUBMIT_PAYMENT_RECONSIDERATION_TIMELINE	PROV_SUBMIT_PAYMENT_RECONSIDERATION_INFO	PROV_SUBMIT_PAYMENT_RECONSIDERATION_PG	PAYER_IDENTIFY_OVERPAYMENT_TIMELINE	PAYER_IDENTIFY_OVERPAYMENT_INFO	PAYER_IDENTIFY_OVERPAYMENT_PG	PROV_SUBMIT_OVERPAYMENT_APPEAL_TIMELINE	PROV_SUBMIT_OVERPAYMENT_APPEAL_INFO	PROV_SUBMIT_OVERPAYMENT_APPEAL_PG	CONTRACT_ALLOW_OFFSET	CONTRACT_ALLOW_OFFSET_PG	LOB_PRICING_TERMS_EFFECTIVE_DT	LOB_PRICING_TERMS_EFFECTIVE_DT_PG	LOB_PRICING_TERMS_TERMINATION_DT	LOB_PRICING_TERMS_TERMINATION_DT_PG	CONTRACT_TYPE	CONTRACT_TYPE_PG	CONTRACT_LOB	CONTRACT_LOB_PG	CONTRACT_NETWORK		CONTRACT_NETWORK_PG	CONTRACT_PROGRAM	CONTRACT_PROGRAM_PG	PROV_TYPE	PROV_TYPE_PG	PROV_SPECIALTYTY	PROV_SPECIALTYTY_PG	RATE_ESCALATOR_IND	RATE_ESCALATOR_IND_PG	RATE_ESCALATOR_BASIS	RATE_ESCALATOR_BASIS_PG	RATE_ESCALATOR_YEARLY_PERCENT_INCREASE	RATE_ESCALATOR_YEARLY_PERCENT_INCREASE_PG	CLAIM_DISCOUNT_IND	PENALTIES_INTEREST_IND	PENALTIES_INTEREST_IND_PG	PENALTIES_INTEREST_TRIGGER	PENALTIES_INTEREST_TRIGGER_PG	PENALTIES_INTEREST_RATE	PENALTIES_INTEREST_RATE_PG	CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE	CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE_PG	LESSER_OF_LANGUAGE_IND	LESSER_OF_LANGUAGE_IND_PG	GREATER_OF_LANGUAGE_IND	GREATER_OF_LANGUAGE_PG	PRIMARY_REIMBURSEMENT_METHODOLOGY	PRIMARY_REIMBURSEMENT_METHODOLOGY_PG	PRIMARY_REIMBURSEMENT_PROC_CODES	PRIMARY_REIMBURSEMENT_PROC_CODES_PG	PRIMARY_REIMBURSEMENT_REVENUE_CODES	PRIMARY_REIMBURSEMENT_REVENUE_CODES_PG	PRIMARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO	PRIMARY_REIMBURSEMENT_PROC_REVENUE_CODE_COMBO_PG	PRIMARY_REIMBURSEMENT_PLACEOFSERVICE_CODES	PRIMARY_REIMBURSEMENT_PLACEOFSERVICE_CODES_PG	PRIMARY_REIMBURSEMENT_STATUS_INDICATOR_CODES	PRIMARY_REIMBURSEMENT_FEE_SCHEDULE	PRIMARY_REIMBURSEMENT_FEE_SCHEDULE_PG	PRIMARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION	PRIMARY_REIMBURSEMENT_FEE_SCHEDULE_VERSION_PG	PRIMARY_REIMBURSEMENT_RATE	PRIMARY_REIMBURSEMENT_RATE_PG	PRIMARY_REIMBURSEMENT_FLAT_FEE	PRIMARY_REIMBURSEMENT_FLAT_FEE_PG	PRIMARY_REIMBURSEMENT_CMS_MEDICARE_RATE	PRIMARY_REIMBURSEMENT_CMS_MEDICARE_RATE_PG	PRIMARY_REIMBURSEMENT_EXCEPTION_IND	PRIMARY_REIMBURSEMENT_EXCEPTION_IND_PG	PRIMARY_REIMBURSEMENT_CARVEOUT_IND	PRIMARY_REIMBURSEMENT_DESCRIBE_EXCEPTION	PRIMARY_REIMBURSEMENT_DESCRIBE_EXCEPTION_PG	SECONDARY_REIMBURSEMENT_METHODOLOGY	SECONDARY_REIMBURSEMENT_METHODOLOGY_PG	SECONDARY_REIMBURSEMENT_PROC_CODES	SECONDARY_REIMBURSEMENT_PROC_CODES_PG	SECONDARY_REIMBURSEMENT_GROUPER_CODES_PG	SECONDARY_REIMBURSEMENT_PLACEOFSERVICE_CODES	SECONDARY_REIMBURSEMENT_PLACEOFSERVICE_CODES_PG	SECONDARY_REIMBURSEMENT_ADMITTYPE_CODES	SECONDARY_REIMBURSEMENT_ADMITTYPE_CODES_PG	SECONDARY_REIMBURSEMENT_STATUS_INDICATOR_CODES	SECONDARY_REIMBURSEMENT_STATUS_INDICATOR_CODES_PG	SECONDARY_REIMBURSEMENT_FEE_SCHEDULE	SECON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T_REIMBURSEMENT_RATE	SURGERY_CARVEOUT_EXCEPTION	SURGERY_CARVEOUT_EXCEPTION	LITHOTRIPSY_CARVEOUT_IND_PG	LITHOTRIPSY_CARVEOUT_CODES	LITHOTRIPSY_CARVEOUT_TYPE_OF_CODE	LITHOTRIPSY_CARVEOUT_REIMBURSEMENT_METHODOLOGY	LITHOTRIPSY_CARVEOUT_SCHEDULE_VERSION	LITHOTRIPSY_CARVEOUT_REIMBURSEMENT_RATE	CARDIAC_SERVICES_CARVEOUT_REIMBURSEMENT_METHODOLOGY	CARDIAC_SERVICES_CARVEOUT_SCHEDULE_NAME	CARDIAC_SERVICES_CARVEOUT_SCHEDULE_VERSION	CARDIAC_SERVICES_CARVEOUT_REIMBURSEMENT_RATE	CARDIAC_SERVICES_CARVEOUT_EXCEPTION	SPECIAL_CARE_UNIT_CARVEOUT_IND	SPECIAL_CARE_UNIT_CARVEOUT_IND_PG	SPECIAL_CARE_UNIT_CARVEOUT_CODES	SPECIAL_CARE_UNIT_CARVEOUT_SCHEDULE_VERSION	SPECIAL_CARE_UNIT_CARVEOUT_REIMBURSEMENT_RATE	SPECIAL_CARE_UNIT_CARVEOUT_EXCEPTION	SKILLED_NURSING_SERVICES_CARVEOUT_IND_PG	SKILLED_NURSING_SERVICES_CARVEOUT_REIMBURSEMENT_METHODOLOGY	SKILLED_NURSING_SERVICES_CARVEOUT_EXCEPTION	INFUSION_SERVICES_CARVEOUT_IND	INFUSION_SERVICES_CARVEOUT_IND_PG	INFUSION_SERVICES_CARVEOUT_CODES	INFUSION_SERVICES_CARVEOUT_TYPE_OF_CODE	INFUSION_SERVICES_CARVEOUT_SCHEDULE_VERSION	SPECIALTY_CARE_PHY_SERVICES_CARVEOUT_TYPE_OF_CODE	SPECIALTY_CARE_PHY_SERVICES_CARVEOUT_REIMBURSEMENT_METHODOLOGY	SPECIALTY_CARE_PHY_SERVICES_CARVEOUT_SCHEDULE_NAME	SPECIALTY_CARE_PHY_SERVICES_CARVEOUT_SCHEDULE_VERSION	SPECIALTY_CARE_PHY_SERVICES_CARVEOUT_REIMBURSEMENT_RATE	HIGH_COST_DRUGS_IMPLANTS_IP_CARVEOUT_IND_PG	HIGH_COST_DRUGS_IMPLANTS_IP_CARVEOUT_SCHEDULE_NAME	HIGH_COST_DRUGS_IMPLANTS_IP_CARVEOUT_SCHEDULE_VERSION	HIGH_COST_DRUGS_IMPLANTS_OP_CARVEOUT_IND	HIGH_COST_DRUGS_IMPLANTS_OP_CARVEOUT_IND_PG	HIGH_COST_DRUGS_IMPLANTS_OP_CARVEOUT_TYPE_OF_CODE	NEURO_CARVEOUT_CODES	NEURO_CARVEOUT_TYPE_OF_CODE	NEURO_PD_CARVEOUT_SCHEDULE_VERSION	NEURO_PD_CARVEOUT_REIMBURSEMENT_RATE	NEURO_PD_CARVEOUT_EXCEPTION
2	MOHTX23	MOHTX23	MOHTX23	MOHTX23_Molina Healthcare of TX_Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS_Medicaid_8-1-2023	Lexi	Ready for QC	Molina Healthcare of TX	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom - Facility	ERROR	Amendment Number Six to Molina Healthcare of Texas, Inc. Hospital Services Agreement	1	Amendment	1	6	1	Hospital Services Agreement	1	40969	1	Y	3	Molina Healthcare of Texas, Inc.	1	Children's Health Clinical Operation dba Children's Medical Center of Dallas	1			Children's Health Clinical Operation dba Children's Medical Center of Dallas	3																																						01-08-2023	1	References Effective Date defined in preamble	3	Y	1, 3	01-08-2025	1	N	1																																						01-08-2023	5	31-07-2024	5	Institutional	1	Medicaid	4				STAR	4	Outpatient	5																		N	5	N		% of billed charges	5														0.3	5					Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5	Y	Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5																											Y	5			% of billed charges		30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)			5			% of billed charges	30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)		Y	5	360, 361, 490	Revenue Codes	% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 39% of billed charges)																																																																																																																																	Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)				Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)																																																																															Y	5			% of billed charges			33% for 8/1/2023-7/31/2025
3	MOHTX23	MOHTX23	MOHTX23	MOHTX23_Molina Healthcare of TX_Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS_Medicaid_8-1-2023	Lexi	Ready for QC	Molina Healthcare of TX	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom - Facility	ERROR	Amendment Number Six to Molina Healthcare of Texas, Inc. Hospital Services Agreement	1	Amendment	1	6	1	Hospital Services Agreement	1	40969	1	Y	3	Molina Healthcare of Texas, Inc.	1	Children's Health Clinical Operation dba Children's Medical Center of Dallas	1			Children's Health Clinical Operation dba Children's Medical Center of Dallas	3																																						01-08-2023	1	References Effective Date defined in preamble	3	Y	1, 3	01-08-2025	1	N	1																																						01-08-2023	5	31-07-2024	5	Institutional	1	Medicaid	4	HMO	HMO		CHIP	4	Outpatient	5																		N	5	N		% of billed charges	5														0.3	5					Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5	Y	Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5																											Y	5			% of billed charges		30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)			5			% of billed charges	30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)		Y	5	360, 361, 490	Revenue Codes	% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 39% of billed charges)																																																																																																																																	Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)				Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)																																																																															Y	5			% of billed charges			33% for 8/1/2023-7/31/2025
4	MOHTX23	MOHTX23	MOHTX23	MOHTX23_Molina Healthcare of TX_Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS_Medicaid_8-1-2023	Lexi	Ready for QC	Molina Healthcare of TX	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom - Facility	ERROR	Amendment Number Six to Molina Healthcare of Texas, Inc. Hospital Services Agreement	1	Amendment	1	6	1	Hospital Services Agreement	1	40969	1	Y	3	Molina Healthcare of Texas, Inc.	1	Children's Health Clinical Operation dba Children's Medical Center of Dallas	1			Children's Health Clinical Operation dba Children's Medical Center of Dallas	3																																						01-08-2023	1	References Effective Date defined in preamble	3	Y	1, 3	01-08-2025	1	N	1																																						01-08-2023	5	31-07-2024	5	Institutional	1	Medicaid	4				CHIP Perinate	4	Outpatient	5																		N	5	N		% of billed charges	5														0.3	5					Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5	Y	Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5																											Y	5			% of billed charges		30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)			5			% of billed charges	30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)		Y	5	360, 361, 490	Revenue Codes	% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 39% of billed charges)																																																																																																																																	Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)				Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)																																																																															Y	5			% of billed charges			33% for 8/1/2023-7/31/2025
5	MOHTX23	MOHTX23	MOHTX23	MOHTX23_Molina Healthcare of TX_Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS_Medicaid_8-1-2023	Lexi	Ready for QC	Molina Healthcare of TX	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom_HSA_AMD 2_EFF08012023_Children's Medical Center_MedicaidFS	Custom - Facility	ERROR	Amendment Number Six to Molina Healthcare of Texas, Inc. Hospital Services Agreement	1	Amendment	1	6	1	Hospital Services Agreement	1	40969	1	Y	3	Molina Healthcare of Texas, Inc.	1	Children's Health Clinical Operation dba Children's Medical Center of Dallas	1			Children's Health Clinical Operation dba Children's Medical Center of Dallas	3																																						01-08-2023	1	References Effective Date defined in preamble	3	Y	1, 3	01-08-2025	1	N	1																																						01-08-2023	5	31-07-2024	5	Institutional	1	Medicaid	4				STAR PLUS	4	Outpatient	5																		N	5	N		% of billed charges	5														0.3	5					Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5	Y	Reimbursement for 8/1/2024-7/31/2025 is 31.5% of Billed charges, rates have no further discounts or reductions	5																											Y	5			% of billed charges		30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)			5			% of billed charges	30% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 31.5% of billed charges)		Y	5	360, 361, 490	Revenue Codes	% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 39% of billed charges)																																																																																																																																	Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)				Y	5			% of billed charges			28% for 8/1/2023-7/31/2024 (reimbursement 8/1/2024-7/31/2025 is 29% of billed charges)																																																																															Y	5			% of billed charges			33% for 8/1/2023-7/31/2025
6	HN4	HN4	HN4	HN4_HealthNet of Cali_2017-07-01 St. Agnes Medical Center AMD_Commercial _7-1-2017	Lexi	Ready for QC	HealthNet of Cali	2017-07-01 St. Agnes Medical Center AMD	2017-07-01 St. Agnes Medical Center AMD	Custom - Facility	ERROR	Amendment to the Hospital Provider Services Agreement between Health Net of California, Inc. and Saint Agnes Medical Center	1	Amendment	1			Hospital Provider Services Agreement	1	40057	1	Y	3	Health Net of California, Inc.	1	Saint Agnes Medical Center	1			Saint Agnes Medical Center	3	94-1437713	4	1205845567	4	1303 East Herndon Ave		Fresno	CA	93720	559-450-3000	559-450-2143	4	HSC00093F	05-0093		4	See "HN4StAgnesCarveouts" tab	4																		General Acute Care Hospital	4	01-07-2017	1	References Effective Date defined in preamble	3			30-06-2019	2	Y	2	1 year	2																																				01-07-2017	5	30-06-2018	5	Institutional	1	Commercial	5						Outpatient	7,8																		Y	5	N		Provider's billed charges	5														1	5							Y																						See "HN4StAgnesCarevouts" tab	5, 6, 7						Y	6	450, 451, 452, 459	Revenue Codes	% of billed charges		73.1% (74.6% starting 7/1/2018)	$2,730 ($2,867 starting 7/1/2018)	Y	6	760, 762	Revenue Codes	% of billed charges not to exceed amount per visit	73.1% (74.6% starting 7/1/2018)	$4,570 ($4,798 starting 7/1/2018)	Y	6	360, 369, 490, 499, 750	Revenue Codes	% of billed charges			73.1% (74.6% starting 7/1/2018)	Not to exceed $9840 ($10,332 starting 7/1/2018)	N	7																																																								Y	7	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			39.4% (40.2% starting 7/1/2018)	45000	Y	7	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			39.4% (40.2% starting 7/1/2018)	45000																																																																																																																																																																																																																																																																																					Y	6	360, 369, 490, 499, 750	Revenue Codes	% of billed charges not to exceed amount per visit	73.1% (74.6% starting 7/1/2018)	$9840 ($10,332 starting 7/1/2018)								Y	6	36902, 36903, 36905 - 36908, 37215, 37217, 37218, 37220-37239,37246-37249, 61630, 61635, 92920, 92921, 92924-92925, 92928-92929, 92933-29234, 92937-92938, 92941, 92943, 92944, 92997-92998	CPT codes	% of billed charges not to exceed $17,215/visit ($18,075/visit starting 7/1/2018)			73.1% (74.6% starting 7/1/2018)																									Y	6,7	33206-33208, 33214, 33222, 33233-33235	CPT Codes	% of billed charges not to exceed $17,215/visit ($18,076/visit starting 7/1/2018)	73.1% (74.6% starting 7/1/2018)	Y	7	93451-93464, 93503, 93505, 93530-93533, 93561-92568	CPT codes	Per visit	Per visit	$7,299 ($7,663 starting 7/1/2018)	Y	6	77370, 77371, 77372, 77300, or G0339, G0340	CPT Codes:	Per case	$34,695 ($35,389 starting 7/1/2018)																									Y	Y, all other outpatient services reimbursed 67.5% of billed charges not to exceed $15,000 per visit (68.9% not to exceed $15,750 starting 7/1/2018)	7
7	HN4	HN4	HN4	HN4_HealthNet of Cali_2017-07-01 St. Agnes Medical Center AMD_Commercial _7-1-2017	Lexi	Ready for QC	HealthNet of Cali	2017-07-01 St. Agnes Medical Center AMD	2017-07-01 St. Agnes Medical Center AMD	Custom - Facility	ERROR	Amendment to the Hospital Provider Services Agreement between Health Net of California, Inc. and Saint Agnes Medical Center	1	Amendment	1			Hospital Provider Services Agreement	1	40057	1	Y	3	Health Net of California, Inc.	1	Saint Agnes Medical Center	1			Saint Agnes Medical Center	3	94-1437713	4	1205845567	4	1303 East Herndon Ave		Fresno	CA	93720	559-450-3000	559-450-2143	4	HSC00093F	05-0093		4	See "HN4StAgnesCarveouts" tab	4																		General Acute Care Hospital	4	01-07-2017	1	References Effective Date defined in preamble	3			30-06-2019	2	Y	2	1 year	2																																				01-07-2017	9	30-06-2018	9	Institutional	1	Commercial	9	PureCare		9, 10, 11			Outpatient	10,11																		Y	9	N		Provider's billed charges	9														1	9							Y																						See "HN4StAgnesCarevouts" tab	9, 10, 11						Y	10	450, 451, 452, 459	Revenue Codes	% of billed charges		66.3% (67.6% starting 7/1/2018)	$2,464 ($2,575 starting 7/1/2018)	Y	10	760, 762	Revenue Codes	% of billed charges not to exceed amount per visit	66.3% (67.6% starting 7/1/2018)	$4,184 ($4,372 starting 7/1/2018)	Y	10	360, 369, 490, 499, 750	Revenue Codes	% of billed charges			66.3% (67.6% starting 7/1/2018)	Not to exceed $9840 ($10,332 starting 7/1/2018)	N	11																																																								Y	11	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			35.7% (36.4% starting 7/1/2018)	45000	Y	11	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			35.7% (36.4% starting 7/1/2018)	45000																																																																																																																																																																																																																																																																																					Y	10	360, 369, 490, 499, 750	Revenue Codes	% of billed charges not to exceed amount per visit	66.3% (67.6% starting 7/1/2018)	$8,883 ($9,282 starting 7/1/2018)								Y	10	36902, 36903, 36905 - 36908, 37215, 37217, 37218, 37220-37239,37246-37249, 61630, 61635, 92920, 92921, 92924-92925, 92928-92929, 92933-29234, 92937-92938, 92941, 92943, 92944, 92997-92998	CPT codes	% of billed charges not to exceed $15,540/visit ($16,240/visit starting 7/1/2018)			66.3% (67.6% starting 7/1/2018)																									Y	11	33206-33208, 33214, 33222, 33233-33235	CPT Codes	% of billed charges not to exceed $15,540/visit ($16,240/visit starting 7/1/2018)	66.3% (67.6% starting 7/1/2018)	Y	11	93451-93464, 93503, 93505, 93530-93533, 93561-92568	CPT codes	Per visit	Per visit	$6,589 ($6,885 starting 7/1/2018)	Y	10	77370, 77371, 77372, 77300, or G0339, G0340	CPT Codes:	Per case	$31,470 ($32,099 starting 7/1/2018)																									Y	Y, all other outpatient services reimbursed 61.2% of billed charges not to exceed $14,000 per visit (62.4% not to exceed $14,630 starting 7/1/2018)	11
8	HN4	HN4	HN4	HN4_HealthNet of Cali_2017-07-01 St. Agnes Medical Center AMD_Commercial _7-1-2017	Lexi	Ready for QC	HealthNet of Cali	2017-07-01 St. Agnes Medical Center AMD	2017-07-01 St. Agnes Medical Center AMD	Custom - Facility	ERROR	Amendment to the Hospital Provider Services Agreement between Health Net of California, Inc. and Saint Agnes Medical Center	1	Amendment	1			Hospital Provider Services Agreement	1	40057	1	Y	3	Health Net of California, Inc.	1	Saint Agnes Medical Center	1			Saint Agnes Medical Center	3	94-1437713	4	1205845567	4	1303 East Herndon Ave		Fresno	CA	93720	559-450-3000	559-450-2143	4	HSC00093F	05-0093		4	See "HN4StAgnesCarveouts" tab	4																		General Acute Care Hospital	4	01-07-2017	1	References Effective Date defined in preamble	3			30-06-2019	2	Y	2	1 year	2																																				01-07-2017	9	30-06-2018	9	Institutional	1	Commercial	9	UC Blue		9, 10, 11			Outpatient	10,11																		Y	9	N		Provider's billed charges	9														1	9							Y																						See "HN4StAgnesCarevouts" tab	9, 10, 11						Y	10	450, 451, 452, 459	Revenue Codes	% of billed charges		66.3% (67.6% starting 7/1/2018)	$2,464 ($2,575 starting 7/1/2018)	Y	10	760, 762	Revenue Codes	% of billed charges not to exceed amount per visit	66.3% (67.6% starting 7/1/2018)	$4,184 ($4,372 starting 7/1/2018)	Y	10	360, 369, 490, 499, 750	Revenue Codes	% of billed charges			66.3% (67.6% starting 7/1/2018)	Not to exceed $9840 ($10,332 starting 7/1/2018)	N	11																																																								Y	11	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			35.7% (36.4% starting 7/1/2018)	45000	Y	11	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			35.7% (36.4% starting 7/1/2018)	45000																																																																																																																																																																																																																																																																																					Y	10	360, 369, 490, 499, 750	Revenue Codes	% of billed charges not to exceed amount per visit	66.3% (67.6% starting 7/1/2018)	$8,883 ($9,282 starting 7/1/2018)								Y	10	36902, 36903, 36905 - 36908, 37215, 37217, 37218, 37220-37239,37246-37249, 61630, 61635, 92920, 92921, 92924-92925, 92928-92929, 92933-29234, 92937-92938, 92941, 92943, 92944, 92997-92998	CPT codes	% of billed charges not to exceed $15,540/visit ($16,240/visit starting 7/1/2018)			66.3% (67.6% starting 7/1/2018)																									Y	11	33206-33208, 33214, 33222, 33233-33235	CPT Codes	% of billed charges not to exceed $15,540/visit ($16,240/visit starting 7/1/2018)	66.3% (67.6% starting 7/1/2018)	Y	11	93451-93464, 93503, 93505, 93530-93533, 93561-92568	CPT codes	Per visit	Per visit	$6,589 ($6,885 starting 7/1/2018)	Y	10	77370, 77371, 77372, 77300, or G0339, G0340	CPT Codes:	Per case	$31,470 ($32,099 starting 7/1/2018)																									Y	Y, all other outpatient services reimbursed 61.2% of billed charges not to exceed $14,000 per visit (62.4% not to exceed $14,630 starting 7/1/2018)	11
9	HN4	HN4	HN4	HN4_HealthNet of Cali_2017-07-01 St. Agnes Medical Center AMD_Commercial _7-1-2017	Lexi	Ready for QC	HealthNet of Cali	2017-07-01 St. Agnes Medical Center AMD	2017-07-01 St. Agnes Medical Center AMD	Custom - Facility	ERROR	Amendment to the Hospital Provider Services Agreement between Health Net of California, Inc. and Saint Agnes Medical Center	1	Amendment	1			Hospital Provider Services Agreement	1	40057	1	Y	3	Health Net of California, Inc.	1	Saint Agnes Medical Center	1			Saint Agnes Medical Center	3	94-1437713	4	1205845567	4	1303 East Herndon Ave		Fresno	CA	93720	559-450-3000	559-450-2143	4	HSC00093F	05-0093		4	See "HN4StAgnesCarveouts" tab	4																		General Acute Care Hospital	4	01-07-2017	1	References Effective Date defined in preamble	3			30-06-2019	2	Y	2	1 year	2																																				01-07-2017	9	30-06-2018	9	Institutional	1	Commercial	9	Gold Narrow Network		9, 10, 11			Outpatient	10,11																		Y	9	N		Provider's billed charges	9														1	9							Y																						See "HN4StAgnesCarevouts" tab	9, 10, 11						Y	10	450, 451, 452, 459	Revenue Codes	% of billed charges		66.3% (67.6% starting 7/1/2018)	$2,464 ($2,575 starting 7/1/2018)	Y	10	760, 762	Revenue Codes	% of billed charges not to exceed amount per visit	66.3% (67.6% starting 7/1/2018)	$4,184 ($4,372 starting 7/1/2018)	Y	10	360, 369, 490, 499, 750	Revenue Codes	% of billed charges			66.3% (67.6% starting 7/1/2018)	Not to exceed $9840 ($10,332 starting 7/1/2018)	N	11																																																								Y	11	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			35.7% (36.4% starting 7/1/2018)	45000	Y	11	274, 275, 276, 278	Revenue Codes	% of total billed charges when Rev Codes 274, 275, 276, or 278 combined billed charges are > than $2,250 per admission not to exceed threshold			35.7% (36.4% starting 7/1/2018)	45000																																																																																																																																																																																																																																																																																					Y	10	360, 369, 490, 499, 750	Revenue Codes	% of billed charges not to exceed amount per visit	66.3% (67.6% starting 7/1/2018)	$8,883 ($9,282 starting 7/1/2018)								Y	10	36902, 36903, 36905 - 36908, 37215, 37217, 37218, 37220-37239,37246-37249, 61630, 61635, 92920, 92921, 92924-92925, 92928-92929, 92933-29234, 92937-92938, 92941, 92943, 92944, 92997-92998	CPT codes	% of billed charges not to exceed $15,540/visit ($16,240/visit starting 7/1/2018)			66.3% (67.6% starting 7/1/2018)																									Y	11	33206-33208, 33214, 33222, 33233-33235	CPT Codes	% of billed charges not to exceed $15,540/visit ($16,240/visit starting 7/1/2018)	66.3% (67.6% starting 7/1/2018)	Y	11	93451-93464, 93503, 93505, 93530-93533, 93561-92568	CPT codes	Per visit	Per visit	$6,589 ($6,885 starting 7/1/2018)	Y	10	77370, 77371, 77372, 77300, or G0339, G0340	CPT Codes:	Per case	$31,470 ($32,099 starting 7/1/2018)																									Y	Y, all other outpatient services reimbursed 61.2% of billed charges not to exceed $14,000 per visit (62.4% not to exceed $14,630 starting 7/1/2018)	11
10	Moda4	Moda4	Moda4	Moda4_Moda Health Plan, Inc._2021-07-15 COMM Agmt FE - Samaritan Health Services_Commercial_This Agreement shall be effective as of the date countersigned by Moda Health	Lexi	Ready for QC	Moda Health Plan, Inc.	2021-07-15 COMM Agmt FE - Samaritan Health Services	Samaritan Health Services	Custom - Multiple	ERROR	Moda Health Plan, Inc. Participating Provider Agreement for Commercial Benefit Plans	1	Base Contract	1							Y	15	Moda Health Plan, Inc.	1	Samaritan Health Services, Inc.	1			Samaritan Health Services	15					815 NW 9th Street		Corvallis	OR	97330			15					See "ModaSamaritanCareveouts" tab	17	See "ModaSamaritanCareveouts" tab	17																		This Agreement shall be effective as of the date countersigned by Moda Health	1	15-07-2021	15			15-07-2022	10	Y	10	12 months	10	60D	prior notice of any such changes	13	12M	from date Member received the services	7				30D	after date Moda receives claim	8	30D	after date Moda receives claim	8	30D	in advance notice of such audit	9										18M	from date claim was originally paid or denied	8	30D	from its receipt of refund request	8							Institutional	1	Commercial	1	Connexus		62, 63			Ambulatory Surgery Center	62																Charge master increase over fiscal year will be capped at 3%, excluding any charges that are determined based on invoice cost (i.e. implantable devices and pharmaceuticals)	64	Y	63			Provider's billed charges	63														1	62							Y																																												Y	63	Covered ASC Services		% of ASC Fee Schedule	CMS ASC Fee Schedule	2020	1.89																																																											Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services					Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services														Y	63	Drugs and biologicals when provided integral to surgical procedure on ASC list (CMS Payment indicator K2)		% of fee schedule	CMS ASC fee schedule	current	1																Y	64	subsequent procedures performed on the same day	follow CMS multiple procedure payment reduction (MPPR) rules																																																																																																																																																																																Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services																																																																																																																								N
11	Moda4	Moda4	Moda4	Moda4_Moda Health Plan, Inc._2021-07-15 COMM Agmt FE - Samaritan Health Services_Commercial_This Agreement shall be effective as of the date countersigned by Moda Health	Lexi	Ready for QC	Moda Health Plan, Inc.	2021-07-15 COMM Agmt FE - Samaritan Health Services	Samaritan Health Services	Custom - Multiple	ERROR	Moda Health Plan, Inc. Participating Provider Agreement for Commercial Benefit Plans	1	Base Contract	1							Y	15	Moda Health Plan, Inc.	1	Samaritan Health Services, Inc.	1			Samaritan Health Services	15					815 NW 9th Street		Corvallis	OR	97330			15					See "ModaSamaritanCareveouts" tab	17	See "ModaSamaritanCareveouts" tab	17																		This Agreement shall be effective as of the date countersigned by Moda Health	1	15-07-2021	15			15-07-2022	10	Y	10	12 months	10	60D	prior notice of any such changes	13	12M	from date Member received the services	7				30D	after date Moda receives claim	8	30D	after date Moda receives claim	8	30D	in advance notice of such audit	9										18M	from date claim was originally paid or denied	8	30D	from its receipt of refund request	8							Institutional	1	Commercial	1	Synergy		62, 63			Ambulatory Surgery Center	62																Charge master increase over fiscal year will be capped at 3%, excluding any charges that are determined based on invoice cost (i.e. implantable devices and pharmaceuticals)	64	Y	63			Provider's billed charges	63														1	62							Y																																												Y	63	Covered ASC Services		% of ASC Fee Schedule	CMS ASC Fee Schedule	2020	1.89																																																											Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services					Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services														Y	63	Drugs and biologicals when provided integral to surgical procedure on ASC list (CMS Payment indicator K2)		% of fee schedule	CMS ASC fee schedule	current	1																Y	64	subsequent procedures performed on the same day	follow CMS multiple procedure payment reduction (MPPR) rules																																																																																																																																																																																Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services
12	Moda4	Moda4	Moda4	Moda4_Moda Health Plan, Inc._2021-07-15 COMM Agmt FE - Samaritan Health Services_Commercial_This Agreement shall be effective as of the date countersigned by Moda Health	Lexi	Ready for QC	Moda Health Plan, Inc.	2021-07-15 COMM Agmt FE - Samaritan Health Services	Samaritan Health Services	Custom - Multiple	ERROR	Moda Health Plan, Inc. Participating Provider Agreement for Commercial Benefit Plans	1	Base Contract	1							Y	15	Moda Health Plan, Inc.	1	Samaritan Health Services, Inc.	1			Samaritan Health Services	15					815 NW 9th Street		Corvallis	OR	97330			15					See "ModaSamaritanCareveouts" tab	17	See "ModaSamaritanCareveouts" tab	17																		This Agreement shall be effective as of the date countersigned by Moda Health	1	15-07-2021	15			15-07-2022	10	Y	10	12 months	10	60D	prior notice of any such changes	13	12M	from date Member received the services	7				30D	after date Moda receives claim	8	30D	after date Moda receives claim	8	30D	in advance notice of such audit	9										18M	from date claim was originally paid or denied	8	30D	from its receipt of refund request	8							Institutional	1	Commercial	1	OHSU PPO for Samaritan Endoscopy Center	PPO	62, 63			Ambulatory Surgery Center	62																Charge master increase over fiscal year will be capped at 3%, excluding any charges that are determined based on invoice cost (i.e. implantable devices and pharmaceuticals)	64	Y	63			Provider's billed charges	63														1	62							Y																																												Y	63	Covered ASC Services		% of ASC Fee Schedule	CMS ASC Fee Schedule	2020	1.89																																																											Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services					Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services														Y	63	Drugs and biologicals when provided integral to surgical procedure on ASC list (CMS Payment indicator K2)		% of fee schedule	CMS ASC fee schedule	current	1																Y	64	subsequent procedures performed on the same day	follow CMS multiple procedure payment reduction (MPPR) rules																																																																																																																																																																																Y	64	N1	Status Indicator	Included in all-inclusive rate for ASC services
13	AvM15 - MCR OP	AvM15	AvM15	AvM15 - MCR OP_AvMed_Custom_2022-01-01 Orlando Health 42nd Amendment_Medicare_1-1-2022	Veena		AvMed	Custom_2022-01-01 Orlando Health 42nd Amendment	Custom_2022-01-01 Orlando Health 42nd Amendment	Custom - Facility	ERROR	FORTY-SECOND AMENDMENT TO HOSPITAL SERVICES AGREEMENT	3	Amendment	3	42	3	Hospital Services Agreement	3	37561	3	Y	4	AvMed, Inc.	3	Orlando Health, Inc.	3																					Orlando Health, Inc.	10																				01-01-2022	1	01-01-2022	4	Y	1,4																																										01-01-2022	10					Medicare	10						Outpatient	10																		N				% Fee Schedule	10										Medicare	10			1	10
14	AvM15 - MCR OP	AvM15	AvM15	AvM15 - MCR OP_AvMed_Custom_2022-01-01 Orlando Health 42nd Amendment_Medicare_1-1-2022	Veena	ready for QC	AvMed	Custom_2022-01-01 Orlando Health 42nd Amendment	Custom_2022-01-01 Orlando Health 42nd Amendment	Custom - Facility	ERROR	FORTY-SECOND AMENDMENT TO HOSPITAL SERVICES AGREEMENT	3	Amendment	3	42	3	Hospital Services Agreement	3	37561	3	Y	4	AvMed, Inc.	3	Orlando Health, Inc.	11																					Orlando Urgent Care, LLC d/b/a Express Care	11																				01-01-2022	1	01-01-2022	4	Y	1,4																																										01-01-2022	11					Medicare	10						Urgent Care	11																		Y				% billed charges	11														1	11							N			% fee schedule	11	99201-99215, S9083									Medicare Allowable	11			1	11
15	CNCAZ16	CNCAZ16	CNCAZ16	CNCAZ16_Centene_West Yavapai Guidance Clinic Inc. 11.02.2021 Practitioner Amendment TEMPLATE 1.22.2020 1_Medicaid_1-1-2022	Veena	QC complete	Centene	West Yavapai Guidance Clinic Inc. 11.02.2021 Practitioner Amendment TEMPLATE 1.22.2020 1	Prof4_West Yavapai Guidance Clinic Inc. 11.01.2021 Care1st Practitioner Amendment Template 1.22.2020.1	Boilerplate - Professional	ERROR	AMENDMENT TO THE CARE1ST HEALTH PLAN ARIZONA, INC. PROVIDER AGREEMENT	1	Amendment	1	Amendment A	2	AMENDMENT TO THE CARE1ST HEALTH PLAN ARIZONA, INC. PROVIDER AGREEMENT	1	44562	1	Y	1	Care1st Health Plan Arizona Inc	1	West Yavapai Guidance Clinic Inc.,	1			West Yavapai Guidance Clinic Inc.,	1	86-0206928	1			3343 N. Windsong Drive		Prescott Valley	Arizona	86314																													01-01-2022	1	08-12-2021	1	N	1			N													60D	of the plan's receipt of a clean claim	2	60D	of the plan's receipt of a clean claim	2																					01-01-2022	1			Professional	2	Medicaid	2						FQHC	2			N						N	N								Y	2	N		% AHCCCS Physician Fee Schedule	2										AHCCCS Physician Fee Schedule	2	Current	2							Y	2,3,4,5	Y			Billed Charges	2														1	2,4					Services with no rates shall be reimbursed according to Plan's criteria until rates are established	2			N																																												Y	4,5		Package Rate	Obstetrical Service Package Rate	current	0.85	N					Y	3	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab																																																									Y	4		Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	4	Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	4		Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	2	% Fee Schedule	ACCCHS Fee Schedule	current	3	N	N						Y	3			% Fee Schedule	ACCCHS Fee Schedule	current	0.7				Y	3			% Fee Schedule & Flat Rate	ACCCHS Fee Schedule	current	90%, $250 PET Scan	N								N	N	N	N	N									N						Y	3	Administration of vaccines	Flat Rate	ACCCHS Fee Schedule	current	Y	3	% Fee Schedule	ACCCHS Fee Schedule	current	0.2	Y	2	% Fee Schedule	ACCCHS Fee Schedule	current	3	Y	2	% Fee Schedule	ACCCHS Fee Schedule	current	0.85	Y	2	% Fee Schedule	ACCCHS Fee Schedule	current	1	Y	2	% Fee Schedule	ACCCHS Fee Schedule	current	3	Y	3	% Fee Schedule	ACCCHS Fee Schedule	current	3	Y	3			Flat Rate	ACCCHS Fee Schedule	current	65		Y	3	A0160	CPT/HCPCS Codes	% Fee Schedule	ACCCHS Fee Schedule	current	3.98	N							N						Y	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	Y	2	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current		Y	2	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current		Y	2	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current		Y	2	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current																																																					N						N																																																																																																													Y	Payment for covered healthcare services provided by provider to plan members that do not qualify for FQHC/RHC payment shall be based on the lesser of the plan�s fee schedule defined in the table below or providers charges, less any applicable Co-payments, deductibles and Coinsurance services with no rates shall be reimbursed according to plans criteria until rates are established. At no time shall plan pay an amount that exceeds provider�s billed charges.	2
16	CNCAZ15	CNCAZ15	CNCAZ15	CNCAZ15_Centene_Prof3_Arizona Children Association - 860096772 MU.pdf_Medicaid_10-2-2018	Veena	QC complete	Centene	Prof3_Arizona Children Association - 860096772 MU.pdf	Prof3_Arizona Children Association - 860096772	Boilerplate - Professional	ERROR	Care1st Health Plan Arizona, Inc. Provider Agreement	2	Base Contract	2							Y	2	Care1st Health Plan Arizona Inc	2	Arizona's Children Association	2	860096772	2	Arizona's Children Association	2	860096772	2			3636 N. Central Ave		Phoenix	Arizona	85012			2																										02-10-2018	2	12-10-2018	2	N	2			Y	20	1 YEAR	20				6M	from the date of service	10				6M	from the date of services	10	6M	from the date of services	10				5WD	of receipt thereof	20	30D	of receipt	20	12M	from the date of service	11									12-10-2018	2			Professional	24	Medicaid	24										N						N	N								Y	24	N		% AHCCCS Physician Fee Schedule	24										AHCCCS Physician Fee Schedule	24	Current	24	1	24					Y	24,25	Y			Billed Charges	24														1	24					Services with no rates shall be reimbursed according to Plan's criteria until rates are established	24			N																																																			N					Y	25	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab																																																																													Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	0.9	N	N						Y	25			% Fee Schedule	ACCCHS Fee Schedule	current	0.7				Y	25			% Fee Schedule & Flat Rate	ACCCHS Fee Schedule	current	80%, $200 PET Scan	N								N	N	N	N	N									N						Y	25	Administration of vaccines	Flat Rate	ACCCHS Fee Schedule	current	N						Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	1	N						Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	1	N						N						N									N								Y	24		% Fee Schedule	ACCCHS Fee Schedule	current	1	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	1.25	Y	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current	1.25	Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current	1.25	Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current		Y	25	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current																																																					N						N																																																																																																													Y	Payment for covered healthcare services provided by provider to plan members that do not qualify for FQHC/RHC payment shall be based on the lesser of the plan�s fee schedule defined in the table below or providers charges, less any applicable Co-payments, deductibles and Coinsurance services with no rates shall be reimbursed according to plans criteria until rates are established. At no time shall plan pay an amount that exceeds provider�s billed charges.	24
17	CNCAZ14	CNCAZ14	CNCAZ14	CNCAZ14_Centene_Prof2_Black Canyon Medical_Malin Medical PLLC_2 - 811754238 MU_Medicaid_10-2-2021	Veena	QC complete	Centene	Prof2_Black Canyon Medical_Malin Medical PLLC_2 - 811754238 MU	Prof2_Black Canyon Medical_Malin Medical PLLC_2 - 811754238	Boilerplate - Professional	ERROR	Care1st Health Plan Arizona, Inc. Provider Agreement	2	Base Contract	2							Y	2	Care1st Health Plan Arizona Inc	2	Malin Medical, PLLC	2	811754238	2	Malin medical, PLLC	2	811754238	2			1780 North State Route 89		Chino Valley	Arizona	86323			2																										02-10-2021	2	02-11-2021	2	N	2			Y	20	1 YEAR	20				6M	from the date of service	10				6M	from the date of services	10	6M	from the date of services	10				5WD	of receipt thereof	20	30D	of receipt	20												01-10-2021	2			Professional	24	Medicaid	24										N						N	N								Y	24	N		% AHCCCS Physician Fee Schedule	24										AHCCCS Physician Fee Schedule	24	Current	2	1	24					Y	24,25	Y			Billed Charges	24														1	24					Services with no rates shall be reimbursed according to Plan's criteria until rates are established	24			N																																												Y	26,27		Package Rate	Obstetrical Service Package Rate	current	0.85	N					Y	25	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab																																																									Y	26		Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	26	Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	26		Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	0.85	N	N						Y	25			% Fee Schedule	ACCCHS Fee Schedule	current	0.7				Y	25			% Fee Schedule & Flat Rate	ACCCHS Fee Schedule	current	90%, $200 PET Scan	N								N	N	N	N	N									N						Y	25	Administration of vaccines	Flat Rate	ACCCHS Fee Schedule	current	Y	25	% Fee Schedule	ACCCHS Fee Schedule	current	0.2	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	1	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	0.85	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	1	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	0.75	Y	25	% Fee Schedule	ACCCHS Fee Schedule	current	0.85	Y	25			Flat Rate	ACCCHS Fee Schedule	current	65		N								N							N						Y	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	See "CNC BH Carveout" Tab	Y	25	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current		Y	25	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current		Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current		Y	25	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current																																																					N						N																																																																																																													Y	Payment for covered healthcare services provided by provider to plan members that do not qualify for FQHC/RHC payment shall be based on the lesser of the plan�s fee schedule defined in the table below or providers charges, less any applicable Co-payments, deductibles and Coinsurance services with no rates shall be reimbursed according to plans criteria until rates are established. At no time shall plan pay an amount that exceeds provider�s billed charges.	24
18	CNCNJ9	CNCNJ9	CNCNJ9	CNCNJ9_Centene_Prof1_ICM135705_ICMProviderAgreement_135705 IPA of NJ MU.pdf_Medicaid_1-1-2022	Veena	QC complete	Centene	Prof1_ICM135705_ICMProviderAgreement_135705 IPA of NJ MU.pdf	IPA of North Jersey	Boilerplate - Professional	ERROR	WELLCARE NEW JERSEY MEDICARE ADVANTAGE AND/OR MEDICAID/FAMILYCARE PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	23	WellCare Health Plans of New Jersey, Inc.	23	IPA of New Jersey	2									703 Main Street		Paterson	NJ	7503			23																										01-01-2022	1	23-08-2021	23	N	1,23			Y	15	1 YEAR	15	15D	after such posting or notice or such other time period required for Health Plan to comply with Laws, Program Requirements or accreditation standards	10	180D	of the date of a Covered Service or the date of discharge from an inpatient facility, as the case may be	8	365D	from the date of service	44	40D	of its receipt of the clean claim	78	30D	of its receipt of the clean claim	78	30D	before the normal disposition date	74										30D	of the providers receipt of notice from health plan of such overpayments shall survive termination of this agreement	13						01-01-2022	1			Professional	78	Medicaid	78										N						N	N								Y	78	N		% CMS Medicare Physician Fee Schedule	78										CMS Medicare Physician Fee Schedule	78	Current	81	1	78					Y	78-80	Y			Billed Charges	78														1	78			Other Medicine ( excluding vaccines):90281-99199, 99500-99602 = 75% CMS Medicare Physician Fee Schedule, All other items and services (including vaccines)= 100% CMS Medicare Physician Fee Schedule																																																																																																										Y	80	See "CNCNJ9 Wellcare Carveouts" tab	See "CNCNJ9 Wellcare Carveouts" tab	See "CNCNJ9 Wellcare Carveouts" tab	current	See "CNCNJ9 Wellcare Carveouts" tab			Y	80	See "CNCNJ9 Wellcare Carveouts" tab		See "CNCNJ9 Wellcare Carveouts" tab	See "CNCNJ9 Wellcare Carveouts" tab	current	See "CNCNJ9 Wellcare Carveouts" tab																																				Y	80	See "CNCNJ9 Wellcare Carveouts" table		% Fee Schedule	CMS Medicare Physician Fee Schedule	current	0.75				Y	80	See "CNCNJ9 Wellcare Carveouts" table		% Fee Schedule	CMS Medicare Physician Fee Schedule	current	0.75	Y	80	See "CNCNJ9 Wellcare Carveouts" table		% Fee Schedule	CMS Medicare Physician Fee Schedule	current	0.75																				Y	78	Administration of vaccines	Flat Rate	DMAHS	current																																																						Y	78	See "CNCNJ9 Wellcare Carveouts" table	% Fee Schedule	CMS Medicare Physician Fee Schedule	current	1																																																																																Y	78	% Fee Schedule	CMS Medicare FS	CURRENT	1
19	CNCDE2 - MCD INP	CNCDE2	CNCDE2	CNCDE2 - MCD INP_Delaware First Health, Inc. _ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf_Medicaid_10-21-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf	NEW CASTLE Health and Rehabilitation Center, LLC	Custom - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	13	Delaware First Health, Inc.	1	New Castle Health and Rehabilitation Center. LLC	1			New Castle Health and Rehabilitation Center. LLC	13	82-3535782	13	1962994905	13	32 Buena Vista Drive		New Castle	DE	19720			11																												21-10-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8				120D	from the date of rendering a covered service	32				30D	of receipt by health plan or payor	48	30D	of receipt by health plan or payor	48													60D	from the date the overpayment is identified	33										Ancillary	42	Medicaid	42						Inpatient	42	Facility Services Skilled Nursing	42																Y	42			Allowable Charges	42														1	42							Y			Contracted Rate	42				Inpatient Services - See " NewCastle_IPSNF Carveout" tab	42											Inpatient Services - See " NewCastle_IPSNF Carveout" tab	42	N																																																																																																																																																																																																																																																																																																																																																																																																																									Y	42	Inpatient Services - See " NewCastle_IPSNF Carveout" tab		Inpatient Services - See " NewCastle_IPSNF Carveout" tab	Inpatient Services - See " NewCastle_IPSNF Carveout" tab
20	CNCDE2 - MCD OP	CNCDE2	CNCDE2	CNCDE2 - MCD OP_Delaware First Health, Inc. _ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf_Medicaid_10-21-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf	NEW CASTLE Health and Rehabilitation Center, LLC	Custom - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	13	Delaware First Health, Inc.	1	New Castle Health and Rehabilitation Center. LLC	1			New Castle Health and Rehabilitation Center. LLC	13	82-3535782	13	1962994905	13	32 Buena Vista Drive		New Castle	DE	19720			11																												21-10-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8				120D	from the date of rendering a covered service	32				30D	of receipt by health plan or payor	48	30D	of receipt by health plan or payor	48													60D	from the date the overpayment is identified	33										Ancillary	42	Medicaid	42						Outpatient	42	Facility Services Skilled Nursing	42																Y	42			Allowable Charges	42														1	42					Y	42	Y	N		Flat Fee per visit	42																$45 per visit	42	N																																																																																																																																																																																																																																																																																																																																																																																																																									Y	42	Inpatient Services - See " NewCastle_IPSNF Carveout" tab		Inpatient Services - See " NewCastle_IPSNF Carveout" tab	Inpatient Services - See " NewCastle_IPSNF Carveout" tab
21	MOHTX11	MOHTX11	MOHTX11	MOHTX11_Molina Healthcare of TX_Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015_Medicaid_4-1-2015	Veena	QC complete	Molina Healthcare of TX	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom - Ancillary	ERROR	SECOND AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	2	1					Y	1	Molina Healthcare of Texas, Inc.	1	DaVita HealthCare Partners Inc	1									5605 MacArthur Blvd, Suite 400		Irving	TX	75038			1																										01-04-2015	3	01-04-2015	1	Y	1,3																30D	of the date such claim is delivered by provider to health plan and health plan determines such claim is complete/clean	5																												Ancillary		Medicaid	4				STAR	4																				Y	4	N		All inclusive treatment rate	4					See "MOHTX11_DavitaCarveout" Tab	4				See "MOHTX11_DavitaCarveout" Tab	4	See "MOHTX11_DavitaCarveout" Tab	4			See "MOHTX11_DavitaCarveout" Tab	4					N			Billed Charges	4														1	4																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event CMS approves the use of a new technology, medication or service that is also considered a Covered Service by Provider and Health Plan, reimbursement will be set at the lesser of one hundred percent (100%) of the current Medicare allowable rate, or Provider's billed charges for such New Technology.	4
22	MOHTX11	MOHTX11	MOHTX11	MOHTX11_Molina Healthcare of TX_Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015_Medicaid_4-1-2015	Veena	QC complete	Molina Healthcare of TX	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom - Ancillary	ERROR	SECOND AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	2	1					Y	1	Molina Healthcare of Texas, Inc.	1	DaVita HealthCare Partners Inc	1									5605 MacArthur Blvd, Suite 400		Irving	TX	75038			1																										01-04-2015	3	01-04-2015	1	Y	1,3																30D	of the date such claim is delivered by provider to health plan and health plan determines such claim is complete/clean	5																												Ancillary		Medicaid	4				STAR PLUS	4																				Y	4	N		All inclusive treatment rate	4					See "MOHTX11_DavitaCarveout" Tab	4				See "MOHTX11_DavitaCarveout" Tab	4	See "MOHTX11_DavitaCarveout" Tab	4			See "MOHTX11_DavitaCarveout" Tab	4					N			Billed Charges	4														1	4																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event CMS approves the use of a new technology, medication or service that is also considered a Covered Service by Provider and Health Plan, reimbursement will be set at the lesser of one hundred percent (100%) of the current Medicare allowable rate, or Provider's billed charges for such New Technology.	4
23	MOHTX11	MOHTX11	MOHTX11	MOHTX11_Molina Healthcare of TX_Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015_Medicaid_4-1-2015	Veena	QC complete	Molina Healthcare of TX	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom - Ancillary	ERROR	SECOND AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	2	1					Y	1	Molina Healthcare of Texas, Inc.	1	DaVita HealthCare Partners Inc	1									5605 MacArthur Blvd, Suite 400		Irving	TX	75038			1																										01-04-2015	3	01-04-2015	1	Y	1,3																30D	of the date such claim is delivered by provider to health plan and health plan determines such claim is complete/clean	5																												Ancillary		Medicaid	4				CHIP	4																				Y	4	N		All inclusive treatment rate	4					See "MOHTX11_DavitaCarveout" Tab	4				See "MOHTX11_DavitaCarveout" Tab	4	See "MOHTX11_DavitaCarveout" Tab	4			See "MOHTX11_DavitaCarveout" Tab	4					N			Billed Charges	4														1	4																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event CMS approves the use of a new technology, medication or service that is also considered a Covered Service by Provider and Health Plan, reimbursement will be set at the lesser of one hundred percent (100%) of the current Medicare allowable rate, or Provider's billed charges for such New Technology.	4
24	MOHTX11	MOHTX11	MOHTX11	MOHTX11_Molina Healthcare of TX_Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015_Medicaid_4-1-2015	Veena	QC complete	Molina Healthcare of TX	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom - Ancillary	ERROR	SECOND AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	2	1					Y	1	Molina Healthcare of Texas, Inc.	1	DaVita HealthCare Partners Inc	1									5605 MacArthur Blvd, Suite 400		Irving	TX	75038			1																										01-04-2015	3	01-04-2015	1	Y	1,3																30D	of the date such claim is delivered by provider to health plan and health plan determines such claim is complete/clean	5																												Ancillary		Medicaid	4				CHIP PERINATE	4																				Y	4	N		All inclusive treatment rate	4					See "MOHTX11_DavitaCarveout" Tab	4				See "MOHTX11_DavitaCarveout" Tab	4	See "MOHTX11_DavitaCarveout" Tab	4			See "MOHTX11_DavitaCarveout" Tab	4					N			Billed Charges	4														1	4																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event CMS approves the use of a new technology, medication or service that is also considered a Covered Service by Provider and Health Plan, reimbursement will be set at the lesser of one hundred percent (100%) of the current Medicare allowable rate, or Provider's billed charges for such New Technology.	4
25	MOHTX11	MOHTX11	MOHTX11	MOHTX11_Molina Healthcare of TX_Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015_Medicare_4-1-2015	Veena	QC complete	Molina Healthcare of TX	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom - Ancillary	ERROR	SECOND AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	2	1					Y	1	Molina Healthcare of Texas, Inc.	1	DaVita HealthCare Partners Inc	1									5605 MacArthur Blvd, Suite 400		Irving	TX	75038			1																										01-04-2015	3	01-04-2015	1	Y	1,3																30D	of the date such claim is delivered by provider to health plan and health plan determines such claim is complete/clean	5																												Ancillary		Medicare	4																									Y	4	N		All inclusive treatment rate	4					See "MOHTX11_DavitaCarveout" Tab	4				See "MOHTX11_DavitaCarveout" Tab	4	See "MOHTX11_DavitaCarveout" Tab	4			See "MOHTX11_DavitaCarveout" Tab	4					N			Billed Charges	4														1	4																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event CMS approves the use of a new technology, medication or service that is also considered a Covered Service by Provider and Health Plan, reimbursement will be set at the lesser of one hundred percent (100%) of the current Medicare allowable rate, or Provider's billed charges for such New Technology.	4
26	MOHTX11	MOHTX11	MOHTX11	MOHTX11_Molina Healthcare of TX_Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015_Medicaid/Medicare_4-1-2015	Veena	QC complete	Molina Healthcare of TX	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom_TX - AMD 2 - MMP - DAVITA 27-0888875 eff 11012015	Custom - Ancillary	ERROR	SECOND AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	2	1					Y	1	Molina Healthcare of Texas, Inc.	1	DaVita HealthCare Partners Inc	1									5605 MacArthur Blvd, Suite 400		Irving	TX	75038			1																										01-04-2015	3	01-04-2015	1	Y	1,3																30D	of the date such claim is delivered by provider to health plan and health plan determines such claim is complete/clean	5																												Ancillary		Medicaid/Medicare	4	MMP		4	Medicare-Medicaid	4																				Y	4	N		All inclusive treatment rate	4					See "MOHTX11_DavitaCarveout" Tab	4				See "MOHTX11_DavitaCarveout" Tab	4	See "MOHTX11_DavitaCarveout" Tab	4			See "MOHTX11_DavitaCarveout" Tab	4					N			Billed Charges	4														1	4																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event CMS approves the use of a new technology, medication or service that is also considered a Covered Service by Provider and Health Plan, reimbursement will be set at the lesser of one hundred percent (100%) of the current Medicare allowable rate, or Provider's billed charges for such New Technology.	4
27	CNCAZ13	CNCAZ13	CNCAZ13	CNCAZ13_Centene_Prof1_ABAN Care Contract - 562592781 MU.pdf_Medicaid_9-27-2018	Veena	QC complete	Centene	Prof1_ABAN Care Contract - 562592781 MU.pdf	Prof1_ABAN Care Contract - 562592781	Boilerplate - Professional	ERROR	Care1st Health Plan Arizona, Inc. Provider Agreement	2	Base Contract	2							Y	2	Care1st Health Plan Arizona Inc	2	Aban Care Clinic LLC	2	562592781	2	Aban Care Clinic LLC	2	562592781	2			2181 Highway 95		Bullhead City	Arizona				2																										27-09-2018	2	13-11-2018	2	N	2			Y	20	1 YEAR	20				6M	from the date of service	10	12M	from the date of service or eligibility	11										5WD	of receipt thereof	20	30D	of receipt	20												27-09-2018	2			Professional	24	Medicaid	24										N						N	N								Y	24	N		% AHCCCS Physician Fee Schedule	24										AHCCCS Physician Fee Schedule	24	Current	2	1	24					Y	24,25	Y			Billed Charges	24														1	24					Services with no rates shall be reimbursed according to Plan's criteria until rates are established	24			N																																												Y	25,26		Package Rate	Obstetrical Service Package Rate	current	0.85	N																																																																				Y	25		Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	25	Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	25		Fee Schedule	ACCCHS Fee Schedule	current	0.5	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	0.85	N	N						Y	25			% Fee Schedule	ACCCHS Fee Schedule	current	0.7				Y	25			% Fee Schedule & Flat Rate	ACCCHS Fee Schedule	current	90%, $200 PET Scan	N								N	N	N	N	N									N						Y	25	Administration of vaccines	Flat Rate	ACCCHS Fee Schedule	current	N						Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	1	Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	0.85	N						Y	24	% Fee Schedule	ACCCHS Fee Schedule	current	0.75	Y	25	% Fee Schedule	ACCCHS Fee Schedule	current	0.85	Y	25			Flat Rate	ACCCHS Fee Schedule	current	65		N								N							N						N					Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current	1	N						Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current	1	Y	25	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current	1	Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current	1	Y	24	% Fee Schedule	AHCCCS Behavioral Fee Schedule	current	1																																								N						N																																																																																																													Y	Payment for covered healthcare services provided by provider to plan members that do not qualify for FQHC/RHC payment shall be based on the lesser of the plan�s fee schedule defined in the table below or providers charges, less any applicable Co-payments, deductibles and Coinsurance services with no rates shall be reimbursed according to plans criteria until rates are established. At no time shall plan pay an amount that exceeds provider�s billed charges.	24
28	CNCNJ9	CNCNJ9	CNCNJ9	CNCNJ9_Centene_Prof1_ICM135705_ICMProviderAgreement_135705 IPA of NJ MU.pdf_Medicare Advantage_1-1-2022	Veena	QC complete	Centene	Prof1_ICM135705_ICMProviderAgreement_135705 IPA of NJ MU.pdf	IPA of North Jersey	Boilerplate - Professional	ERROR	WELLCARE NEW JERSEY MEDICARE ADVANTAGE AND/OR MEDICAID/FAMILYCARE PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	23	WellCare Health Plans of New Jersey, Inc.	23	IPA of New Jersey	2									703 Main Street		Paterson	NJ	7503			23																										01-01-2022	1	23-08-2021	23	N	1,23			Y	15	1 YEAR	15	15D	after such posting or notice or such other time period required for Health Plan to comply with Laws, Program Requirements or accreditation standards	10	180D	of the date of a Covered Service or the date of discharge from an inpatient facility, as the case may be	8	365D	from the date of service	44	45D	of its receipt of the clean claim	81	45D	of its receipt of the clean claim	81	30D	before the normal disposition date	74										30D	of the providers receipt of notice from health plan of such overpayments shall survive termination of this agreement	13						01-01-2022	1			Professional	81	Medicare Advantage	81			81		22					N						N	N								Y	81	N		% CMS Medicare Physician Fee Schedule	81										CMS Medicare Physician Fee Schedule	81	Current	81	1	81					Y	81-82	Y			Billed Charges	81														1	81									N																																																			N																																																																																														N																										N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								Y	81		% Fee Schedule	CMS Medicare Physician Fee Schedule	current	1	N						N					N						N						N						N						N						N																																						Y	81	% Fee Schedule	CMS Medicare FS	CURRENT	1		N						N
29	CHC7	CHC7	CHC7	CHC7_Community Health Choice_2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf_Medicaid_1-20-2022	Veena	QC complete	Community Health Choice	2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf	West Park Primary Care	Boilerplate - Professional	ERROR	Contract Review Form	1	Base Contract	2							Y	21	Community Health Choice, Inc.	2	Internal Medicine & Nephrology Associates, P.A. dba West Park Primary Care	2					202618150	21	1528183621	21	210 West Park Drive	Suite 104	Livingston	TX	77351	936-328-5820	936-328-5824	21					West Park Primary Care			22,23	1639175797, 1073576401, 1700236510	22,23	210 West Park Dr	Ste 104	Livingston	TX	77351	936-328-5820	936-328-5824	22,23	10592883, 12017989, 14995343	047563402, 173349503	8F0730, 281740YRE5, 535070YRE5		22,23	Internal Medicine; Nephrology, Family Practice, Nurse Practitioner-Certified	22,23	20-01-2022	21	20-01-2022	21	Y	1,21			Y	16	1 YEAR	16	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	10	95D	of the provision of the covered services	11				45D	for claims received by payor	11	30D	for claims received by payor	11				180D	payor's adjudication of a claim	11	180D	of the date of the original claim adjudication	11	15D	following receipt of physicians response to payors request	11	180D	from the date of the overpayment	12	45D	of the receipt of refund request	12	If Physician fails to refund overpayments, Physician agrees that Payor may recover overpayments through offsets against future payments.	12					Professional	24	Medicaid	24				CHIP	22					N						N	N								Y	24	N		% Fee Schedule											Texas Medicaid	24	Current	24	1.05	24					Y	24	Y			Billed Charges	24														1	24					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	24	N																																												Y	24	59612	Flat Fee + Code	Texas Medicaid Fee Schedule	current	$400+ 59514 rate	N																																																										Y	24	J2788,J2790-2792 All others		% Fee Schedule	Texas Medicaid	current	100% 120%																													N							Y	24	80000-87999	CPT Codes	0.6	Texas Medicaid Fee Schedule	current	0.6				Y	24	700000-79999	CPT codes	% Fee Schedule	Texas Medicaid Fee Schedule	current	0.8	N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																																						N							N						N																																																																																																													Y	Community shall process Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and according to Texas Medicaid reimbursement methodology	24
30	CHC7	CHC7	CHC7	CHC7_Community Health Choice_2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf_Medicaid_1-20-2022	Veena	QC complete	Community Health Choice	2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf	West Park Primary Care	Boilerplate - Professional	ERROR	Contract Review Form	1	Base Contract	2							Y	21	Community Health Choice, Inc.	2	Internal Medicine & Nephrology Associates, P.A. dba West Park Primary Care	2					202618150	21	1528183621	21	210 West Park Drive	Suite 104	Livingston	TX	77351	936-328-5820	936-328-5824	21					West Park Primary Care			22,23	1639175797, 1073576401, 1700236510	22,23	210 West Park Dr	Ste 104	Livingston	TX	77351	936-328-5820	936-328-5824	22,23	10592883, 12017989, 14995343	047563402, 173349503	8F0730, 281740YRE5, 535070YRE5		22,23	Internal Medicine; Nephrology, Family Practice, Nurse Practitioner-Certified	22,23	20-01-2022	21	20-01-2022	21	Y	1,21			Y	16	1 YEAR	16	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	10	95D	of the provision of the covered services	11				45D	for claims received by payor	11	30D	for claims received by payor	11				180D	payor's adjudication of a claim	11	180D	of the date of the original claim adjudication	11	15D	following receipt of physicians response to payors request	11	180D	from the date of the overpayment	12	45D	of the receipt of refund request	12	If Physician fails to refund overpayments, Physician agrees that Payor may recover overpayments through offsets against future payments.	12					Professional	24	Medicaid	24				STAR	2					N						N	N								Y	24	N		% Fee Schedule											Texas Medicaid	24	Current	24	1.05	24					Y	24	Y			Billed Charges	24														1	24					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	24	N																																												Y	24	59612	Flat Fee + Code	Texas Medicaid Fee Schedule	current	$400+ 59514 rate	N																																																										Y	24	J2788,J2790-2792 All others		% Fee Schedule	Texas Medicaid	current	100% 120%																													N							Y	24	80000-87999	CPT Codes	0.6	Texas Medicaid Fee Schedule	current	0.6				Y	24	700000-79999	CPT codes	% Fee Schedule	Texas Medicaid Fee Schedule	current	0.8	N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																																						N							N						N																																																																																																													Y	Community shall process Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and according to Texas Medicaid reimbursement methodology	24
31	CHC7	CHC7	CHC7	CHC7_Community Health Choice_2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf_Marketplace_1-20-2022	Veena	QC complete	Community Health Choice	2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf	West Park Primary Care	Boilerplate - Professional	ERROR	Contract Review Form	1	Base Contract	2							Y	21	Community Health Choice, Inc.	2	Internal Medicine & Nephrology Associates, P.A. dba West Park Primary Care	2					202618150	21	1528183621	21	210 West Park Drive	Suite 104	Livingston	TX	77351	936-328-5820	936-328-5824	21					West Park Primary Care			22,23	1639175797, 1073576401, 1700236510	22,23	210 West Park Dr	Ste 104	Livingston	TX	77351	936-328-5820	936-328-5824	22,23	10592883, 12017989, 14995343	047563402, 173349503	8F0730, 281740YRE5, 535070YRE5		22,23	Internal Medicine; Nephrology, Family Practice, Nurse Practitioner-Certified	22,23	20-01-2022	21	20-01-2022	21	Y	1,21			Y	16	1 YEAR	16	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	10	95D	of the provision of the covered services	11				45D	for claims received by payor	11	30D	for claims received by payor	11				180D	payor's adjudication of a claim	11	180D	of the date of the original claim adjudication	11	15D	following receipt of physicians response to payors request	11	180D	from the date of the overpayment	12	45D	of the receipt of refund request	12	If Physician fails to refund overpayments, Physician agrees that Payor may recover overpayments through offsets against future payments.	12					Professional	25	Marketplace	25	HIM				2					N						N	N								Y	25	N		% Fee Schedule											Medicare	25	Current	25	1.05	25					Y	25	Y			Billed Charges	25														1	25					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	25	N																																																			N															Y	25	Pediatric Vaccine pricing List	Flat Fee	CDC	CURRENT	1	Y	25			% Fee Schedule	Medicare DMEPOS Fee Schedule	CURRENT	0.8																													Y	25			% Fee Schedule	APS/Medicare	current	1																													N							Y	25	80000-87999	CPT Codes	1	Medicare Clinical Lab Fee Schedule	current	1				Y	25	700000-79999	CPT codes	% Fee Schedule	Medicare Fee Schedule	current	1	N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																																						N							N						N																																																																																																													Y	Community shall process Claims based on the then current Medicare Fee Schedule as applicable to services rendered and according to Medicare reimbursement methodology, including the geographic practice cost index (GPCI)	25
32	CHC7	CHC7	CHC7	CHC7_Community Health Choice_2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf_Medicare_1-20-2022	Veena	QC complete	Community Health Choice	2022 01 20 West Park Primary Care_Master (Master) PHY Executed.pdf.filepart MU.pdf	West Park Primary Care	Boilerplate - Professional	ERROR	Contract Review Form	1	Base Contract	2							Y	21	Community Health Choice, Inc.	2	Internal Medicine & Nephrology Associates, P.A. dba West Park Primary Care	2					202618150	21	1528183621	21	210 West Park Drive	Suite 104	Livingston	TX	77351	936-328-5820	936-328-5824	21					West Park Primary Care			22,23	1639175797, 1073576401, 1700236510	22,23	210 West Park Dr	Ste 104	Livingston	TX	77351	936-328-5820	936-328-5824	22,23	10592883, 12017989, 14995343	047563402, 173349503	8F0730, 281740YRE5, 535070YRE5		22,23	Internal Medicine; Nephrology, Family Practice, Nurse Practitioner-Certified	22,23	20-01-2022	21	20-01-2022	21	Y	1,21			Y	16	1 YEAR	16	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	10	95D	of the provision of the covered services	11				45D	for claims received by payor	11	30D	for claims received by payor	11				180D	payor's adjudication of a claim	11	180D	of the date of the original claim adjudication	11	15D	following receipt of physicians response to payors request	11	180D	from the date of the overpayment	12	45D	of the receipt of refund request	12	If Physician fails to refund overpayments, Physician agrees that Payor may recover overpayments through offsets against future payments.	12					Professional	26	Medicare	26				Dual Special Needs Plan (DSNP)	2					N						N	N								Y	26	N		% Fee Schedule											Medicare	26	Current	26	1	26							N			Billed Charges	26														1	26					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	26	N																																																			N																																																																																														N							N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																																						N							N						N																																																																																																													Y	Community shall process Claims based on the then current Medicare of 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 validation CLIA certification	26
33	CHC18	CHC18	CHC18	CHC18_Community Health Choice_Progressive Women's Health, PLLC_Physician Agreement MU.pdf_Medicaid_7-11-2022	Veena	QC complete	Community Health Choice	Progressive Women's Health, PLLC_Physician Agreement MU.pdf	Progressive Women's Health PLLC Physician Agreement	Custom - Professional	ERROR	Physician Agreement	1	Base Contract	1							Y	20	Community Health Choice, Inc.	1	Progressive Womens Health, PLLC	1			Progressive Womens Health, PLLC	20	274037380	20	1205130804	20	Po Box 799		Friendswood	TX	77549	281-993-4072	281-993-8051	20			220327502	21					1760622401, 1740810928	21	308 F Friendswood Dr	Ste 110	Friendswood	TX	77546	281-993-4072	281-993-8051	21	11955449, 15491525	2143257, Pending	TXB123875, 2B7648		21	Obstetrics and Gynecology, Family Nurse Practitioner	21			11-07-2022	20	N	1,20			Y	15	1 YEAR	15	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	9	95D	of the provision of the covered services	29	120D	of initial claim disposition	29	95D	from the date of services	28	95D	from the date of services	28	2Y	after receipt of a clean claim	29	45D	to submit a refund check or appeal the refund request	30	180D	of the date of the original claim adjudication	11	180D	of the date of the original claim adjudication	11	45D	to submit a refund check or appeal the refund request	30	45D	to submit a refund check or appeal the refund request	30							Professional	22	Medicaid	22				STAR+Plus	2					N	N					N	N								Y	22	N		% Fee Schedule											Medicaid	22	Current	22	1.05	22					Y	22	Y			Billed Charges	22														1	22					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	22	N																																												Y	22	59612	Flat Fee + Code	Texas Medicaid Fee Schedule	current	$400+ 59514 rate	N																																																											22	J2788,J2790-2792 All others		% Fee Schedule	Texas Medicaid	current																														N							Y	22	80000-87999	CPT Codes	% Fee Schedule	Texas Medicaid Clinical Lab Fee Schedule	current	0.6				Y	22	700000-79999	CPT codes	% Fee Schedule	Texas Medicaid Fee Schedule	current	0.8	N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																																						N							N						N																																																																																																													Y	Community shall process Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and according to Texas Medicaid reimbursement methodology	22
34	CHC18	CHC18	CHC18	CHC18_Community Health Choice_Progressive Women's Health, PLLC_Physician Agreement MU.pdf_Medicaid_7-11-2022	Veena	QC complete	Community Health Choice	Progressive Women's Health, PLLC_Physician Agreement MU.pdf	Progressive Women's Health PLLC Physician Agreement	Custom - Professional	ERROR	Physician Agreement	1	Base Contract	1							Y	20	Community Health Choice, Inc.	1	Progressive Womens Health, PLLC	1			Progressive Womens Health, PLLC	20	274037380	20	1205130804	20	Po Box 799		Friendswood	TX	77549	281-993-4072	281-993-8051	20			220327502	21					1760622401, 1740810928	21	308 F Friendswood Dr	Ste 110	Friendswood	TX	77546	281-993-4072	281-993-8051	21	11955449, 15491525	2143257, Pending	TXB123875, 2B7648		21	Obstetrics and Gynecology, Family Nurse Practitioner	21			11-07-2022	20	N	1,20			Y	15	1 YEAR	15	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	9	95D	of the provision of the covered services	29	120D	of initial claim disposition	29	95D	from the date of services	28	95D	from the date of services	28	2Y	after receipt of a clean claim	29	45D	to submit a refund check or appeal the refund request	30	180D	of the date of the original claim adjudication	11	180D	of the date of the original claim adjudication	11	45D	to submit a refund check or appeal the refund request	30	45D	to submit a refund check or appeal the refund request	30							Professional	22	Medicaid	22				STAR	2					N	N					N	N								Y	22	N		% Fee Schedule											Medicaid	22	Current	22	1.05	22					Y	22	Y			Billed Charges	22														1	22					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	22	N																																												Y	22	59612	Flat Fee + Code	Texas Medicaid Fee Schedule	current	$400+ 59514 rate	N																																																											22	J2788,J2790-2792 All others		% Fee Schedule	Texas Medicaid	current																														N							Y	22	80000-87999	CPT Codes	% Fee Schedule	Texas Medicaid Clinical Lab Fee Schedule	current	0.6				Y	22	700000-79999	CPT codes	% Fee Schedule	Texas Medicaid Fee Schedule	current	0.8	N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																																						N							N						N																																																																																																													Y	Community shall process Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and according to Texas Medicaid reimbursement methodology	22
35	CHC18	CHC18	CHC18	CHC18_Community Health Choice_Progressive Women's Health, PLLC_Physician Agreement MU.pdf_Medicaid_7-11-2022	Veena	QC complete	Community Health Choice	Progressive Women's Health, PLLC_Physician Agreement MU.pdf	Progressive Women's Health PLLC Physician Agreement	Custom - Professional	ERROR	Physician Agreement	1	Base Contract	1							Y	20	Community Health Choice, Inc.	1	Progressive Womens Health, PLLC	1			Progressive Womens Health, PLLC	20	274037380	20	1205130804	20	Po Box 799		Friendswood	TX	77549	281-993-4072	281-993-8051	20			220327502	21					1760622401, 1740810928	21	308 F Friendswood Dr	Ste 110	Friendswood	TX	77546	281-993-4072	281-993-8051	21	11955449, 15491525	2143257, Pending	TXB123875, 2B7648		21	Obstetrics and Gynecology, Family Nurse Practitioner	21			11-07-2022	20	N	1,20			Y	15	1 YEAR	15	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	9	95D	of the provision of the covered services	29	120D	of initial claim disposition	29	95D	from the date of services	28	95D	from the date of services	28	2Y	after receipt of a clean claim	29	45D	to submit a refund check or appeal the refund request	30	180D	of the date of the original claim adjudication	11	180D	of the date of the original claim adjudication	11	45D	to submit a refund check or appeal the refund request	30	45D	to submit a refund check or appeal the refund request	30							Professional	22	Medicaid	22				STAR	2					N	N					N	N								Y	22	N		% Fee Schedule											Medicaid	22	Current	22	1.05	22					Y	22	Y			Billed Charges	22														1	22					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	22	N																																												Y	22	59612	Flat Fee + Code	Texas Medicaid Fee Schedule	current	$400+ 59514 rate	N																																																											22	J2788,J2790-2792 All others		% Fee Schedule	Texas Medicaid	current																														N							Y	22	80000-87999	CPT Codes	% Fee Schedule	Texas Medicaid Clinical Lab Fee Schedule	current	0.6				Y	22	700000-79999	CPT codes	% Fee Schedule	Texas Medicaid Fee Schedule	current	0.8	N								N	N	N	N	N															N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																						N																N							N						N																																																																																																													Y	Community shall process Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and according to Texas Medicaid reimbursement methodology	22
36	CHC18	CHC18	CHC18	CHC18_Community Health Choice_Progressive Women's Health, PLLC_Physician Agreement MU.pdf_Marketplace_7-11-2022	Veena	QC complete	Community Health Choice	Progressive Women's Health, PLLC_Physician Agreement MU.pdf	Progressive Women's Health PLLC Physician Agreement	Custom - Professional	ERROR	Physician Agreement	1	Base Contract	1							Y	20	Community Health Choice, Inc.	1	Progressive Womens Health, PLLC	1			Progressive Womens Health, PLLC	20	274037380	20	1205130804	20	Po Box 799		Friendswood	TX	77549	281-993-4072	281-993-8051	20			220327502	21					1760622401, 1740810928	21	308 F Friendswood Dr	Ste 110	Friendswood	TX	77546	281-993-4072	281-993-8051	21	11955449, 15491525	2143257, Pending	TXB123875, 2B7648		21	Obstetrics and Gynecology, Family Nurse Practitioner	21			11-07-2022	20	N	1,20			Y	15	1 YEAR	15	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	9	95D	of the provision of the covered services	29	120D	of initial claim disposition	29	95D	from the date of services	28	95D	from the date of services	28	2Y	after receipt of a clean claim	29	45D	to submit a refund check or appeal the refund request	30	180D	of the date of the original claim adjudication	11	180D	of the date of the original claim adjudication	11	45D	to submit a refund check or appeal the refund request	30	45D	to submit a refund check or appeal the refund request	30							Professional	22	Marketplace	23	Health Insurance Marketplace (HIKM)									N	N					N	N								Y	23	N		% Fee Schedule											Medicare	23	Current	23	1	23					Y	23	Y			Billed Charges	23														1	23					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	23	N																																																			N															Y	23	Covered Vaccines for which there is no allowable	% Fee Schedule	Medicaid Fee Schedule	CURRENT	1.05	Y	23			% Fee Schedule	Medicare DMEPOS Fee Schedule	current APS reimbursement	0.8																														23			% Fee Schedule	Medicare	current APS reimbursement	1																													N							Y	23	80000-87999	CPT Codes	% Fee Schedule	Medicare Clinical Lab Fee Schedule	current	0.6				Y	23	700000-79999	CPT codes	% Fee Schedule	Medicare Fee Schedule	current	0.8	N								N	N	N	N	N															N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																						N																N							N						N																																																																																																													Y	Community shall process Claims based on the then current Medicare Fee Schedule as applicable to services rendered and according to Medicare reimbursement methodology, including the geographic practice cost index (GPCI)	23
37	CHC18	CHC18	CHC18	CHC18_Community Health Choice_Progressive Women's Health, PLLC_Physician Agreement MU.pdf_Medicare_7-11-2022	Veena	QC complete	Community Health Choice	Progressive Women's Health, PLLC_Physician Agreement MU.pdf	Progressive Women's Health PLLC Physician Agreement	Custom - Professional	ERROR	Physician Agreement	1	Base Contract	1							Y	20	Community Health Choice, Inc.	1	Progressive Womens Health, PLLC	1			Progressive Womens Health, PLLC	20	274037380	20	1205130804	20	Po Box 799		Friendswood	TX	77549	281-993-4072	281-993-8051	20			220327502	21					1760622401, 1740810928	21	308 F Friendswood Dr	Ste 110	Friendswood	TX	77546	281-993-4072	281-993-8051	21	11955449, 15491525	2143257, Pending	TXB123875, 2B7648		21	Obstetrics and Gynecology, Family Nurse Practitioner	21			11-07-2022	20	N	1,20			Y	15	1 YEAR	15	90D	prior to the effective date of changes that materially affect the rights or responsibilities of provider under this agreement	9	95D	of the provision of the covered services	29	120D	of initial claim disposition	29	95D	from the date of services	28	95D	from the date of services	28	2Y	after receipt of a clean claim	29	45D	to submit a refund check or appeal the refund request	30	180D	of the date of the original claim adjudication	11	180D	of the date of the original claim adjudication	11	45D	to submit a refund check or appeal the refund request	30	45D	to submit a refund check or appeal the refund request	30							Professional	22	Medicare	24	HMO	HMO		CHIP	2					N	N					N	N								Y	24	N		% Fee Schedule											Medicare/Medicaid	24	Current	24	1	24							N			Billed Charges	24														1	24					If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods		30% billed charges	24	N																																																			N																																																																																														N							N											N								N								N	N	N	N	N															N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N																						N																N							N						N																																																																																																													Y	Community shall process Claims based on the then current Medicare of 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 validation CLIA certification	24
38	CHC19	CHC19	CHC19	CHC19_Community Health Choice_Progressive Women's Health, PLLC_Physician Services Agreement MU.pdf_Medicaid_5-5-2011	Veena	QC complete	Community Health Choice	Progressive Women's Health, PLLC_Physician Services Agreement MU.pdf	Progressive Women's Health PLLC Physician Services Agreement	Custom - Professional	ERROR	Physician Services Agreement ( Medicaid Group Provider)	1	Base Contract	3							Y	51	Community Health Choice, Inc.	3	Progressive Womens Health, PLLC	3					274037380	21	1205130804	21	P.O. Box 89708		Houston	TX	77289-0708			51									1760622401	57																		05-05-2011	51	Y	3,51			Y	38	1 YEAR	38	30D	after HMO notifies THHSC of the change in writing	43							30D	from the date of receipt	44	30D	from the date of receipt	44										30D	from the receipt of the required information (date the claim becomes clean)	44													Professional	52,53	Medicaid	52,53				STAR+PLUS	29			Obstetrics-Gynecology, Dermatology, Neurology, Cardiology, Hematology, Allergy, General Surgery, Urology, Ophthalmology, Orthopedics, Otolaryngology, Thoracic Surgery, Podiatry, Radiology, Nuclear Medicine, Rehabilitation Medicine, Outpatient Sterilization Services, Outpatient Lab, X-Ray and other ambulatory diagnostic tests(inclusive of facility charges), Any other physician services the Beneficiary/Member is entitled to under the applicable Benefit Program	55	N				N		N	Y	27	claims not paid within such 30-day period	27	1.5% per month (18% annual( for each month the claim remains unpaid	27			Y	52,53	N		% Fee Schedule											Texas Medicaid	52,53	Current	52,53	1	52,53					Y	52,53	Y			Billed Charges	52,53														1	52,53									N																																																			N																																																																																														N							N											N								N								N	N	N	N	N															N						N						N						N						N						N						N						N									N								Y	52		% Fee Schedule	Texas Medicaid Fee Schedule	CURRENT	1	N						N					N						N						N						N						N						N						N									N							N		N		N								N		N		Y	53	% Fee Schedule	Texas Medicaid Fee schedule	CURRENT	1	N	N						N																																																																																																													Y	N
39	HN10	HN10	HN10	HN10_HealthNet of Cali_ASMG MU.pdf_Commercial_3-1-2017	Veena	QC complete	HealthNet of Cali	ASMG MU.pdf	ASMG	Custom - Professional	ERROR	THIRD AMENDMENT TO THE PROVIDER PARTICIPATION AGREEMENT BETWEEN ANESTHESIA SERVICE MEDICAL GROUP, INC AND HEALTH NET OF CALIFORNIA, INC	1	Amendment	1	3	1					Y	2	Health Net of California, Inc.	1	Anesthesia Service Medical Group, Inc.	1			Anesthesia Service Medical Group, Inc.	2	951965700	2																																						01-03-2017	2	Y	1,2			N				30D	in advance	1																																					Professional	3	Commercial	3					1					N						N	N								Y	3	N		$ per ASA unit													Current	3			86.79 3/1/2017-2/28/2018 89.39 after 3/1/2018				Y	3	Y			Billed Charges	3														1	3									N																																																			N															Y	3	Procedures not listed and procedures with Relatives not Established	% billed charges	By Report Codes	current	0.85																												Y			$/ unit		3/1/2017 - 2/28/2018 3/1/2018- thereafter	$85.79/ASA unit $89.39/ASA unit																																							N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N				N		N						N									N							N		N	N	N								N	N	N	N	N			N			N	N						N																																																																																																													Y	N
40	HN12 - commercial	HN12	HN12	HN12 - commercial_HealthNet of Cali_Orange Co Radiation Oncology MU.pdf_Commercial_11-1-2013	Veena	QC complete	HealthNet of Cali	Orange Co Radiation Oncology MU.pdf	Orange Co Radiation Oncology	Custom - Professional	ERROR	CALIFORNIA PROVIDER PARTICIPATION AGREEMENT FEE-FOR-SERVICE DIRECT NETWORK TEMPLATE	1	Base Contract	1							Y	18	Health Net of California, Inc.	1					Orange County Radiation Oncology Med group	18	20718314	18	1992712699	19	1100-A N. Tastin Ave.		Santa Ana	CA	92705	714-835-8520	714-835-3610	19									1366454415, 1922010073	21	1100-A N. TUSTIN AVENUE, 31872 COAST HIGHWAY		SANTA ANA, LAGUNA BEACH	CA	92705, 92677	714-835-8520, 949-499-7196	714-835-3610, 949-499-4391	21	10964979, 10949729			G25051, A66204	21	Radiation Oncology	21			01-11-2013	18	Y	1,18			Y	12	1 YEAR	12	30D	before the effective date	32	120D	after Provider renders Contracted Services unless provider demonstrates good cause pursuant to applicable State law	8,9				180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29	180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29				365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9									Commercial	22	HMO	HMO	22		1					N						N	Y	29	# of months after the month of service	29	75% of usual allowance for claims submitted during the seventh through ninth month, 50% usual allowance for claims submitted during the tenth through twelfth month	29			Y	23			% Fee Schedule	23										CMS Allowable	23							0.8	23	Y	23	Y			Billed Charges	23														0.75	23																																																					Y	23	59400, 59510, 59610, 59618	Flat Fee			1700	N															Y	36	By report (BR) procedures, procedures not listed and procedures with relativities not established	% billed charges			0.75																												Y	23	Anesthesia Services when provided by an Anesthesiologist or Certified Registered Nurse Anesthetist, Medical/Surgical Services by an Anesthesiologist or Certified Registered Nurse Anesthetist	$/ASA unit , % Fee Schedule	ASA, CMS Allowable		$39/ASA unit , 80%			Y	23	With an established Medicare Value,		% Fee Schedule	CMS Allowable	current	100%,	Without an established Medicare Value: 90% AWP																																			Y	23	80050, 80055	CPT Codes	% Fee Schedule, Flat Fee for CPTs 80080, 80055	CMS Allowable		80%, CPT 80050: $20 CPT: 80055: $15																																																																																																																																																																	Y	23	With an established Medicare Value	% Fee Schedule	CMS Allowable	current	1	N	Without an established Medicare Value: 90% AWP
41	HN12 - commercial	HN12	HN12	HN12 - commercial_HealthNet of Cali_Orange Co Radiation Oncology MU.pdf_Commercial_11-1-2013	Veena	QC complete	HealthNet of Cali	Orange Co Radiation Oncology MU.pdf	Orange Co Radiation Oncology	Custom - Professional	ERROR	CALIFORNIA PROVIDER PARTICIPATION AGREEMENT FEE-FOR-SERVICE DIRECT NETWORK TEMPLATE	1	Base Contract	1							Y	18	Health Net of California, Inc.	1					Orange County Radiation Oncology Med group	18	20718314	18	1992712699	19	1100-A N. Tastin Ave.		Santa Ana	CA	92705	714-835-8520	714-835-3610	19									1366454415, 1922010073	21	1100-A N. TUSTIN AVENUE, 31872 COAST HIGHWAY		SANTA ANA, LAGUNA BEACH	CA	92705, 92677	714-835-8520, 949-499-7196	714-835-3610, 949-499-4391	21	10964979, 10949729			G25051, A66204	21	Radiation Oncology	21			01-11-2013	18	Y	1,18			Y	12	1 YEAR	12	30D	before the effective date	32	120D	after Provider renders Contracted Services unless provider demonstrates good cause pursuant to applicable State law	8,9				180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29	180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29				365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9									Commercial	22	POS	POS	22		1					N						N	Y	29	# of months after the month of service	29	75% of usual allowance for claims submitted during the seventh through ninth month, 50% usual allowance for claims submitted during the tenth through twelfth month	29			Y	23			% Fee Schedule	23										CMS Allowable	23							0.8	23	Y	23	Y			Billed Charges	23														0.75	23																																																					Y	23	59400, 59510, 59610, 59618	Flat Fee			1700	N															Y	36	By report (BR) procedures, procedures not listed and procedures with relativities not established	% billed charges			0.75																												Y	23	Anesthesia Services when provided by an Anesthesiologist or Certified Registered Nurse Anesthetist, Medical/Surgical Services by an Anesthesiologist or Certified Registered Nurse Anesthetist	$/ASA unit , % Fee Schedule	ASA, CMS Allowable		$39/ASA unit , 80%			Y	23	With an established Medicare Value,		% Fee Schedule	CMS Allowable	current	100%,	Without an established Medicare Value: 90% AWP																																			Y	23	80050, 80055	CPT Codes	% Fee Schedule, Flat Fee for CPTs 80080, 80055	CMS Allowable		80%, CPT 80050: $20 CPT: 80055: $15																																																																																																																																																																	Y	23	With an established Medicare Value	% Fee Schedule	CMS Allowable	current	1	N	Without an established Medicare Value: 90% AWP
42	HN12 - commercial	HN12	HN12	HN12 - commercial_HealthNet of Cali_Orange Co Radiation Oncology MU.pdf_Commercial_11-1-2013	Veena	QC complete	HealthNet of Cali	Orange Co Radiation Oncology MU.pdf	Orange Co Radiation Oncology	Custom - Professional	ERROR	CALIFORNIA PROVIDER PARTICIPATION AGREEMENT FEE-FOR-SERVICE DIRECT NETWORK TEMPLATE	1	Base Contract	1							Y	18	Health Net of California, Inc.	1					Orange County Radiation Oncology Med group	18	20718314	18	1992712699	19	1100-A N. Tastin Ave.		Santa Ana	CA	92705	714-835-8520	714-835-3610	19									1366454415, 1922010073	21	1100-A N. TUSTIN AVENUE, 31872 COAST HIGHWAY		SANTA ANA, LAGUNA BEACH	CA	92705, 92677	714-835-8520, 949-499-7196	714-835-3610, 949-499-4391	21	10964979, 10949729			G25051, A66204	21	Radiation Oncology	21			01-11-2013	18	Y	1,18			Y	12	1 YEAR	12	30D	before the effective date	32	120D	after Provider renders Contracted Services unless provider demonstrates good cause pursuant to applicable State law	8,9				180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29	180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29				365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9									Commercial	22	Tier 1 (HMO Tier)	HMO	22		1					N						N	Y	29	# of months after the month of service	29	75% of usual allowance for claims submitted during the seventh through ninth month, 50% usual allowance for claims submitted during the tenth through twelfth month	29			Y	23			% Fee Schedule	23										CMS Allowable	23							0.8	23	Y	23	Y			Billed Charges	23														0.75	23																																																					Y	23	59400, 59510, 59610, 59618	Flat Fee			1700	N															Y	36	By report (BR) procedures, procedures not listed and procedures with relativities not established	% billed charges			0.75																												Y	23	Anesthesia Services when provided by an Anesthesiologist or Certified Registered Nurse Anesthetist, Medical/Surgical Services by an Anesthesiologist or Certified Registered Nurse Anesthetist	$/ASA unit , % Fee Schedule	ASA, CMS Allowable		$39/ASA unit , 80%			Y	23	With an established Medicare Value,		% Fee Schedule	CMS Allowable	current	100%,	Without an established Medicare Value: 90% AWP																																			Y	23	80050, 80055	CPT Codes	% Fee Schedule, Flat Fee for CPTs 80080, 80055	CMS Allowable		80%, CPT 80050: $20 CPT: 80055: $15																																																																																																																																																																	Y	23	With an established Medicare Value	% Fee Schedule	CMS Allowable	current	1	N	Without an established Medicare Value: 90% AWP
43	HN12 - Medicare advantage	HN12	HN12	HN12 - Medicare advantage_HealthNet of Cali_Orange Co Radiation Oncology MU.pdf_Medicare_11-1-2013	Veena	QC complete	HealthNet of Cali	Orange Co Radiation Oncology MU.pdf	Orange Co Radiation Oncology	Custom - Professional	ERROR	CALIFORNIA PROVIDER PARTICIPATION AGREEMENT FEE-FOR-SERVICE DIRECT NETWORK TEMPLATE	1	Base Contract	1							Y	18	Health Net of California, Inc.	1					Orange County Radiation Oncology Med group	18	20718314	18	1992712699	19	1100-A N. Tastin Ave.		Santa Ana	CA	92705	714-835-8520	714-835-3610	19									1366454415, 1922010073	21	1100-A N. TUSTIN AVENUE, 31872 COAST HIGHWAY		SANTA ANA, LAGUNA BEACH	CA	92705, 92677	714-835-8520, 949-499-7196	714-835-3610, 949-499-4391	21	10964979, 10949729			G25051, A66204	21	Radiation Oncology	21			01-11-2013	18	Y	1,18			Y	12	1 YEAR	12	30D	before the effective date	32	120D	after Provider renders Contracted Services unless provider demonstrates good cause pursuant to applicable State law	8,9				180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29	180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29				365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9									Medicare	28					2					N						N	Y	29	# of months after the month of service	29	75% of usual allowance for claims submitted during the seventh through ninth month, 50% usual allowance for claims submitted during the tenth through twelfth month	29			Y	28			% Fee Schedule	28										CMS Allowable	28							1	28	Y	28	Y			Billed Charges	28														0.75	28									N																																																																		Y	36	By report (BR) procedures, procedures not listed and procedures with relativities not established	% billed charges			0.75																																																																																Y	28	80050, 80055	CPT Codes	Flat fee			80050: $20 80055: 15
44	HN12- Medical	HN12	HN12	#REF!	Veena	QC complete	HealthNet of Cali	Orange Co Radiation Oncology MU.pdf	Orange Co Radiation Oncology	Custom - Professional	ERROR	CALIFORNIA PROVIDER PARTICIPATION AGREEMENT FEE-FOR-SERVICE DIRECT NETWORK TEMPLATE	1	Base Contract	1							Y	18	Health Net of California, Inc.	1					Orange County Radiation Oncology Med group	18	20718314	18	1992712699	19	1100-A N. Tastin Ave.		Santa Ana	CA	92705	714-835-8520	714-835-3610	19									1366454415, 1922010073	21	1100-A N. TUSTIN AVENUE, 31872 COAST HIGHWAY		SANTA ANA, LAGUNA BEACH	CA	92705, 92677	714-835-8520, 949-499-7196	714-835-3610, 949-499-4391	21	10964979, 10949729			G25051, A66204	21	Radiation Oncology	21			01-11-2013	18	Y	1,18			Y	12	1 YEAR	12	30D	before the effective date	32	120D	after Provider renders Contracted Services unless provider demonstrates good cause pursuant to applicable State law	8,9				180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29	180D	after the month in which the Covered Service is rendered unless Provider demonstrates good cause pursuant to applicable State law	29				365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	of Health net's action or in the case of inaction	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9	365D	on the overpaid amount for claims arising from Benefit Programs regulated by the California Department of Managed Health Care	9														Medi-Cal	36					N						N	Y	29	# of months after the month of service	29	75% of usual allowance for claims submitted during the seventh through ninth month, 50% usual allowance for claims submitted during the tenth through twelfth month	29			Y	36	N		% Fee Schedule	36										California Medi-Cal Fee Schedule rates	36			1	36					Y	36	Y			Billed Charges	36														0.75	36									N																																																																		Y	36	By report (BR procedures and procedures not listed) - procedure with Medi-Cal Units not established but with a Medicare Value, By report (BR procedures and procedures not listed) - procedures without Medi-Cal Units or a Medicare established Value	% Fee Schedule, % Billed Charges	Medicare Allowable, Billed Charges	CURRENT	80%, 15%																																					Y	36	Pharmaceuticals without an established Medi-Cal Value		% Fee Schedule	Average Wholesale Price (AWP)	current	0.82																																																																																																																																																																																																												Y	36	Immunizations without an established Medi-Cal Value	% Fee Schedule	Average Wholesale Price (AWP)	current	0.82	N																																																																																																																																										Y	subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Exhibit E, Health Net shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 75% of Provider's billed charges.	36
45	CNCNJ10	CNCNJ10	CNCNJ10	CNCNJ10_Centene_22-3146927_ICMproviderAgreement_Medicaid_3-2-2021	Veena	QC complete	Centene	22-3146927_ICMproviderAgreement	22-3146927_ICMProviderAgreement_273971_1	Boilerplate - Professional	ERROR	WellCare New Jersey Medicare Advantage and/or Medicaid/FamilyCare Participating Provider Agreement	1	Base Contract	1							Y	21	WellCare Health Plans of New Jersey, Inc.	1	Rutgers, The State University of New Jersey, by and behalf of Robert Wood Johnson medical School (RWJMS)	1			Rutgers, The State University of New Jersey, by and behalf of Robert Wood Johnson Medical School (RWJMS)	21					89 French Street Suite 2300		New Brunswick	NJ	8901			21					Rutgers Health Group, Inc.	26					89 French Street, Suite 4100		New Brunswick	NJ	8901	732-235-6066		26		813423110			26					02-03-2021	21	N	1,21							30D	after such written notice is received by contracted provider	9	180D	from the date of covered service	36				30D		36	40D		36													18M	from the date of the first payment on the claim	38	45D	to submit reimbursement	38							Professional Services	76	Medicaid	76				New Jersey Medicaid/FamilyCare	17					N						N	N								Y	76	N		% Fee Schedule											CMS Medicare Fee Schedule	76	Current	76	100						Y	76	Y			Billed Charges	76														1	76									N																																																			N															Y	76		% Fee Schedule	CMS Medicare Physician Fee Schedule	current	1																																																																									N	N						N											N								N								N	N	N	N	N									N						Y	76		Flat Rate	Vaccines for Children Program (VFC)	current	N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						N									Y	36	Immunizations without an established Medi-Cal Value	% Fee Schedule	Average Wholesale Price (AWP)	current	0.82	N		N		N								N		N		N						N	N						Y	76	Fee for service	New Jersey contract	current	N																																																																																																										N
46	CNCNJ10	CNCNJ10	CNCNJ10	CNCNJ10_Centene_22-3146927_ICMproviderAgreement_Medicare Advantage_3-2-2021	Veena	QC complete	Centene	22-3146927_ICMproviderAgreement	22-3146927_ICMProviderAgreement_273971_1	Boilerplate - Professional	ERROR	WellCare New Jersey Medicare Advantage and/or Medicaid/FamilyCare Participating Provider Agreement	1	Base Contract	1							Y	21	WellCare Health Plans of New Jersey, Inc.	1	Rutgers, The State University of New Jersey, by and behalf of Robert Wood Johnson medical School (RWJMS)	1			Rutgers, The State University of New Jersey, by and behalf of Robert Wood Johnson Medical School (RWJMS)	21					89 French Street Suite 2300		New Brunswick	NJ	8901			21					Rutgers Health Group, Inc.	26					89 French Street, Suite 4100		New Brunswick	NJ	8901	732-235-6066		26		813423110			26					02-03-2021	21	N	1,21							30D	after such written notice is received by contracted provider	9	180D	from the date of covered service	36				30D		36	40D		36													18M	from the date of the first payment on the claim	38	45D	to submit reimbursement	38							Professional Services	76	Medicare Advantage	76					17					N						N	N								Y	78	N		% Fee Schedule											CMS Medicare Fee Schedule	78	Current	78	100						Y	78	Y			Billed Charges	78														1	78									N																																																			N																																																																																														N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								Y	78		% Fee Schedule	CMS Medicare Fee Schedule	current	1	N						N					N						N						N						N						N						N						N									Y	36	Immunizations without an established Medi-Cal Value	% Fee Schedule	Average Wholesale Price (AWP)	current	0.82	N		N		N								N		N		Y	78	% Fee Schedule	CMS Medicare Physician Fee Schedule	CURRENT	1	N	N						N					N																																																																																																								Y	Health plan shall only pay professional fees for such Covered Services, and shall not pay facility charges. Also Provider agrees not to bill Members for facility charges or to include such charges in the calculation of ember Expenses	78
47	MOHTX2-MCD	MOHTX2	MOHTX2	MOHTX2-MCD_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicaid_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicaid	2				STAR	26					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service.	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
48	MOHTX2-MCR	MOHTX2	MOHTX2	MOHTX2-MCR_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicare_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicare	2				CHIP	26					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost).	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
49	MOHTX2-MCD	MOHTX2	MOHTX2	MOHTX2-MCD_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicaid_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicaid	2				STAR	26					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service.	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
50	MOHTX2-MCD	MOHTX2	MOHTX2	MOHTX2-MCD_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicaid_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicaid	2				STAR	1					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service.	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
51	MOHTX2-MCD	MOHTX2	MOHTX2	MOHTX2-MCD_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicaid_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicaid	2				CHIP	1					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service.	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
52	MOHTX2-MCR	MOHTX2	MOHTX2	MOHTX2-MCR_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicare_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicare	2					1					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost).	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
53	MOHTX2-MCD	MOHTX2	MOHTX2	MOHTX2-MCD_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicaid_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicaid	2				STAR	1					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service.	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
54	MOHTX2-MCR	MOHTX2	MOHTX2	MOHTX2-MCR_Molina Healthcare of Texas, Inc._CustomFac_AMD - University of Medical Center of El Paso_Medicare_3-1-2012	Veena	QC Completed	Molina Healthcare of Texas, Inc.	CustomFac_AMD - University of Medical Center of El Paso	Medical Center of El Paso	Boilerplate - Facility	ERROR	AMENDMENT NUMBER001 TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1					Y	1	Molina Healthcare of Texas, Inc.	1	El Paso County Hospital District, DBA, University Medical Center of El Paso	1			El Paso County Hospital District, DBA, University Medical Center of El Paso	1	746000756	1																																				01-03-2012	1	01-03-2012	1	Y	1			N																																											Institutional	2	Medicare	2				CHIP	1					N						N	N								Y	2	N		% of Fee Schedule	2										Texas Medicaid Fee for Service Program	2	Current	2							Y	2	Y	Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost).	1	Providers allowable charge master rate	2																																																																											N																															Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7											Y	2	634, 636	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7																													N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	2	274-276, 278	REVENUE CODES	% billed charges equal to Provider's acquisition cost plus 5%	Billed Charges	current	0.7		N									N		N								N		N		N						N												N
55	HN13	HN13	HN13	HN13_HealthNet of Cali_Sierra Hematology & Oncology MU.pdf_Medicare_10-1-2006	Veena	QC complete	HealthNet of Cali	Sierra Hematology & Oncology MU.pdf	Sierra Hematology & Oncology	Custom - Professional	ERROR	Physician Group Services Agreement	1	Base Contract	1							Y	8	Health Net, Inc.	1					Sierra Hematology and Oncology	8	680305843	8			6555 Coyce ave ste 301		CARMICHAEL	CA	95608	916-961-0258	916-962-1973	8																												01-10-2006	8					Y	5	1 YEAR	5				120D	of rendering Covered Services	4	30BD	of receipt of such claim	3	30BD	of receipt of such claim	3	30BD	of receipt of such claim	3	5D	advance notice	5	365D	of the receipt o the denial	4											of notiication,unless contested pursuant to the Arbitration process	4							Professional	9	Medicare	9	PPO	PPO	9		22					N						N	N								Y	9	N		% Fee Schedule	9										CMS Medicare	9	Current	9							Y	9	Y			Billed Charges	9						by report procedures, unlisted procedures and relativities not established in RBRVS, Physicians services	9							75%, 100%	9									N																																												Y	9	59400, 59510	Flat Rate		CURRENT	1700	N															Y	9	"BY REPORT" procedures, unlisted procedures and relativities not established in RBRVS	% billed charges	Billed Charges		0.75																												Y	9		lesser of $39/unit,% billed charges	American Society of Anesthesiology (ASA) unit scale	current	$39/UNIT	Y	0.75	Y	9			% Fee Schedule, $ of Average Wholesale price, Billed Charges	CMS Provider Fee Schedule for Physicians locality, Average Wholesale Price, Billed Charges	current	110%		Y																											N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	9			% Fee Schedule, $ of Average Wholesale price, Billed Charges	CMS Provider Fee Schedule for Physicians locality, Average Wholesale Price, Billed Charges	current	110%	Y	Y	9		% Billed Charges, $ on Average Wholesale Price as established by MediSpan less 10%	Billed Charges, Average Wholesale Price as established by MediSpan less 10%	current	% Billed Charges, $ on Average Wholesale Price as established by MediSpan less 10%	Y		N		N								N		N		N						N												N																																																																																																								Y	Compensation shall be based on the Resource Based Relative Value Scale(RBRVS), the Conversion Factors(CF) and the Geographic Practice Cost Indices(GPCI) adjustment factors promulgates by the Centers for Medicare and Medicaid Services(CMS) for the Medicare Program	9
56	HN13	HN13	HN13	HN13_HealthNet of Cali_Sierra Hematology & Oncology MU.pdf_Medicare_10-1-2006	Veena	QC complete	HealthNet of Cali	Sierra Hematology & Oncology MU.pdf	Sierra Hematology & Oncology	Custom - Professional	ERROR	Physician Group Services Agreement	1	Base Contract	1							Y	8	Health Net, Inc.	1					Sierra Hematology and Oncology	8	680305843	8			6555 Coyce ave ste 301		CARMICHAEL	CA	95608	916-961-0258	916-962-1973	8																												01-10-2006	8					Y	5	1 YEAR	5				120D	of rendering Covered Services	4	30BD	of receipt of such claim	3	30BD	of receipt of such claim	3	30BD	of receipt of such claim	3	5D	advance notice	5	365D	of the receipt o the denial	4											of notiication,unless contested pursuant to the Arbitration process	4							Professional	9	Medicare	9	EPO	EPO	9		22					N						N	N								Y	9	N		% Fee Schedule	9										CMS Medicare	9	Current	9							Y	9	Y			Billed Charges	9						by report procedures, unlisted procedures and relativities not established in RBRVS, Physicians services	9							75%, 100%	9									N																																												Y	9	59400, 59510	Flat Rate		CURRENT	1700	N															Y	9	"BY REPORT" procedures, unlisted procedures and relativities not established in RBRVS	% billed charges	Billed Charges		0.75																												Y	9		lesser of $39/unit,% billed charges	American Society of Anesthesiology (ASA) unit scale	current	$39/UNIT	Y	0.75	Y	9			% Fee Schedule, $ of Average Wholesale price, Billed Charges	CMS Provider Fee Schedule for Physicians locality, Average Wholesale Price, Billed Charges	current	110%		Y																											N	N						N											N								N								N	N	N	N	N									N						N						N						N						N						N						N						N						N									N								N							N						N					N						N						N						N						N						N						Y	9			% Fee Schedule, $ of Average Wholesale price, Billed Charges	CMS Provider Fee Schedule for Physicians locality, Average Wholesale Price, Billed Charges	current	110%	Y	Y	9		% Billed Charges, $ on Average Wholesale Price as established by MediSpan less 10%	Billed Charges, Average Wholesale Price as established by MediSpan less 10%	current	% Billed Charges, $ on Average Wholesale Price as established by MediSpan less 10%	Y		N		N								N		N		N						N												N																																																																																																								Y	Compensation shall be based on the Resource Based Relative Value Scale(RBRVS), the Conversion Factors(CF) and the Geographic Practice Cost Indices(GPCI) adjustment factors promulgates by the Centers for Medicare and Medicaid Services(CMS) for the Medicare Program	9
57	CSNP23	CSNP23	CSNP23	CSNP23_CareSource_Custom_Norton Community Medical Associates__1-0-1900	Veena	QC complete	CareSource	Custom_Norton Community Medical Associates	Custom_Norton Community Medical Associates-IN MCD-ID C13931037AA	Custom - Professional	ERROR	ATTACHMENT A.4 REIMBURSEMENT FOR CareSource Just4Me Addendum to Agreement	1	Addendum	1																																																														N																																																		CHIP																					y	1	N	1	% Fee Schedule	1										CMS Medicare	1	Current	1							Y	1	Y			Billed Charges	1														100	1									N																																																																																																													Y	1			Flate Fee	Medicare Fee Schedule	current			N																																																																																																																																																																																																																																																																																																																																																											Y	For Medically Necessary Covered Services rendered to Members by Provider or by Group Practice Providers, in accordance with the terms of this Agreement, Provider or Group Practice Providers shall accept as payment in full the lesser of:	1
58	CSNP22	CSNP22	CSNP22	CSNP22_CareSource_Custom Community Medical Associates_20150217_Dually Executed_IN MP-ID C12324214AA_Marketplace_2-17-2015	Veena	QC complete	CareSource	Custom Community Medical Associates_20150217_Dually Executed_IN MP-ID C12324214AA	Custom_Community Medical Associates_20150217_Dually Executed_IN MP-ID C12324214AA	Custom - Professional	ERROR	CareSource Indiana, Inc. Group Practice Agreement	1	Base Contract	1			CareSource Indiana, Inc. Group Practice Agreement	1	42052	20	y	20	CareSource Indiana, Inc	1					Community Medical Associates, Norton Louisville Primary Care Center, Louisville Oncology	20	611276316, 610978438, 610703799	20			1930 Bishop Lane, Suite 1017		Louisville	KY	40218			20																												17-02-2015	20	42052	1,20			N				40D	prior written notice of an material change	5	180D	of the date covered services were rendered	25	30D	to pay corrected claim	12	30D	of receipt	25													60D	after discovery of any overpayment or any underpayment	11	18M	from the date of service	11	60D	of written notice from plan	6									Marketplace	21																	Y	25		31st day after receipt	25				Y	21			% Fee Schedule	21										CMS Medicare	21	Current	21	1.25	21					Y	21	Y			Billed Charges	21														1	21									N																																																																		Y	21	Services not on the Medicare Fee Schedule	% billed charges	Billed Charges	current	0.35																																					Y	21			% Fee Schedule	Medicare Fee Schedule	current	1.1	drugs that may be available through a specialty pharmacy benefits manager																													Y	21	% Fee Schedules	Medicare Allowed Amount for Adult Covered Persons, Medicare Allowed Amount for Pediatric Covered Persons	current	125%, 135%																																																																																																																																																																																				Y	21	covered codes under age of 18 years unless pregnant or legally emancipated		% Medicare Fee Schedule	Medicare Allowed Amount	CURRENT	1.35																																																																																																																															Y	Pediatric Covered Persons are defined as those Covered Persons who are under the age of eighteen (18) years unless pregnant or unless legally emancipated. All other Covered Persons who are not defined as Pediatric Covered Persons are referred to as Adult Covered Persons	21
59	CSNP21	CSNP21	CSNP21	CSNP21_CareSource_Custom_KentuckyOne Group Practice Provider Agreement_20140806_Dually Executed (1)_Marketplace_8-6-2014	Veena	QC Complete	CareSource	Custom_KentuckyOne Group Practice Provider Agreement_20140806_Dually Executed (1)	Custom_KentuckyOne Group Practice Provider Agreement_20140806_Dually Executed (1)	Custom - Professional	ERROR	CareSource Kentucky Co. Group Practice Agreement	1	Base Contract	1			CareSource Kentucky Co.	1			y	22	CareSource Kentucky Co.	22	KentuckyOne Health, inc.	1			KentuckyOne Health, Inc. behalf of itself and its Affiliates, Kentucky One Health Medical Group, Saint Joseph Health System, Inc., Flaget Professional Services, and Meade County Rural Health Clinic	22	See: "CSNP21_CS KentuckyOne Roster"	26 - 65			10200 Forest Green Blvc, Suite 400		Louisville	KY	40223			22																												06-08-2014	22					y	15	1 year	15	90D	prior written notice of the change	5													30D	in advance	67							24M	after discovery of any overpayment or any underpayment	12	24M	after discovery of any overpayment or any underpayment	12			12									Marketplace	23																									Y	23			Fee Schedule	23										CMS Medicare	23	Current	23	1.3						Y	23	Y			Billed Charges	23														1	23									N																																																																		Y	23	Valid codes recognized by the Centers for Medicare and Medicaid Services (CMS)	% fee schedule	Medicare Allowed Amount	current	1.3																																					Y	23			% Fee Schedule	Medicare Fee Schedule	current	1.3																														Y	23	% Fee Schedules	Medicare Allowed Amount	current	1.3
60	HN15	HN15	HN15	HN15_HealthNet of Cali_2014-01-01 United Health Centers San Joaquin AMD MU.pdf_Commercial_1-1-2014	Veena	QC complete	HealthNet of Cali	2014-01-01 United Health Centers San Joaquin AMD MU.pdf	2014-01-01 United Health Centers San Joaquin AMD	Custom - Professional	ERROR	AMENDMENT to the PROVIDER PARTICIPATION AGREEMENT between HEALTH NET OF CALIFORNIA, INC. and UNITED HEALTH CENTERS	1	Amendment	1							Y	1	Health Net of California. Inc.	1					United Health Centers	1																	Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	01-01-2014	Y	04-09-2013	1	N	1							30D	from the date of such request	2																																							Commercial	2	HMO	HMO	2							N															Y	3	N		Rates listed in Exhibit B.1-1	3																				Y	3	Y			Billed Charges	3														1	3									N																																												Y	3	59400, 59510, 59610, 59618	flat rate			1700																Y	3	Covered Services delivered or arranged by Provider, excluding Laboratory, By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established, and Pharmaceuticals/Immunizations without an established Medicare or AWP value	% Fee Schedule, % Billed Charges	CMS Allowable, Billed Charges	current	95%, 75%																												Y	3		$/unit	American Society of Anesthesiology (ASA) unit scale	current	$39/ASA unit	N		Y	3	With an established Medicare value, Without an established Medicare Value		% Fee Schedule	CMS Allowable, Average Wholesale Price (AWP)	current	95%, 95%		N																																		Y	3			% Fee Schedule	CMS Allowable	current	0.95	N		CPT 80050: $20 CPT 80055: $15																																																																																																																																																														Y	3	With an established Medicare Value, Without an established Medicare Value	% Fee Schedule	CMS Allowable, Average Whole Price (AWP)	current	95%, 95%	N																							Y	3	% Fee Schedule	CMS Allowable	current	0.95																																																																																																														Y	Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum G.1, Health Net or Payor shall pay and Provider shall accept as payment in full for noncapitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges	3
61	HN15	HN15	HN15	HN15_HealthNet of Cali_2014-01-01 United Health Centers San Joaquin AMD MU.pdf_Commercial_1-1-2014	Veena	QC complete	HealthNet of Cali	2014-01-01 United Health Centers San Joaquin AMD MU.pdf	2014-01-01 United Health Centers San Joaquin AMD	Custom - Professional	ERROR	AMENDMENT to the PROVIDER PARTICIPATION AGREEMENT between HEALTH NET OF CALIFORNIA, INC. and UNITED HEALTH CENTERS	1	Amendment	1							Y	1	Health Net of California. Inc.	1					United Health Centers	1																	Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	01-01-2014	Y	04-09-2013	1	N	1							30D	from the date of such request	2																																							Commercial	2	PPO	PPO	2							N															Y	3	N		Rates listed in Exhibit B.1-1	3																				Y	3	Y			Billed Charges	3														1	3									N																																												Y	3	59400, 59510, 59610, 59618	flat rate			1700																Y	3	Covered Services delivered or arranged by Provider, excluding Laboratory, By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established, and Pharmaceuticals/Immunizations without an established Medicare or AWP value	% Fee Schedule, % Billed Charges	CMS Allowable, Billed Charges	current	95%, 75%																												Y	3		$/unit	American Society of Anesthesiology (ASA) unit scale	current	$39/ASA unit	N		Y	3	With an established Medicare value, Without an established Medicare Value		% Fee Schedule	CMS Allowable, Average Wholesale Price (AWP)	current	95%, 95%		N																																		Y	3			% Fee Schedule	CMS Allowable	current	0.95	N		CPT 80050: $20 CPT 80055: $15																																																																																																																																																														Y	3	With an established Medicare Value, Without an established Medicare Value	% Fee Schedule	CMS Allowable, Average Whole Price (AWP)	current	95%, 95%	N																							Y	3	% Fee Schedule	CMS Allowable	current	0.95																																																																																																														Y	Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum G.1, Health Net or Payor shall pay and Provider shall accept as payment in full for noncapitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges	3
62	HN15	HN15	HN15	HN15_HealthNet of Cali_2014-01-01 United Health Centers San Joaquin AMD MU.pdf_Commercial_1-1-2014	Veena	QC complete	HealthNet of Cali	2014-01-01 United Health Centers San Joaquin AMD MU.pdf	2014-01-01 United Health Centers San Joaquin AMD	Custom - Professional	ERROR	AMENDMENT to the PROVIDER PARTICIPATION AGREEMENT between HEALTH NET OF CALIFORNIA, INC. and UNITED HEALTH CENTERS	1	Amendment	1							Y	1	Health Net of California. Inc.	1					United Health Centers	1																	Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	01-01-2014	Y	04-09-2013	1	N	1							30D	from the date of such request	2																																							Commercial	2	EPO	EPO	2							N															Y	3	N		Rates listed in Exhibit B.1-1	3																				Y	3	Y			Billed Charges	3														1	3									N																																												Y	3	59400, 59510, 59610, 59618	flat rate			1700																Y	3	Covered Services delivered or arranged by Provider, excluding Laboratory, By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established, and Pharmaceuticals/Immunizations without an established Medicare or AWP value	% Fee Schedule, % Billed Charges	CMS Allowable, Billed Charges	current	95%, 75%																												Y	3		$/unit	American Society of Anesthesiology (ASA) unit scale	current	$39/ASA unit	N		Y	3	With an established Medicare value, Without an established Medicare Value		% Fee Schedule	CMS Allowable, Average Wholesale Price (AWP)	current	95%, 95%		N																																		Y	3			% Fee Schedule	CMS Allowable	current	0.95	N		CPT 80050: $20 CPT 80055: $15																																																																																																																																																														Y	3	With an established Medicare Value, Without an established Medicare Value	% Fee Schedule	CMS Allowable, Average Whole Price (AWP)	current	95%, 95%	N																							Y	3	% Fee Schedule	CMS Allowable	current	0.95																																																																																																														Y	Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum G.1, Health Net or Payor shall pay and Provider shall accept as payment in full for noncapitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges	3
63	HN15	HN15	HN15	HN15_HealthNet of Cali_2014-01-01 United Health Centers San Joaquin AMD MU.pdf_Commercial_1-1-2014	Veena	QC complete	HealthNet of Cali	2014-01-01 United Health Centers San Joaquin AMD MU.pdf	2014-01-01 United Health Centers San Joaquin AMD	Custom - Professional	ERROR	AMENDMENT to the PROVIDER PARTICIPATION AGREEMENT between HEALTH NET OF CALIFORNIA, INC. and UNITED HEALTH CENTERS	1	Amendment	1							Y	1	Health Net of California. Inc.	1					United Health Centers	1																	Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	01-01-2014	Y	04-09-2013	1	N	1							30D	from the date of such request	2																																							Commercial	2	POS	POS	2							N															Y	3	N		Rates listed in Exhibit B.1-1	3																				Y	3	Y			Billed Charges	3														1	3									N																																												Y	3	59400, 59510, 59610, 59618	flat rate			1700																Y	3	Covered Services delivered or arranged by Provider, excluding Laboratory, By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established, and Pharmaceuticals/Immunizations without an established Medicare or AWP value	% Fee Schedule, % Billed Charges	CMS Allowable, Billed Charges	current	95%, 75%																												Y	3		$/unit	American Society of Anesthesiology (ASA) unit scale	current	$39/ASA unit	N		Y	3	With an established Medicare value, Without an established Medicare Value		% Fee Schedule	CMS Allowable, Average Wholesale Price (AWP)	current	95%, 95%		N																																		Y	3			% Fee Schedule	CMS Allowable	current	0.95	N		CPT 80050: $20 CPT 80055: $15																																																																																																																																																														Y	3	With an established Medicare Value, Without an established Medicare Value	% Fee Schedule	CMS Allowable, Average Whole Price (AWP)	current	95%, 95%	N																							Y	3	% Fee Schedule	CMS Allowable	current	0.95																																																																																																														Y	Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum G.1, Health Net or Payor shall pay and Provider shall accept as payment in full for noncapitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges	3
64	HN15	HN15	HN15	HN15_HealthNet of Cali_2014-01-01 United Health Centers San Joaquin AMD MU.pdf_Commercial_1-1-2014	Veena	QC complete	HealthNet of Cali	2014-01-01 United Health Centers San Joaquin AMD MU.pdf	2014-01-01 United Health Centers San Joaquin AMD	Custom - Professional	ERROR	AMENDMENT to the PROVIDER PARTICIPATION AGREEMENT between HEALTH NET OF CALIFORNIA, INC. and UNITED HEALTH CENTERS	1	Amendment	1							Y	1	Health Net of California. Inc.	1					United Health Centers	1																	Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	01-01-2014	Y	04-09-2013	1	N	1							30D	from the date of such request	2																																							Commercial	2	Leased PPO Benefits Program	PPO	2							N															Y	3	N		Rates listed in Exhibit B.1-1	3																				Y	3	Y			Billed Charges	3														1	3									N																																												Y	3	59400, 59510, 59610, 59618	flat rate			1700																Y	3	Covered Services delivered or arranged by Provider, excluding Laboratory, By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established, and Pharmaceuticals/Immunizations without an established Medicare or AWP value	% Fee Schedule, % Billed Charges	CMS Allowable, Billed Charges	current	95%, 75%																												Y	3		$/unit	American Society of Anesthesiology (ASA) unit scale	current	$39/ASA unit	N		Y	3	With an established Medicare value, Without an established Medicare Value		% Fee Schedule	CMS Allowable, Average Wholesale Price (AWP)	current	95%, 95%		N																																		Y	3			% Fee Schedule	CMS Allowable	current	0.95	N		CPT 80050: $20 CPT 80055: $15																																																																																																																																																														Y	3	With an established Medicare Value, Without an established Medicare Value	% Fee Schedule	CMS Allowable, Average Whole Price (AWP)	current	95%, 95%	N																							Y	3	% Fee Schedule	CMS Allowable	current	0.95																																																																																																														Y	Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum G.1, Health Net or Payor shall pay and Provider shall accept as payment in full for noncapitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges	3
65	MOHTX36	MOHTX36	MOHTX36	MOHTX36_Molina Healthcare of TX_Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923_Medicaid_9-15-2018	Veena	Qc complete	Molina Healthcare of TX	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom - Professional	ERROR	MOLINA HEALTHCARE OF TEXAS, INC. PROVIDER SERVICES AGREEMENT	1	Base Contract	1							Y	1							Advanced Gastroenterology of Texas PLLC	1	464543923	1	1942685409	1	po Box 801344		Dallas	TX	75380			1					Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	15-09-2018	2	15-09-2018	1	Y	1			Y	9	IN EFFECT UNTIL TEMRINATED BY EITHRE PARTY IN ACCORDANCE	9				30D	from the date the claim is received by Health Plan	21				21D	of receipt for pharmacy covered services	21	18D	of receipt for pharmacy covered services	21				120D	OF THE INITIAL DENIAL	22	120D	DATE OF REMITTANCE ADVICE	22	30D	OF RECEIPT	22															Medicaid	14																	Y	21	all clean claims that are not adjudicated within 30 days	21	0.18	21			y	15			Fee for Service	15										Medicaid Fee-For-Service Program Fee Schedule	15	current	15									N			Billed Charges	15														1	15																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	Date of Service, Covered Services determined by Health Plan to be In the event that there is no payment rate in the Texas Medicaid Fee-For-Service Program Fee Schedule as of the Date of Service, covered services determined by Health Plan to be payable and submitted on a Clean Claim will be paid on a fee-for-service basis, less any applicable Member copayments, of: deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any, at the lesser(i) Provider's billed charges; or (ii) an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate set forth by CMS (adjusted for locality or geography), as of the Date of Service.	15
66	MOHTX36	MOHTX36	MOHTX36	MOHTX36_Molina Healthcare of TX_Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923_Medicaid_9-15-2018	Veena	QC complete	Molina Healthcare of TX	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom - Professional	ERROR	MOLINA HEALTHCARE OF TEXAS, INC. PROVIDER SERVICES AGREEMENT	1	Base Contract	1							Y	1							Advanced Gastroenterology of Texas PLLC	1	464543923	1	1942685409	1	po Box 801344		Dallas	TX	75380			1					Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	15-09-2018	2	15-09-2018	1	Y	1			Y	9	IN EFFECT UTIL TEMRINATED BY EITHRE PARTY IN ACCORDANCE	9				30D	from the date the claim is received by Health Plan	21				21D	of receipt for pharmacy covered services	21	18D	of receipt for pharmacy covered services	21				120D	OF THE INITIAL DENIAL	22	120D	DATE OF REMITTANCE ADVICE	22	30D	OF RECEIPT	22															Medicaid	14				CHIP	14																				y	15			Fee for Service	15										Medicaid Fee-For-Service Program Fee Schedule	15	current	15									N			Billed Charges	15														1	15																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event that there is no payment rate in the Texas Medicaid Fee-For-Service Program fee schedule as of the Date of Service, Covered Services determined by Health Plan to be payable and submitted on a Clean Claim will be paid on a fee-for-service basis, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any, at the lesser of: (i) Provider's billed charges; or (ii) an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate set forth by CMS (adjusted for locality or geography), as of the Date of Service.	15
67	MOHTX36	MOHTX36	MOHTX36	MOHTX36_Molina Healthcare of TX_Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923_Medicare Advantage_9-15-2018	Veena	QC Complete	Molina Healthcare of TX	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom - Professional	ERROR	MOLINA HEALTHCARE OF TEXAS, INC. PROVIDER SERVICES AGREEMENT	1	Base Contract	1							Y	1							Advanced Gastroenterology of Texas PLLC	1	464543923	1	1942685409	1	po Box 801344		Dallas	TX	75380			1					Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	15-09-2018	2	15-09-2018	1	Y	1			Y	9	IN EFFECT UTIL TEMRINATED BY EITHRE PARTY IN ACCORDANCE	9				30D	from the date the claim is received by Health Plan	21				21D	of receipt for pharmacy covered services	21	18D	of receipt for pharmacy covered services	21	10Y	FROM THE END OF THE CONTRACT PERIOD BETWEEN HEALTH PLAN AND CMS OR COMPLETION OF AUDIT,WHICHEVER IS LATER	26	120D	OF THE INITIAL DENIAL	22	120D	DATE OF REMITTANCE ADVICE	22	30D	OF RECEIPT	22															Medicare Advantage	14																									y	15			Fee for Service	15										Medicare Fee-For-Service Program Fee Schedule	15	current	15									N			Billed Charges	15														1	15																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	Service. The Medicare Fee-For-Service Program allowable payment rate deducts any cost sharing amounts, including, but not limited to, co-payments, deductibles, coinsurance, or amounts paid or to be paid by other liable third parties that would have been deducted if the Member were enrolled in the Medicare Fee-For-Service Program	15
68	MOHTX36	MOHTX36	MOHTX36	MOHTX36_Molina Healthcare of TX_Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923_Medicaid/Medicare_9-15-2018	Veena	Qc Complete	Molina Healthcare of TX	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom - Professional	ERROR	MOLINA HEALTHCARE OF TEXAS, INC. PROVIDER SERVICES AGREEMENT	1	Base Contract	1							Y	1							Advanced Gastroenterology of Texas PLLC	1	464543923	1	1942685409	1	po Box 801344		Dallas	TX	75380			1					Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	15-09-2018	2	15-09-2018	1	Y	1			Y	9	IN EFFECT UTIL TEMRINATED BY EITHRE PARTY IN ACCORDANCE	9				30D	from the date the claim is received by Health Plan	21				21D	of receipt for pharmacy covered services	21	18D	of receipt for pharmacy covered services	21	10Y	FROM THE END OF THE CONTRACT PERIOD BETWEEN HEALTH PLAN AND CMS OR COMPLETION OF AUDIT,WHICHEVER IS LATER	30	120D	OF THE INITIAL DENIAL	22	120D	DATE OF REMITTANCE ADVICE	22	30D	OF RECEIPT	22															Medicaid/Medicare	14																									Y	16			Medicare Fee for Service then Medicaid/Medicaid Managed care plan	16										Medicare/Medicaid Fee-For-Service Program Fee Schedules	16	current	16									N			Billed Charges	16														1	16																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	Provider will receive an amount equivalent to the Medicare Fee-For-Service Program allowable payment rates (adjusted for place of service or geography) as of the Date of Service, and any portion, if any, that the Medicaid agency or Medicaid managed care plan would have been responsible for paying if the Member was enrolled in the Medicare Fee-For-Service Program. The Medicare Fee-For-Service Program allowable payment rate deducts any cost sharing amounts, including, but not limited to, co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties that would have been deducted if the Member were enrolled in the Medicare Fee-For-Service Program. In the event the Provider bills for Services covered by Medicaid or that are primary to Medicaid, but not Medicare, Health Plan agrees to compensate Provider on a fee-for-service basis for such Covered Services provided that are determined by Health Plan to be payable and submitted on a Clean Claim, less any applicable Member copayments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any, at the lesser of: (i) Provider's billed charges; or (ii) at an amount equivalent to the Medicaid Fee-For-Service Program allowable payment rates set forth by the State of Texas in effect on the Date of Service. Provider agrees to the above reimbursement and participation in Medicare-	16
69	MOHTX36	MOHTX36	MOHTX36	MOHTX36_Molina Healthcare of TX_Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923_Marketplace_9-15-2018	Veena	QC complete	Molina Healthcare of TX	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923	Custom - Professional	ERROR	MOLINA HEALTHCARE OF TEXAS, INC. PROVIDER SERVICES AGREEMENT	1	Base Contract	1							Y	1							Advanced Gastroenterology of Texas PLLC	1	464543923	1	1942685409	1	po Box 801344		Dallas	TX	75380			1					Advanced Gastroenterology of Texas PLC																			Nurse Practitioner - Family	42	15-09-2018	2	15-09-2018	1	Y	1			Y	9	IN EFFECT UTIL TEMRINATED BY EITHRE PARTY IN ACCORDANCE	9				30D	from the date the claim is received by Health Plan	21				21D	of receipt for pharmacy covered services	21	18D	of receipt for pharmacy covered services	21	10Y	FROM THE END OF THE CONTRACT PERIOD BETWEEN HEALTH PLAN AND CMS OR COMPLETION OF AUDIT,WHICHEVER IS LATER	30	120D	OF THE INITIAL DENIAL	22	120D	DATE OF REMITTANCE ADVICE	22	30D	OF RECEIPT	22															Marketplace	14	Health Insurance Marketplace																								Y	16			Medicare/Medicaid Fee for Service	16										Medicare/Medicaid Fee-For-Service Program Fee Schedules	16	current	16							N		N	N		Billed Charges	16														1	16																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	health Plan agrees to compensate Provider on a fee-for service basis for Covered Services provided in accordance with the Health Insurance Marketplace Product, that are determined by Health Plan to be payable and submitted on a Clean Claim, less any applicable Member copayments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any, at the lesser of: (i) Provider's billed charges; or (ii) an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the Date of Service. In the event that there is no payment rate in the Medicare Fee-For-Service Program fee schedule as of the Date of Service, Covered Services determined by Health Plan to be payable and submitted on a Clean Claim will be paid on a fee-for-service basis, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any, at the lesser of: (i) Provider's billed charges; or (ii) an amount equivalent to the allowable rate under the applicable Medicaid Fee-For-Service Program fee schedule set forth by the State of Texas, in effect on the Date of Service. Notwithstanding the above, in no event will payment for any Covered Service exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the Date of Service.	16
70	MOHTX37	MOHTX37	MOHTX37	MOHTX37_Molina Healthcare of TX_Custom_TX - MP AMENDMENT - MISSION HEALTH NETWORK -MU.pdf_Marketplace_1-1-2014	Veena	QC Complete	Molina Healthcare of TX	Custom_TX - MP AMENDMENT - MISSION HEALTH NETWORK -MU.pdf	Custom_TX - MP AMENDMENT - MISSION HEALTH NETWORK -	Custom - Professional	ERROR	HEALTH BENEFIT EXCHANGE AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. PROVIDER SERVICES AGREEMENT	1	Base Contract	1							Y	1							Mission Health Network	1					910 S. Bryan Rd Ste 301		Mission	TX	78572			1																										01-01-2014	4	17-07-2013	1	N	1,4										95D	AFTER THE DATE THE PROVIDER PROVIDES HEALTH CARE SERVICES FOR WHICH THE CLAIM IS MADE	6			6	45D	AFTER THE DATE THE HEALTH PLAN RECEIVES A LEAN CLAIM FROM A PROVIDER	6	30D	AFTER THE DATE THE HEALTH PLAN RECEIVES A LEAN CLAIM FROM A PROVIDER	6			6												6			6									Marketplace	1, 3																	Y	7	1) FAILS TO MAKE A PAYMENT ON A CLEAN CLAIM WIHTIN THE REQUIRED TIME FRAMES; 2) pays only a portion of the amount of a Clean Claim within the required time frames,	7	1A. Payment is made on or after the 1st day and before the 46th - Health Plan will pay the Provider making the claim the contracted rate owed on the claim plus a penalty in the amount of the lesser of: (1) 50 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate or (2) $100,000 1B. Payment is made on or after the 46th day and before the 91st days after the Health Plan is required to make a determination and make payment of claim: Health Plan will pay the Provider making the claim the contracted rate owed on the claim plus a penalty in the amount of the lesser of: (1) 100 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate or (2) $200,000. 1C. Payment is made on or after the 91st day after the Health Plan is required to make a determination and make payment of claim: Health Plan will pay a penalty in the amount of the lesser of: (1) 100 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate or (2) $200,000, plus 18 percent annual interest on that amount 2A. Payment is made on or after the 1st say and before the 46th after the Health Plan is required to make a determination and make payment of claim: Health Plan will pay the Provider making the claim the remainder of the contracted rate owed on the claim plus a penalty on the amount not timely paid in the amount of the lesser of: (1) 50 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate or (2) $100,000. The underpaid amount is calculated on the ratio of the amount underpaid on the contracted rate to the contracted rate as applied to an amount equal to the billed charges as submitted on the claim minus the contracted rate. 2B. Payment is made on or after the 46th day and before the 91st days after the Health Plan is required to make a determination and make payment of claim: Health Plan will pay the Provider making the claim the remainder of the contracted rate owed on the claim plus a penalty on the amount not timely paid in the amount of the lesser of: (1) 100 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate or (2) $200,000. 2C. Payment is made on or after the 91st day after the Health Plan is required to make a determination and make payment of claim: Health Plan will pay a penalty on the balance of the claim computed in the amount of the lesser of: (1) 100 percent of the underpaid amount or (2) $200,000, plus 18 percent annual interest on that amount. Interest accrues beginning on the date the Health Plan was required to pay the claim and ending on the date the claim and the penalty are paid in full.	7			Y	5			Billed Charges	5														1	5					N		N	Y	6	% Fee Schedule	5										Texas Medicaid Fee for Service Program		current	5	1	5			If there is no payment rate in the prevailing State of Texas Medicaid Fee-For-Service Program as of the date(s) of service, payment will be at seventy (70%) percent of the prevailing local and geographically adjusted Medicare Fee-For-Service fee schedule, as of the date(s) of service.	5																																																																																																																																																																																																																																																																																																																																																																																																																																																																																						Y	Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with the Molina Health Benefit Exchange Product, on a fee-for-service basis, at the lesser of: (i) Provider's billed charges, or (ii) the amounts set forth below; less any applicable Member copayments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if an	5
71	CNCDE1	CNCDE1	CNCDE1	CNCDE1_Delaware First Health, Inc. _ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf_Medicaid_9-8-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf	101 E Delaware Ave Operations LLC	Boilerplate - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							T	13	Delaware First Health, Inc.	1	101 E Delaware Ave Operations LLC	1			101 E Delaware Ave Operations LLC	13	47-2878252	13	1336539717	13	101 E Delaware Ave		Delmar	DE	19940			11																												08-09-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8				120D	from the date of rendering a covered service	32				30D	of receipt by health plan or payor	48	30D	of receipt by health plan or payor	48													60D	from the date the overpayment is identified	33										Ancillary	42	Medicaid	42					42			Facility Services Skilled Nursing	42																Y	42			Allowable Charges	42							Skilled Nursing Care	42						1	42					N		N	N		% Fee Schedule	42										Payor's Medicaid fee schedule	42	current	42	1	42			N																																																																																																																																																																																																																																																																																																																																																																																																																																																																																							Y	This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for Covered Services provided by Contracted Providers to Covered Persons enrolled in a Medicaid Product. Where the Contracted Provider's tax identification number ("TIN") has been designated by the Payor as subject to this Compensation Schedule, Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider according to the terms of, and subject to the requirements set forth in, the Agreement and this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the applicable Product Attachment, or the Definitions section set forth at the end of this Compensation Schedule.	42
72	CNCDE1	CNCDE1	CNCDE1	CNCDE1_Delaware First Health, Inc. _ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf_Medicare_9-8-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf	101 E Delaware Ave Operations LLC	Boilerplate - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							T	13	Delaware First Health, Inc.	1	101 E Delaware Ave Operations LLC	1			101 E Delaware Ave Operations LLC	13	47-2878252	13	1336539717	13	101 E Delaware Ave		Delmar	DE	19940			11																												08-09-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	52	Medicare	52				MA PLAN	52			Facility Services Skilled Nursing	52																Y	52			Allowable Charges	52							Skilled Nursing Care	52						1	52					N		N	N		% Fee Schedule	52										Medicare Fee Schedule	52	current	52	1	52			N																																																																																																																																																																																																																																																																																																																																																																																																																																																																																							Y	This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for Covered Services provided by Contracted Providers to Covered Persons enrolled in a Medicare Product. Where the Contracted Provider's tax identification number ("TIN") has been designated by the Payor as subject to this Compensation Schedule, Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider according to the terms of, and subject to the requirements set forth in, the Agreement and this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the applicable Product Attachment, or the Definitions section set forth at the end of this Compensation Schedule.	52
73	CNCDE1	CNCDE1	CNCDE1	CNCDE1_Delaware First Health, Inc. _ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf_Medicare_9-8-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf	101 E Delaware Ave Operations LLC	Boilerplate - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							T	13	Delaware First Health, Inc.	1	101 E Delaware Ave Operations LLC	1			101 E Delaware Ave Operations LLC	13	47-2878252	13	1336539717	13	101 E Delaware Ave		Delmar	DE	19940			11																												08-09-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	52	Medicare	52				MA-PD PLAN	52			Facility Services Skilled Nursing	52																Y	52			Allowable Charges	52							Skilled Nursing Care	52						1	52					N		N	N		% Fee Schedule	52										Medicare Fee Schedule	52	current	52	1	52			N																																																																																																																																																																																																																																																																																																																																																																																																																																																																																							Y	This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for Covered Services provided by Contracted Providers to Covered Persons enrolled in a Medicare Product. Where the Contracted Provider's tax identification number ("TIN") has been designated by the Payor as subject to this Compensation Schedule, Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider according to the terms of, and subject to the requirements set forth in, the Agreement and this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the applicable Product Attachment, or the Definitions section set forth at the end of this Compensation Schedule.	52
74	CNCDE1	CNCDE1	CNCDE1	CNCDE1_Delaware First Health, Inc. _ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf_Medicare_9-8-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf	101 E Delaware Ave Operations LLC	Boilerplate - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							T	13	Delaware First Health, Inc.	1	101 E Delaware Ave Operations LLC	1			101 E Delaware Ave Operations LLC	13	47-2878252	13	1336539717	13	101 E Delaware Ave		Delmar	DE	19940			11																												08-09-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	52	Medicare	52				DSNP PLAN	52			Facility Services Skilled Nursing	52																Y	52			Allowable Charges	52							Skilled Nursing Care	52						1	52					N		N	N		% Fee Schedule	52										Medicare Fee Schedule	52	current	52	1	52			N																																																																																																																																																																																																																																																																																																																																																																																																																																																																																							Y	This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for Covered Services provided by Contracted Providers to Covered Persons enrolled in a Medicare Product. Where the Contracted Provider's tax identification number ("TIN") has been designated by the Payor as subject to this Compensation Schedule, Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider according to the terms of, and subject to the requirements set forth in, the Agreement and this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the applicable Product Attachment, or the Definitions section set forth at the end of this Compensation Schedule.	52
75	CNCDE1	CNCDE1	CNCDE1	CNCDE1_Delaware First Health, Inc. _ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf_Commercial_9-8-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_101eDelawareAveOperations_211248_9 MU.pdf	101 E Delaware Ave Operations LLC	Boilerplate - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							T	13	Delaware First Health, Inc.	1	101 E Delaware Ave Operations LLC	1			101 E Delaware Ave Operations LLC	13	47-2878252	13	1336539717	13	101 E Delaware Ave		Delmar	DE	19940			11																												08-09-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	58	Commercial	58	Exchange		58					Facility Services Skilled Nursing	58																Y	58			Allowable Charges	58							Skilled Nursing Care	58						1	58					N		N	N		% Fee Schedule	58										Payor's Fee Schedule	58	current	58	1	58			N																																																																																																																																																																																																																																																																																																																																																																																																																																																																																							Y	This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for Covered Services provided by Contracted Providers to Covered Persons enrolled in a Commercial-Exchange Product. Where the Contracted Provider's tax identification number ("TIN") has been designated by the Payor as subject to this Compensation Schedule, Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider according to the terms of, and subject to the requirements set forth in, the Agreement and this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the applicable Product Attachment, or the Definitions section set forth at the end of this Compensation Schedule.	58
76	CNCDE2 - MCR	CNCDE2	CNCDE2	CNCDE2 - MCR_Delaware First Health, Inc. _ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf_Medicare_10-21-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf	NEW CASTLE Health and Rehabilitation Center, LLC	Custom - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	13	Delaware First Health, Inc.	1	New Castle Health and Rehabilitation Center. LLC	1			New Castle Health and Rehabilitation Center. LLC	13	82-3535782	13	1962994905	13	32 Buena Vista Drive		New Castle	DE	19720			11																												21-10-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	52	Medicare	52				MA Plan	52			Facility Services Skilled Nursing	52																Y	52			Allowable Charges	52														1	52					N		N	N		% Fee Schedule	52										Medicare fee schedule	52	current	52	1	52			N
77	CNCDE2 - MCR	CNCDE2	CNCDE2	CNCDE2 - MCR_Delaware First Health, Inc. _ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf_Medicare_10-21-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf	NEW CASTLE Health and Rehabilitation Center, LLC	Custom - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	13	Delaware First Health, Inc.	1	New Castle Health and Rehabilitation Center. LLC	1			New Castle Health and Rehabilitation Center. LLC	13	82-3535782	13	1962994905	13	32 Buena Vista Drive		New Castle	DE	19720			11																												21-10-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	52	Medicare	52				MA-PD PLAN	52			Facility Services Skilled Nursing	52																Y	52			Allowable Charges	52														1	52					N		N	N		% Fee Schedule	52										Medicare fee schedule	52	current	52	1	52			N
78	CNCDE2 - MCR	CNCDE2	CNCDE2	CNCDE2 - MCR_Delaware First Health, Inc. _ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf_Medicare_10-21-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf	NEW CASTLE Health and Rehabilitation Center, LLC	Custom - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	13	Delaware First Health, Inc.	1	New Castle Health and Rehabilitation Center. LLC	1			New Castle Health and Rehabilitation Center. LLC	13	82-3535782	13	1962994905	13	32 Buena Vista Drive		New Castle	DE	19720			11																												21-10-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	52	Medicare	52				DSNP PLAN	52			Facility Services Skilled Nursing	52																Y	52			Allowable Charges	52														1	52					N		N	N		% Fee Schedule	52										Medicare fee schedule	52	current	52	1	52			N
79	CNCDE2 - COMM	CNCDE2	CNCDE2	CNCDE2 - COMM_Delaware First Health, Inc. _ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf_Commercial_10-21-2022	Veena	QC Complete	Delaware First Health, Inc.	ICMProviderAgreement_NewCastleHealthandRehabilitationCenter_212261_13 MU.pdf	NEW CASTLE Health and Rehabilitation Center, LLC	Custom - Ancillary	ERROR	PARTICIPATING PROVIDER AGREEMENT	1	Base Contract	1							Y	13	Delaware First Health, Inc.	1	New Castle Health and Rehabilitation Center. LLC	1			New Castle Health and Rehabilitation Center. LLC	13	82-3535782	13	1962994905	13	32 Buena Vista Drive		New Castle	DE	19720			11																												21-10-2022	13	Y	1,13	3 years from effective date	8	Y	8	1 YEAR	8																																								Ancillary	58	Commercial	58	Exchange		58					Facility Services Skilled Nursing	58																Y	58			Allowable Charges	58														1	58					N		N	N		% Fee Schedule	58										Medicare fee schedule	58	current	58	1	58			N
80	PCHP5 - IP	PCHP5	PCHP5	PCHP5 - IP_Parkland Community Health Plan Inc._BSW _ Original Contract _ 1.1.2000 MU.pdf_Medicaid_1-1-2000	Veena	Veena to update	Parkland Community Health Plan Inc.	BSW _ Original Contract _ 1.1.2000 MU.pdf	Baylor Health Care System	Custom - Facility	ERROR	HOSPITAL PROVIDER AGREEMENT	1	Base Contract	1							Y	25	Parkland Community Health Plan	1	Baylor Health Care System	1			Baylor Healthcare System	25	75-1837454	25			2625 Elm Street	Suite 110	Dallas	Texas	75226			24							See "PCHP5_Baylor Health Providers" Tab	25-29																		01-01-2000	1	15-12-1999	25	N	1,25	1 year	18	Y	18	1 YEAR	18	30D	in advance of the effective date of any modifications to the Provider Manual	8	30D	of receipt	11										60D	of the date the claim was originally submitted by hospital	12	30D	after Hospital's receipt of PCHP'S final determination	16	180D	of the date of service which will be paid	12	30D	of notification of the audit results or exhaustion of member appeal rights	12													Facility	31	Medicaid	31						Inpatient											Y	11	Clean Claims which are not paid within 30 days	11	1.5% per month for each month the claim remains unpaid	11			N		N		See "PCHP5_Baylor Health Providers" Tab	31														See "PCHP5_Baylor Health Providers" Tab	31							Y																																																																																											Y	31	Transplants and Transplant Related Services																																																																																							Y	31	All Medically Necessary outpatient laboratory hospital covered services		% Fee Schedule	TEXAS MEDICAID FEE SCHEDULE	CURRENT	1	N			Y	31			% Fee Schedule	TEXAS MEDICAID FEE SCHEDULE	CURRENT	1													Y	31	Rach additional day greater than the outlier length of stay	Total allowable amount for the specific DRG divided by the current yearly State-wide mean length of stay for each DRG	Hospital's charge schedule	1999	65% of hospitals billed charges			Y	31	250000	65% of hospitals billed charges
81	PCHP6	PCHP6	PCHP6	PCHP6_Parkland Community Health Plan Inc._North Texas Division, Inc._Medicaid_5-1-2014	Veena	Ready for QC	Parkland Community Health Plan Inc.	2014 LOA MU.pdf	2014 LOA	Custom - Facility	ERROR	Letter of Agreement	1	Letter of Agreement	1							Y	4	Parkland Community Health Plan	1	North Texas Division, Inc.	1			North Texas Division, Inc.	4	See "PCHP6 North Division Providers" Tab	5,6	See "PCHP6 North Division Providers" Tab	5,6	See "PCHP6 North Division Providers" Tab	See "PCHP6 North Division Providers" Tab	See "PCHP6 North Division Providers" Tab	See "PCHP6 North Division Providers" Tab	See "PCHP6 North Division Providers" Tab	See "PCHP6 North Division Providers" Tab	See "PCHP6 North Division Providers" Tab	5,6	See "PCHP6 North Division Providers" Tab	See "PCHP6 North Division Providers" Tab		5,6			See "PCHP6 North Division Providers" Tab																			01-05-2014	1	28-04-2014	4	N	1,4	31-12-2014	3	y	3	30 days	3																																																																																Y	7	Facility's cost to charge ratio (CCR)	HHSC CCR SCHEDULE		current																	Y	7			% Fee Schedule	TEXAS MEDICAID	CURRENT	100$																																									Y	7	All Medically Necessary outpatient laboratory hospital covered services	Y	% Fee Schedule	TEXAS MEDICAID FEE SCHEDULE	CURRENT	1	N	Y	7	All Medically Necessary outpatient radiology hospital covered services	% Fee Schedule	TEXAS MEDICAID FEE SCHEDULE	CURRENT	1	N																																																																																																																																																																																																																																																																																																																																																																																									In addition, PCHP shall reimburse Hospital for any item or service that are Texas Medicaid allows additional reimbursement for, including but not limited to, cochlear implants and neurostimulators at one hundred percent (100%) of then current and prevailing traditional Texas Medicaid reimbursement at the time of service less any applicable co-payment, co-insurance or deductibles.	7
82	AvM10 - Medicare	AvM10	AvM10	AvM10 - Medicare_AvMed_Custom_2009-08-10 Adventist - University Community Hospital LTAC_Medicare_8-10-2009	Veena	ready for QC	AvMed	Custom_2009-08-10 Adventist - University Community Hospital LTAC	Custom_2009-08-10 Adventist - University Community Hopstial LTAC	Custom - Facility	ERROR	Hospital Services Agreement with University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	1	Base Contract	1							Y	12	AvMed Health insurance Company Inc.	12	University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12			University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12	59- 1113901	13			9441 Health Center Drive		Tampa	FL	34637			13																										10-08-2009	1	30-06-2009	13	N	1,13	1 year	7	yes	7	1 year	7				60D	after receipt of a non-contested claim	15										1Y	from final billing date	11				150D	of the date of processing or the original adjudication	10	150D	of the date of processing or the original adjudication	10													Facility		Medicare	14	Medicare Point-of-Service (gatekeeper model)	Point-of-Service	19		14	Long Term Acute Care Hospital	18																		Y				See "AvM10_UCHLTAC" tab	18	See "AvM10_UCHLTAC Rates & Exclusions" tab	18														See "AvM10_UCHLTAC" tab	18					Y			% billed charges	18														1	18																																																																																																																						Y		250	Revenue Code	flat fee per day			195																																																																												Y		80000	0.6																																													Y	19			per visit			55																																																																																																																																																																																																																					Y	800-809, 820-839	Revenue Codes	% billed charges	0.6
83	AvM10 - Medicare	AvM10	AvM10	AvM10 - Medicare_AvMed_Custom_2009-08-10 Adventist - University Community Hospital LTAC_Medicare_8-10-2009	Veena	ready for QC	AvMed	Custom_2009-08-10 Adventist - University Community Hospital LTAC	Custom_2009-08-10 Adventist - University Community Hopstial LTAC	Custom - Facility	ERROR	Hospital Services Agreement with University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	1	Base Contract	1							Y	12	AvMed Health insurance Company Inc.	12	University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12			University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12	59- 1113901	13			9441 Health Center Drive		Tampa	FL	34637			13																										10-08-2009	1	30-06-2009	13	N	1,13	1 year	7	yes	7	1 year	7				60D	after receipt of a non-contested claim	15										1Y	from final billing date	11				150D	of the date of processing or the original adjudication	10	150D	of the date of processing or the original adjudication	10													Facility		Medicare	14	Medicare PPO	PPO	19		14	Long Term Acute Care Hospital	18																		Y				See "AvM10_UCHLTAC" tab	18	See "AvM10_UCHLTAC Rates & Exclusions" tab	18														See "AvM10_UCHLTAC" tab	18					Y			% billed charges	18														1	18																																																																																																																						Y		250	Revenue Code	flat fee per day			195																																																																												Y		80000	0.6																																													Y	19			per visit			55																																																																																																																																																																																																																					Y	800-809, 820-839	Revenue Codes	% billed charges	0.6
84	AvM10 - commercial	AvM10	AvM10	AvM10 - commercial_AvMed_Custom_2009-08-10 Adventist - University Community Hospital LTAC_Commercial/ Group_8-10-2009	Veena	ready for QC	AvMed	Custom_2009-08-10 Adventist - University Community Hospital LTAC	Custom_2009-08-10 Adventist - University Community Hopstial LTAC	Custom - Facility	ERROR	Hospital Services Agreement with University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	1	Base Contract	1							Y	12	AvMed Health insurance Company Inc.	12	University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12			University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12	59- 1113901	13			9441 Health Center Drive		Tampa	FL	34637			13																										10-08-2009	1	30-06-2009	13	N	1,13	1 year	7	yes	7	1 year	7				60D	after receipt of a non-contested claim	15										1Y	from final billing date	11				150D	of the date of processing or the original adjudication	10	150D	of the date of processing or the original adjudication	10													Facility		Commercial/ Group	14	Commercial HMO	HMO	19			Long Term Acute Care Hospital	18																		Y				See "AvM10_UCHLTAC" tab	18	See "AvM10_UCHLTAC" tab	18														See "AvM10_UCHLTAC" tab	18					Y			% billed charges	18														1	18																																																																																																																						Y		250	Revenue Code	flat fee per day			195																																																																												Y		80000	0.6																																													Y	19			per visit			55																																																																																																																																																																																																																				`	Y	800-809, 820-839	Revenue Codes	% billed charges	0.6
85	AvM10 - commercial	AvM10	AvM10	AvM10 - commercial_AvMed_Custom_2009-08-10 Adventist - University Community Hospital LTAC_Commercial/ Group_8-10-2009	Veena	ready for QC	AvMed	Custom_2009-08-10 Adventist - University Community Hospital LTAC	Custom_2009-08-10 Adventist - University Community Hopstial LTAC	Custom - Facility	ERROR	Hospital Services Agreement with University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	1	Base Contract	1							Y	12	AvMed Health insurance Company Inc.	12	University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12			University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12	59- 1113901	13			9441 Health Center Drive		Tampa	FL	34637			13																										10-08-2009	1	30-06-2009	13	N	1,13	1 year	7	yes	7	1 year	7				60D	after receipt of a non-contested claim	15										1Y	from final billing date	11				150D	of the date of processing or the original adjudication	10	150D	of the date of processing or the original adjudication	10													Facility		Medicare	14	Medicare HMO	HMO	19			Long Term Acute Care Hospital	18																		Y				See "AvM10_UCHLTAC" tab	18	See "AvM10_UCHLTAC" tab	18														See "AvM10_UCHLTAC" tab	18					Y			% billed charges	18														1	18																																																																																																																						Y		250	Revenue Code	flat fee per day			195																																																																												Y		80000	0.6																																													Y	19			per visit			55																																																																																																																																																																																																																				`	Y	800-809, 820-839	Revenue Codes	% billed charges	0.6
86	AvM10 - commercial	AvM10	AvM10	AvM10 - commercial_AvMed_Custom_2009-08-10 Adventist - University Community Hospital LTAC_Commercial/ Group_8-10-2009	Veena	ready for QC	AvMed	Custom_2009-08-10 Adventist - University Community Hospital LTAC	Custom_2009-08-10 Adventist - University Community Hopstial LTAC	Custom - Facility	ERROR	Hospital Services Agreement with University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	1	Base Contract	1							Y	12	AvMed Health insurance Company Inc.	12	University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12			University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12	59- 1113901	13			9441 Health Center Drive		Tampa	FL	34637			13																										10-08-2009	1	30-06-2009	13	N	1,13	1 year	7	yes	7	1 year	7				60D	after receipt of a non-contested claim	15										1Y	from final billing date	11				150D	of the date of processing or the original adjudication	10	150D	of the date of processing or the original adjudication	10													Facility		Commercial/ Group	14	Commercial PPO	PPO	19			Long Term Acute Care Hospital	18																		Y				See "AvM10_UCHLTAC" tab	18	See "AvM10_UCHLTAC" tab	18														See "AvM10_UCHLTAC" tab	18					Y			% billed charges	18														1	18																																																																																																																						Y		250	Revenue Code	flat fee per day			195																																																																												Y		80000	0.6																																													Y	19			per visit			55																																																																																																																																																																																																																				`	Y	800-809, 820-839	Revenue Codes	% billed charges	0.6
87	AvM10 - commercial	AvM10	AvM10	AvM10 - commercial_AvMed_Custom_2009-08-10 Adventist - University Community Hospital LTAC_Commercial/ Group_8-10-2009	Veena	ready for QC	AvMed	Custom_2009-08-10 Adventist - University Community Hospital LTAC	Custom_2009-08-10 Adventist - University Community Hopstial LTAC	Custom - Facility	ERROR	Hospital Services Agreement with University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	1	Base Contract	1							Y	12	AvMed Health insurance Company Inc.	12	University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12			University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12	59- 1113901	13			9441 Health Center Drive		Tampa	FL	34637			13																										10-08-2009	1	30-06-2009	13	N	1,13	1 year	7	yes	7	1 year	7				60D	after receipt of a non-contested claim	15										1Y	from final billing date	11				150D	of the date of processing or the original adjudication	10	150D	of the date of processing or the original adjudication	10													Facility		Commercial/ Group	14	Self Funded Member		19			Long Term Acute Care Hospital	18																		Y				See "AvM10_UCHLTAC" tab	18	See "AvM10_UCHLTAC" tab	18														See "AvM10_UCHLTAC" tab	18					Y			% billed charges	18														1	18																																																																																																																						Y		250	Revenue Code	flat fee per day			195																																																																												Y		80000	0.6																																													Y	19			per visit			55																																																																																																																																																																																																																				`	Y	800-809, 820-839	Revenue Codes	% billed charges	0.6
88	AvM10 - commercial	AvM10	AvM10	AvM10 - commercial_AvMed_Custom_2009-08-10 Adventist - University Community Hospital LTAC_Commercial/ Group_8-10-2009	Veena	ready for QC	AvMed	Custom_2009-08-10 Adventist - University Community Hospital LTAC	Custom_2009-08-10 Adventist - University Community Hopstial LTAC	Custom - Facility	ERROR	Hospital Services Agreement with University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	1	Base Contract	1							Y	12	AvMed Health insurance Company Inc.	12	University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12			University Community Hospital Long Term Acute Care Hospital (UCHLTAC)	12	59- 1113901	13			9441 Health Center Drive		Tampa	FL	34637			13																										10-08-2009	1	30-06-2009	13	N	1,13	1 year	7	yes	7	1 year	7				60D	after receipt of a non-contested claim	15										1Y	from final billing date	11				150D	of the date of processing or the original adjudication	10	150D	of the date of processing or the original adjudication	10													Facility		Commercial/ Group	14	Commercial Point-of-Service (gatekeeper model)	Point-of-Service	19			Long Term Acute Care Hospital	18																		Y				See "AvM10_UCHLTAC" tab	18	See "AvM10_UCHLTAC" tab	18														See "AvM10_UCHLTAC" tab	18					Y			% billed charges	18														1	18																																																																																																																						Y		250	Revenue Code	flat fee per day			195																																																																												Y		80000	0.6																																													Y	19			per visit			55																																																																																																																																																																																																																				`	Y	800-809, 820-839	Revenue Codes	% billed charges	0.6
89	AvM12	AvM12	AvM12	AvM12_AvMed_Custom_2018-01-1 Adentist adding SOF Rates MU.pdf__1-0-1900	Veena	ready for QC	AvMed	Custom_2018-01-1 Adentist adding SOF Rates MU.pdf	Custom_2018-01-1 Adentist adding SOF Rates	Custom - Facility	ERROR	Hospital Participation Agreement Modification - Exhibit A Adventist Health System/Sunbelt, Inc.	1	Amendment	1	Exhibit A	1			40909	1	y	1							Adventit Health System/Subelt, Inc.	1																																																																																																																					N		N		% reduction for providers	1																11% reduction for :Florida Hospital Watermann,Floriday Hospital Flagler 10% reduction: Florida Hospital Tampa, Florida Hospital Carrollwood,Florida Hospital Wesley Chapel,Florida Hospital Heartland Medical Center,Florida Hospital Lake Placid,Florida Hospital Wauchula,Florida Hospital Memorial Medical Center 5% reduction for: Florida Hospital Fish Memorial,Florida Hospital DeLand	1			N		N	N		Billed Charges	1														1	1			N
90	AvM13 - inp	AvM13	AvM13	AvM13 - inp_AvMed_AvMed ,Inc. 31st Amendment to the Hospital Services Agreement (Internal file name: Custom_2019-07-01 31st Aligned Amend and Exhibit B MU.pdf)__7-1-2019	Veena	Veena to update	AvMed	AvMed ,Inc. 31st Amendment to the Hospital Services Agreement (Internal file name: Custom_2019-07-01 31st Aligned Amend and Exhibit B MU.pdf)	Custom_2019-07-01 31st Aligned Amend and Exhibit B	Custom - Facility	ERROR	AvMed ,Inc. 31st Amendment to the Hospital Services Agreement	1	Amendment	1	31	1			36192	1	y	2	AvMed, Inc.	1	Shands Teaching Hospital and Clinics, Inc. d/b/a Shands and University of Florida Health Care Network ("SUFHCN")	1			SUFHCN	2					1329 SW 16th Street Suite 2170		Gainesville	FL	32640			2																										01-07-2019	1	02-08-2019	2	n	1,2																																																											Y	8	All fixed rates as well as: DRG Conversion Factors, Maternity Case Rates, ER Rates, Outpatient Therapies, Lithotripsy, MRI,CT Scans and Transportation	8	0.04	8								Increase is limited to 4% per year beginning January 1, 2020	8	N				conversation factor	3																11109	3					Y	Y, Non-weighted DRGs will be reimbursed at 62% billed charges	3																	1			N																																																		Y	3	See" AvMed Maternity Carveouts" tab	See" AvMed Maternity Carveouts" tab	See" AvMed Maternity Carveouts" tab	See" AvMed Maternity Carveouts" tab	See" AvMed Maternity Carveouts" tab	N																						Y	6	274	Rev Code	% billed charges			0.39	where submitted charges are $562 or more when covered	Y	6	2.75E+11	Revenue Codes	% BILLED CHARGES			0.39	$562 or more																																																																																													Y	3	186523	% Billed Charges			0.59	Maternity Case Rates	Prosthetic devices, DME and Medical implants with per item charge >$562																																																																																																																																																																																	Y	7			Flat Fee/ Per diem	Physical: 1832/per day, Head Injury: $2213	Physical: 1832/per day, Head Injury: $2213	Chronic or extended rehabilitation not covered
91	AvM13 - op	AvM13	AvM13	AvM13 - op_AvMed_AvMed ,Inc. 31st Amendment to the Hospital Services Agreement_Commercial_7-1-2019	Veena	ready for QC	AvMed	AvMed ,Inc. 31st Amendment to the Hospital Services Agreement	Custom_2019-07-01 31st Aligned Amend and Exhibit B	Custom - Facility	ERROR	AvMed ,Inc. 31st Amendment to the Hospital Services Agreement	1	Amendment	1	31	1			36192	1	y	2	AvMed, Inc.	1	Shands Teaching Hospital and Clinics, Inc. d/b/a Shands and University of Florida Health Care Network ("SUFHCN")	1			SUFHCN	2					1329 SW 16th Street Suite 2170		Gainesville	FL	32640			2																										01-07-2019	1	02-08-2019	2	n	1,2																																																Commercial		Engage/Empower					Outpatient				Y	8	All fixed rates as well as: DRG Conversion Factors, Maternity Case Rates, ER Rates, Outpatient Therapies, Lithotripsy, MRI,CT Scans and Transportation	8	0.04	8								Increase is limited to 4% per year beginning January 1, 2020	8	N		N		Billed Charges	5														0.52	5							Y																													Y	4	450-459	Revenue Codes	Flat fee		871		Y	4	762	Revenue Codes	% BILLED CHARGES	6$%																																																											Y	6	274	Revenue Codes	% billed charges			0.39		Y	6	2.75E+11	Revenue Codes	% BILLED CHARGES		0.39		`																													Y	11	0.5																															Y	5	300-309	Revenue Codes	% fee schedule	Medicare Allowable Lab location 99	current	0.94		services with after hours pediatric urgent care services= 58% current Medicare allowable		Y	5	330, 333	Revenue Codes	% billed charges			64%,	Y	4	320, 324	Revenue Codes	% BILLED CHARGES			0.64					Y	10	15383	% Billed Charges			0.63	Prosthetic devices and medical implants with per item charge> $562 are deducted from total charges prior to calculation of outlier payment																																																		Y	5	PT: 420-429 OT: 430-439 ST:440-449	Revenue Codes				145	DME excluded	Y	6	540, 542, 545	Revenue Codes	Flat fee			A0434 : $1305/BASE A0425: $16.50/MILE A0431: $6816/BASE A0436: $49.50/MILE A030: $5857																																																																																																										Y	4	331, 332, 335 96401-96549	Revenue Codes, CPT	% billed charges	0.64									Y	5	See " AvMed OP Surgery Rates" tab		See " AvMed OP Surgery Rates" tab	See " AvMed OP Surgery Rates" tab		Y	5	43265, 50590, 52353	CPT codes	Flat fee		9397	y	5	92920-92944, 92997, 92998, C9600-C9608 93452-99461, 93462-93464, 93530-93533, 93563-93568	CPT codes	% BILLED CHARGES		0.64																																														Y	6	6.11E+12	Revenue Codes	PER UNIT	1262	Y	6	350351352	Revenue Codes	PER UNIT	710
92	AvM13 - comm	AvM13	AvM13	AvM13 - comm_AvMed_AvMed ,Inc. 31st Amendment to the Hospital Services Agreement__7-1-2019	Veena	READY FOR QC	AvMed	AvMed ,Inc. 31st Amendment to the Hospital Services Agreement	Custom_2019-07-01 31st Aligned Amend and Exhibit B	Custom - Facility	ERROR	AvMed ,Inc. 31st Amendment to the Hospital Services Agreement	1	Amendment	1	31	1			36192	1	y	2	AvMed, Inc.	1	Shands Teaching Hospital and Clinics, Inc. d/b/a Shands and University of Florida Health Care Network ("SUFHCN")	1			SUFHCN	2					1329 SW 16th Street Suite 2170		Gainesville	FL	32640			2																										01-07-2019	1	02-08-2019	2	n	1,2																																																											Y	8	All fixed rates as well as: DRG Conversion Factors, Maternity Case Rates, ER Rates, Outpatient Therapies, Lithotripsy, MRI,CT Scans and Transportation	8	0.04	8								Increase is limited to 4% per year beginning January 1, 2020	8	N		N		Billed Charges	5														0.52	5							Y																													Y	4	450-459	Revenue Codes	Flat fee		871		Y	4	762	Rev Code	% BILLED CHARGES	6$%																																																											Y	6	274	Revenue Codes	% billed charges			0.39		Y	6	2.75E+11	Revenue Codes	% BILLED CHARGES			0.39	$562 or more																													Y	11	0.5																															Y	5	300-309	Revenue Codes	% fee schedule	Medicare Allowable Lab location 99	current	0.94			services with after hours pediatric urgent care services= 58% current Medicare allowable	Y	5	330, 333	Revenue Codes	% billed charges			64%,	Y	4	320, 324	Revenue Codes	% BILLED CHARGES			0.64					Y	10	15383	% Billed Charges			0.63	Prosthetic devices and medical implants with per item charge> $562 are deducted from total charges prior to calculation of outlier payment																																																		Y	5	PT: 420-429 OT: 430-439 ST:440-449	Revenue Codes				145	DME excluded	Y	6	540, 542, 545	Revenue Codes	Flat fee			A0434 : $1305/BASE A0425: $16.50/MILE A0431: $6816/BASE A0436: $49.50/MILE A030: $5857																																																																																																										Y	4	331, 332, 335 96401-96549	Revenue Codes, CPT	% billed charges	0.64									Y	5	See " AvMed OP Surgery Rates" tab		See " AvMed OP Surgery Rates" tab	See " AvMed OP Surgery Rates" tab		Y	5	43265, 50590, 52353	CPT codes	Flat fee		9397	y	5	92920-92944, 92997, 92998, C9600-C9608 93452-99461, 93462-93464, 93530-93533, 93563-93568	CPT codes	% BILLED CHARGES		0.64																																														Y	6	6.11E+12	Revenue Codes	PER UNIT	1262	Y	6	350351352	Revenue Codes	PER UNIT	710
93	MOHFL1 - inpatient	MOHFL1	MOHFL1	MOHFL1 - inpatient_Molina Healthcare of FL_Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward__1-0-1900	Veena	Ready for QC	Molina Healthcare of FL	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom - Facility	ERROR	Fourth Amendment to the Molina Health	1	Amendment	1	4	1					Y	1	Molina Healthcare of Florida, Inc.	1	North Broward Hospital District	1			North Broward Hospital District d/b/a/ Broward Health	1	See "Molina FL Provider Roster" Tab	2,3,4	See "Molina FL Provider Roster" Tab	2,3,4								2,3,4				2,3,4																																																																																		Inpatient																			N		N		DRGs Based Payment System using MS DRG associated weights	5																Broward Health medical Center - $10,951 base rate North Boroward North - $9,700base rate Broward Health Imperial Point - $9,517base rate Broward Health Coral Springs - $9,646base rate Special Care Unit: $1,875 per diem Rehab: $1,000 per diem				Y		Y																																																																																																														Y	7	274-279	Revenue Codes	% of billed charges if charges => $550			0.55																																																																																																							Y	5	150000	0.48	681	3538																																																																																																																																																																																																									Y	5	169	Flat fee	$1,875: Broward Health North, Broward Health medical Center
94	MOHFL1 - OP	MOHFL1	MOHFL1	MOHFL1 - OP_Molina Healthcare of FL_Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward_Marketplace_1-0-1900	Veena	ready for QC	Molina Healthcare of FL	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom - Facility	ERROR	Fourth Amendment to the Molina Health	1	Amendment	1	4	1					Y	1	Molina Healthcare of Florida, Inc.	1	North Broward Hospital District	1			North Broward Hospital District d/b/a/ Broward Health	1	See "Molina FL Provider Roster" Tab	2,3,4	See "Molina FL Provider Roster" Tab	2,3,4								2,3,4				2,3,4																																																																											Marketplace	1	EXCHANGE		1			Outpatient	6		6																N				Billed Charges	6														0.45	6							Y	Gold Coast Hospice - Rev Codes 651,652,655,656: 125% current Browad County Medicare Allowable, Gold Coast Home Health : 125% current Browad County Medicare Allowable	6																											Y	5	450-451, 459 and/or 68X, 450,451,459 Discharge Status 20	Revenue Codes	Flat fee per visit		450-451 : $775 459 and/or 68X : $2,850 450,451,459 Discharge Status 20: $2,850		Y	5	762,720,721, 61X, 35X, 340-342	Rev Code	Flat fee per visit, % Broward County Medicare allowable	762,720,721: $1,900 61X: $800 35X: $780 340-342: 121%																																																																				Y	7	274-279	Revenue Codes	% of billed charges			0.55	$550 or more																			Y	6	331,332,33 259,636	Revenue Codes	Flat Fee per visit, Codes: 259 & 636 if charges => $500			525%, Rev Codes: 259 or 636 = 40%			Y	6	Outpatient Surgery	50% of negotiated rate		0.5																																							Y	5	323	Revenue Code	% fee schedule	Broward County Medicare allowable	CURRENT	1.21	Y	5	32X, 401, 403, 402, 404	Revenue Codes	% fee schedule	Broward County Medicare allowable	CURRENT	1.21																																																														Y	5	43X, 43X, 46X,410,44X,942,943 and 94010, 94060, 94240, 94260-94360, 94070,94620,94621,94726,94720,94727,G0237-G0239,G0108-G0109,93798	Revenue Codes, CPT Codes	Flat fee per visit			95																																																																																																																																	Y	6	360361750	Revenue Codes	Flat Fee per visit	3160		Y	6	79X, 50590-rt, 50590-lt, 50590-50	CPT with modifiers	Flat fee per visit	6700	Y	Y	6	See "Molina Cardiac Carveouts" Tab		See "Molina Cardiac Carveouts" Tab	See "Molina Cardiac Carveouts" Tab	See "Molina Cardiac Carveouts" Tab	See "Molina Cardiac Carveouts" Tab
95	MOHFL1 - outpatient URGENT CARE	MOHFL1	MOHFL1	MOHFL1 - outpatient URGENT CARE_Molina Healthcare of FL_Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward__1-0-1900	Veena	Ready for QC	Molina Healthcare of FL	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom - Facility	ERROR	Fourth Amendment to the Molina Health	1	Amendment	1	4	1					Y	1	Molina Healthcare of Florida, Inc.	1	North Broward Hospital District	1			North Broward Hospital District d/b/a/ Broward Health	1	See "Molina FL Provider Roster" Tab	2,3,4	See "Molina FL Provider Roster" Tab	2,3,4								2,3,4				2,3,4																																																																																		Outpatient	6	Urgent Care	6																N				Flat Fee	6	99201-99205, 99211-99215	6	516	6												305	6					N	N
96	MOHFL1 - outpatient Hospice	MOHFL1	MOHFL1	MOHFL1 - outpatient Hospice_Molina Healthcare of FL_Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward__1-0-1900	Veena	Ready for QC	Molina Healthcare of FL	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom - Facility	ERROR	Fourth Amendment to the Molina Health	1	Amendment	1	4	1					Y	1	Molina Healthcare of Florida, Inc.	1	North Broward Hospital District	1			North Broward Hospital District d/b/a/ Broward Health	1	See "Molina FL Provider Roster" Tab	2,3,4	See "Molina FL Provider Roster" Tab	2,3,4								2,3,4				2,3,4																																																																																		Outpatient	6	Hospice	6																N				% Fee Schedule	6			6.52E+11	6						Broward County Medical Allowable	6			1.25	6							N	N
97	MOHFL1 - outpatient home health	MOHFL1	MOHFL1	MOHFL1 - outpatient home health_Molina Healthcare of FL_Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward__1-0-1900	Veena	Ready for QC	Molina Healthcare of FL	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom_AMD - IV - HSA eff 2017 (amd 4) - Broward	Custom - Facility	ERROR	Fourth Amendment to the Molina Health	1	Amendment	1	4	1					Y	1	Molina Healthcare of Florida, Inc.	1	North Broward Hospital District	1			North Broward Hospital District d/b/a/ Broward Health	1	See "Molina FL Provider Roster" Tab	2,3,4	See "Molina FL Provider Roster" Tab	2,3,4								2,3,4				2,3,4																																																																																		Outpatient	6	Home Health	6																N				% Fee Schedule	6										Broward County Medical Allowable	6			1.25	6							N	N
98	MOHTX9	MOHTX9	MOHTX9	MOHTX9_Molina Healthcare of TX_Custom_PSA - TX - Fresenius BIOMEDICAL APPLICATIONS OF TEXAS INC - 11-2226275 - 06012010 (1) (2)_Medicaid_6-1-2010	Veena	QC Complete	Molina Healthcare of TX	Custom_PSA - TX - Fresenius BIOMEDICAL APPLICATIONS OF TEXAS INC - 11-2226275 - 06012010 (1) (2)	Custom_PSA - TX - Fresenius BIOMEDICAL APPLICATIONS OF TEXAS INC - 11-2226275 - 06012010 (1) (2)	Custom - Ancillary	ERROR	MOLINA HEALTHCARE OF TEXAS, INC. PROVIDER SERVICES AGREEMENT	1	Base Contract	1							Y	23	Molina Healthcare of Texas, Inc.	1	Bio-Medical Applications of Amarillo, Inc. Bio-Medical Applications of San Antonio, Inc. Bio-Medical Applications of Texas, Inc. Dialysis Management Corporation Everest Healthcare Texas, LP Fondron Dialysis Clinic, Inc. National Nephrology Associates of Texas, LP RCG East Texas, LLP RCG Irving, LLC Renal Care Group Harlingen, LP Renal Care Group Texas, Inc. San Antonio Kidney Disease Center, Inc. STAT Dialysis Corporation Terrell Dialysis Center, LLC	1			Bio-Medical Applications of Amarillo, Inc. Bio-Medical Applications of San Antonio, Inc. Bio-Medical Applications of Texas, Inc. Dialysis Management Corporation Everest Healthcare Texas, LP Fondron Dialysis Clinic, Inc. National Nephrology Associates of Texas, LP RCG East Texas, LLP RCG Irving, LLC Renal Care Group Harlingen, LP Renal Care Group Texas, Inc. San Antonio Kidney Disease Center, Inc. STAT Dialysis Corporation Terrell Dialysis Center, LLC	23																	See " Fresenius Providers" tab	23																				01-06-2010	1	01-06-2010	23	y	1,23	1 year	17	Y	17	1 year	17	90D	prior to implementing a change	11	30D	from the date the claim is received	9													120D	of the date of the remittance advice	12	60D	of when the issue arises	20	30D	of receipt	12	45D	OF WRITTEN NOTIFICATION BY THE HEALTH PLAN	10	45D	OF WRITTEN NOTIFICATION BY THE HEALTH PLAN	10							Ancillary	24	Medicaid	29										Y	30	FIXED RATES ON THE ANNIVERSARY OF THE AGREEMENTS EFFECTIVE DATE	30	0.03	30		Y	9	clean claims that are not adjudicated within 30 days	9	0.18	9			Y	30	N	30	Inclusive rates	30			821, 825, 845, 855, 841, 851	30												821: $315 INCLUSIVE 825, 845, 855: $3355 INCLUSIVE 841: $135 INCLUSIVE 851: $140 INCLUSIVE	30					N			Billed Charges	30														1	30																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for-services basis	30
99	MOHTX10	MOHTX10	MOHTX10	MOHTX10_Molina Healthcare of TX_Custom_TX - AMD 1 - Davita - 27-0888875 eff 04012015__4-1-2015	Veena	QC Complete	Molina Healthcare of TX	Custom_TX - AMD 1 - Davita - 27-0888875 eff 04012015	Custom_TX - AMD 1 - Davita - 27-0888875 eff 04012015	Custom - Ancillary	ERROR	FIRST AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	1	1			40452	1	Y	2	Molina Healthcare of Texas, Inc.	2	DaVita HealthCare Partners Inc.	2			DaVita HealthCare Partners Inc.	2																																						01-04-2015	1	01-04-2015	2	Y	1,2	3 YEARS	1	Y	1	1 YEAR	1																																																																				Y		N		Flat Fee						821 & 90999, 821 & 90999 UJ, 881 & 90999, 821 & 90999, 841 & 90945, 851 & 90945 821 & 90993, 841 & 90993, 851 & 90993	4										821 & 90999= $371.42 821 & 90999 UJ = $393.93 881 & 90999 = $371.42 821 & 90999= $371.42 841 & 90945= $163.20 851 & 90945= $163.20 821 & 90993= $393.93 841 & 90993= $393.93 851 & 90993= $393.93	4					N			Billed Charges	3														1	3																																																																																																																																																																																																																																																																																																																																																																																																																																																																																										Y	In the event CMS approves the use ofa new technology, medication or service that is also considered a Covered Service by Provider and Health Plan, reimbursement will be set at the lesser of one hundred percent (100%) of the current Medicare allowable rate, or Provider's billed charges for such New Technology.	3
100	MOHTX12	MOHTX12	MOHTX12	MOHTX12_Molina Healthcare of TX_Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018_Medicaid_1-1-2018	Veena	QC Complete	Molina Healthcare of TX	Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018	Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018	Custom - Ancillary	ERROR	FOURTH AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	4	1			40452	1	Y	2	Molina Healthcare of Texas, Inc.	2	DaVita Inc.	2			DaVita Inc.	2																																						01-01-2018	1	01-01-2018	2	Y	1,2																																														Ancillary		Medicaid	1																									N	1			AWP	1	Cinacalcet and Etelcalcetide	1												AWP - 12%	1							N
101	MOHTX12	MOHTX12	MOHTX12	MOHTX12_Molina Healthcare of TX_Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018_Medicare_1-1-2018	Veena	QC Complete	Molina Healthcare of TX	Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018	Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018	Custom - Ancillary	ERROR	FOURTH AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	4	1			40452	1	Y	2	Molina Healthcare of Texas, Inc.	2	DaVita Inc.	2			DaVita Inc.	2																																						01-01-2018	1	01-01-2018	2	Y	1,2																																														Ancillary		Medicare	1																									N	1			See "MOHTX12_MolinaDavitaRates" tab	1	See "MOHTX12_MolinaDavitaRates" tab	1								See "MOHTX12_MolinaDavitaRates" tab	1	See "MOHTX12_MolinaDavitaRates" tab	1									N	If CMS ceases to maintain for calcimimetic medications a rate separate and apart from, or in addition to, any bundled payment amount paid for dialysis related services, then calcimimetics medications shall continue to be separately payable under the Agreement at 100% of the most recent separate allowable amount established by CMS.	2
102	MOHTX12	MOHTX12	MOHTX12	MOHTX12_Molina Healthcare of TX_Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018_Medicaid/Medicare_1-1-2018	Veena	QC Complete	Molina Healthcare of TX	Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018	Custom_TX - AMD 4 - DAVITA J0604 J0606 - 27-0888875 eff 01012018	Custom - Ancillary	ERROR	FOURTH AMENDMENT TO MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1	4	1			40452	1	Y	2	Molina Healthcare of Texas, Inc.	2	DaVita Inc.	2			DaVita Inc.	2																																						01-01-2018	1	01-01-2018	2	Y	1,2																																														Ancillary		Medicaid/Medicare	1	MMP		1	Medicare-Medicaid	1																				N	1			See "MOHTX12_MolinaDavitaRates" tab	1	See "MOHTX12_MolinaDavitaRates" tab	1								See "MOHTX12_MolinaDavitaRates" tab	1	See "MOHTX12_MolinaDavitaRates" tab	1									N	If CMS ceases to maintain for calcimimetic medications a rate separate and apart from, or in addition to, any bundled payment amount paid for dialysis related services, then calcimimetics medications shall continue to be separately payable under the Agreement at 100% of the most recent separate allowable amount established by CMS.	2
103	MOHTX13	MOHTX13	MOHTX13	MOHTX13_Molina Healthcare of TX_CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid_Medicaid_9-1-2019	Veena	QC Complete	Molina Healthcare of TX	CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid	CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid	Custom - Ancillary	ERROR	MUTUAL AMENDMENT HARRIS COUNTY HOSPITAL DISTRICT MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1					38961	1	Y	2	Molina Healthcare of Texas, Inc.	2	Harris County Hospital District d/b/a Harris Health System, a political subdivision of the State of Texas	1			43647	2																	Harris County Hospital District d/b/a Harris Health System - Ambulatory Surgery Center (ASC)	2																				01-09-2019	1	01-09-2019	1	Y	1																																														Ancillary		Medicaid	1																									Y	1			% fee schedule	1										Medicaid	1			1.05	1							N
104	MOHTX13	MOHTX13	MOHTX13	MOHTX13_Molina Healthcare of TX_CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid_Medicare_9-1-2019	Veena	QC Complete	Molina Healthcare of TX	CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid	CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid	Custom - Ancillary	ERROR	MUTUAL AMENDMENT HARRIS COUNTY HOSPITAL DISTRICT MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1					38961	1	Y	2	Molina Healthcare of Texas, Inc.	2	Harris County Hospital District d/b/a Harris Health System, a political subdivision of the State of Texas	1			43647	2																	Harris County Hospital District d/b/a Harris Health System - Ambulatory Surgery Center (ASC)	2																				01-09-2019	1	01-09-2019	1	Y	1																																														Ancillary		Medicare	1																									Y	1			% fee schedule	1										Medicare fee for service allowable	1			1.05	1							N
105	MOHTX13	MOHTX13	MOHTX13	MOHTX13_Molina Healthcare of TX_CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid_Medicaid/Medicare_9-1-2019	Veena	QC Complete	Molina Healthcare of TX	CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid	CustomAnc_HSA_AMD 5_EFF09012019_Harris County Hospital_Amb. Surgery Center_Medicaid	Custom - Ancillary	ERROR	MUTUAL AMENDMENT HARRIS COUNTY HOSPITAL DISTRICT MOLINA HEALTHCARE OF TEXAS, INC. HOSPITAL SERVICES AGREEMENT	1	Amendment	1					38961	1	Y	2	Molina Healthcare of Texas, Inc.	2	Harris County Hospital District d/b/a Harris Health System, a political subdivision of the State of Texas	1			43647	2																	Harris County Hospital District d/b/a Harris Health System - Ambulatory Surgery Center (ASC)	2																				01-09-2019	1	01-09-2019	1	Y	1																																														Ancillary		Medicaid/Medicare	1																									Y	1			% fee schedule	1										Medicaid fee for services	1			1	1							N
106	CSNP18	CSNP18	CSNP18	CSNP18_CareSource Network Partners LLC_Community Health Network_Base Contract MU.pdf_Medicare_10-6-2015	Veena	Ready for QC	CareSource Network Partners LLC	Community Health Network_Base Contract MU.pdf	Community Health Network, Inc.	Custom - Multiple	ERROR	CARESOURCE HOSPITAL AGREEMENT	1	Base Contract	1							Y	20	CareSource Indiana, Inc	1	undersigned hospital	1			CareSource Indiana, Inc.	20					201 N Illinois 15th Floor South Tower		Indianapolis	IN	46204			20																												06-10-2015	20	42283	1,20	06-10-2016	14	Y	14	year to year	14				180D	of the date covered services were rendered	21	30D	of receipt	21	30D	pay 95% of clean claims of receipt	25	30D	pay 95% of clean claims of receipt	25	10Y	date of completion of any audit	11				30D	From dispute notice	17	30D	after receipt of the appeal notice	10	60D	after discover of any overpayment	11	2Y	after the other partys receipt	11							Multiple	23	Medicare	23						Inpatient	23										Y	21	fails to pay or deny a clean claim within 30 days	21	lesser of the usual, customary, and reasonable charge or the reimbursement rate agreed by the plan and the hospital	21	30 days written notice of any increase	12	Y	23			Billed Charges	23														1	23					Y	23	Y			% Fee Schedule	23										Medicare Allowed Amount	23			1	23			Y	23																																																																														Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																								Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																																																																																																																																																																																																																																																																		Y	The Inpatient Reimbursement shall be calculated as the sum of the Provider's operating base rate and capital base rate multiplied by the Medicare DRG weight, plus adjustments for indirect medical education (IME), disproportional share (DSH) and outlier payments if applicable. Any co-payment, co-insurance or deductible shall be offset against the allowed amount for Covered Services, without regard to whether Provider has collected such amounts. When combined with all other sources of payment, CareSource's Payment cannot exceed the Payment listed in this Medicare Addendum	23
107	CSNP18	CSNP18	CSNP18	CSNP18_CareSource Network Partners LLC_Community Health Network_Base Contract MU.pdf_Medicare_10-6-2015	Veena	Ready for QC	CareSource Network Partners LLC	Community Health Network_Base Contract MU.pdf	Community Health Network, Inc.	Custom - Multiple	ERROR	CARESOURCE HOSPITAL AGREEMENT	1	Base Contract	1							Y	20	CareSource Indiana, Inc	1	undersigned hospital	1			CareSource Indiana, Inc.	20					201 N Illinois 15th Floor South Tower		Indianapolis	IN	46204			20																												06-10-2015	20	42283	1,20	06-10-2016	14	Y	14	year to year	14				180D	of the date covered services were rendered	21	30D	of receipt	21	30D	pay 95% of clean claims of receipt	25	30D	pay 95% of clean claims of receipt	25	10Y	date of completion of any audit	11				30D	From dispute notice	17	30D	after receipt of the appeal notice	10	60D	after discover of any overpayment	11	2Y	after the other partys receipt	11							Multiple	23	Medicare	23						Outpatient	23										Y	21	fails to pay or deny a clean claim within 30 days	21	lesser of the usual, customary, and reasonable charge or the reimbursement rate agreed by the plan and the hospital	21	30 days written notice of any increase	12	Y	23			Billed Charges	23														1	23					Y	23	Y			% Fee Schedule	23										Medicare Allowed Amount	23			1	23			Y	23																																																																														Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																								Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																																																																																																																																																																																																																																																																		Y	Any co-payment, co-insurance or deductible shall be offset against the allowed amount for Covered Services, without regard to whether Provider has collected such amounts. When combined with all other sources of payment, CareSource's Payment cannot exceed the Payment listed in this Medicare Addendum	23
108	CSNP18	CSNP18	CSNP18	CSNP18_CareSource Network Partners LLC_Community Health Network_Base Contract MU.pdf_Medicare_10-6-2015	Veena	Ready for QC	CareSource Network Partners LLC	Community Health Network_Base Contract MU.pdf	Community Health Network, Inc.	Custom - Multiple	ERROR	CARESOURCE HOSPITAL AGREEMENT	1	Base Contract	1							Y	20	CareSource Indiana, Inc	1	undersigned hospital	1			CareSource Indiana, Inc.	20					201 N Illinois 15th Floor South Tower		Indianapolis	IN	46204			20																												06-10-2015	20	42283	1,20	06-10-2016	14	Y	14	year to year	14				180D	of the date covered services were rendered	21	30D	of receipt	21	30D	pay 95% of clean claims of receipt	25	30D	pay 95% of clean claims of receipt	25	10Y	date of completion of any audit	11				30D	From dispute notice	17	30D	after receipt of the appeal notice	10	60D	after discover of any overpayment	11	2Y	after the other partys receipt	11							Multiple	23	Medicare	23						Home Health	23										Y	21	fails to pay or deny a clean claim within 30 days	21	lesser of the usual, customary, and reasonable charge or the reimbursement rate agreed by the plan and the hospital	21	30 days written notice of any increase	12	Y	23			Billed Charges	23														1	23					Y	23	Y			% Fee Schedule	23										Medicare Allowed Amount	23			1	23			Y	23																																																																														Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																								Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																																																																																																																																																																																																																																																																		Y	Any co-payment, co-insurance or deductible shall be offset against the allowed amount for Covered Services, without regard to whether Provider has collected such amounts. When combined with all other sources of payment, CareSource's Payment cannot exceed the Payment listed in this Medicare Addendum	23
109	CSNP18	CSNP18	CSNP18	CSNP18_CareSource Network Partners LLC_Community Health Network_Base Contract MU.pdf_Medicare_10-6-2015	Veena	Ready for QC	CareSource Network Partners LLC	Community Health Network_Base Contract MU.pdf	Community Health Network, Inc.	Custom - Multiple	ERROR	CARESOURCE HOSPITAL AGREEMENT	1	Base Contract	1							Y	20	CareSource Indiana, Inc	1	undersigned hospital	1			CareSource Indiana, Inc.	20					201 N Illinois 15th Floor South Tower		Indianapolis	IN	46204			20																												06-10-2015	20	42283	1,20	06-10-2016	14	Y	14	year to year	14				180D	of the date covered services were rendered	21	30D	of receipt	21	30D	pay 95% of clean claims of receipt	25	30D	pay 95% of clean claims of receipt	25	10Y	date of completion of any audit	11				30D	From dispute notice	17	30D	after receipt of the appeal notice	10	60D	after discover of any overpayment	11	2Y	after the other partys receipt	11							Multiple	23	Medicare	23						Hospice	23										Y	21	fails to pay or deny a clean claim within 30 days	21	lesser of the usual, customary, and reasonable charge or the reimbursement rate agreed by the plan and the hospital	21	30 days written notice of any increase	12	Y	23			Billed Charges	23														1	23					Y	23	Y			% Fee Schedule	23										Medicare Allowed Amount	23			1	23			Y	23																																																																														Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																								Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																																																																																																																																																																																																																																																																		Y	Any co-payment, co-insurance or deductible shall be offset against the allowed amount for Covered Services, without regard to whether Provider has collected such amounts. When combined with all other sources of payment, CareSource's Payment cannot exceed the Payment listed in this Medicare Addendum	23
110	CSNP18	CSNP18	CSNP18	CSNP18_CareSource Network Partners LLC_Community Health Network_Base Contract MU.pdf_Medicare_10-6-2015	Veena	Ready for QC	CareSource Network Partners LLC	Community Health Network_Base Contract MU.pdf	Community Health Network, Inc.	Custom - Multiple	ERROR	CARESOURCE HOSPITAL AGREEMENT	1	Base Contract	1							Y	20	CareSource Indiana, Inc	1	undersigned hospital	1			CareSource Indiana, Inc.	20					201 N Illinois 15th Floor South Tower		Indianapolis	IN	46204			20																												06-10-2015	20	42283	1,20	06-10-2016	14	Y	14	year to year	14				180D	of the date covered services were rendered	21	30D	of receipt	21	30D	pay 95% of clean claims of receipt	25	30D	pay 95% of clean claims of receipt	25	10Y	date of completion of any audit	11				30D	From dispute notice	17	30D	after receipt of the appeal notice	10	60D	after discover of any overpayment	11	2Y	after the other partys receipt	11							Multiple	23	Medicare	23						SNF	23										Y	21	fails to pay or deny a clean claim within 30 days	21	lesser of the usual, customary, and reasonable charge or the reimbursement rate agreed by the plan and the hospital	21	30 days written notice of any increase	12	Y	23			Billed Charges	23														1	23					Y	23	Y			% Fee Schedule	23										Medicare Allowed Amount	23			1	23			Y	23																																																																														Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																								Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																																																																																																																																																																																																																																																																		Y	Any co-payment, co-insurance or deductible shall be offset against the allowed amount for Covered Services, without regard to whether Provider has collected such amounts. When combined with all other sources of payment, CareSource's Payment cannot exceed the Payment listed in this Medicare Addendum	23
111	CSNP18	CSNP18	CSNP18	CSNP18_CareSource Network Partners LLC_Community Health Network_Base Contract MU.pdf_Medicare_10-6-2015	Veena	Ready for QC	CareSource Network Partners LLC	Community Health Network_Base Contract MU.pdf	Community Health Network, Inc.	Custom - Multiple	ERROR	CARESOURCE HOSPITAL AGREEMENT	1	Base Contract	1							Y	20	CareSource Indiana, Inc	1	undersigned hospital	1			CareSource Indiana, Inc.	20					201 N Illinois 15th Floor South Tower		Indianapolis	IN	46204			20																												06-10-2015	20	42283	1,20	06-10-2016	14	Y	14	year to year	14				180D	of the date covered services were rendered	21	30D	of receipt	21	30D	pay 95% of clean claims of receipt	25	30D	pay 95% of clean claims of receipt	25	10Y	date of completion of any audit	11				30D	From dispute notice	17	30D	after receipt of the appeal notice	10	60D	after discover of any overpayment	11	2Y	after the other partys receipt	11							Multiple	23	Medicare	23						Dialysis	23										Y	21	fails to pay or deny a clean claim within 30 days	21	lesser of the usual, customary, and reasonable charge or the reimbursement rate agreed by the plan and the hospital	21	30 days written notice of any increase	12	Y	23			Billed Charges	23														1	23					Y	23	Y			% Fee Schedule	23										Medicare Allowed Amount	23			1	23			Y	23																																																																														Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																								Y	23			% FEE SCHEDULE	MEDICARE ALLOWED AMOUNT	CURRENT	1																																																																																																																																																																																																																																																																																																																		Y	Any co-payment, co-insurance or deductible shall be offset against the allowed amount for Covered Services, without regard to whether Provider has collected such amounts. When combined with all other sources of payment, CareSource's Payment cannot exceed the Payment listed in this Medicare Addendum	23
112	CSNP10	CSNP10	CSNP10	CSNP10_CareSource Network Partners LLC_CSNP10_Cabell Huntington_OH MCD Compensation_Medicaid_4-30-2007	Veena	Ready for QC	CareSource Network Partners LLC	CSNP10_Cabell Huntington_OH MCD Compensation	CSNP10_Cabell Huntington_OH MCD Compensation	Boilerplate - Multiple	ERROR	ATTACHMENT A.1 Reimbursement	1	Amendment	1							Y	1	CareSource	1	Cabell Huntington Hospital	1			Cabell Huntington Hospital	1																																								30-04-2007	2	39202	2																																														Multiple	23	Medicaid	23						Inpatient	1																		Y	1			Ohio Medicaid DRG ( Current ODJFS payment rate)	1										Ohio Medicaid	1			1	1					Y	1	Y			Billed Charges	1														1	1			Neonatal Intensive Care Services	1																																																									Y	1	Lesser of 110% of OHIO MCD DRG or 100% Billed Charges	1.1																																																						Y	2			% FEE SCHEDULE	OHIO MEDICAID FEE SCHEDULE	CURRENT	1	except for those drugs that may be available through a specialty pharmacy benefits manager.																																																																		Y	1	3293.46	Inlier= Base rate+ Med-ed X DRG RW + Cap Outlier ( Where billed charges> drg specific charge high trim) = Inlier payment + (Billed Charges-DRG specific charge high trim) X IP Ratio (.50)
113	CSNP10	CSNP10	CSNP10	CSNP10_CareSource Network Partners LLC_CSNP10_Cabell Huntington_OH MCD Compensation_Medicaid_4-30-2007	Veena	Ready for QC	CareSource Network Partners LLC	CSNP10_Cabell Huntington_OH MCD Compensation	CSNP10_Cabell Huntington_OH MCD Compensation	Boilerplate - Multiple	ERROR	ATTACHMENT A.1 Reimbursement	1	Amendment	1							Y	1	CareSource	1	Cabell Huntington Hospital	1			Cabell Huntington Hospital	1																																								30-04-2007	2	39202	2																																														Multiple	23	Medicaid	23						Outpatient	1																		Y	1			% fee schedule	1										Ohio Medicaid	1			1	1							Y			Billed Charges	1														1	1																																																																																																																						Y	2			% FEE SCHEDULE	OHIO MEDICAID FEE SCHEDULE	CURRENT	1	except for those drugs that may be available through a specialty pharmacy benefits manager.
114	CSNP10	CSNP10	CSNP10	CSNP10_CareSource Network Partners LLC_CSNP10_Cabell Huntington_OH MCD Compensation_Medicaid_4-30-2007	Veena	Ready for QC	CareSource Network Partners LLC	CSNP10_Cabell Huntington_OH MCD Compensation	CSNP10_Cabell Huntington_OH MCD Compensation	Boilerplate - Multiple	ERROR	ATTACHMENT A.1 Reimbursement	1	Amendment	1							Y	1	CareSource	1	Cabell Huntington Hospital	1			Cabell Huntington Hospital	1																																								30-04-2007	2	39202	2																																														Multiple	23	Medicaid	23						Home Health	1																		Y	1			% fee schedule	1										Ohio Medicaid	1			1	1							Y			Billed Charges	1														1	1																																																																																																																						Y	2			% FEE SCHEDULE	OHIO MEDICAID FEE SCHEDULE	CURRENT	1	except for those drugs that may be available through a specialty pharmacy benefits manager.
115	CSNP10	CSNP10	CSNP10	CSNP10_CareSource Network Partners LLC_CSNP10_Cabell Huntington_OH MCD Compensation_Medicaid_4-30-2007	Veena	Ready for QC	CareSource Network Partners LLC	CSNP10_Cabell Huntington_OH MCD Compensation	CSNP10_Cabell Huntington_OH MCD Compensation	Boilerplate - Multiple	ERROR	ATTACHMENT A.1 Reimbursement	1	Amendment	1							Y	1	CareSource	1	Cabell Huntington Hospital	1			Cabell Huntington Hospital	1																																								30-04-2007	2	39202	2																																														Multiple	23	Medicaid	23						Hospice	1																		Y	1			% fee schedule	1										Ohio Medicaid	1			1	1							Y			Billed Charges	1														1	1																																																																																																																						Y	2			% FEE SCHEDULE	OHIO MEDICAID FEE SCHEDULE	CURRENT	1	except for those drugs that may be available through a specialty pharmacy benefits manager.
116	CSNP10	CSNP10	CSNP10	CSNP10_CareSource Network Partners LLC_CSNP10_Cabell Huntington_OH MCD Compensation_Medicaid_4-30-2007	Veena	Ready for QC	CareSource Network Partners LLC	CSNP10_Cabell Huntington_OH MCD Compensation	CSNP10_Cabell Huntington_OH MCD Compensation	Boilerplate - Multiple	ERROR	ATTACHMENT A.1 Reimbursement	1	Amendment	1							Y	1	CareSource	1	Cabell Huntington Hospital	1			Cabell Huntington Hospital	1																																								30-04-2007	2	39202	2																																														Multiple	23	Medicaid	23						Physician Group	2																		Y	1			% fee schedule	1	Physician Services	1								Ohio Medicaid	1			1.05	1							Y			% Fee Schedule	1	Non-Physician Services	2								Medicaid	1			1	1			Y	2	Billed Charges	1	1	1																																																																																																														Y	2			% FEE SCHEDULE	OHIO MEDICAID FEE SCHEDULE	CURRENT	1	except for those drugs that may be available through a specialty pharmacy benefits manager.
117	AvM24 - inpatient	AvM24	AvM24	AvM24 - inpatient_AvMed_Boilerplate_2015-10-01 AvMed Hospital Services Agreement Bayfront Health St Petersburg_Commercial/Group_1-0-1900	Veena	QC Completed	AvMed	Boilerplate_2015-10-01 AvMed Hospital Services Agreement Bayfront Health St Petersburg	Boilerplate_2015-10-01 AvMed Hospital Services Agreement Bayfront Health St Petersburg	Boilerplate - Facility	ERROR	AVMED, INC. Hospital Services Agreement With Bayfront HMA Medical Center, LLC DBA Bayfront Health St. Petersburg	1	Base Contract	1							Y	14	AvMed, Inc.	1	Bayfront HMA Medical Center, LLC dba Bayfront Health St. Petersburg	3					300759177	14			701 6th Street		St. Petersburg	FL	33701			3																																3 years or 9/30/2018	7	Y	7	3 YEARS	7																																										Commercial/Group	15	HMO	HMO	3, 5			Inpatient	15																		N	15			Conversion Factor Multiplied by current CMS Medicare relative weights as published by CMS and amended as updated by CMS from time to time	15										CMS Medicare	15					7330	15			Y	15	Y	Y, *The reimbursement for Normal Newborns (MS-DRG795) is included in mother's reimbursement. Nonweighted DRGs will be reimbursed at 37% of billed charges.	15																																																																																																												Y	17	273-276,278, 274, 333	Revenue Codes, CPT	% billed charges			0.56	$500 or more																																																																																													Y	15	78035	% billed charges			0.56	Prosthetic devices and Medical implants are deducted from total charges prior to calculation of outlier payment.																																																											Y	15			Per Diem/ PER DAY			1605																																																																																																																Y	15	1.18E+14	Revenue Codes	Per Diem	current	986	Chronic or extended Rehabilitation not covered																												Y	15	190-199	Revenue Codes	per day	685
118	AvM24 - outpatient	AvM24	AvM24	AvM24 - outpatient_AvMed_Boilerplate_2015-10-01 AvMed Hospital Services Agreement Bayfront Health St Petersburg_Commercial/Group_1-0-1900	Veena	QC Completed	AvMed	Boilerplate_2015-10-01 AvMed Hospital Services Agreement Bayfront Health St Petersburg	Boilerplate_2015-10-01 AvMed Hospital Services Agreement Bayfront Health St Petersburg	Boilerplate - Facility	ERROR	AVMED, INC. Hospital Services Agreement With Bayfront HMA Medical Center, LLC DBA Bayfront Health St. Petersburg	1	Base Contract	1							Y	14	AvMed, Inc.	1	Bayfront HMA Medical Center, LLC dba Bayfront Health St. Petersburg	3					300759177	14			701 6th Street		St. Petersburg	FL	33701			3																																3 years or 9/30/2018	7	Y	7	3 YEARS	7																																										Commercial/Group	15	HMO	HMO	3, 5			Outpatient	15			Y	20	Conversion Factor, Transferring Members, Physical Rehabilitation, SNF/SNU,Emergency Room Cap, Observation Cap, Outpatient Therapy, Cardiac Case Rates, Gamma Knife, and MRI,	20	0.04	20										N				% BILLED CHARGES	16														0.47	16							Y																													Y	15	450-452, 459	Revenue Codes	% Billed Charges		47% <= $1,030		Y	16	762	Rev Code	% billed charges per 23-hour observation	47% <= $1,605																																																																				Y	17	273-276,278, 274	Revenue Codes	% billed charges			56% =>$500																																																																																		Y	16			% Billed Charges			0.47																																																														Y	16	420-449	Revenue Codes	Per visit			97																																																																																																																																	Y	17	360-369, 490-499, 750-759	Revenue Codes	% Fee Schedule for Groups 1-56	140% of Carveout Table in tab									Y	17	92920-92944, 361,481 & 93451-93462, 93530-93533, 93563-93568	CPT CODES				92920-92944: $8,912, 361,481 & 93451-93462, 93530-93533, 93563-93568: $5,999																																						Y	18	77371-77373, 77435, 61796-61800, 63620 - 63621, G0340, G0251, G0339, G0173	cpt	Case Rate	24482	Covers 5 visits, Payment is made when billed with initial visit (G0339)	Y	18	6.11E+17	Revenue Codes	Flat fee	1114							Y	16	cpt/ hcpcs	% BILLED CHARGES	0.47							Y	A surgical procedure authorized by Plan to be performed on an outpatient basis not assigned to a Group Leveling the above "Outpatient Surgery Group Rates" table will be reimbursed by Plan at the respective Groulpevel reimbursement rate listed below, less any applicable co-payments and ineligible charges.	22
119	AvM8- INP	AvM8	AvM8	AvM8- INP_AvMed_Boilerplate_2016-01-01 17th BayCare Amendment Adding Bartow Regional_Commerical/Group_1-1-2016	Veena	QC Complete	AvMed	Boilerplate_2016-01-01 17th BayCare Amendment Adding Bartow Regional	Boilerplate_2016-01-01 17th BayCare Amendment Adding Bartow Regional	Boilerplate - Facility	ERROR	Seventeenth Amendment to the Hospital Services Agreement	1	Amendment	1	7th	1			37135	1	Y	1	AvMed Health Plans	1	BayCare Health System Inc.	1									2985 Drew Street		Clearwater	FL	33759			1					See "Avm8 BaycareProviders" Tab	2	See "Avm8 BaycareProviders" Tab	2																		01-01-2016	1	03-02-2016	1	N	1																																																Commerical/Group	2						Inpatient	2																						Conversion Factor	2																$12,152 Multiplied by current CMS Medicare Relative Weights as published by CMS and amended as updated by CMS from time to time.	2			Y		Y	Non-weighted MS-DRGs will be reimbursed at 41% of billed charges.	2																																																																																																																																																																																																																	Y	2	90344	Case Rate payment in addition to % billed charges			0.6																																																																																																																																														Y	2	25-27, 31-33, 40-42, 215-244, 246-251, 255-264, 280-287, 955 and any other Cardiac/Nuero DRGs, Ages 0-17	MS-DRGs	% Billed Charges			0.81																																																																							Y	2	619-621 and 44.21, 44.38, 44.39	drg and ICD9	DRG or Case Rate	27881
120	AvM8 - OP	AvM8	AvM8	AvM8 - OP_AvMed_Boilerplate_2016-01-01 17th BayCare Amendment Adding Bartow Regional_Commerical/Group_1-1-2016	Veena	QC Complete	AvMed	Boilerplate_2016-01-01 17th BayCare Amendment Adding Bartow Regional	Boilerplate_2016-01-01 17th BayCare Amendment Adding Bartow Regional	Boilerplate - Facility	ERROR	Seventeenth Amendment to the Hospital Services Agreement	1	Amendment	1	7th	1			37135	1	Y	1	AvMed Health Plans	1	BayCare Health System Inc.	1									2985 Drew Street		Clearwater	FL	33759			1					See "Avm8 BaycareProviders" Tab	2	See "Avm8 BaycareProviders" Tab	2																		01-01-2016	1	03-02-2016	1	N	1																																																Commerical/Group	2						Outpatient	3																Adjusted by (1 +/- % adjustment in charge master)	7					% BILLED CHARGES	3														0.47	3							Y	In the event Hospital provides services to an AvMed Medicare Member covered under Plan's Medicare Risk Contract, Plan shall reimburse Hospital 100% of the Medicare MS-DRG Allowed Amount and 100% of the Medicare Outpatient Allowed Amount. For Covered Medical Services not assigned a Medicare MS-DRG Allowed Amount, Plan shall reimburse Hospital at 60% of the Total Billed Charges.	3,5																																																																																																																																																																																		y	3	80047-89398, 0300-0319	CPT, Revenue Codes	% Billed Charges			0.29	N
121	FNY10	FNY10	FNY10	FNY10_Fidelis NY_Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14_Medicaid_1-1-2014	Veena	Ready for QC	Fidelis NY	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate - Facility	ERROR	AMENDMENT TO AGREEMENT BETWEEN NEW YORK STATE CATHOLIC HEALTH PLAN, INC. d/b/a Fidelis Care New York AND BRONX LEBANON HOSPITAL CENTER	1	Amendment	1					36859	1	Y	4,5	Fidelis Care New York	1	Bronx Lebanon Hospital Center and its affiliate, Dr. Martin Luther King Jr. Health Center, Inc.	1					13-1974191, 132707945	4,5	1417027558, 1437231693	4,5	1650 Grand Concourse, 1265 Franklin Avenue		Bronx	NY	10457, 10456			4,5																										01-01-2014	1	12-06-2013	4	N	1,4																																														Ancillary	1	Medicaid	3				Child Health Plus	3																																															N																																																																																																																																																																																																						1.1
122	FNY10	FNY10	FNY10	FNY10_Fidelis NY_Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14_Medicaid_1-1-2014	Veena	Ready for QC	Fidelis NY	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate - Facility	ERROR	AMENDMENT TO AGREEMENT BETWEEN NEW YORK STATE CATHOLIC HEALTH PLAN, INC. d/b/a Fidelis Care New York AND BRONX LEBANON HOSPITAL CENTER	1	Amendment	1					36859	1	Y	4,5	Fidelis Care New York	1	Bronx Lebanon Hospital Center and its affiliate, Dr. Martin Luther King Jr. Health Center, Inc.	1					13-1974191, 132707945	4,5	1417027558, 1437231693	4,5	1650 Grand Concourse, 1265 Franklin Avenue		Bronx	NY	10457, 10456			4,5																										01-01-2014	1	12-06-2013	4	N	1,4																																														Ancillary	1	Medicaid	3	Family Health Plus																																																			N																																																																																																																																																																																																						1.1
123	FNY10	FNY10	FNY10	FNY10_Fidelis NY_Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14_Medicaid_1-1-2014	Veena	Ready for QC - question about LOB	Fidelis NY	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate - Facility	ERROR	AMENDMENT TO AGREEMENT BETWEEN NEW YORK STATE CATHOLIC HEALTH PLAN, INC. d/b/a Fidelis Care New York AND BRONX LEBANON HOSPITAL CENTER	1	Amendment	1				z	36859	1	Y	4,5	Fidelis Care New York	1	Bronx Lebanon Hospital Center and its affiliate, Dr. Martin Luther King Jr. Health Center, Inc.	1					13-1974191, 132707945	4,5	1417027558, 1437231693	4,5	1650 Grand Concourse, 1265 Franklin Avenue		Bronx	NY	10457, 10456			4,5																										01-01-2014	1	12-06-2013	4	N	1,4																																														Ancillary	1	Medicaid	3	Management Long Term Care		3																																																	N
124	FNY10	FNY10	FNY10	FNY10_Fidelis NY_Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14_Commercial_1-1-2014	Veena	Ready for QC	Fidelis NY	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate - Facility	ERROR	AMENDMENT TO AGREEMENT BETWEEN NEW YORK STATE CATHOLIC HEALTH PLAN, INC. d/b/a Fidelis Care New York AND BRONX LEBANON HOSPITAL CENTER	1	Amendment	1					36859	1	Y	4,5	Fidelis Care New York	1	Bronx Lebanon Hospital Center and its affiliate, Dr. Martin Luther King Jr. Health Center, Inc.	1					13-1974191, 132707945	4,5	1417027558, 1437231693	4,5	1650 Grand Concourse, 1265 Franklin Avenue		Bronx	NY	10457, 10456			4,5																										01-01-2014	1	12-06-2013	4	N	1,4																																														Ancillary	1	Commercial	3	Health Benefit Exchange		3			Inpatient	6																						% Fee Schedule	6										Medicare DRG	6			1.1	6					Y		Y	Rates exclude IME. Rates for inpatient services are all inclusive	6																											Y	6			% Fee Schedule	Medicare APC	1.1																																																																																				Y	6	274275278	Revenue Codes	% BILLED CHARGES			0.5																																																																	Y	6			% fee schedule	Medicare APC Rate		1.1																																																																																							Y	6		% FEE SCHEDULE	MEDICARE RBRVS RATE		1.1																																																																																																																																																								Y	6	% FEE SCHEDULE	MEDICARE RBRVS	1.1
125	FNY10	FNY10	FNY10	FNY10_Fidelis NY_Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14_Commercial_1-1-2014	Veena	Ready for QC	Fidelis NY	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14	Boilerplate - Facility	ERROR	AMENDMENT TO AGREEMENT BETWEEN NEW YORK STATE CATHOLIC HEALTH PLAN, INC. d/b/a Fidelis Care New York AND BRONX LEBANON HOSPITAL CENTER	1	Amendme

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