Ubuntu
254 KiB
254 KiB
| 1 | Contract Name | Contract ID | Field Name | SF_DB_COL_NAME | Actual Value Stored | New Extracted value | Confidence Level | Snippet | Original Page Number | New Page Number | Revised Prompt | Result |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 | 2017 01 01 Raul A. Rivera & Associates, P.A. (Master)PHY Executed | training-data/contract-text-file/0. Professional Boilerplate/2017 01 01 Raul A. Rivera & Associates, P.A. (Master)PHY Executed MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 760528768 | 7605-28768 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 3 | 2023 10 26_Pediatrix Medical Group of T...ment CHIP_STAR_Removed HIM_executed | training-data/contract-text-file/0. Professional Boilerplate/2023 10 26_Pediatrix Medical Group of T...ment CHIP_STAR_Removed HIM_executed MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 65-0578395 | 65-0578395 | dba Pediatrix Community Health Choice, Inc Medical Group of Texas 2636 South Loop West, Suite 125 1301 Concord Terrace, Sunrise, FL 33323 Houston, TX 77054 Attn: AVP, Managed Care Phone: 713-295-2294 Phone: 800-243-3839 Email: payorcontracting@pediatrix com and Facsimile: 713-295-7058 legalnotice@pediatrix com Ryan Sorrell DanGer Daniel Corcoran (Oct 19, 2023 13:23 EDT) Community Signature: Authorized Signature: Ryan Sorrell Daniel Corcoran Printed Name: Printed Name VP, Network Management Operations SVP, Administration and Managed Care Title Title 10/26/2023 Oct 19, 2023 Date Date 65-0578395 TIN TO BE COMPLETED BY COMMUNITY 1649377359 ONLY: NPI Effective Date: 10/26/2023 1/1/2020 CHC_Hospital-Based Physician Agreement Page 19 of 43 Start of Page No = 20 EXHIBIT A HOSPITAL-BASED PROVIDER DEMOGRAPHICS This Exhibit may be updated at any time without the need of a signed amendment by both parties However, Provider must comply with notification requirements under this Agreement and any guidelines or protocols located in the Provider Manual, as well as Community's credentialing policies. Legal Business Name Pediatrix Medical Group of Texas Billing, Inc. Business Name (dba) Pediatrix Medical Group of Texas Website Tax Identification Number 65-0578395 Group NPI Number 1649377359 Group TPI Group THSteps TPI, if applicable Remit Address Address: PO BOX 840384 City/State/ZIP: Dallas, TX 75284-0384 Phone: (972) 437-5099 Fax: (972) 479-9588 Specialty / Type of Service Name of Hospital(s) or Physician or Mid-Level Surgery Center(s) Medicare Practitioner **If more than one where Hospital-Based CAQH Individual Medicaid Physician or Mid-Level Number NPI Number Participation Last Name, First Name, MI specialty, create a Number Number and Degree new record for Practitioner renders each specialty/type services of service 1/1/2020 CHC_Hospital-Based Physician Agreement Page 20 of 43 -------TABLE Start----- Legal Business Name Pediatrix Medical Group of Texas Billing, Inc. Business Name (dba) Pediatrix Medical Group of Texas Website Tax Identification Number 65-0578395 Group NPI Number 1649377359 Group TPI Group THSteps TPI, if applicable Remit Address Address: PO BOX 840384 City/State/ZIP: Dallas, TX 75284-0384 Phone: (972) 437-5099 Fax: (972) 479-9588 -------TABLE End----- -------TABLE Start----- Specialty / Type of Service Name of Hospital(s) or Physician or Mid-Level Surgery Center(s) Medicare Practitioner **If more than one where Hospital-Based CAQH Individual Medicaid Physician or Mid-Level Number NPI Number Participation Last Name, First Name, MI specialty, create a Number Number and Degree new record for Practitioner renders each specialty/type services of service -------TABLE End----- Start of Page No = 21 EXHIBIT B-1 COMPENSATION CHIP Does not participate in CHIP Applicable Benefit CHIP Perinatal Does not participate in CHIP/P Plan(s): STAR Does not participate in STAR STAR+PLUS Does not participate in STAR+PLUS Primary Care Physician Hospital-Based PCP or OB/Gyn Provider Type: OB/Gyn Other: Mid-Level/Physician Extender Services: Professional Services Physician/Provider agrees to participate in the Benefit Plan/Program described in this Exhibit and authorizes, through its signature below, the transfer of all payment/reimbursement terms and obligations under the Agreement to Payors as set forth in this Agreement. Subject to allowed reductions that Community may apply as a result of Physician/Provider's non-compliance with any applicable credentialing, billing, Prior Authorization, Referral, or Utilization Management guidelines, or other Community Protocols referenced in this Agreement, Physician/Provider shall accept as payment in full for Covered Services and all other services rendered to Members under this Agreement, the lesser of Physician/Provider's Billed Charges or the agreed compensation set forth in this Exhibit, less any applicable Member Expense: All Covered Services: one hundred and ten percent (110%) of the then current Texas Medicaid Fee Schedule, except: Vaginal delivery only, after previous cesarean delivery (Current Procedural Coding (CPT) 59612): four hundred and dollars ($400.00) above the then current reimbursement for CPT R code 59514 (Cesarean delivery only). Radiology services (CPT codes 70000 through 76505): eighty (80%) of the Texas Medicaid Fee Schedule. Ultrasound services (CPT R) codes 76506 through 79999): one hundred and ten (110%) of the Texas Medicaid Fee Schedule. Clinical Laboratory services (CPT® codes 80000 through 87999): sixty percent (60%) of the Texas Medicaid Clinical Laboratory Fee Schedule. Drugs dispensed and administered by Physician/Provider: one hundred percent (100%) of the Texas Medicaid reimbursement, except: Rho (D) immune globulin billed with Healthcare Common Procedure Code System (HCPCS) codes defined herein shall be reimbursed at one hundred and twenty percent (120%) of the Texas Medicaid Fee Schedule: J2788 - injection, Rho (D) immune globulin, human, mini dose, 50 mcg (250 IU) J2790 - injection, Rho (D) immune globulin, human, full dose, 300 mcg (1500 IU) J2791 - injection, Rho (D) immune globulin (human), (Rhophylac), intramuscular or intravenous, 100 IU J2792 - injection, Rho (D) immune globulin, intravenous, human, solvent detergent, 100 IU Compensation Notes: Community shall process Clean Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and according to Texas Medicaid reimbursement methodology. Physician/Provider agrees to only bill for and Community shall be obligated to only pay for clinical laboratory services for which Physician/Provider holds a valid CLIA certification. If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods listed above, Community shall compensate Physician/Provider according to thirty percent (30%) of Physician/Provider's Billed Charges. In the event a service is not specifically mentioned above, the intent of reimbursement will follow Texas Medicaid Methodology. Govt Oct 19, 2023 Provider Signature: Daniel Corcoran (Oct 19, 2023 13:23 EDT) Date: 1/1/2020 CHC_Hospital-Based Physician Agreement Page 21 of 43 -------TABLE Start----- CHIP Does not participate in CHIP Applicable Benefit CHIP Perinatal Does not participate in CHIP/P Plan(s): STAR Does not participate in STAR STAR+PLUS Does not participate in STAR+PLUS Primary Care Physician Hospital-Based PCP or OB/Gyn Provider Type: OB/Gyn Other: Mid-Level/Physician Extender Services: Professional Services -------TABLE End----- Start of Page No = 22 EXHIBIT B-1 COMPENSATION CHIP Does not participate in CHIP Applicable CHIP Perinatal Does not participate in CHIP/P Benefit Plan(s): STAR Does not participate in STAR STAR+PLUS Does not participate in STAR+PLUS Hospital-Based Specialist Provider Type: Specialist Other: Mid-Level/Physician Extender Services: Professional Services Physician/Provider agrees to participate in the Benefit Plan/Program described in this Exhibit and authorizes, through its signature below, the transfer of all payment/reimbursement terms and obligations under the Agreement to Payors as set forth in this Agreement. Subject to allowed reductions that Community may apply as a result of Physician/Provider's non-compliance with any applicable credentialing, billing, Prior Authorization, Referral, or Utilization Management guidelines, or other Community Protocols referenced in this Agreement, Physician/Provider shall accept as payment in full for Covered Services and all other services rendered to Members under this Agreement, the lesser of Physician/Provider's Billed Charges or the agreed compensation set forth in this Exhibit, less any applicable Member Expense: All Covered Services: one hundred ten percent (110%) of the then current Texas Medicaid Fee Schedule, except: Radiology services (CPT ) codes 70000 through 79999): eighty (80%) of the Texas Medicaid Fee Schedule. Clinical Laboratory services (CPT6 codes 80000 through 87999): sixty percent (60%) of the Texas Medicaid Clinical Laboratory Fee Schedule. Durable Medical Equipment, Prosthetics/Orthotics, and Supplies: eighty (80%) of the then current Medicaid Fee Schedule. Drugs dispensed and administered by Physician/Provider: one hundred percent (100%) of the Texas Medicaid Fee Schedule. Compensation Notes: Community shall process Clean Claims based on the then current Texas Medicaid Fee Schedule as applicable to services rendered and according to Texas Medicaid reimbursement methodology. Physician/Provider agrees to only bill for and Community shall be obligated to only pay for clinical laboratory services for which Physician/Provider holds a valid CLIA certification. If Physician/Provider bills for a Covered Service for which no reimbursement is defined by any of the methods listed above, Community shall compensate Physician/Provider according to thirty percent (30%) of Physician/Provider's Billed Charges. Gov Physician/Provider Signature: Daniel Corcoran (Oct 19, 2023 13:23 EDT) Date: Oct 19,2023 1/1/2020 CHC_Hospital-Based Physician Agreement Page 22 of 43 -------TABLE Start----- CHIP Does not participate in CHIP Applicable CHIP Perinatal Does not participate in CHIP/P Benefit Plan(s): STAR Does not participate in STAR STAR+PLUS Does not participate in STAR+PLUS Hospital-Based Specialist Provider Type: Specialist Other: Mid-Level/Physician Extender Services: Professional Services -------TABLE End----- Start of Page No | 19 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 4 | Boilerplate_Benjamin Bieber MD - Amendment 5.30.16 | training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Benjamin Bieber MD - Amendment 5.30.16_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 15-2487027 | 15-2487027 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 5 | Boilerplate_Benjamin Bieber | training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Benjamin Bieber_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 15-2487027 | 15-2487027 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 6 | Boilerplate_Bethpage Medical, PLLC - Agreement | training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Bethpage Medical, PLLC - Agreement_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 26-3847741 | 26-3847741 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 7 | Boilerplate_Bethpage Medical, PLLC - Amendment 9.23.13 | training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Bethpage Medical, PLLC - Amendment 9.23.13_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 26-3847741 | 26-3847741 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 8 | Boilerplate_Prof_Premier Health Specialists Inc Third Amendment_A.4_20160101 | training-data/contract-text-file/0. Professional Boilerplate/Boilerplate_Prof_Premier Health Specialists Inc Third Amendment_A.4_20160101_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 06-1744704 | 06-1744704 | Cohum By By Craig Thiele, M D Mark W Shaw Printed Name Printed Name Chief Medical Officer VP Managed Care & Chief Revenue Officer Title Title 10-19-15 10/16/15 Date Date 06-1744704 Tax ID No. Start of Page No = 2 ATTACHMENT A.4 REIMBURSEMENT FOR CareSource Just4Me TM Addendum to Agreement For Medically Necessary Covered Services rendered to Covered Persons by Group Practice or by Group Practice Providers in accordance with the terms of this Agreement, Group Practice shall accept as payment in full the lesser of: (i) Group Practice or Group Practice Providers Allowable Billed Charges; or (ii) One-hundred and fifty percent (150%) of the Medicare Fee Schedule applicable to Providers as published annually in the Federal Register and based on valid codes recognized by the Centers for Medicare and Medicaid Services ("CMS") in effect on the date of service (Any co-payment, co- insurance or deductible shall be offset against the allowed amount for Covered Services without regard to whether Group Practice Providers has collected such amounts.). Fee Schedule To determine unit prices for any specific code or service, please refer to the Medicare link below: Medicare: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 9 | ICMProviderAgreement_AlisonUnitisLPCMH_227710_5 | training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AlisonUnitisLPCMH_227710_5.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 47-2541674 | 47-2541674 | = 13 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Delaware First Health, Inc Alison Unitis, LPCMH (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Alison Unitis Aaron Brace (Aug 16, 2022 08:28 EDT) Alison Unitis (Aug 15, 2022 16:50 EDT) Print Name: Aaron Brace Print Name: Alison Unitis Title: Regional Vice President, New Business Network Title: LPCMH Development Signature Date: Aug 16, 2022 Signature Date: Aug 15, 2022 ICM #: ICMProviderAgreement_227710 Tax Identification Number: 47-2541674 To be completed by Health Plan only: National Provider Identifier: 1154468593 Effective Date: Sep 14, 2022 Medicare Number: Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 10 | ICMProviderAgreement_AmyRiceMA_223388_5 | training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AmyRiceMA_223388_5.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-1235543 | 86-1235543 | = 13 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Delaware First Health, Inc Amy Rice MA (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Amy Rice LPCMH Aaron Brace (Aug 16, 2022 15:22 EDT) Amy Rice LPCMH (Aug 16, 2022 10:14 PDT) Print Name: Aaron Brace Print Name: Amy Rice LPCMH Title: Regional Vice President, New Business Network Title: provider Development Signature Date: Aug 16, 2022 Signature Date: Aug 16, 2022 ICM #: ICMProviderAgreement_223388 Tax Identification Number: 86-1235543 To be completed by Health Plan only: National Provider Identifier: 1023691201 Effective Date: Sep 15, 2022 Medicare Number: Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 11 | ICMProviderAgreement_AnnEWhite-TheCenterForHealingConversations_227589_4 | training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AnnEWhite-TheCenterForHealingConversations_227589_4.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 83-3773736 | 83-3773736 | Ann E White DBA The Center for Healing Conversations, LLC (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Ann E White Aaron Brace (Sep 15, 2022 13:42 EDT) Ann E White (Sep 14, 2022 12:45 EDT) Print Name: Aaron Brace Print Name: Ann E White Title: Regional Vice President, New Business Network Title: Psychotherapist/Owner Development Signature Date: Sep 15, 2022 Signature Date: Sep 14, 2022 ICM #: (CMProviderAgreement_227589 Tax Identification Number: 83-3773736 To be completed by Health Plan only: National Provider Identifier: 1700405727 Effective Date: Oct 14, 2022 Medicare Number: Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 12 | ICMProviderAgreement_AvenueMedicalAssociatesPA_212330_5 | training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_AvenueMedicalAssociatesPA_212330_5.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 01-0927020 | 01-0927020 | = 13 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Granite State Health Inc d/b/a Delaware First Health Avenue Medical Associates PA (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Avani Virani MD Aaron Brace (Aug 9, 2022 11:23 EDT) Avani Virani MD (Aug 8, 2022 18:31 EDT) Print Name: Aaron Brace Print Name: Avani Virani Title: Regional Vice President, New Business Network Title: President Development Signature Date: Aug 9, 2022 Signature Date: Aug 8, 2022 ICM #: ICMProviderAgreement_212330 Tax Identification Number: 01-0927020 To be completed by Health Plan only: National Provider Identifier: Effective Date: Sep 07, 2022 Medicare Number: Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 13 | ICMProviderAgreement_BalancedMindCounselingCenter_217525_6 | training-data/contract-text-file/0. Professional Boilerplate/ICMProviderAgreement_BalancedMindCounselingCenter_217525_6.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 47-4931000 | 47-4931000 | = 13 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Delaware First Health, Inc BALANCED MIND COUNSELING CENTER LLC (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Jennifer Ewald, LCSW Aaron Brace (Aug 11, 2022 13:02 EDT) Jennifer Ewald, LCSW (Aug 11, 2022 10:16 EDT) Print Name: Aaron Brace Print Name: Jennifer Ewald, LCSW Title: Corporate Vice President, National Contracting Title: Owner/Clinician Officer Signature Date: Aug 11, 2022 Signature Date: Aug 11, 2022 ICM #: ICMProviderAgreement_217525 Tax Identification Number: 47-4931000 To be completed by Health Plan only: National Provider Identifier: 1518335876 Effective Date: Sep 10, 2022 Medicare Number: Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 14 | CustomProf_Behavior Analysit Professional Services PLLC - Amendment Provider Signed 1.1.19 | training-data/contract-text-file/1. Professional Custom/CustomProf_Behavior Analysit Professional Services PLLC - Amendment Provider Signed 1.1.19_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 81-3535131 | 813535131 | = 3 IN WITNESS WHEREOF, the parties here have signed this AMENDMENT on the date referenced above PROVIDER PLANS Behavioral Analyst Professional Services, NEW YORK STATE CATHOLIC HEALTH PLLC PLAN, INC Provider (Please Print) NEW YORK QUALITY HEALTHCARE CORPORATION 95-25 Queens Boulevard 1326 East 10th Street Rego Park, New York 11374 Address By: Alicia Delmont Brooklyn, N Y 11230 City, State, Zip Code Its: Chief Provider Operations Officer and Entity Tax ID#: 813535131 Authorized Signatory, respectively Date: Entity NPI#: 1427502939 Signature Name: Yocheved Wassermen (Please Print) Title: BCBA Date: 2/1/19 Signature: M n Behavioral Analyst Professional Service PLLC - 3 ABA New Code Amendment Start of Page No = 4 SCHEDULE 1.1 ANCILLARY SERVICES Provider will provide to Enrollees, pursuant to the terms and conditions of this Agreement and the applicable Program Contract, the following Ancillary Services: Autism Services Behavioral Analyst Professional Service PLLC - 4 ABA New Code Amendment Start of Page No = 5 SCHEDULE 1.14 IDENTIFICATION OF THE PROGRAMS AND PROGRAM CONTRACTS Program: Essential Plan Program (EPP) Program Contract: The contract for the provision of managed care services under the New York State Essential Plan Program entered into by and between New York Quality Healthcare Corporation, and the New York State Department of Health/New York State of Health, including all attachments thereto. Program: Child Health Plus Program Contract: The contract for the provision of managed care services under the New York State Child Health Plus program entered into by and New York Quality Healthcare Corporation, and the New York State Department of Health including all attachments thereto. Program: Health Benefit Exchange Program Contract: The contract for the provision of health care services pursuant to the health insurance program created under the Patient Protection and Affordable Care Act through which individuals and small businesses can purchase qualified coverage, entered into between the New York State Department of Health and New York Quality Healthcare Corporation. The Plan(s) may amend this schedule to include additional Programs from time to time Provider agrees that Provider will participate in all new Programs for which Provider is qualified as determined by Plan. Provider's participation in any new Program will be effective upon thirty (30) calendar days notice of Plan's amendment of this Schedule 1.14. Behavioral Analyst Professional Service PLLC - 5 ABA New Code Amendment Start of Page No = 6 Fee Schedule for ABA CPT Codes CPT Code 97151, Behavioral assessment by $12.50 per 15 min unit Professional per 15 Min Unit CPT Code 97152, Behavioral assessment by $12.50 per 15 min unit Technician per 15 Min Unit CPT Code 97153, Behavior treatment by $12.50 per 15 min unit Technician under the direction of a physician or other qualified healthcare professional, face to face with one patient per 15 Min Unit CPT Code 97154, Group behavioral treatment $12.50 per 15 min unit by technician per 15 Min Unit CPT Code 97155, Behavioral treatment by $12.50 per 15 min unit professional (May include simultaneous supervision of technician) per 15 Min Unit CPT Code 97156, Caregiver guidance by $12.50 per 15 min unit professional 15 min unit CPT Code 97157 , Multiple family behavioral $12.50 per 15 min unit guidance (caregivers of >1 clients) without client present by professional per 15 min unit CPT Code 97158, Group behavioral treatment $12.50 per 15 min unit by professional with multiple clients per 15 min Unit CPT Code 0362T, Assessment by professional $12.50 - per 15 min unit + 2 or more technicians for destructive patient per 15 min unit. CPT Code 0373T, Treatment by professional $12.50 - per 15 min unit + 2 or more technicians for destructive patient per 15 minute unit. If QHP is directing the technician without the client present, this is a bundled service and is captured by the new codes listed | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 15 | Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923 | training-data/contract-text-file/1. Professional Custom/Custom_PSA - Advanced Gastroenterology of Texas PLLC -Executed 47-4543923 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 464543923 | 47-4543923 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 16 | Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed | training-data/contract-text-file/1. Professional Custom/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 263143681 | 263-143681 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 17 | Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed | training-data/contract-text-file/1. Professional Custom/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 263143681 | 263-143681 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 18 | Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC | training-data/contract-text-file/1. Professional Custom/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0290033 | 86-0290033 | , (hereinafter "PROVIDER") IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written PLAN PROVIDER By: Scott Cummings 9-27-2018 Date Signature of to CPA State Plan President Michael Fett, CPA Printed Name Title Chief Financial officer Southwest Behavioral Health Services, Inc Address for Plan Notices: Contracting Entity/Group Name 86-0290033 CareIst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Network Management 9/25/2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Care1st Provider Agreement Page 2 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No = 3 RECITALS R.1 WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); R.2 WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership organized and in good standing under the laws of the State of Arizona, which professional corporation or partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) and independent contractors. R.3 WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- For-Service ("FFS") basis, to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Active Labor" means a labor at a time at which either of the following would occur: (1) there is inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a threat to the health and safety of the patient or the unborn child. 1.2 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.3 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services and other services customarily deemed ancillary. 1.4 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. § 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.5 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. Care1st Provider Agreement Page 3 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 19 | Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC | training-data/contract-text-file/1. Professional Custom/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0290033 | 86-0290033 | , (hereinafter "PROVIDER") IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written PLAN PROVIDER By: Scott Cummings 9-27-2018 Date Signature of to CPA State Plan President Michael Fett, CPA Printed Name Title Chief Financial officer Southwest Behavioral Health Services, Inc Address for Plan Notices: Contracting Entity/Group Name 86-0290033 CareIst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Network Management 9/25/2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Care1st Provider Agreement Page 2 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No = 3 RECITALS R.1 WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); R.2 WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership organized and in good standing under the laws of the State of Arizona, which professional corporation or partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) and independent contractors. R.3 WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- For-Service ("FFS") basis, to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Active Labor" means a labor at a time at which either of the following would occur: (1) there is inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a threat to the health and safety of the patient or the unborn child. 1.2 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.3 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services and other services customarily deemed ancillary. 1.4 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. § 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.5 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. Care1st Provider Agreement Page 3 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 20 | BoilerplateAnc_Bentley Medical PLLC - Amendment 8.1.14 | training-data/contract-text-file/2. Ancillary Boilerplate/BoilerplateAnc_Bentley Medical PLLC - Amendment 8.1.14_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 26-2637727 | 26-2637727 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 21 | BoilerplateAnc_Boro Park Obstetrics & Gynecology PC - Amendment 11.2.12 | training-data/contract-text-file/2. Ancillary Boilerplate/BoilerplateAnc_Boro Park Obstetrics & Gynecology PC - Amendment 11.2.12_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 11-2799543 | 112799543 | = 2 IN WITNESS WHEREOF, the parties here have signed this MENDMENT to become effective on the date referenced above Boro Park Obstetrics & Gynecology, PC NEW YORK STATE CATHOLIC HEALTH Provider (Please Print) PLAN, INC d/b/a Fillelis Care New York 95-25 Queens Boulevard 5925 15th Avenue Rego Park, New York 11374 Address By: David P Thomas Brooklyn, NY 11229 City, State, Zip Code Its: Senior Vice President & Chief Administrative Officer Entity Tax ID#: 112799543 Date: 10/31/12 Entity NPI#: 1467586792 Signature: DAUR Name: ELLA Alexa (Please Print) Title: PRactice administrator Date: 10/15/12 Signature: Ealexa Bore Park Obstetrics Gynecology PC__amend_ml_6711 3 Start of Page No = 3 6. This Amendment to the Agreement may be executed in one or more counterparts, each of which shall be deemed an original and all of which shall constitute but one and the same instrument. Bore Park Obstetrics Gynecology PC_amend_m_0712 2 Start of Page No = 4 SCHEDULE 1.19A ANCILLARY SERVICES REIMBURSEME NT PROGRAM: Medicaid Managed Care, Family Health Plus, Child 2013 Health Plus In addition to Primary Care and Specialist Services, Provider will provide to Enrollees, pursuant to the terms and conditions of this Agreement and the applicable Program Contract, all Ancillary Services available from Provider Ancillary Services will be reimbursed it 90% of the Medicaid fee schedule existing at the time the applicable service was rendered. Boro Park Obstetrics Gynecology PC_amend_mt_6712 4 Start of Page No = 5 APPENDIX A2 NEW YORK STATE DEPARTMENT OF HEALTH STANDARD CLAUSES FOR MANAGED CARE PROVIDER/IPA CONT RACTS March 1 | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 22 | Boilerplate_Anc_Better Living Now, Inc. - Agreement | training-data/contract-text-file/2. Ancillary Boilerplate/Boilerplate_Anc_Better Living Now, Inc. - Agreement_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 13-3683081 | 13-3683081 | BETTER LIVING NOW, INC NEW YORK STATE CATHOLIC HEALTH Provider (Please Print) PLAN, INC d/b/a Fidelis Care New York 95-25 Queens Boulevard Rego Park, New York 11374 185 oser Ave By: David P Thomas Address Hauppauge NY 11788 Its: Senior Vice President & Chief Administrative Officer City, State, Zip Code Entity Tax ID#: 13-3683081 Date: 1/26/10 Entity NPI#: 109 3711 996 WOR Signature: Name: DaniEL S POPE (Please Print) Title: PRESIDENT/CEO Date: 1/11/2010 Signature: QUAD Fidelis Care New York TM 19 THIS AGREEMENT IS SUBJECT TO THE APPROVAL Standard Ancillary 6.2007 OF THE NEW YORK STATE DEPARTMENT OF HEALTH BetterLivingNow.SASA.JC.12.23.2009 Start of Page No = 22 SCHEDULE 1.1 ANCILLARY SERVICES Provider will provide to Enrollees, pursuant to the terms and conditions of this Agreement and the applicable Program Contract, the following Ancillary Services: DME Fidelis Care New YorkTM 20 THIS AGREEMENT IS SUBJECT TO THE APPROVAL Standard Ancillary 6.2007 OF THE NEW YORK STATE DEPARTMENT OF HEALTH BetterLivingNow.SASA.JC.12.23.2009 Start of Page No = 23 SCHEDULE 1.14 IDENTIFICATION OF THE PROGRAMS AND PROGRAM CONTRACTS Program: Medicaid Managed Care program. Program Contract: The contract for the provision of Medicaid managed care services entered into by and between New York State Catholic Health Plan, Inc., the and the New York State Department of Health, including all attachments thereto. Program: Child Health Plus program. Program Contract: The contract for the provision of managed care services under the New York State Child Health Plus program entered into by and between New York State Catholic Health Plan, Inc., and the New York State Department of Health including all attachments thereto. Program: Family Health Plus program. Program Contract: The contract for the provision of managed care services under the New York State Family Health Plus program entered into by and between New York State Catholic Health Plan, Inc., and the New York State Department of Health including all attachments thereto. Program : Medicare Advantage program. Program Contract: The contract for the provision of Medicare Advantage services entered into by and between New York State Catholic Health Plan, Inc., and Center for Medicare and Medicaid Services, including all attachments thereto. Plan may amend this schedule to include additional Programs from time to time Provider agrees that Provider will participate in all new Programs for which Provider is qualified as determined by Plan. Provider's participation in any new Program will be effective upon thirty (30) calendar days notice of Plan's amendment of this Schedule 1.14. Fidelis Care New YorkTM 21 THIS AGREEMENT IS SUBJECT TO THE APPROVAL Standard Ancillary 6.2007 OF THE NEW YORK STATE DEPARTMENT OF HEALTH BetterLivingNow.SASA.JC.12.23.2009 Start of Page No | 21 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 23 | Boilerplate_Anc_Bio Reference Laboratories Inc - Amendment 8.1.17 | training-data/contract-text-file/2. Ancillary Boilerplate/Boilerplate_Anc_Bio Reference Laboratories Inc - Amendment 8.1.17_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 222405059 | 222-405059 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 24 | Boilerplate_Anc_Borbas Surgical Supply Inc - Amendment 7.15.12 | training-data/contract-text-file/2. Ancillary Boilerplate/Boilerplate_Anc_Borbas Surgical Supply Inc - Amendment 7.15.12_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 11-3568895 | 113568895 | Borbas Surgical Supply, Inc NEW YORK STATE CATHOLIC HEALTH Provider (Please Print) PLAN, INC d/b/a Fidelis Care New York 95-25 Queens Boulevard Rego Park, New York 11374 2046 Bath Avenue By: David P Thomas Address Brooklyn, NY 11214 Its: Senior Vicc President & Chief Administrative Officer City, State, Zip Code Entity Tax ID#: 113568895 Date: 7/26/12 Entity NPI#: 1134259328 Signature: David Name: Kanstanda Bas (Please Print) Title: President Signature: Date: 7-20-17 BorbasSurgicalSupply,Inc.AMD.07.20.12 2 Start of Page No = 3 Schedule 1.14A IDENTIFICATION OF THE PROGRAMS AND PROGRAM CONTRACTS Program: Medicaid Managed Care program. Program Contract: The contract for the provision of Medicaid managed care services entered into by and between New York State Catholic Health Plan, Inc., and the New York State Department of Health, including all attachments thereto. Program: Child Health Plus program. Program Contract: The contract for the provision of managed care services under the New York State Child Health Plus program entered into by and between New York State Catholic Health Plan, Inc., and the New York State Department of Health including all attachments thereto. Program: Family Health Plus program. Program Contract: The contract for the provision of managed care services under the New York State Family Health Plus program entered into by and between New York State Catholic Health Plan, Inc., and the New York State Department of Health including all attachments thereto. Program : Medicare Advantage program Program Contract: The contract for the provision of Medicare Advantage services entered into by and between New York State Catholic Health Plan, Inc., and Center for Medicare and Medicaid Services, including all attachments thereto. Program: Managed Long Term Care program Program Contract: The contract for the provision of managed long term care services entered into by and between the New York State Catholic Health Plan, d/b/a Fidelis Care New York, and the New York State Department of Health including all attachments thereto. Plan may amend this schedule to include additional Programs from time to time Provider agrees that Provider will participate in all new Programs for which Provider is qualified as determined by Plan Provider's participation in any new Program will be effective upon thirty (30) calendar days notice of Plan's amendment of this Schedule 1.14. BorbasSurgicalSupply,Inc.AMD.07.20.12 3 Start of Page No = 4 Schedule 5.2A ANCILLARY SERVICES REIMBURSEMENT Programs: Medicaid Managed Care, Child Health Plus, Family Health Plus Rates, & Managed Long Term Care Ancillary Services will be reimbursed at 73.5% of the prevailing Medicaid fee schedule existing at the time the applicable service was rendered. Program: Medicare Advantage Ancillary Services will be reimbursed at 73.5% of the prevailing Medicare rate for Provider's geographical area effective at the date of service. BorbasSurgicalSupply,Inc.AMD.07.20.12 4 Start of Page No | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 25 | Anc10_040121 Nationwide Vision Center Care 1st Amendment | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0560663 | 86-0560663 | In the event of a conflict between the terms of the Agreement and this Amendment, the terms of this Amendment shall control IN WITNESS WHEREOF, the parties have executed this Amendment to the Agreement in duplicate by their respective officers duly authorized to do so PLAN PROVIDER By: 6/3/21 Scott Cummings Date Signature Vincent Hayes Chief Administrative Officer Printed Name Vincent Hayes Title Vice President Managed Care NAtion wide Vision Center INC Address for Plan Notices: Contracting Entity/Group Name 86-0560663 Carels Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 5-6-2021 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 220 N McKemy Ave Chandler, Az 85226 Carelst Revised 050817 Start of Page No = 2 ATTACHMENT A ANCILLARY COMPENSATION AND COVERED SERVICES Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds PROVIDER's billed charges. Routine Vision Care Effective Contracted Rates HCIF Rates* Frames $39.00 $47.51 Single Vision Lenses $38.00 $46.30 Bifocal Lenses** $59.00 $71.88 Trifocal Lenses** $69.00 $84.06 Contact Lenses 95% of the current AHCCCS 95% of the current AHCCCS Fee Schedule Fee Schedule * Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are required by AHCCCS | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 26 | Anc10_040121 Nationwide Vision Center Care 1st Amendment | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0560663 | 86-0560663 | In the event of a conflict between the terms of the Agreement and this Amendment, the terms of this Amendment shall control IN WITNESS WHEREOF, the parties have executed this Amendment to the Agreement in duplicate by their respective officers duly authorized to do so PLAN PROVIDER By: 6/3/21 Scott Cummings Date Signature Vincent Hayes Chief Administrative Officer Printed Name Vincent Hayes Title Vice President Managed Care NAtion wide Vision Center INC Address for Plan Notices: Contracting Entity/Group Name 86-0560663 Carels Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 5-6-2021 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 220 N McKemy Ave Chandler, Az 85226 Carelst Revised 050817 Start of Page No = 2 ATTACHMENT A ANCILLARY COMPENSATION AND COVERED SERVICES Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds PROVIDER's billed charges. Routine Vision Care Effective Contracted Rates HCIF Rates* Frames $39.00 $47.51 Single Vision Lenses $38.00 $46.30 Bifocal Lenses** $59.00 $71.88 Trifocal Lenses** $69.00 $84.06 Contact Lenses 95% of the current AHCCCS 95% of the current AHCCCS Fee Schedule Fee Schedule * Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are required by AHCCCS | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 27 | Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 56-2589722 | 86-0713148 | By: 6 8 2017 Soldiering Scott Cummings Date Signature Chief Administrative Officer MARK R osenberg Printed Name CEO Title Barnet Dulaney Perkins Eye Center, PLLC Address for Plan Notices: Barnet Dulaney Surgery Centers, LLC Contracting Entity/Group Name Care1st Health Plan Arizona, Inc Attention: Director, Provider Network Operations 56-2589722/ 86-0713148 2355 E Camelback Road, #300 Contracting Entity/Group Tax I.D. Phoenix, Arizona 85016 4-12-2017 Date Address for Provider Notices: 4800 N, 22nd Street PhoeNix , AZ 85016 artn: Contrating Carelst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 28 | Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 56-2589722 | 86-0713148 | By: 6 8 2017 Soldiering Scott Cummings Date Signature Chief Administrative Officer MARK R osenberg Printed Name CEO Title Barnet Dulaney Perkins Eye Center, PLLC Address for Plan Notices: Barnet Dulaney Surgery Centers, LLC Contracting Entity/Group Name Care1st Health Plan Arizona, Inc Attention: Director, Provider Network Operations 56-2589722/ 86-0713148 2355 E Camelback Road, #300 Contracting Entity/Group Tax I.D. Phoenix, Arizona 85016 4-12-2017 Date Address for Provider Notices: 4800 N, 22nd Street PhoeNix , AZ 85016 artn: Contrating Carelst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 29 | Anc4_White Mountain Phys Contract | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0460643 | 86-0460643 | Michael L Johnson PT IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written Scott By: Gummings 10-23-2018 Date Sellbury Signature Dechange Chief Administrative Officer Printed Name Michael L Johnson PT PT, TIN owner Title White Mountain Physical therapy, Address for Plan Notices: Contracting Entity/Group Name LTD 86-0460643 Carel 1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 05-03-2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: PO Box 1420 Show Low, AZ 85902-1420 CareIst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 30 | Anc4_White Mountain Phys Contract | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0460643 | 86-0460643 | Michael L Johnson PT IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written Scott By: Gummings 10-23-2018 Date Sellbury Signature Dechange Chief Administrative Officer Printed Name Michael L Johnson PT PT, TIN owner Title White Mountain Physical therapy, Address for Plan Notices: Contracting Entity/Group Name LTD 86-0460643 Carel 1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 05-03-2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: PO Box 1420 Show Low, AZ 85902-1420 CareIst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 31 | Anc5_Tipton | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc5_Tipton MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 30487744 | 030497744 | IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written By: Cummings 10 18 2018 Date Anita Phelps Scott Signature Chief Administrative Officer Anita Phelps Printed Name Contracts/Medical Biller Title Tipton Physical Therapy, LLC Address for Plan Notices: Contracting Entity/Group Name 030497744 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 2/2/2017 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Tipton Physical Therapy, LLC 8400 E Florentine Road Prescott Valley, AZ 86314-8653 Start of Page No = 3 RECITALS A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1,3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 32 | Anc5_Tipton | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc5_Tipton MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 30487744 | 030497744 | IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written By: Cummings 10 18 2018 Date Anita Phelps Scott Signature Chief Administrative Officer Anita Phelps Printed Name Contracts/Medical Biller Title Tipton Physical Therapy, LLC Address for Plan Notices: Contracting Entity/Group Name 030497744 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 2/2/2017 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Tipton Physical Therapy, LLC 8400 E Florentine Road Prescott Valley, AZ 86314-8653 Start of Page No = 3 RECITALS A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1,3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 33 | Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0872873 | 86-0872873 | PLAN PROVIDER Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life Chief Administrative Officer DAVID A DEXTER Printed Name CEO Title Address for Plan Notices: Contracting Entity/Group Name 86-0872873 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 8/21/2019 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 1255 W Washington SI. Tempe, Az 85281 Page 1 of 1 Start of Page No = 2 ATTACHMENT C LABORATORY SERVICES COMPENSATION Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the effective date of the new AHCCCS Fee Schedule | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 34 | Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st | training-data/contract-text-file/2. Ancillary Boilerplate/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0872873 | 86-0872873 | PLAN PROVIDER Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life Chief Administrative Officer DAVID A DEXTER Printed Name CEO Title Address for Plan Notices: Contracting Entity/Group Name 86-0872873 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 8/21/2019 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 1255 W Washington SI. Tempe, Az 85281 Page 1 of 1 Start of Page No = 2 ATTACHMENT C LABORATORY SERVICES COMPENSATION Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the effective date of the new AHCCCS Fee Schedule | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 35 | 2.2000_OptionalCare.INC_ServicesAgreement | training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/2.2000_OptionalCare.INC_ServicesAgreement MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 75-2496435 | 75-2496435 | reboran too Ancillary Provider: By: L Deborah Strane, CPA, MBA Slenda By: Executive Director, PCHP Title: Title: V P Date: MAY 01 2000 Date: Mark , 2000 Tax ID: 75-2496435 Ancillary Agreement 2 02/22/00 12:47 PM Start of Page No = 30 Start of Page No = 31 PARKLAND COMMUNITY HEALTH PLAN, INC. A PROGRAM OF DALLAS COUNT HOSPITAL DISTRICT PARTICIPATING ANCILLARY SERVICES PROVIDER AGREEMENT Attachment B SECTION 1 - PCHP MEDICAID STAR HMO SERVICES Participating Ancillary Services Provider shall be reimbursed for medically necessary Covered Services provided to HEALTHfirst Members as follows: 1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for the State of Texas or the Participating Ancillary Services Provider's usual and customary charge, whichever is less. SECTION 2 PCHP CHIP HMO SERVICES Participating Ancillary Services Provider shall be reimbursed for Covered Services provided to KIDSfirst Members as follows: 1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for the State of Texas or the Participating Ancillary Services Provider's usual and customary charge, whichever is less. Ancillary Agreement 3 02/22/00 12:47 PM Start of Page No | 29 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 36 | 5.2000_Rehab Designs of America_VendorAgreement | training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/5.2000_Rehab Designs of America_VendorAgreement MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 48-1165993 | 48-1165993 | IN WITNESS WHEREOF, PCHP and Ancillary Provider have entered into this Agreement as of the Effective Date Parkland Community Health Plan Ancillary Provider: Rehab Designs U Debonah StRane Ar of America By: L Deborah Strane, CPA, MBA By: Jult/Sirley Executive Director, PCHP Title: Title: U-P, Business Develop next MAY 01 2000 Date: Date: 3-16-00 Tax ID: 48-1165993 Ancillary Agreement 2 02/22/00 12:47 PM Start of Page No = 31 PARKLAND COMMUNITY HEALTH PLAN, INC. A PROGRAM OF DALLAS COUNT HOSPITAL DISTRICT PARTICIPATING ANCILLARY SERVICES PROVIDER AGREEMENT Attachment B SECTION 1 - PCHP MEDICAID STAR HMO SERVICES Participating Ancillary Services Provider shall be reimbursed for medically necessary Covered Services provided to HEALTHfirst Members as follows: 1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for the State of Texas or the Participating Ancillary Services Provider's usual and customary charge, whichever is less. SECTION 2 PCHP CHIP HMO SERVICES Participating Ancillary Services Provider shall be reimbursed for Covered Services provided to KIDSfirst Members as follows: 1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for the State of Texas or the Participating Ancillary Services Provider's usual and customary charge, whichever is less. Ancillary Agreement 3 02/22/00 12:47 PM Start of Page No = 32 | 30 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 37 | 6.2000_Omni Transport Systems_ServicesAgreement | training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/6.2000_Omni Transport Systems_ServicesAgreement MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 75-2809999 | 75-2809994 | Any notice given by telecopy or personal delivery shall be deemed received on the date of transmission or delivery, as the case may be IN WITNESS WHEREOF, PCHP and Ancillary Provider have entered into this Agreement as of the Effective Date Parkland Ancillary Provider: North Tx LifeStar,L By: By: L Deborah Strane, CPA, MBA Executive Director, PCHP Title: Title: QUALCED JUN 12 2000 Date: Date: March 8, 2000 Tax ID: 75-2809994 Ancillary Agreement 2 02/22/00 12:47 PM Start of Page No = 17 PARKLAND COMMUNITY HEALTH PLAN, INC. A PROGRAM OF DALLAS COUNT HOSPITAL DISTRICT PARTICIPATING ANCILLARY SERVICES PROVIDER AGREEMENT Attachment B SECTION 1 - PCHP MEDICAID STAR HMO SERVICES Participating Ancillary Services Provider shall be reimbursed for medically necessary Covered Services provided to HEALTHfirst Members as follows: 1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for the State of Texas or the Participating Ancillary Services Provider's usual and customary charge, whichever is less. SECTION 2 PCHP CHIP HMO SERVICES Participating Ancillary Services Provider shall be reimbursed for Covered Services provided to KIDSfirst Members as follows: 1 One hundred percent (100%) of the prevailing yearly and current Medicaid fee schedule for the State of Texas or the Participating Ancillary Services Provider's usual and customary charge, whichever is less. Ancillary Agreement 3 02/22/00 12:47 PM Start of Page No = 18 PARKLAND COMMUNITY HEALTH PLAN, INC., A PROGRAM OF DALLAS COUNTY HOSPITAL DISTRICT STAR Medicaid Managed Care Program Provider Information Form Please Note: This information is requested in order to demonstrate to the Texas Department of Health that V will have an adequate network with sufficient capacity to care for Medicaid patients. PROVIDER NAME OMNI TRANSPORT SYSTEMS, LLC, DALLAS PROVIDER D.B.A NORTH TEXAS LIFESTAR, LLC, DALLAS PROVIDER TYPE HELICOPTER Ambulance TYPE OF SERVICES PROVIDED (LIST FULL SCOPE OF SERVICES) Air Ambulance Services for Trauma and cutical care. ARE YOU LICENSED BY THE STATE OF TEXAS? LICENSE TYPE (IF APPLICABLE) (IMPORTANT: Please attach copy of state license) MICU N/A YES NO LICENCE NO# 300241 ADDRESS 1 ADDRESS 2 4650 Airport Parkway CITY STATE ZIP CITY STATE. ZIP Addison Tx 75001 NOTE: If you have additional addresses attach a separate page BILLING ADDRESS ARE YOU A HISTORICALLY UNDERUTILIZED BUSINESS (HUB)? MEDBILL RESOURCES CORP. YES NO 1890 W | 16 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 38 | Advanced Respiratory Inc. - signed | training-data/contract-text-file/2. Ancillary Boilerplate/Parkland - Ancillary Boilerplate/Advanced Respiratory Inc. - signed MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 41-1419350 | 41-1419350 | Smith By: kari Roehrich (Feb 9,2023 15:26 CST) By: Nicholas J Smith (Feb 9, 2023 15:48 CST) Printed Name: Kari Roehrich Printed Name: Nicholas Smith Title: Authorized Signer Title: VP, Network Development & Provider Relations Contract Effective Date: 3/1/2023 (TO BE COMPLETED BY HEALTH PLAN) REIMBURSEMENT ADDRESS: 1020 County Road F W Saint Paul, MN 55126-2910 MAIN TELEPHONE NUMBER: 1-800-426-4224 CHIEF EXECUTIVE OFFICER: N/A CHIEF FINANCIAL OFFICER: N/A BUSINESS OFFICE MANAGER: N/A FEDERAL TAX I D NUMBER : 41-1419350 NPI NUMBER: 1053357905 As required by Section 10.8 ("Notices") of this Agreement, notices shall be sent to each Party at the following addresses: To Provider at: Advanced Respiratory Inc, Address: 1020 County Road F W Saint Paul, MN 55126-2910 To Parkland at: Community Health Plan, Inc. 1341 West Mockingbird Lane Dallas, Texas 75247 Attention: Nicholas Smith Email: NICHOLAS.SMITH@phhs.org 23 Start of Page No = 24 Exhibit 1 Electronic Claims Submission The following are requirements for the submission of claims electronically to Payors: 1 In transmitting EDI, Provider will transmit such claims edited and formatted according to the specifications indicated within the most current Provider User Guide or the ANSI X12 837 Implementation Guide Provider understands that Payors shall be the final authority in resolving any disputes about how electronic data shall be submitted. 2. Provider agrees and understands that all claims submitted via EDI, for all legal and other purposes will be considered signed by Provider or Provider's authorized representative and Provider attests as to the accuracy and truthfulness of such claims. 3. Provider acknowledges that Payors shall have no obligation with respect to the content of the information in claims either to verify, check or otherwise inspect the information supplied by Provider, except to reformat the claim data to the specification required by Payors Provider further acknowledges that Payors will determine whether a claim qualifies as a Clean Claim, including, but not limited to, whether Provider has submitted enough information in the EDI claims in order to determine the completeness, accuracy and validity of the information and claims and that source documents for claims data are the responsibility of Provider. 24 Start of Page No | 23 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 39 | Custom_2015-08-01 COMM Amend FE - Slocum Surgery Center | training-data/contract-text-file/3. Ancillary Custom/Custom_2015-08-01 COMM Amend FE - Slocum Surgery Center MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 77-0590285 | 77-0590285 | Johnson, MD, MBA michelle yuva (Print Name) (Print Name) President, Moda Health Sr Vice President, Moda Inc Administrator (Title) (Title) 7/27/2015 6/16/15 (Date) (Date) 77-0590285 (Tax ID Number) Prepared by: Darren Dromgoole (6/12/2015) Moda Health Participating Provider Amendment Slocum Surgery Center 3 of 8 Start of Page No = 4 02:27:04p.m.06-15-2015 , 541 743 2517 Jun 16 2015 2:30PM Slocum 541 743 2517 No 0262 P. 5 EXHIBIT A PRACTICE INFORMATION Tax ID#: 77-90285 NPI: 1679696157 Claims Remittance / Billing Location Remittance/Billing Address* 55 Coberg Rd Eugene OR 97401 Telephone Number (544)743-2500 Fax Number: (541) 743-2517 Office Contact: Shelley yuva Email address (if applicable): Payments will be made to Group/Clinic unless otherwise requested *Remittance address listed must match information provided in box 33 on CMS 1500 or equivalent form, or box 2 on a UB-04 or equivalent form. Practice Location(s) Physical Address (Primary): as above Telephone Numbers Fax Number: Physical Address 2 (if applicable): N/A Telephone Number: Fax Number: Please attach a separate locations listing, as necessary. Moda Health Participating Provider Amendment Slocum Surgery Center 4 of 8 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 40 | Custom_2017-09-15 COMM Agmt FE - Plaza Ambulatory Surgery Center, LLC | training-data/contract-text-file/3. Ancillary Custom/Custom_2017-09-15 COMM Agmt FE - Plaza Ambulatory Surgery Center, LLC MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 35-2480914 | 35-2480914 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 41 | Custom_2018-09-15 COMM Amend FE Plaza Ambulatory Surgery Center, LLC | training-data/contract-text-file/3. Ancillary Custom/Custom_2018-09-15 COMM Amend FE Plaza Ambulatory Surgery Center, LLC MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 35-2480914 | 35-2480914 | Plaza Ambulatory Surgery Center, LLC 601 SW Second Avenue 5050 NE Hoyt Street, Suite 156 Portland, OR 97204 Portland, OR 97213 mys pawn (Signature) IIAM JOHNSON (Signature) William E Johnson, MD, MBA Daniel Weber (Print Name) (Print Name) President, Moda Health Sr Vice President, Moda, Inc Administrator (Title) (Title) 9/17/2018 8/21/2018 (Date) (Date) 35-2480914 (Tax ID Number) 2016 Moda Health PPO-POS Provider Amendment Plaza Ambulatory Surgery Center, LLC Page 2 Start of Page No = 3 EXHIBIT A PROVIDER INFORMATION Tax ID#: 35-2480914 Location(s) Physical Address (Primary): 5050 we Hoyt St STE # 156 City: State: Zip: PORtland OR 97203 Phone #: Fax #: 971-229-8100 971-229-8101 NPI: 1891127981 Physical Address 2 (if applicable): City: State: Zip: Phone #: Fax #: NPI: (Attach any additional locations on a separate sheet) Claims Remittance / Billing Location Remittance / Billing Address*: Plaza Ambulatory # I P.O Box 84201 City: State: Zip: Seattle WA 98124 5501 Phone #: Fax #: 971-229-8100 971-229-8101 Office Contact: Daniel weber Contract Administrator email address (if applicable): A woodell@Regard Surgical health.com Payments will be made to Group/Clinic unless otherwise requested *Remittance address listed must match information provided in box 33 on CMS 1500 or equivalent form, or box 2 on a UB-04 or equivalent 2016 Moda Health PPO-POS Provider Amendment Plaza Ambulatory Surgery Center, LLC Page 3 -------TABLE Start----- Physical Address 2 (if applicable): City: State: Zip: Phone #: Fax #: NPI: -------TABLE End----- Start of Page No | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 42 | Custom_Anc_Better Living Now Inc - Amendment Provider Signed 4.29.19 | training-data/contract-text-file/3. Ancillary Custom/Custom_Anc_Better Living Now Inc - Amendment Provider Signed 4.29.19_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 13-3683081 | 133-683081 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 43 | Custom_Bestcare Inc - Amendment 7.1.14 | training-data/contract-text-file/3. Ancillary Custom/Custom_Bestcare Inc - Amendment 7.1.14_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 13-3121904 | 133-121904 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 44 | BoilerplateFac_Bertrand Chaffee Hospital - Amendment 4.17.15 | training-data/contract-text-file/4. Facility Boilerplate/BoilerplateFac_Bertrand Chaffee Hospital - Amendment 4.17.15 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 160743921 | 160-743921 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 45 | Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14 | training-data/contract-text-file/4. Facility Boilerplate/Boilerplate_Fac_Bronx Lebanon Hospital Center - Amendment 1.1.14 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 13-1974191, 132707945 | 13-1974191 | = 4 IN WITNESS WHEREOF, the parties here have signed this AMENDMENT to become effective on the date referenced above Bronx Lebanon Hospital NEW YORK STATE CATHOLIC HEALTH Provider (Please Print) PLAN, INC d/b/a Fidelis Care New York 95-25 Queens Boulevard Rego Park, New York 11374 1650 Grand Concourse By: David P Thomas Address Its: Executive Vice President & Chief Operating Bronx, NY 10457 Officer City, State, Zip Code Entity Tax ID#: 13-1974191 Date: 6/24/13 Entity NPI#: 1417027558 Signature: Duna Name: Victor Dellarco (Please Print) Title SUP Chief FINANCIAL Officer Date: 6/12/13 Signature: 4 BronxLebanonHospital.HEX.Amend.04.09.13 Start of Page No = 5 IN WITNESS WHEREOF, the parties here have signed this AMENDMENT to become effective on the date referenced above. Dr Martin Luther King Jr Health Center NEW YORK STATE CATHOLIC HEALTH Provider (Please Print) PLAN, INC | 4 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 46 | Boilerplate_HSA_EFF03012012_Children's Medical Center | training-data/contract-text-file/4. Facility Boilerplate/Boilerplate_HSA_EFF03012012_Children's Medical Center MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 75-0800628 | 75-0800628 | Box 844007 Email Address Dallas, TX 75284-4007 Tax I D No 75-0800628 License No. 000143 Physical Address (if di fferent than above): Texas Provider Identification 1389108-07 Number (TPIN) NPI (or UPIN if NPI not yet NPI: 1194743013 designated) UPIN: DEA No. AC2260242 (Use continuation pages if multiple providers under common ownership will submit bills under this Agreement) I, the undersigned, am authorized to and do hereby verify the accuracy of the foregoing Provider information. Provider Signature: Signatory Name (Printed) Signatory Title (Printed): Signature Date: Mirr HSA 02/10/10 Page 26 of 40 Provider or authorized representatives intinis Run -------TABLE Start----- Provider Name Children's Medical Center of Dallas Billing Address: Telephone No. 214-456-7000 Facsimile No. P.O Box 844007 Email Address Dallas, TX 75284-4007 Tax I.D No. 75-0800628 License No. 000143 Physical Address (if di fferent than above): Texas Provider Identification 1389108-07 Number (TPIN) NPI (or UPIN if NPI not yet NPI: 1194743013 designated) UPIN: DEA No. AC2260242 -------TABLE End----- -------TABLE Start----- Provider Signature: Signatory Name (Printed) Signatory Title (Printed): Signature Date: -------TABLE End----- Start of Page No = 27 ATTACHMENT A Provider Identification Sheet Continuation Page Use one or more continuation pages as necessary when multiple providers under common ownership (the Provider is signing on behalf of all of them) are expected to bill Health Plan under more than one TIN. Provider Name Children's Dallas Ambulatory Billing Address: Care Pavilion Telephone No. 214-730-KIDS (5437) P.O Box 844007 Facsimile No. Dallas, TX75284-4007 Email Address Taxl.D | 26 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 47 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/4. Facility Boilerplate/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | Except as specifically amended by this Amendment, the Agreement shall continue in full force and effect IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their duly authorized officers as of the Effective Date set forth by Health Plan below El Paso County Hospital District, DBA, Molina Healthcare of Texas, Inc , University Medical Center of El Paso - Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Pres / CEO Signatory Title Title (Printed): (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 Amendment to Page I of 3 Provider or authorized gar HSA - UMC El Paso 03122012 representative's initials: -------TABLE Start----- Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Title (Printed): Pres / CEO Signatory Title (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 -------TABLE End----- Start of Page No = 2 ATTACHMENT D Compensation Schedule Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for- services basis, at the lesser of; (i) Provider's allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any: STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-For-Service Program fee schedule in effect on the date of service. Notwithstanding the above, payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service. In addition to the above listed compensation rates, payment for the following services for all Health Plan products & programs shall be reimbursed according to the table below: Outpatient Services Revenue Codes Negotiated Payment Implants/Prosthetics/Pacemakers 274,275,276,278 70% of Billed Charges equal paid when any one single item is to Provider's Acquisition Cost over $500 plus five percent (5%) High Cost Drugs - paid when any 634,636 70% of Billed Charges equal one single item is over $500 to Provider's Acquisition Cost plus five percent (5%) Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written notification At any time Health Plan may request a copy of an invoice from Provider to validate Provider's Acquisition Cost | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 48 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/4. Facility Boilerplate/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | Except as specifically amended by this Amendment, the Agreement shall continue in full force and effect IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their duly authorized officers as of the Effective Date set forth by Health Plan below El Paso County Hospital District, DBA, Molina Healthcare of Texas, Inc , University Medical Center of El Paso - Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Pres / CEO Signatory Title Title (Printed): (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 Amendment to Page I of 3 Provider or authorized gar HSA - UMC El Paso 03122012 representative's initials: -------TABLE Start----- Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Title (Printed): Pres / CEO Signatory Title (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 -------TABLE End----- Start of Page No = 2 ATTACHMENT D Compensation Schedule Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for- services basis, at the lesser of; (i) Provider's allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any: STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-For-Service Program fee schedule in effect on the date of service. Notwithstanding the above, payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service. In addition to the above listed compensation rates, payment for the following services for all Health Plan products & programs shall be reimbursed according to the table below: Outpatient Services Revenue Codes Negotiated Payment Implants/Prosthetics/Pacemakers 274,275,276,278 70% of Billed Charges equal paid when any one single item is to Provider's Acquisition Cost over $500 plus five percent (5%) High Cost Drugs - paid when any 634,636 70% of Billed Charges equal one single item is over $500 to Provider's Acquisition Cost plus five percent (5%) Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written notification At any time Health Plan may request a copy of an invoice from Provider to validate Provider's Acquisition Cost | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 49 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/4. Facility Boilerplate/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | Except as specifically amended by this Amendment, the Agreement shall continue in full force and effect IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their duly authorized officers as of the Effective Date set forth by Health Plan below El Paso County Hospital District, DBA, Molina Healthcare of Texas, Inc , University Medical Center of El Paso - Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Pres / CEO Signatory Title Title (Printed): (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 Amendment to Page I of 3 Provider or authorized gar HSA - UMC El Paso 03122012 representative's initials: -------TABLE Start----- Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Title (Printed): Pres / CEO Signatory Title (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 -------TABLE End----- Start of Page No = 2 ATTACHMENT D Compensation Schedule Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for- services basis, at the lesser of; (i) Provider's allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any: STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-For-Service Program fee schedule in effect on the date of service. Notwithstanding the above, payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service. In addition to the above listed compensation rates, payment for the following services for all Health Plan products & programs shall be reimbursed according to the table below: Outpatient Services Revenue Codes Negotiated Payment Implants/Prosthetics/Pacemakers 274,275,276,278 70% of Billed Charges equal paid when any one single item is to Provider's Acquisition Cost over $500 plus five percent (5%) High Cost Drugs - paid when any 634,636 70% of Billed Charges equal one single item is over $500 to Provider's Acquisition Cost plus five percent (5%) Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written notification At any time Health Plan may request a copy of an invoice from Provider to validate Provider's Acquisition Cost | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 50 | Fac1_Bullhead City_Western Arizona Med Center - 860982071 | training-data/contract-text-file/4. Facility Boilerplate/Fac1_Bullhead City_Western Arizona Med Center - 860982071 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-1027746 | 86-0982071 | IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written PLAN PROVIDER By: Scott Cummings Efficiency 10-5-2018 Date State Plan resident Signature MICHAEL J STENGER Printed Name: INTERIM CEO Title Address for Plan Notices: Contracting Entity/Group Name 86-0982071 86-1027746 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Network Management 1/27/18 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Community Health Systems Attn: Managed Care Departmetn 4000 Meridian Blvd Franklin, TN37067 Careist Hospital Services Agreement 120114 Page 1 of23 Start of Page No = 4 RECITALS WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); WHEREAS, Plan desires to enter into contracts with licensed and experienced Health Care Professionals, hospitals and other providers to provide or arrange for the provision of certain health care services to Plan Members; WHEREAS, Hospital is licensed and experienced to provide or arrange for the provision of certain hospital and other services and supplies; and WHEREAS, Plan and Hospital desire to enter into this Agreement for Hospital to provide or arrange for the provision of certain hospital and other services and supplies to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt of which is hereby acknowledged, the parties mutually agree as follows: I, DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Active Labor" means a labor at a time at which either of the following would occur: (1) There is inadequate time to effect safe transfer to another hospital prior to delivery, (2) A transfer may pose a threat to the health and safety of the patient or the unborn child. 1.2 "Acts and Regulations" means the Federal and Arizona codes and regulations that govern the services to be provided under this Agreement which are more fully described in Article VII. 1,3 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services and other services customarily deemed ancillary. 1,4 "AHCCCS" " means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. Carelst Hospital Services Agreement 120114 Page 2 of 23 Start of Page No = 5 1.5 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 51 | Fac3_Phoenix Children Hosp_2 | training-data/contract-text-file/4. Facility Boilerplate/Fac3_Phoenix Children Hosp_2 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0422559 | 86-0422559 | PLAN HOSPITAL By: Scott Cummings Selfining 10 24 2014 Date Robert bleyn Signature Chief Administrative Officer Robert L Meyer Printed Name President & Chief Executive Officer Title Phoenix Children's Hospital Address for Plan Notices: Contracting Entity/Group Name 86-0422559 Carelst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 10/16/14 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Phoenix Children's Hospital, Inc. ATTN: Managed Care 1919 E Thomas Road, Bldg 2108, #101 Phoenix, AZ 85016 CC: Address for Provider Notices: Phoenix Children's Hospital, Inc. ATTN: Office of General Counsel 1919 E Thomas Road Phoenix, AZ 85016 Page 3 of 5 Start of Page No = 4 ATTACHMENT C HOSPITAL COMPENSATION Hospital is responsible for providing all necessary Covered Health Care Services to Plan Members deemed to be necessary by the Plan Medical Director or AHCCCS, whether Member presents for emergency services or is admitted by Plan Provider upon authorization from Plan, consistent with the standards and limitations of Hospital's licensure and the AHCCCS statutes, regulations and policies and payment methodology, and consistent with Federal regulations. Plan shall pay to Hospital for those services properly billed (see Article IV of Agreement) which are Medically Necessary Covered Health Care Services and which are compliant with all AHCCCS and Plan policies, including notification and authorization policies as follows: 1 Payment conditions for Services rendered from date of contract. Hospital shall bill Plan for Services rendered within six months of discharge of Member. Plan shall adjudicate the bills and inform Hospital of the results of the adjudication within AHCCCS claims payment timeliness guidelines of bills correctly submitted under this Agreement and that constitute "clean claims" under the AHCCCS Requirements | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 52 | HSA_EFF TBD_PrimeHealthcare_MissionRegionalMedicalCenter | training-data/contract-text-file/4. Facility Boilerplate/HSA_EFF TBD_PrimeHealthcare_MissionRegionalMedicalCenter MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-2206635 | 74-2206635 | III 09/06/2022 Telephone Number: Fax Number - Official Correspondence: 956-323-9000 956-323-9102 Mailing Address - Official Correspondence: Payment Address - If different than Mailing Address: 900 S Bryan Rd, Mission, TX 78572 P O Box 674059, Dallas, TX 75267-4059 Email Address - Official Correspondence: Tax ID Number - As listed on corresponding tax form: healthplanops@primehealthcare com 74-2206635 NPI - That corresponds to the above Tax ID Number: Notice Address: 3480 E Guasti Rd., Ontario, CA 91761 1205833985 Health Plan Signature and Information: Molina Healthcare of Texas, Inc., a Texas Corporation ("Health Plan") Authorized Representative's Signature: Authorized Representative's Name - Printed: Chris Coffey Authorized Representative's Title: Authorized Representative's Countersignature Date: Plan President Mailing Address - Official Correspondence: Email Address - Official Correspondence: 1660 North Westridge Circle, Irving, TX 785038 MHTContract@MolinaHealthcare.com Molina Texas HSA (FFS) Page 1 of 48 MHTHSA030218 -------TABLE Start----- Provider's Legal Name ("Provider") - as listed on applicable tax form (i.e W-9): Mission Hospital, Inc. Authorized Representative's Signature: Authorized Representative's Name - Printed: Harsha Upadhyay Authorized Representative's Title: Authorized Representative's Signature Date: Regional Chief Executive Officer, Reg III 09/06/2022 Telephone Number: Fax Number - Official Correspondence: 956-323-9000 956-323-9102 Mailing Address - Official Correspondence: Payment Address - If different than Mailing Address: 900 S Bryan Rd, Mission, TX 78572 P.O Box 674059, Dallas, TX 75267-4059 Email Address - Official Correspondence: Tax ID Number - As listed on corresponding tax form: healthplanops@primehealthcare.com 74-2206635 NPI - That corresponds to the above Tax ID Number: Notice Address: 3480 E | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 53 | ICMProviderAgreementAmendment_ICMProviderAgreementAmendment_169834_6 - Hope Community | training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreementAmendment_ICMProviderAgreementAmendment_169834_6 - Hope Community MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 73-1098634 | 73-1098634 | = 2 IN WITNESS WHEREOF, the Parties hereto have executed and delivered this Amendment as of the date above Health Plan: PROVIDER: Oklahoma Complete Health, Inc Hope Community Services, Inc Authorized Signature Authorized Signature Clayton Franklin Jeanette L Moore, CEO Clayton Franklin (Oct 20, 2023 10:06 CDT) Jeanette L Moore, CEO (Oct 13, 2023 10:03 CDT) Printed Name: Clayton Franklin Printed Name: Jeanette Moore Title: President & CEO Title: CEO Date: Oct 20, 2023 Date: Oct 13, 2023 ICM #: ICMProviderAgreementAmendment_16983 Tax ID Number: 73-1098634 State Medicaid Number: NPI: ICMProviderAgreementAmendment_169834 Page 2 of 28 Start of Page No = 3 Attachment A: Medicaid PRODUCT ATTACHMENT OKLAHOMA MEDICAID PRODUCT (SOONERSELECT) (INCLUDING REGULATORY REQUIREMENTS) THIS PRODUCT ATTACHMENT (this "Attachment") is made and entered between Oklahoma Complete Health, Inc ("Health Plan") and Hope Community Services, Inc ("Provider"). WHEREAS, Health Plan and Provider entered into that certain provider agreement, as the same may have been amended and supplemented from time to time (the "Agreement"), pursuant to which Provider and its Contracted Providers participate in certain Products offered by or available from or through a Company; WHEREAS, pursuant to the provisions of the Agreement, Contracted Providers will be designated and participate as "Participating Providers" in the Product described in this Attachment; and WHEREAS, Health Plan has contracted with the Oklahoma Health Care Authority ("OHCA") to be a State Medicaid Care Management Organization to provide Covered Services to Covered Persons in the State's Medicaid program known as SoonerSelect, and such other programs (hereafter referred to as "Medicaid Product") as may be awarded to Health Plan by OHCA. WHEREAS, the Agreement is modified or supplemented as hereafter provided. NOW THEREFORE, in consideration of the recitals, the mutual promises herein stated, the parties hereby agree to the provisions set forth below. 1. Defined Terms All capitalized terms not specifically defined in this Attachment will have the meanings given to such terms in the Agreement | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 54 | ICMProviderAgreement_ChampionsForChildrensMentalHealth_219129_5 | training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreement_ChampionsForChildrensMentalHealth_219129_5.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 81-3580335 | 81-3580335 | = 13 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Delaware First Health, Inc CHAMPIONS FOR CHILDREN'S MENTAL HEALTH (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Barbara Messick Aaron Brace (Aug 30, 2022 10:49 EDT) Barbara Messick (Aug 22, 2022 14:17 EDT) Print Name: Aaron Brace Print Name: Barbara Messick Title: Corporate Vice President, National Contracting Title: Executive Director Officer Signature Date: Aug 30, 2022 Signature Date: Aug 22, 2022 ICM #: ICMProviderAgreement_219129 Tax Identification Number: 81-3580335 To be completed by Health Plan only: National Provider Identifier: 1750809729 Effective Date: Sep 21, 2022 Medicare Number: -------TABLE Start----- Delaware First Health, Inc. CHAMPIONS FOR CHILDREN'S MENTAL HEALTH (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Barbara Messick Aaron Brace (Aug 30, 2022 10:49 EDT) Barbara Messick (Aug 22, 2022 14:17 EDT) Print Name: Aaron Brace Print Name: Barbara Messick Title: Corporate Vice President, National Contracting Title: Executive Director Officer Signature Date: Aug 30, 2022 Signature Date: Aug 22, 2022 ICM #: ICMProviderAgreement_219129 Tax Identification Number: 81-3580335 To be completed by Health Plan only: National Provider Identifier: 1750809729 Effective Date: Sep 21, 2022 Medicare Number: -------TABLE End----- Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 55 | ICMProviderAgreement_ICMProviderAgreement_49186_5 - Hope Community | training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreement_ICMProviderAgreement_49186_5 - Hope Community MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 73-1098634 | 73-1098634 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 56 | ICMProviderAgreement_RecoveryInnovations_223416_5 | training-data/contract-text-file/4. Facility Boilerplate/ICMProviderAgreement_RecoveryInnovations_223416_5.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 71-1018775 | 71-1018775 | IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Delaware First Health, Inc Recovery Innovations, Inc (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Aaron Brace Paul Galdys Aaron Brace (Oct 3, 2022 14:33 EDT) Paul Galdys (Sep 28, 2022 10:02 PDT) Print Name: Aaron Brace Print Name: Paul Galdys Title: Regional Vice President, New Business Network Title: Deputy CEO Development Signature Date: Oct 3,2022 Signature Date: Sep 28, 2022 ICM #: ICMProviderAgreement_223416 Tax Identification Number: 71-1018775 To be completed by Health Plan only: National Provider Identifier: 1912381344 Effective Date: Oct 28, 2022 Medicare Number: Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 57 | St. Joseph_Fac2_MEDICAID 22-1487602 Amendment_121367 | training-data/contract-text-file/4. Facility Boilerplate/St. Joseph_Fac2_MEDICAID 22-1487602 Amendment_121367 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 22-1487602 | 22-1487602 | = 2 IN WITNESS WHEREOF, the Parties hereto have executed and delivered this Amendment as of the date above HEALTH PLAN: CONTRACTED PROVIDER: WellCare Health Plans of New Jersey, Inc St Joseph's Regional Medical Center Authorized Signature Authorized Signature Kevin Slavin DIGITALLY SIGNED John g Kirchner Printed Name: John Kirchner Printed Name: {{*Name_es_:Signer1 Title: Plan President & CEO Title: {{*Ttll_es_:Signer1:title }} 12/18/22 Date: {{$IntDate }} Date: { {$ExtDate }} 12/14/2022 09:15 AM EST ICM #: (CMProviderAgreementAmendment_121637 Tax ID Number: 22-1487602 State Medicaid Number: NPI: { {#ExtDate=ExtSignDate_es_:signer1:date }} { {#IntDate=IntSignDate_es_:signer2:date }} ICMProviderAgreementAmendment_121637 Page 2 of 3 -------TABLE Start----- Authorized Signature Kevin Slavin DIGITALLY SIGNED Printed Name: {{*Name_es_:Signer1 Title: {{*Ttll_es_:Signer1:title }} Date: { {$ExtDate }} 12/14/2022 09:15 AM EST -------TABLE End----- Start of Page No = 3 ATTACHMENT C-2 NEW JERSEY MEDICAID/FAMILYCARE COMPENSATION SCHEDULE HOSPITAL SERVICES [St Joseph's Regional Medical Center] This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for Covered Services provided by Providers to Members enrolled in a Medicaid Program Where the Provider's tax identification number ("TIN") has been designated by the Health Plan as subject to this Compensation Schedule, Health Plan shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Provider according to the terms of, and subject to the requirements set forth in, the Agreement and this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set forth herein less all applicable Member Expenses All capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the applicable Program Attachment, or the Definitions section set forth at the end of this Compensation Schedule. The maximum compensation for hospital Covered Services rendered to a Member shall be the "Allowed Amount." Except as otherwise provided in this Compensation Schedule, the Allowed Amount for hospital Covered Services is the lesser of: (i) Allowable Charges; or (ii) the rates set forth in Table 1 below. Table 1 Covered Services Rates 107 percent of the applicable New Jersey Medicaid/FamilyCare inpatient prospective payment Inpatient Covered Services system rates of Diagnosis Related Groups (DRG) published on DMAHS's website, or otherwise provided by DMAHS, on the date of the Member's discharge. 107 percent of the New Jersey Medicaid/FamilyCare outpatient fee schedule or hospital specific payment Outpatient Covered Services amount for outpatient services published on DMAHS's website, or as otherwise provided by DMAHS, on the date the Covered Services are rendered. Definitions: 1. Allowed Amount means the amount designated in this Compensation Schedule as the maximum amount payable to a Provider for any particular Covered Service provided to any particular Member, pursuant to this Agreement or its Attachments. 2. Allowable Charges means a Provider's billed charges for services that qualify as Covered Services. ICMProviderAgreementAmendment_121637 Page 3 of 3 -------TABLE Start----- Covered Services Rates 107 percent of the applicable New Jersey Medicaid/FamilyCare inpatient prospective payment Inpatient Covered Services system rates of Diagnosis Related Groups (DRG) published on DMAHS's website, or otherwise provided by DMAHS, on the date of the Member's discharge. 107 percent of the New Jersey Medicaid/FamilyCare outpatient fee schedule or hospital specific payment Outpatient Covered Services amount for outpatient services published on DMAHS's website, or as otherwise provided by DMAHS, on the date the Covered Services are rendered. -------TABLE End----- | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 58 | 2017-07-01 St. Agnes Medical Center AMD | training-data/contract-text-file/4. Facility Custom/2017-07-01 St. Agnes Medical Center AMD MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 94-1437713 | 94-1437713 | 07 12 09:36:42 -07'00' Signature Signature NANCY HOLLINGSWORTH Thomas Hamilton Print Name Regional Health Plan Officer CEO Title 7-6-17 Date Date Saint Agnes Medical Center 3 July 1, 2017 Amendment Start of Page No = 4 Provider/Facility Name, State Federal Tax Medicare National Medi-Cal Other Drug Address, Telephone and License Identification Provider Specialty Provider Contract Language( Enforcement Facsimile Phone Number Number Number Number Identifier s) Agency Number Saint Agnes Medical Center 1303 East Herndon Ave General 040000173 94-1437713 05-0093 1205845567 HSC00093F Fresno, CA 93720 Acute 559-450-3000 Care 559-450-2143 Hospital Additional Location(s): 040000173 94-1437713 05-0093 1205845567 HSC00093F Outpatient Services - Bone Density Services at Hologic Discovery SL Bone Density Unit 7202 N Millbrook Ave #206 Fresno, CA 93720 Outpatient Services - Breast Center 1105 E Spruce, Ste 102 Fresno, CA 93720 Outpatient Services - Mammography at Outpatient Mammography 7202 N Millbrook, Ste | 4 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 59 | Custom_2017-01-01 Amendment & Addendum A & B Bayfront Health St Pete | training-data/contract-text-file/4. Facility Custom/Custom_2017-01-01 Amendment & Addendum A & B Bayfront Health St Pete MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 300759177 | 30-0759177 | The effective date of this Amendment shall be January 1, 2017 IN WITNESS THEREOF, the parties, through their duly authorized representatives, hereby execute this Amendment and agree to be bound by its terms Hospital By: H Date: 1/4/17 Name: Eric Smith Title: CFO, Bayfront St Pete Tax ID: 30-0759177 Provider #: 363518 AvMed, Inc. By: am 0 with Date: 2/6/17 Ann O Wehr, MD SVP, Chief Medical Officer AvMed, Inc. 1800 Pembrook Drive, Suite 190 Orlando, FL 32810 Dr Start of Page No = 10 AvMED, INC. REIMBURSEMENT SCHEDULE ADDENDUM A [Commercial] BAYFRONT HMA MEDICAL CENTER, LLCDBA BAYFRONT HEALTH ST PETERSBURG Effective: 01/01/17 through 9/30/18 Service Description Reimbursement Description COMMERCIAL (INPATIENT): All Commercial Inpatient Services $7,928 Conversion Factor* Multiplied by current CMS Medicare Relative Weights as published by CMS and amended as updated by CMS from time to time. *The reimbursement for Normal Newborns (MS-DRG 795) is included in mother's reimbursement Non- weighted DRGs will be reimbursed at 35% of billed charges. Transferring Members Per diem $1,736 Per day for any AvMed member who is (Per diem is in lieu of DRG payment). transferred to another acute facility | 9 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 60 | Custom_2017-04-05 Lee Memorial Amendment Exhibits A-B | training-data/contract-text-file/4. Facility Custom/Custom_2017-04-05 Lee Memorial Amendment Exhibits A-B MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | See " Lee Memorial Providers" tab | 65-0319983 | Document Index AVMED, INC 1AMENDMENT TO THE 1PHYSICIAN-HOSPITAL ORGANIZATION SERVICES AGREEMENT 1 The effective date of this Amendment shall be July 1, 2017 4 EXHIBIT A 5PRODUCT AND COMPENSATION SCHEDULE 5[Commercial] 5 COMMERCIAL (OUTPATIENT/ANCILLARY SERVICES): 5 EXHIBIT A 6PRODUCT AND COMPENSATION SCHEDULE 6[Commercial] 6 Charge Master Price Protection 6 Calculation Example 6 EXHIBIT A 7PRODUCT AND COMPENSATION SCHEDULE 7[Commercial] 7 REIMBURSEMENT SCHEDULE 8EXHIBIT B [Commercial] 8 Health Park Care and Rehabilitation Center 8TIN 65-0319983, NPI 1699786061 8 Effective: July 1, 2017 8 REIMBURSEMENT SCHEDULE 9EXHIBIT B [Commercial] 9 Health Park Care and Rehabilitation Center 9TIN 65-0319983, NPI 1699786061 9 Charge Master Price Protection 9 Calculation Example 9 REIMBURSEMENT SCHEDULE 10EXHIBIT B [Commercial] 10 Health Park Care and Rehabilitation Center 10TIN 65-0319983, NPI 1699786061 10 Start of Page No = 1 AVMED, INC. AMENDMENT TO THE PHYSICIAN-HOSPITAL ORGANIZATION SERVICES AGREEMENT THIS AMENDMENT TO THE PHYSICIAN-HOSPITAL ORGANIZATION SERVICES AGREEMENT (the "Amendment") is by and between AvMed, Inc., a State Certified Health Maintenance Organization ("Company") and Lee Physicians Hospital Organization, a sub-agency of Lee Memorial Health System, which operates a physician-hospital organization duly established in accordance with the laws of the State of Florida ("PHO"). WHEREAS, Company and PHO entered into that certain Physician-Hospital Organization Services Agreement effective as of June 29, 2001, as amended previously by the parties (hereinafter referred to collectively as the "Agreement"); NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions contained in the Agreement and herein, the parties hereto agree as follows: 1. Lee Physicians Hospital Organization is removed as a party to the Agreement and is replaced by Lee Memorial Health System (hereinafter "LMHS") LMHS through its execution of this Amendment, agrees to replace Physicians Hospital Organization and be the party to the Agreement bound by all of the terms and conditions in the Agreement. 2. All references in the Agreement to PHO shall be deleted and replaced with "LMHS." All references in the Agreement, including in the title, to "PHYSICIAN-HOSPITAL ORGANIZATION AGREEMENT" are replaced with "HOSPITAL ORGANIZATION AGREEMENT." 3. EXHIBIT A PRODUCT AND COMPENSATION SCHEDULE attached to the Agreement is deleted in its entirety and replaced with the new EXHIBIT A PRODUCT AND COMPENSATION SCHEDULE [Commercial], attached hereto and made a part hereof. 4. REIMBURSEMENT SCHEDULE EXHIBIT B [Commercial] attached hereto and made a part hereof is hereby added to the Agreement. 5. The definition of "Ancillary Provider" in Section 1.1 of the Agreement is deleted in its entirety and all references in the Agreement to "Ancillary Provider" are deleted from the Agreement. 6. The definition of "PHO Hospital" in Section 1.12 of the Agreement is deleted in its entirety and all references in the Agreement to "PHO Hospital" are deleted and replaced with "LMHS Provider". 7. The definition of "PHO Physician" in Section 1.13 of the Agreement is deleted in its entirety and all references in the Agreement to "PHO Physician" are deleted and replaced with "LMHS Provider." 8. The definition of "PHO Provider" in Section 1.14 of the Agreement is deleted in its entirety and replaced with the following definition: "LMHS Provider" shall mean only the hospitals or skilled nursing facilities that are listed in the Facility Listing Exhibit I [Commercial] attached to this Amendment to the Agreement, which have agreed to furnish such Covered Services to Covered Persons Page 1 of 4 Start of Page No = 2 pursuant to an agreement with LMHSO No hospitals or skilled nursing facilities will be added to or removed from this Agreement and/or Exhibit I, unless specifically agreed to by both parties and a proper written amendment to the Agreement is executed by both parties. 9. The language in Section 2.1 "General Representation" of the Agreement is deleted in its entirety and replaced with the following: General Representation | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 61 | Custom_2020-01-01 Com Affinity Amend FE - St Charles Health System | training-data/contract-text-file/4. Facility Custom/Custom_2020-01-01 Com Affinity Amend FE - St Charles Health System MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 93-0602940 | 93-0602940 | Vice President, Moda, Inc (Title) (Title) 1 1 2020 March 27, 2019 (Date) (Date) 93-0602940 (Tax ID Number) Prepared by: T Metzler Moda Health Provider Amendment-Affinity 2020 2 St Charles Health System Inc. Start of Page No = 3 DocuSign Envelope ID: F7EB71C9-869B-4A09-8DA1-6E60E3ADB0CC EXHIBIT -1b HOSPITAL REIMBURSEMENT ST | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 62 | Custom_2023-01-01 COMM (CMI-Compression) Amend FE - Samaritan Health Services | training-data/contract-text-file/4. Facility Custom/Custom_2023-01-01 COMM (CMI-Compression) Amend FE - Samaritan Health Services MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 930391573, 930110095, 930396847, 931305493, 931329784 | 930-391573 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 63 | ICMProviderAgreement_CorasWellnessAndBehavioralHealth_212482_8 | training-data/contract-text-file/4. Facility Custom/ICMProviderAgreement_CorasWellnessAndBehavioralHealth_212482_8.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 87-0846562 | I do not see a taxpayer identification number stated on the signatory page. The document does not contain that information | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 64 | ICMProviderAgreement_ICMProviderAgreement_143342_10_Landmark of Midwest City Rehab and Nursing Center | training-data/contract-text-file/4. Facility Custom/ICMProviderAgreement_ICMProviderAgreement_143342_10_Landmark of Midwest City Rehab and Nursing Center.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 82-1580561 | 82-1580561 | = 12 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Oklahoma Complete Health, Inc LANDMARK OF MIDWEST CITY REHABILITATION AND NURSING CENTER, LLC (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: Clayton Franklin the Clayton Franklin (Mar 31, 2022 09:13 CDT) Angela Jackson (Mar 30, 2022 14:20 CDT) Print Name: Clayton Franklin Print Name: Angela Jackson Title: President & CEO Title: Administrator Signature Date: Mar 31, 2022 Signature Date: Mar 30, 2022 ICM #: ICMProviderAgreement_143342 Tax Identification Number: 82-1580561 To be completed by Health Plan only: National Provider Identifier: 1902323694 Effective Date: Apr 29, 2022 Medicare Number: Page 12 of 56 Start of Page No = 13 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 12 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 65 | ICMProviderAgreement_ICMProviderAgreement_34251_10_Summit Medical Center | training-data/contract-text-file/4. Facility Custom/ICMProviderAgreement_ICMProviderAgreement_34251_10_Summit Medical Center MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 27-0826862 | 27-0826862 Question: What is the name of the provider organization stated on the signatory page? | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 66 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/4. Facility Custom/Molina/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | Except as specifically amended by this Amendment, the Agreement shall continue in full force and effect IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their duly authorized officers as of the Effective Date set forth by Health Plan below El Paso County Hospital District, DBA, Molina Healthcare of Texas, Inc , University Medical Center of El Paso - Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Pres / CEO Signatory Title Title (Printed): (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 Amendment to Page I of 3 Provider or authorized gar HSA - UMC El Paso 03122012 representative's initials: -------TABLE Start----- Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Title (Printed): Pres / CEO Signatory Title (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 -------TABLE End----- Start of Page No = 2 ATTACHMENT D Compensation Schedule Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for- services basis, at the lesser of; (i) Provider's allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any: STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-For-Service Program fee schedule in effect on the date of service. Notwithstanding the above, payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service. In addition to the above listed compensation rates, payment for the following services for all Health Plan products & programs shall be reimbursed according to the table below: Outpatient Services Revenue Codes Negotiated Payment Implants/Prosthetics/Pacemakers 274,275,276,278 70% of Billed Charges equal paid when any one single item is to Provider's Acquisition Cost over $500 plus five percent (5%) High Cost Drugs - paid when any 634,636 70% of Billed Charges equal one single item is over $500 to Provider's Acquisition Cost plus five percent (5%) Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written notification At any time Health Plan may request a copy of an invoice from Provider to validate Provider's Acquisition Cost | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 67 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/4. Facility Custom/Molina/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | Except as specifically amended by this Amendment, the Agreement shall continue in full force and effect IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their duly authorized officers as of the Effective Date set forth by Health Plan below El Paso County Hospital District, DBA, Molina Healthcare of Texas, Inc , University Medical Center of El Paso - Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Pres / CEO Signatory Title Title (Printed): (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 Amendment to Page I of 3 Provider or authorized gar HSA - UMC El Paso 03122012 representative's initials: -------TABLE Start----- Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Title (Printed): Pres / CEO Signatory Title (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 -------TABLE End----- Start of Page No = 2 ATTACHMENT D Compensation Schedule Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for- services basis, at the lesser of; (i) Provider's allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any: STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-For-Service Program fee schedule in effect on the date of service. Notwithstanding the above, payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service. In addition to the above listed compensation rates, payment for the following services for all Health Plan products & programs shall be reimbursed according to the table below: Outpatient Services Revenue Codes Negotiated Payment Implants/Prosthetics/Pacemakers 274,275,276,278 70% of Billed Charges equal paid when any one single item is to Provider's Acquisition Cost over $500 plus five percent (5%) High Cost Drugs - paid when any 634,636 70% of Billed Charges equal one single item is over $500 to Provider's Acquisition Cost plus five percent (5%) Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written notification At any time Health Plan may request a copy of an invoice from Provider to validate Provider's Acquisition Cost | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 68 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/4. Facility Custom/Molina/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | Except as specifically amended by this Amendment, the Agreement shall continue in full force and effect IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Amendment by their duly authorized officers as of the Effective Date set forth by Health Plan below El Paso County Hospital District, DBA, Molina Healthcare of Texas, Inc , University Medical Center of El Paso - Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Pres / CEO Signatory Title Title (Printed): (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 Amendment to Page I of 3 Provider or authorized gar HSA - UMC El Paso 03122012 representative's initials: -------TABLE Start----- Provider Signature: Molina Signature: Signatory Name Signatory Name (Printed): (Printed): Stephanie Slaughts Signatory Title (Printed): Pres / CEO Signatory Title (Printed): Vr Operations Signature Date: 5-7-12 Signature Date: 5-17-2012 (To be completed by Molina) Tax ID: 74-6000756 Effective Date: 3/1/2012 -------TABLE End----- Start of Page No = 2 ATTACHMENT D Compensation Schedule Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for- services basis, at the lesser of; (i) Provider's allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any: STAR, CHIP HMO, CHIP PERINATE, and STAR+PLUS: Covered Services shall be paid at an amount equivalent to the payable rate under the State of Texas Medicaid Fee-For-Service Program fee schedule in effect on the date of service. Notwithstanding the above, payment for Covered Services, including, but not limited to, certain Covered Services where there is no payment rate in the State of Texas Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed an amount equivalent to the Medicare Fee-For-Service Program allowable payment rate (adjusted for locality or geography), as of the date of service. In addition to the above listed compensation rates, payment for the following services for all Health Plan products & programs shall be reimbursed according to the table below: Outpatient Services Revenue Codes Negotiated Payment Implants/Prosthetics/Pacemakers 274,275,276,278 70% of Billed Charges equal paid when any one single item is to Provider's Acquisition Cost over $500 plus five percent (5%) High Cost Drugs - paid when any 634,636 70% of Billed Charges equal one single item is over $500 to Provider's Acquisition Cost plus five percent (5%) Health Plan shall compensate Provider at seventy percent (70%) of billed charges equal to one hundred five percent (105%) of the amount Provider paid for the item (Acquisition Cost) Provider shall disclose its current mark-up methodology to Health Plan to ensure the seventy percent (70%) of billed charges equals Provider's Acquisition Cost plus five percent (5%) If any changes are made to Provider's mark-up methodology, Provider will provide ninety (90) day prior written notification At any time Health Plan may request a copy of an invoice from Provider to validate Provider's Acquisition Cost | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 69 | Custom_Dallas County Hospital Parkland 75-6004221 - Amendment 5 | training-data/contract-text-file/4. Facility Custom/Molina/Custom_Dallas County Hospital Parkland 75-6004221 - Amendment 5 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 75-6004221 | 75-6004221 | All other services to be reimbursed at 16 8% of billed which is 105% of their OP Interim rate) Request Date 8/18/17 PAR Yes NON PAR Provider Name Parkland Health & Hospital System Provider/Facility Type (Example: HOSPITAL Hospital, FQHC, Physician, etc ) TIN Number 75-6004221 NPI Number 127295703 Provider ID QMP000003368804 that have more than one Impact assessment None Desired Effective Date 9/1/17 If non Standard Effective date Reason: 1 John J McGuinness COO Approval for non-Standard Effective date/ Rates 3/21/17 New, Existing or Correction to Existing Contract (Provide contract for existing/correction contract) NOTE: Existing Contracts and Corrections requires Contracting Leadership approval prior to submission Line of Business New MP Rate Inpatient Services: Covered Services shall be paid at One Hundred Thirty-Five (135%) of Hospital's Standard Dollar Amount in accordance with the State of Texas Medicaid DRG reimbursement methodology in effect on the date of service. List any applicable details on how Inpatient Service reimbursement will follow the terms and conditions that the contract should be set up for currently exist in Providers Hospital Service Agreement Professional reimbursement services are included in this case rate except Hospitalists as defined by Parkland Exhibit A. -------TABLE Start----- Request Date 8/18/17 PAR Yes NON PAR Provider Name Parkland Health & Hospital System Provider/Facility Type (Example: HOSPITAL Hospital, FQHC, Physician, etc.) TIN Number 75-6004221 NPI Number 127295703 Provider ID QMP000003368804 that have more than one Impact assessment None Desired Effective Date 9/1/17 If non Standard Effective date Reason: 1 John J | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 70 | Custom_HSA_AMD 1_EFF07152023_Children's Medical Center_Marketplace Agreement | training-data/contract-text-file/4. Facility Custom/Molina/Custom_HSA_AMD 1_EFF07152023_Children's Medical Center_Marketplace Agreement MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 75-0800628 | 75-0800628 | Provider's Legal Name ("Provider") - Matching the applicable tax form (i e W-9, Line 1): Children's Health System of Texas Authorized Representative's Signature: Authorized Representative's Name - Printed: Rulfs Robert Fries Robert Fries (Jun 28, 2023 16:50 CDT) Authorized Representative's Title: Authorized Representative's Signature Date: Executive Vice President, CFO Mailing Address - Official Correspondence: Payment Address - If different than Mailing Address: 1935 Medical District Drive PO Box 844007 Dallas, Texas 75235 Dallas, Texas 75284-4007 IRS 1099 Address - If different than Mailing Address: Tax ID Number - As listed on corresponding tax form: 75-0800628 NPI - That corresponds to the above Tax ID Number: 1194743013 and 1720480627 Health Plan Signature and Information. Molina Healthcare of Texas, a Texas Corporation ("Health Plan") Authorized Representative's Signature: Authorized Representative's Name - Printed: Scott Albosta Authorized Representative's Title: Authorized Representative's Countersignature Date: VP, Network Strategy & Services July 7, 2023 Mailing Address - Official Correspondence: 1660 North Westridge Circle Irving, TX 75038 Effective Date of Agreement ("Effective Date") July 15, 2023 Page 1 of 7 Molina Texas SCA - Marketplace MHI v07192018r04222020 -------TABLE Start----- Provider's Legal Name ("Provider") - Matching the applicable tax form (i.e W-9, Line 1): Children's Health System of Texas Authorized Representative's Signature: Authorized Representative's Name - Printed: Rulfs. Robert Fries Robert Fries (Jun 28, 2023 16:50 CDT) Authorized Representative's Title: Authorized Representative's Signature Date: Executive Vice President, CFO Mailing Address - Official Correspondence: Payment Address - If different than Mailing Address: 1935 Medical District Drive PO Box 844007 Dallas, Texas 75235 Dallas, Texas 75284-4007 IRS 1099 Address - If different than Mailing Address: Tax ID Number - As listed on corresponding tax form: 75-0800628 NPI - That corresponds to the above Tax ID Number: 1194743013 and 1720480627 -------TABLE End----- -------TABLE Start----- Molina Healthcare of Texas, a Texas Corporation ("Health Plan") Authorized Representative's Signature: Authorized Representative's Name - Printed: Scott Albosta Authorized Representative's Title: Authorized Representative's Countersignature Date: VP, Network Strategy & Services July 7, 2023 Mailing Address - Official Correspondence: 1660 North Westridge Circle Irving, TX 75038 Effective Date of Agreement ("Effective Date") July 15, 2023 -------TABLE End----- Start of Page No = 2 LETTER OF AGREEMENT Provider and Health Plan enter into this Agreement as of the Effective Date set forth on the Signature Page of this Agreement The Provider and Health Plan each are referred to as a "Party" and collectively as the "Parties". 1.1 Provision of Covered Services Provider agrees to provide medically necessary services and supplies covered under the Health Plan's benefit plan ("Covered Services") for individuals enrolled in Health Plan's Exchange plan ("Members") | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 71 | Custom_HSA_EFF07012010_Driscoll Children's Hospital | training-data/contract-text-file/4. Facility Custom/Molina/Custom_HSA_EFF07012010_Driscoll Children's Hospital MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-2577746 | 74-2577746 | 2089 P O Box 926 Email Address San Antonio, TX 78294 Tax I D No 74-2577746 License No. 000488 Physical Address (if different than above): Texas Provider Identification 1328122 Driscoll Children's Hospital Number (TPIN) 3533 S Alameda NPI (or UPIN if NPI not yet NPI: 1548286172 Corpus Christi, TX 78411 designated) UPIN: DEA No. AD0894952 (Use continuation pages if multiple providers under common ownership will submit bills under this Agreement) I, the undersigned, am authorized to and do hereby verify the accuracy of the foregoing Provider information. Provider Signature: E.An Signatory Name (Printed): Eric Hamon Signatory Title (Printed): Executive Vice President / CFO Signature Date: 3/4/10 Driscoll Children's Hospital (Final) 02-18-10.doc Page 22 of 30 Initials of authorized representative of Provider -------TABLE Start----- Provider Name Driscoll Children's Hospital Billing Address: Telephone No. 361.694.5000 Driscoll Children's Hospital Facsimile No. 361.808.2089 P O Box 926 Email Address San Antonio, TX 78294 Tax I.D No. 74-2577746 License No. 000488 Physical Address (if different than above): Texas Provider Identification 1328122 Driscoll Children's Hospital Number (TPIN) 3533 S Alameda NPI (or UPIN if NPI not yet NPI: 1548286172 Corpus Christi, TX 78411 designated) UPIN: DEA No. AD0894952 -------TABLE End----- -------TABLE Start----- Provider Signature: E.An Signatory Name (Printed): Eric Hamon Signatory Title (Printed): Executive Vice President / CFO Signature Date: 3/4/10 -------TABLE End----- Start of Page No = 23 ATTACHMENT B Definitions 1. Advance Directive is a Member's written instructions, recognized under state law, relating to the provision of health care when the Member is not competent to make a health care decision as determined under state law Examples of Advance Directives are living wills and durable powers of attorney for health care. 2 Agreement means this Provider Services Agreement and all attachments 3 | 22 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 72 | Adena_First_Amendment_and_2022_Quality_Rewards_and_Shared_Savings_Duall Exec | training-data/contract-text-file/5. Multiple Custom/Adena_First_Amendment_and_2022_Quality_Rewards_and_Shared_Savings_Duall Exec.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 31-4379443 | 31-4379443 | = 4 DocuSign Envelope ID: 9E64A5DA-DF01-4DD7-BF52-204C86F7A04E IN WITNESS WHEREOF, the parties have executed this Amendment as of the Effective Date: July 1 2022 CARESOURCE NETWORK PARTNERS Adena Health System LLC, on behalf of itself and its Affiliates Provider Name DocuSigned by: By: Matthew Barrett By: James P JPM fameman McManus John 3598A4BB47D64C8 Matthew Barrett James McManus Title: VP, Network Strategy and Contracting Title: Chief Financial Officer Date: 7/21/2022 Chief Financial Officer Date: 31-4379443 Federal Tax ID Start of Page No = 5 DocuSign Envelope ID: 19E64A5DA-DF01-4DD7-BF52-204C86F7A04E Exhibit A.4 COMPENSATION SCHEDULE CareSource Marketplace - Ohio Addendum to Agreement For Medically Necessary Covered Services rendered to Covered Persons by Hospital in accordance with the terms of this Agreement, Hospital shall accept as payment in full the lesser the amounts set forth below under subsections (1) (2) and (3). For purposes of this Attachment, the terms "CMS Hospital Per Diem Rate", "CMS Part B % Rate", and "CMS Swing Bed Per Diem Rate" shall mean the Hospital Per Diem, Part B %, and Swing Bed Per Diem rates set forth in the Rate Review letter issued to Hospital by the fiscal intermediary acting on behalf of the Centers for Medicare and Medicaid Services ("CMS") and that are in effect on the date the service or admission, as the case may be ("Rate Review Letter") Hospital shall provide Plan with the most recent Rate Review Letter prior to the effective date of the rates set forth in the Rate Review Letter and whenever specifically requested by Plan. For purposes of this Attachment, the term "Medicare Allowed Amount" shall mean the Medicare allowed amount that is published annually in the Federal Register, is based on valid codes recognized by CMS and is in effect on the date of service *or admission, as the case may be. 1. Inpatient and Outpatient Hospital Services: the Plan shall pay the Hospital the lesser of billed charges or the following: Effective July 1, 2022 Inpatient / Outpatient Services: 190% of MCR Effective July 1, 2023 Inpatient / Outpatient Services: 185% of MCR Effective July 1, 2024 Inpatient / Outpatient Services: 180% of MCR Effective July 1, 2025 Inpatient / Outpatient Services: 175% of MCR 2 Other Outpatient Services: the Plan shall pay Hospital the rate set forth below, as determined by the type of Covered Services rendered: a. Laboratory: The lesser of 100% of Allowable Billed Charges or 100% of the Medicare Allowed Amount b Durable Medical Equipment: The lesser of 100% of Allowable Billed Charges or 100% of the Medicare Allowed Amount c | 4 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 73 | Bon Secours Mercy Health_20190101_Base Contract | training-data/contract-text-file/5. Multiple Custom/Bon Secours Mercy Health_20190101_Base Contract.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | See tab: Bon Secours Base Carveouts | 34-1105619 | Main Street 23Dayton, OH 45402 23Attn: Ohio Market President 23 SIGNATURES 25 EXHIBIT A 26 LEGAL NAMES OF AFFILIATES AND FEDERAL EMPLOYER IDENTIFICATION 26NUMBERS 26 EXHIBIT B 45PROVISIONS APPLICABLE TO 45CARESOURCE MEDICARE PRODUCTS 45 EXHBIT C - OHIO 47 STATE SPECIFC PROVISIONS 47FOR OHIO 47 Payment of Claims 47 Governing Law and Venue 47 Amendment 48 EXHIBIT C - OHIO 49OHIO MEDICAID ADDENDUM 49 ADDENDUM DEFINITIONS 49 ADDENDUM PROVISIONS 49 EXHIBIT C - OHIO 55 PLAN COMPENSATION SCHEDULE 55 MEDICAID PROVIDER REIMBURSEMENT AND COMPENSATION 55 1 FACILITYREIMBURSEMENT 55 St Rita's Medical Center Hospital TIN 34-1105619 56 Mercy Regional Medical Center TIN 34-0714704 56Mercy Allen Hospital TIN 34-0864230 56 Our Lady of Bellefonte Hospital 61-1356023 56 Outliers: 56 Transfer Policy: 56 Outpatient Services: 56 Outpatient Services are reimbursed as follows: 56 2 OTHER SERVICES 57 Skilled Nursing Facilities: St Rita's Medical Center Hospital TIN 34-1105619 62 Outpatient Therapy Services: St Rita's Medical Center Hospital TIN 34-1105619 63 3 | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 74 | Bon_Secours_Mercy_Third_Amendment | training-data/contract-text-file/5. Multiple Custom/Bon_Secours_Mercy_Third_Amendment MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | See "Bon Secours Mercy Providers" tab | 31-1091597 | O Box 636500 and Pediatrics fka Mercy Avenue OH 43078 6157 I Services Cincinnati, OH 45263-6500 Well Child Pediatrics Mercy Health Physicians 31-1007881 1205887023, Varies Varies Varies Professiona P O Box 632110Cincinnati, OH Cincinnati, LLC 1013974161, I Services 45263-2110 1154851178 Mercy Health - Harrison 31-1091597 1366532301 10450 New Harrison, 513-367- 24-Hour P.O Box 631774 Medical Center (fka Mercy Haven Road OH 45030 2222 Emergency Cincinnati, OH 45263-2244 Medical Center Harrison) Room; Diagnostic Svcs: CT Scan, Lab & X-Ray Mercy Hospital West 31-1091597 1740368851 3300 Mercy Cincinnati, 513-215- IP Rehab P.O Box 631774 Hospital Rehab Unit Health Blvd. OH 45211 5000 Cincinnati, OH 45263-2244 Queen City Medical 31-1091597 1912007931 3131 Queen Cincinnati, 513-389- 24-Hour P.O Box 631774 Center (FKA Western Hills City Avenue OH 45238 5000 Emergency Cincinnati, OH 45263-2244 Medical Center) Room; Diagnostic Svcs: CT Scan, Lab & X-Ray Mercy Health West 31-1091597 1912007931 3300 Mercy Cincinnati, 513-215- Acute Care P.O Box 631774 Hospital LLC Health Blvd. OH 45211 5000 Hospital Cincinnati, OH 45263-2244 Outpatient Surgery at 31-1091597 1912007931 3300 Mercy Cincinnati, 513-215- Ambulatory/ P.O | 9 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 75 | CustomFac_Benedictine Hospital - Amendment 1.1.16 (HBX,HARP,EPP) (REVISED) | training-data/contract-text-file/5. Multiple Custom/CustomFac_Benedictine Hospital - Amendment 1.1.16 (HBX,HARP,EPP) (REVISED).txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 141338470 | 14-1338470 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 76 | Custom_AncProf_Keith C Chang MD PLLC - Agreement Provider Signed 1.1.16 | training-data/contract-text-file/5. Multiple Custom/Custom_AncProf_Keith C Chang MD PLLC - Agreement Provider Signed 1.1.16.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 208623734 | 20-8623734 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 77 | MarionCounty_Caresource Exchange Hosp 110121 Partial_MP | training-data/contract-text-file/5. Multiple Custom/MarionCounty_Caresource Exchange Hosp 110121 Partial_MP.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 35-6005697 | 35-6005697 | 20 13:55:32 -04'00 Print Name: Christopher M Scott, PharmD Title : Chief Clinical & Revenue Officer Date: 10 20 2021 Provider Tax ID: 35-6005697 Page 3 of 10 -------TABLE Start----- By: Print Steve Smitherman Name: Title : IN Market President Date: 11/5/2021 -------TABLE End----- -------TABLE Start----- By: Christopher M Scott, CM Suith PharmD, FCCM, FASHP, BCPS 2021.10.20 13:55:32 -04'00 Print Name: Christopher M Scott, PharmD Title : Chief Clinical & Revenue Officer Date: 10.20.2021 -------TABLE End----- Start of Page No = 4 EXHIBIT A PROVIDER AFFILIATION ATTACHMENT LEGAL IRS NAMES AND FEDERAL EMPLOYER IDENTIFICATION NUMBERS OF PROVIDER AFFILIATES, ENTITIES, AND SUBSIDIARIES BILLING FOR COVERED SERVICES AND/OR OPERATING UNDER THIS AGREEMENT: Federal Tax ID Legal IRS Name 35-6005697 The Health and Hospital Corporation of Marion County Page 4 of 10 Start of Page No = 5 EXHIBIT C- INDIANA PLAN COMPENSATION SCHEDULES CARESOURCE INDIANA MARKETPLACE HOSPITAL For Medically Necessary Covered Services rendered to Covered Persons by Provider, in accordance with the terms of this Agreement, Provider shall accept as payment in full the lesser of: (i) Provider's billed charges; or (ii) The percentage, listed below, of the Hospital's current year Medicare Allowed Amount applicable to Provider as published annually in the Federal Register and based on valid codes recognized by the Centers for Medicare and Medicaid Services (CMS) in effect on the date of service (the "Medicare Allowed Amount"). Any Cost Share shall be offset against the Medicare Allowed Amount for Covered Services, without regard to whether the Provider has collected such amounts. Inpatient and Outpatient Facility Reimbursement Rate: 160% of the Medicare Allowed Amount. Home Health, Hospice and Dialysis Reimbursement Rate: 125% of the current Medicare Allowed Amount | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 78 | 221487173_EnglewoodHospitalandMedicalCenter_ICMSupportingDocuments_566705 | training-data/contract-text-file/6. Multiple - Boilerplate/221487173_EnglewoodHospitalandMedicalCenter_ICMSupportingDocuments_566705 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 22-1487173 | 22-1487173 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 79 | ICMProviderAgreement_ICMProviderAgreement_295973_15 | training-data/contract-text-file/6. Multiple - Boilerplate/ICMProviderAgreement_ICMProviderAgreement_295973_15.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 83-0410970 | 83-0410970 | IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments noted on Schedule B, effective as of the date set forth beneath their respective signatures HEALTH PLAN: PROVIDER: Oklahoma Complete Health, Inc Fairfax Medical Facilities, Inc (Legibly Print Name of Provider) Authorized Signature: Authorized Signature: 417 Karen McConnell Clayton Franklin (Oct 11, 2023 15:12 CDT) Karen McConnell (Oct 10, 2023 13:36 CDT) Print Name: Clayton Franklin Print Name: Karen McConnell Title: President & CEO Title: Chief Executive Officer Signature Date: Oct 11, 2023 Signature Date: Oct 10, 2023 ICM #: ICMProviderAgreement_295973 Tax Identification Number: 83-0410970 To be completed by Health Plan only: National Provider Identifier: 1538183173 Effective Date: Nov 09, 2023 Medicare Number: Page 13 of 46 Start of Page No = 14 PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. 1. Hospitals If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions apply. 1.1 24 Hour Coverage Each Hospital shall be available to provide Covered Services to Covered Persons 24 hours per day, 7 days per week. 1.2 Emergency Care Each Hospital shall provide Emergency Care (as hereafter defined) in accordance with Regulatory Requirements | 13 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 80 | Mult6_VirtuaMemorialHospitalofBurlington_Amendment | training-data/contract-text-file/6. Multiple - Boilerplate/Mult6_VirtuaMemorialHospitalofBurlington_Amendment MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 210634562 | 21-0635001 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 81 | Custom_KentuckyOne Group Practice Provider Agreement_20140806_Dually Executed (1) | training-data/contract-text-file/CareSource -Professional/Custom_KentuckyOne Group Practice Provider Agreement_20140806_Dually Executed (1) MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | See: "CSNP21_CS KentuckyOne Roster" | 61-1334601 | 65 2014 Page 24 of 67 Bll Start of Page No = 25 EXHIBIT A - GROUP PRACTICE SERVICE LOCATIONS Page 25 of 67 Bill Start of Page No = 26 Medicare Tax Id Last Name First Name Specialty PCP Practice Name Individual Practice Address City Zip Group NPI Group # NPI (B)PartB (A)Part A Jeanetta MD Family KentuckyOne Primary Care, 61-1029768 Bosley Y Medicine a Department of Jewish 534 Hillcrest Drive Brandenburg KY 40108-1222 1679632939 1447312129 8514 (B) Hospital 183838 (A) KentuckyOne Primary Care, 61-1029768 Gibson Kimberly NP Family Y a Department of Jewish 534 Hillcrest Drive Brandenburg KY Medicine 40108-1222 1093931487 1447312129 8515 (B) Hospital 183838 (A) Robert Family KentuckyOne Primary Care, 61-1029768 Smith MD Y Medicine a Department of Jewish 534 Hillcrest Drive Brandenburg KY 40108-1222 1457479396 1447312129 8516 (B) Hospital 183838 (A) Family KentuckyOne Primary Care, 61-1029768 Stegner Sharron NP Y Medicine a Department of Jewish 534 Hillcrest Drive Brandenburg KY 40108-1222 1821157173 1447312129 8517 (B) Hospital 183838 (A) 61-1334601 Abdeen Anwar MD IM/Emergency N Med Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1821141763 1720211774 1254 61-1334601 Ahmed Ali MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1144485822 1164854675 K095100 61-1334601 Ali Amjad MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1598739617 1164854675 K095100 61-1334601 Ali London Pediatric & Muhammad MD Peds Y 21 Middleground Way London KY 40741-8345 Adolescent Medicine 1073587143 1164854675 183435 61-1334601 Aliu Peter MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1205008703 1164854675 K095100 61-1334601 Almagdub lhab MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1801050984 1164854675 K095100 61-1334601 Ammisetty Vijaya MD FM Y Seton Family Health Center 11087 Main Street Martin KY 41649 1164662508 1184651994 183440 61-1334601 Arekapudi Aruna MD Hem/Onc N Saint Joseph Hematology 165 London Mountain London KY 40741-6601 1811992852 Oncology London View Dr 1740550615 K041590 61-1334601 Baeker Thomas Hem/Onc Saint Joseph Hematology 165 London Mountain MD N London KY 40741-6601 1992700926 Oncology London View Dr 1740550615 K041590 61-1334601 Bhopatkar Shailesh MD Anesthesiology N Anesthesia Program 1001 Saint Joseph Ln London KY 40741-8345 1407806318 1164854675 K095100 61-1334601 Browning Ben DO FM N Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1184685703 1720211774 1254 61-1334601 Burns Patricia APRN NP Y Saint Joseph Berea Family 305 Estill St, 4th Floor Berea KY 40403-1742 Medicine 1619232311 1982955290 pending 61-1334601 Caddell Joseph PA PA N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1588737621 1164854675 pending Page 26 of 67 -------TABLE Start----- Medicare Tax Id Last Name First Name Specialty PCP Practice Name Individual Practice Address City Zip Group NPI Group # NPI (B)PartB (A)Part A Jeanetta MD Family KentuckyOne Primary Care, 61-1029768 Bosley Y Medicine a Department of Jewish 534 Hillcrest Drive Brandenburg KY 40108-1222 1679632939 1447312129 8514 (B) Hospital 183838 (A) KentuckyOne Primary Care, 61-1029768 Gibson Kimberly NP Family Y a Department of Jewish 534 Hillcrest Drive Brandenburg KY Medicine 40108-1222 1093931487 1447312129 8515 (B) Hospital 183838 (A) Robert Family KentuckyOne Primary Care, 61-1029768 Smith MD Y Medicine a Department of Jewish 534 Hillcrest Drive Brandenburg KY 40108-1222 1457479396 1447312129 8516 (B) Hospital 183838 (A) Family KentuckyOne Primary Care, 61-1029768 Stegner Sharron NP Y Medicine a Department of Jewish 534 Hillcrest Drive Brandenburg KY 40108-1222 1821157173 1447312129 8517 (B) Hospital 183838 (A) 61-1334601 Abdeen Anwar MD IM/Emergency N Med Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1821141763 1720211774 1254 61-1334601 Ahmed Ali MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1144485822 1164854675 K095100 61-1334601 Ali Amjad MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1598739617 1164854675 K095100 61-1334601 Ali London Pediatric & Muhammad MD Peds Y 21 Middleground Way London KY 40741-8345 Adolescent Medicine 1073587143 1164854675 183435 61-1334601 Aliu Peter MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1205008703 1164854675 K095100 61-1334601 Almagdub lhab MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1801050984 1164854675 K095100 61-1334601 Ammisetty Vijaya MD FM Y Seton Family Health Center 11087 Main Street Martin KY 41649 1164662508 1184651994 183440 61-1334601 Arekapudi Aruna MD Hem/Onc N Saint Joseph Hematology 165 London Mountain London KY 40741-6601 1811992852 Oncology London View Dr 1740550615 K041590 61-1334601 Baeker Thomas Hem/Onc Saint Joseph Hematology 165 London Mountain MD N London KY 40741-6601 1992700926 Oncology London View Dr 1740550615 K041590 61-1334601 Bhopatkar Shailesh MD Anesthesiology N Anesthesia Program 1001 Saint Joseph Ln London KY 40741-8345 1407806318 1164854675 K095100 61-1334601 Browning Ben DO FM N Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1184685703 1720211774 1254 61-1334601 Burns Patricia APRN NP Y Saint Joseph Berea Family 305 Estill St, 4th Floor Berea KY 40403-1742 Medicine 1619232311 1982955290 pending 61-1334601 Caddell Joseph PA PA N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1588737621 1164854675 pending -------TABLE End----- Start of Page No = 27 Medicare Tax Id Last Name First Name Specialty PCP Practice Name Individual Practice Address City Zip Group NPI Group # NPI (B)PartB (A)Part A 61-1334601 Caddell Kevin PA PA N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1578838116 1164854675 pending 61-1334601 Chang Jake CANA CRNA N Saint Joseph Martin 11203 Main Street Martin KY 41649 1700062726 Physicians 1720211774 pending 61-1334601 Clark Judy APRN NP Y Saint Joseph Berea Family 305 Estill St, 4th Floor Berea KY Medicine 40403-1742 1932404761 1982955290 pending 61-1334601 Combs Pamela Saint Joseph East Sleep 160 N Eagle Creek Ste. Lexington KY Wellness Center 40509-2124 1225468275 302 P100027079 61-1334601 Compton Ralph MD FM Y Saint Joseph Berea Family Medicine 305 Estill St, 4th Floor Berea KY 40403-1742 1538107826 1982955290 183473(B) 0016403(A) 61-1334601 Croley Jessica MD Hem/Onc N Saint Joseph Hematology 3470 Blazer Pkwy, Ste 150 Lexington KY 40509-1078 1629231170 1740550615 Oncology P100027079 61-1334601 Davenport- Rachel APRN APRN N Campbell Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1710281399 1164854675 pending 61-1334601 D'Costa Gina MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1184653842 1164854675 K095100 61-1334601 Foster Ben CRNA Anesthesia N Anesthesia Program 1001 Saint Joseph Ln London KY 40741-8345 1023241700 1164854675 K095100 61-1334601 Gardner Jennie APRN NP-FM Y Bath Family Health Services 44 Water St Owingsville KY 40360-8944 1790869071 1720211774 1254 61-1334601 Goodin Donald MD Hem/Onc N Saint Joseph Hematology 3470 Blazer Pkwy, Ste 150 Lexington KY 40509-1078 1922102391 1740550615 Oncology P100027079 61-1334601 Grentz Liesel DO FM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1821276130 1164854675 K095100 61-1334601 Griffin Wendell CRNA CRNA N Anesthesia Program 1001 Saint Joseph Ln London KY 40741-8345 1518205269 1164854675 K095100 61-1334601 Hall Maryann PA PA Y Martin Clinic 12579 Main St, Ste 101 Martin KY 41649 1245238518 1487689519 183442 61-1334601 Hamilton Ronald MD IM, EM N Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1417971755 1720211774 1254 London Pediatric & 61-1334601 Hampton Sheila APRN APAN N 21 Middleground Way London KY 40741-8345 1205890142 Adolescent Medicine 1164854675 pending 61-1334601 Hardy Donny MD IM Y Saint Joseph Berea Family 305 Estill St, 4th Floor Berea KY 40403-1742 Medicine RHC 1811981533 1982955290 183473(B) 0016403(A) 61-1334601 Hays Jeremie MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1063611564 1164854675 K095100 61-1334601 Helwani Hassan MD IM N Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1477532422 1720211774 1254 Page 27 of 67 -------TABLE Start----- Medicare Tax Id Last Name First Name Specialty PCP Practice Name Individual Practice Address City Zip Group NPI Group # NPI (B)PartB (A)Part A 61-1334601 Caddell Kevin PA PA N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1578838116 1164854675 pending 61-1334601 Chang Jake CANA CRNA N Saint Joseph Martin 11203 Main Street Martin KY 41649 1700062726 Physicians 1720211774 pending 61-1334601 Clark Judy APRN NP Y Saint Joseph Berea Family 305 Estill St, 4th Floor Berea KY Medicine 40403-1742 1932404761 1982955290 pending 61-1334601 Combs Pamela Saint Joseph East Sleep 160 N Eagle Creek Ste. Lexington KY Wellness Center 40509-2124 1225468275 302 P100027079 61-1334601 Compton Ralph MD FM Y Saint Joseph Berea Family Medicine 305 Estill St, 4th Floor Berea KY 40403-1742 1538107826 1982955290 183473(B) 0016403(A) 61-1334601 Croley Jessica MD Hem/Onc N Saint Joseph Hematology 3470 Blazer Pkwy, Ste 150 Lexington KY 40509-1078 1629231170 1740550615 Oncology P100027079 61-1334601 Davenport- Rachel APRN APRN N Campbell Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1710281399 1164854675 pending 61-1334601 D'Costa Gina MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1184653842 1164854675 K095100 61-1334601 Foster Ben CRNA Anesthesia N Anesthesia Program 1001 Saint Joseph Ln London KY 40741-8345 1023241700 1164854675 K095100 61-1334601 Gardner Jennie APRN NP-FM Y Bath Family Health Services 44 Water St Owingsville KY 40360-8944 1790869071 1720211774 1254 61-1334601 Goodin Donald MD Hem/Onc N Saint Joseph Hematology 3470 Blazer Pkwy, Ste 150 Lexington KY 40509-1078 1922102391 1740550615 Oncology P100027079 61-1334601 Grentz Liesel DO FM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1821276130 1164854675 K095100 61-1334601 Griffin Wendell CRNA CRNA N Anesthesia Program 1001 Saint Joseph Ln London KY 40741-8345 1518205269 1164854675 K095100 61-1334601 Hall Maryann PA PA Y Martin Clinic 12579 Main St, Ste 101 Martin KY 41649 1245238518 1487689519 183442 61-1334601 Hamilton Ronald MD IM, EM N Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1417971755 1720211774 1254 London Pediatric & 61-1334601 Hampton Sheila APRN APAN N 21 Middleground Way London KY 40741-8345 1205890142 Adolescent Medicine 1164854675 pending 61-1334601 Hardy Donny MD IM Y Saint Joseph Berea Family 305 Estill St, 4th Floor Berea KY 40403-1742 Medicine RHC 1811981533 1982955290 183473(B) 0016403(A) 61-1334601 Hays Jeremie MD IM N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1063611564 1164854675 K095100 61-1334601 Helwani Hassan MD IM N Saint Joseph Martin ER 11203 Main Street Martin KY 41649 1477532422 1720211774 1254 -------TABLE End----- Start of Page No = 28 Medicare Tax Id Last Name First Name Specialty PCP Practice Name Individual Practice Address City Zip Group NPI Group # NPI (B)PartB (A)Part A 61-1334601 Hensley Edith APAN APRN N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1194045104 1164854675 pending 61-1334601 Hickman Kerrie PA PA N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1659518165 1164854675 pending 61-1334601 Idrees Muhammad MD Peds Y Seton Family Health Center 11087 Main Street Martin KY 41649 1912960774 1184651994 183440 61-1334601 lqbal Muhammad MD Pulm Dis N Hospitalist Program 1001 Saint Joseph Ln London KY 40741-8345 1356547491 1164854675 K095100 61-1334601 Johnson Dana MD Med Onc N Saint Joseph Hemalology 701 Bob-O-Link Dr, Ste Lexington KY 40504-3760 1073512133 1740550615 Oncology 100 P100027079 Saint Joseph Hematology Oncology London 61-1334601 Kassem 165 London Mountain Bachar MD Hem/Onc N manager Erin Wilcher London KY 40741-6601 1548266844 View Dr 1740550615 K041590 Andrea Sponcil does credentialing 61-1334601 Kern Caroline APRN APRN N Saint Joseph East Sleep 160 N | 26 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 82 | Custom_Parkview Health Systems-OH MP, IN MP-ID C15656222AA | training-data/contract-text-file/CareSource -Professional/Custom_Parkview Health Systems-OH MP, IN MP-ID C15656222AA MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 35-1972384 | 35-1972384 | 3 do not apply if the delay caused by such notices could result in imminent harm to a Covered Person, if the material amendment is required by state or federal law, rule, or regulation, or if Provider affirmatively accepts the material amendment in writing and agrees to an earlier effective date than otherwise required by Ohio Revised Code section 3963 04 Start of Page No = 4 EXHIBIT A - AFFILIATIONS ATTACHMENT LEGAL NAMES OF AFFILIATES AND FEDERAL EMPLOYER IDENTIFICATION NUMBERS Group(s) under the Agreement cover and all of its entities, subsidiaries and affiliates and facilities billing for Covered Services and/or operating under the following federal tax identification numbers: Federal Tax ID Legal IRS Name 34-1045870 Midwest Community Health Associates 35-1972384 Parkview Physicians Group Start of Page No = 5 Exhibit A.4 OHIO PLAN COMPENSATION SCHEDULES CARESOURCE OHIO MARKETPLACE For Medically Necessary Covered Services rendered to Covered Persons by Provider or by Group Practice Providers, in accordance with the terms of this Agreement, Provider or Group Practice Provider, as the case may be, shall accept as payment in full the lesser of: (i) Provider's or Group Practice Provider's billed charges; or (ii) The percentage listed below, of the current prevailing Medicare allowed amount applicable to Providers as published annually in the Federal Register and based on valid codes recognized by the Centers for Medicare and Medicaid Services (CMS) in effect on the date of service (the "Medicare Allowed Amount") Any co- payment, deductible or coinsurance shall be offset against the Medicare Allowed Amount for Covered Services, without regard to whether the Provider or Group Practice Provider has collected such amounts. Professional Services Reimbursement Rate: 110% of the Medicare Allowed Amount for primary care physician services Professional Services Reimbursement Rate: 120% of the Medicare Allowed Amount for specialty physician services (iii) For those services that do not have a Medicare Allowed Amount, Plan shall reimbursement Provider Group 60% of billed charges. Injectable medications will be paid according to 100% of the Medicare Allowed Amount, except for those drugs that may be available through a specialty pharmacy benefits manager. Medicare: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx Parkview Health Systems d/b/a CareSource Indiana, Inc. Parkview Physician Group By: BR Provider Name By: Jeanne Wuckers Jeanne' Wickens Senior Vice President and Title: Executive Donotor Title: Chief Financial Officer Date: 11/8/17 Date: 10/25/17 Start of Page No = 6 EXHIBIT C- INDIANA PLAN COMPENSATION SCHEDULES CARESOURCE INDIANA MARKETPLACE For Medically Necessary Covered Services rendered to Covered Persons by Provider, in accordance with the terms of this Agreement, Provider shall accept as payment in full the lesser of: (iv) Provider's or Group Practice Provider's billed charges; or (v) The percentage listed below, of the current prevailing Medicare allowed amount applicable to Providers as published annually in the Federal Register and based on valid codes recognized by the Centers for Medicare and Medicaid Services (CMS) in effect on the date of service (the "Medicare Allowed Amount") Any co- payment, deductible or coinsurance shall be offset against the Medicare Allowed Amount for Covered Services, without regard to whether the Provider or Group Practice Provider has collected such amounts. Professional Services Reimbursement Rate: 110% of the Medicare Allowed Amount for primary care physician services Professional Services Reimbursement Rate: 120% of the Medicare Allowed Amount for specialty physician services (vi) For those services that do not have a Medicare Allowed Amount, Plan shall reimbursement Provider Group 60% of billed charges. Injectable medications will be paid according to 100% of the Medicare Allowed Amount, except for those drugs that may be available through a specialty pharmacy benefits manager. Fee Schedule To determine unit prices for any specific code or service, please refer to the Medicare link below: Medicare: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx Start of Page No | 4 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 83 | Anc10_040121 Nationwide Vision Center Care 1st Amendment | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0560663 | 86-0560663 | In the event of a conflict between the terms of the Agreement and this Amendment, the terms of this Amendment shall control IN WITNESS WHEREOF, the parties have executed this Amendment to the Agreement in duplicate by their respective officers duly authorized to do so PLAN PROVIDER By: 6/3/21 Scott Cummings Date Signature Vincent Hayes Chief Administrative Officer Printed Name Vincent Hayes Title Vice President Managed Care NAtion wide Vision Center INC Address for Plan Notices: Contracting Entity/Group Name 86-0560663 Carelst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 5-6-2021 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 220 N McKemy Ave Chandler, Az 85226 Carelst Revised 050817 Start of Page No = 2 ATTACHMENT A ANCILLARY COMPENSATION AND COVERED SERVICES Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds PROVIDER's billed charges. Routine Vision Care Effective Contracted Rates HCIF Rates* Frames $39.00 $47.51 Single Vision Lenses $38.00 $46.30 Bifocal Lenses** $59.00 $71.88 Trifocal Lenses** $69.00 $84.06 Contact Lenses 95% of the current AHCCCS 95% of the current AHCCCS Fee Schedule Fee Schedule * Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are required by AHCCCS | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 84 | Anc10_040121 Nationwide Vision Center Care 1st Amendment | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc10_040121 Nationwide Vision Center Care 1st Amendment.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0560663 | 86-0560663 | In the event of a conflict between the terms of the Agreement and this Amendment, the terms of this Amendment shall control IN WITNESS WHEREOF, the parties have executed this Amendment to the Agreement in duplicate by their respective officers duly authorized to do so PLAN PROVIDER By: 6/3/21 Scott Cummings Date Signature Vincent Hayes Chief Administrative Officer Printed Name Vincent Hayes Title Vice President Managed Care NAtion wide Vision Center INC Address for Plan Notices: Contracting Entity/Group Name 86-0560663 Carelst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 5-6-2021 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 220 N McKemy Ave Chandler, Az 85226 Carelst Revised 050817 Start of Page No = 2 ATTACHMENT A ANCILLARY COMPENSATION AND COVERED SERVICES Payment for Covered Ancillary Services (prior authorized, if required) provided by Provider to Members shall be based on the lesser of the Plan's Fee Schedule defined below or Provider's charges, less any applicable Co-Payments, Deductibles and Coinsurance At no time shall Plan pay an amount that exceeds PROVIDER's billed charges. Routine Vision Care Effective Contracted Rates HCIF Rates* Frames $39.00 $47.51 Single Vision Lenses $38.00 $46.30 Bifocal Lenses** $59.00 $71.88 Trifocal Lenses** $69.00 $84.06 Contact Lenses 95% of the current AHCCCS 95% of the current AHCCCS Fee Schedule Fee Schedule * Rates effective as long as Health Care Investment Fund Assessment (HCIF) pass-through rates are required by AHCCCS | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 85 | Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 56-2589722 | 86-0713148 | By: 6 8 2017 Soldiering Scott Cummings Date Signature Chief Administrative Officer MARK R osenberg Printed Name CEO Title Barnet Dulaney Perkins Eye Center, PLLC Address for Plan Notices: Barnet Dulaney Surgery Centers, LLC Contracting Entity/Group Name Care1st Health Plan Arizona, Inc Attention: Director, Provider Network Operations 56-2589722/ 86-0713148 2355 E Camelback Road, #300 Contracting Entity/Group Tax I.D. Phoenix, Arizona 85016 4-12-2017 Date Address for Provider Notices: 4800 N, 22nd Street PhoeNix , AZ 85016 artn: Contrating Carelst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 86 | Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc2_060117 Barnet Dulaney Perkins Eye Cntr Care1st Anc - 562589722 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 56-2589722 | 86-0713148 | By: 6 8 2017 Soldiering Scott Cummings Date Signature Chief Administrative Officer MARK R osenberg Printed Name CEO Title Barnet Dulaney Perkins Eye Center, PLLC Address for Plan Notices: Barnet Dulaney Surgery Centers, LLC Contracting Entity/Group Name Care1st Health Plan Arizona, Inc Attention: Director, Provider Network Operations 56-2589722/ 86-0713148 2355 E Camelback Road, #300 Contracting Entity/Group Tax I.D. Phoenix, Arizona 85016 4-12-2017 Date Address for Provider Notices: 4800 N, 22nd Street PhoeNix , AZ 85016 artn: Contrating Carelst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 87 | Anc4_White Mountain Phys Contract | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0460643 | 86-0460643 | Michael L Johnson PT IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written Scott By: Gummings 10-23-2018 Date Sellbury Signature Dechange Chief Administrative Officer Printed Name Michael L Johnson PT PT, TIN owner Title White Mountain Physical therapy, Address for Plan Notices: Contracting Entity/Group Name LTD 86-0460643 Carel 1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 05-03-2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: PO Box 1420 Show Low, AZ 85902-1420 CareIst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 88 | Anc4_White Mountain Phys Contract | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc4_White Mountain Phys Contract MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0460643 | 86-0460643 | Michael L Johnson PT IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written Scott By: Gummings 10-23-2018 Date Sellbury Signature Dechange Chief Administrative Officer Printed Name Michael L Johnson PT PT, TIN owner Title White Mountain Physical therapy, Address for Plan Notices: Contracting Entity/Group Name LTD 86-0460643 Carel 1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 05-03-2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: PO Box 1420 Show Low, AZ 85902-1420 CareIst Ancillary Services Agreement 120114 Page 1 of 22 Start of Page No = 4 RECITALS A. WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D. WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1.3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S § 36- 2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.4 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. 1.5 "Attachment(s)" means the attachments, numbered A and B to this Agreement which are incorporated herein as if set forth in full. Carelst Ancillary Services Agreement 120114 Page 2 of 22 Start of Page No | 3 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 89 | Anc5_Tipton | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc5_Tipton MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 30487744 | 030497744 | IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written By: Cummings 10 18 2018 Date Anita Phelps Scott Signature Chief Administrative Officer Anita Phelps Printed Name Contracts/Medical Biller Title Tipton Physical Therapy, LLC Address for Plan Notices: Contracting Entity/Group Name 030497744 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 2/2/2017 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Tipton Physical Therapy, LLC 8400 E Florentine Road Prescott Valley, AZ 86314-8653 Start of Page No = 3 RECITALS A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1,3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 90 | Anc5_Tipton | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc5_Tipton MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 30487744 | 030497744 | IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written By: Cummings 10 18 2018 Date Anita Phelps Scott Signature Chief Administrative Officer Anita Phelps Printed Name Contracts/Medical Biller Title Tipton Physical Therapy, LLC Address for Plan Notices: Contracting Entity/Group Name 030497744 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 2/2/2017 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Tipton Physical Therapy, LLC 8400 E Florentine Road Prescott Valley, AZ 86314-8653 Start of Page No = 3 RECITALS A WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); B. WHEREAS, Plan desires to enter into contracts with licensed and experienced health care providers to provide or arrange for the provision of Covered Services to Plan Members; C. WHEREAS, Provider is licensed and in good standing under the laws of the State of Arizona. D WHEREAS, Plan and Provider desire to enter into this Agreement for Provider to provide or arrange for the provision of certain Covered Ancillary Services to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties, having freely negotiated all provisions herein, agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.2 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, urgent care services, skilled nursing facilitiy, home health services, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services, infusion and enteral therapies, and other services customarily deemed ancillary. 1,3 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||
| 91 | Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0872873 | 86-0872873 | PLAN PROVIDER Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life Chief Administrative Officer DAVID A DEXTER Printed Name CEO Title Address for Plan Notices: Contracting Entity/Group Name 86-0872873 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 8/21/2019 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 1255 W Washington SI. Tempe, Az 85281 Page 1 of 1 Start of Page No = 2 ATTACHMENT C LABORATORY SERVICES COMPENSATION Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the effective date of the new AHCCCS Fee Schedule | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 92 | Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st | training-data/contract-text-file/Centene/CNC AZ - Ancillary/Anc6_090119 SONORA QUEST LABORATORIES LLC Care1st MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0872873 | 86-0872873 | PLAN PROVIDER Scott By: Self-uning Cummings 8 21 2019 Date Signature Dea Life Chief Administrative Officer DAVID A DEXTER Printed Name CEO Title Address for Plan Notices: Contracting Entity/Group Name 86-0872873 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 8/21/2019 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 1255 W Washington SI. Tempe, Az 85281 Page 1 of 1 Start of Page No = 2 ATTACHMENT C LABORATORY SERVICES COMPENSATION Payment for Covered Health Care Services (which are prior authorized, if required) provided by Provider to Plan Members shall be based on the lesser of the Plan's Fee Schedule defined as sixty five (65%) of the AHCCCS Fee Schedule prevailing as of the date of service or Provider's charges, less any applicable Co- Payments, Deductibles and Coinsurance Plan shall reimburse new technologies and those laboratory services deemed covered by Plan that do not have an established rate on the AHCCCS Fee Schedule at fifty (50%) of the billed charges until a rate is mutually agreed upon in writing. For any AHCCCS Fee Schedule changes, if Provider determines that the new AHCCCS Fee Schedule will result in a material adverse impact, Provider shall make best efforts to notify Plan prior to the effective date of the new AHCCCS Fee Schedule | 1 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 93 | Anc8_Hanger Pros & Ortho West Contract | training-data/contract-text-file/Centene/Care1st/Anc8_Hanger Pros & Ortho West Contract.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 95-2667855 | 95-2667855 | PLAN PROVIDER By: Salt fining Signature ScottCummings Chief Administrative Officer Katie Burkholder Printed Name 3 25 2011 National Director, Contracts Date Title Hanger Prosthetics & Orthotics, Inc Address for Plan Notices: Contracting Entity/Group Name 95-2667855/52-1486235 Care1st Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations February 18, 2011 2355 E Camelback Rd, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: 4155 E La Palma Ave B400 Anaheim, CA 92807 10910 Domain Drive Ste 300 Austin, TX 78758 Revised 04.21.08; 10.28.08; 2.17.09,11.10.10 Page 21 of 21 Start of Page No = 24 ATTACHMENT A ANCILLARY COMPENSATION AND COVERED SERVICES Payment for Covered Health Services (which are prior authorized, if required) provided by Provider to Care1st Health Plan Arizona, Inc.(Plan) members shall be based on the lesser of 75% of the January 1, 2011 AHCCCS Fee for Service rates or Provider's charges less any applicable Co-Payments, Deductibles and Coinsurance with the exception of those services listed below New HCPCS codes established after January 1, 2011, shall be reimbursed at the lesser of 75% of the AHCCCS Fee for Service rates prevailing as of the date of service or Provider's charges, less any applicable Co-Payments, Deductibles and Coinsurance HCPC codes with no rates shall be reimbursed according to AHCCCS methodology until rates are established At no time shall Plan pay an amount that exceeds Provider's billed charges. Plan and Provider agree that the Metropolitan Phoenix Area as pertaining to this Agreement shall be a 30 mile radius from the center of Phoenix in any direction | 23 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 94 | Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC | training-data/contract-text-file/Centene/Care1st/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0290033 | 86-0290033 | , (hereinafter "PROVIDER") IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written PLAN PROVIDER By: Scott Cummings 9-27-2018 Date Signature of to CPA State Plan President Michael Fett, CPA Printed Name Title Chief Financial officer Southwest Behavioral Health Services, Inc Address for Plan Notices: Contracting Entity/Group Name 86-0290033 CareIst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Network Management 9/25/2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Care1st Provider Agreement Page 2 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No = 3 RECITALS R.1 WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); R.2 WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership organized and in good standing under the laws of the State of Arizona, which professional corporation or partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) and independent contractors. R.3 WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- For-Service ("FFS") basis, to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Active Labor" means a labor at a time at which either of the following would occur: (1) there is inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a threat to the health and safety of the patient or the unborn child. 1.2 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.3 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services and other services customarily deemed ancillary. 1.4 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. § 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.5 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. Care1st Provider Agreement Page 3 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 95 | Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC | training-data/contract-text-file/Centene/Care1st/Custom_SOUTHWEST BEHAVIORAL & HEALTH SERVICES INC.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0290033 | 86-0290033 | , (hereinafter "PROVIDER") IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written PLAN PROVIDER By: Scott Cummings 9-27-2018 Date Signature of to CPA State Plan President Michael Fett, CPA Printed Name Title Chief Financial officer Southwest Behavioral Health Services, Inc Address for Plan Notices: Contracting Entity/Group Name 86-0290033 CareIst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Network Management 9/25/2018 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Care1st Provider Agreement Page 2 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No = 3 RECITALS R.1 WHEREAS, Plan has entered into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); R.2 WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist Physician practicing in a recognized speciality, or (iii) a professional corporation or medical group partnership organized and in good standing under the laws of the State of Arizona, which professional corporation or partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) and independent contractors. R.3 WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- For-Service ("FFS") basis, to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Active Labor" means a labor at a time at which either of the following would occur: (1) there is inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a threat to the health and safety of the patient or the unborn child. 1.2 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action, such as a denial of authorization from which a Member can file an appeal and subsequent request for hearing. 1.3 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services and other services customarily deemed ancillary. 1.4 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. § 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a member. 1.5 "Appeal" means a disagreement by a Member with a Plan action/adverse decision such as denial of authorization A Member may request a hearing if dissatisfied with the Plan's decision on the appeal. Care1st Provider Agreement Page 3 of 23 Southwest Behavioral Health Services, Inc.9.25.18 Start of Page No | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 96 | Mult1_Arizona Oncology_1 - 860938204 | training-data/contract-text-file/Centene/Mult1_Arizona Oncology_1 - 860938204 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 86-0938204 | 86-0938204 | , an Arizona Corporation, (hereinafter "Plan") and Arizona Oncology Associates, PC (hereinafter "PROVIDER") IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the day and year first above written PLAN PROVIDER By: Sale Guing UCI 23 2013 Sam Alber Scott Cummings Date Signature Chief Administrative Officer Lanny I Hecker, MD, PhD Printed Name Practice President Title Arizona Oncology Associates, PC Address for Plan Notices: Contracting Entity/Group Name 86-0938204 Carelst Health Plan Arizona, Inc. Contracting Entity/Group Tax I.D. Attention: Director, Provider Network Operations 5/3/113 2355 E Camelback Road, #300 Date Phoenix, Arizona 85016 Address for Provider Notices: Arizona Oncology Associates, PC Attn: Managed Care 1760 E River Rd, Suite 350 Tucson, AZ 85718 Carelst Provider Agreement RFP14 072712 Page 1 of 21 Start of Page No = 3 RECITALS R.1 WHEREAS, Plan has or intends to enter into a Contract with the Arizona Health Care Cost Containment System (hereinafter "AHCCCS") to provide or arrange for certain health care services to Plan Members eligible through a program administered and/or regulated by AHCCCS (hereinafter "AHCCCS Members"); R.2 WHEREAS, if Plan secures an AHCCCS contract in Provider's service area Plan intends to contract directly with CMS to provide, arrange for or administer the provision of health care services to dual eligible beneficiaries and Provider agrees to work with Plan to negotiate a contract to provide services to dual eligible beneficiaries enrolled with Plan; R.3 WHEREAS, as indicated on the signature page of this Agreement, Provider is either (i) a Primary Care Physician who is duly licensed to practice medicine in the State of Arizona, practicing in the area of general practice, family practice, pediatrics, internal medicine or primary care obstetrics/ gynecology; or (ii) a Specialist Physician practicing in a recognized specialty, or (iii) a professional corporation or medical group partnership organized and in good standing under the laws of the State of Arizona, which professional corporation or partnership will provide services hereunder through its physician shareholder(s) or partners and/or employee(s) and independent contractors. R.4 WHEREAS, Plan and PROVIDER desire to enter into an agreement under which the Plan will contract with PROVIDER to provide or arrange for certain health care services and supplies, on a capitated and/or Fee- For-Service ("FFS") basis, to AHCCCS Members enrolled with Plan (hereinafter "Plan Members"). AGREEMENT NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration the receipt of which is hereby acknowledged, the parties agree as follows: ARTICLE I DEFINITIONS The following terms shall have the following meanings for purposes of this Agreement: 1.1 "Active Labor" means a labor at a time at which either of the following would occur: (1) there is inadequate time to affect safe transfer to another hospital prior to delivery (2) A transfer may pose a threat to the health and safety of the patient or the unborn child. 1.2 "Adverse Action/Decision" means (1) any action (such as a claim denial) from which a provider may file a grievance, or (2) an action, such as a denial of authorization from which a Plan Member can file an appeal and subsequent request for hearing. 1.3 "Ancillary Services" means those Covered Health Care Services necessary to the diagnosis and treatment of Plan Members, including, but not limited to, ambulance, ambulatory or day surgery, durable medical equipment, imaging services, laboratory, pharmacy, physical or occupational therapy, Emergency Services and other services customarily deemed ancillary. 1.4 "AHCCCS" means the Arizona Health Care Cost Containment System, as authorized by A.R.S. § 36-2901 et seq., which is composed of the Administration, contractors, and other arrangement through which health care services are provided to a Plan Member. Carelst Provider Agreement RFP14 072712 Page 2 of 21 Start of Page No | 2 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 97 | Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed | training-data/contract-text-file/To Be Reorganized Upon Completion/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 263143681 | 263-143681 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 98 | Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed | training-data/contract-text-file/To Be Reorganized Upon Completion/Custom_Prof_Anna Suponya MD PC - Agreement Provider Signed_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 263143681 | 263-143681 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 99 | Custom_ULP Inc_ULRF_20160311_Dually Executed KY J4M_MA-C13371728AA | training-data/contract-text-file/To Be Reorganized Upon Completion/Custom_ULP Inc_ULRF_20160311_Dually Executed KY J4M_MA-C13371728AA_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 27-3645560 | 27-3645560 | , Suite 400 Louisville, KY 40223 By: Danea C Magin Title: VP Health Partiver Services Date: 3-11-16 GROUP PRACTICE: University of Louisville Physicians, Inc Address: 300 E Market Street, Suite 400, Louisville, KY 40202 By: Title: CEO Acting Rabulaus Date: 3/10/16 Group Practice Tax ID: 27-3645560 101-1029626 university of Louisville Research Franaction Page 21 of 22 Start of Page No = 22 EXIMBIT A - GROUP PRACTICE SERVICE LOCATIONS with wood Page 22 of 22 Start of Page No = 23 CARESOURCE JUST4MET PLAN COMPENSATION SCHEDULE For Medically Necessary Covered Services rendered to Covered Persons by Provider or by Group Practice Providers, in accordance with the terms of this Agreement, Provider or Group Practice Provider, as the case may be, shall accept as payment in full the lesser of: (i) Provider's or Group Practice Provider's billed charges: or (ii) The percentage, listed below, of the Medicare allowed amount applicable lo Providers as published annually in the Federal Register and based on valid codes recognized by the Centers for Medicare and Medicaid Services (CMS) in effect on the date of service (the "Medicare Allowed Amount") Any co-payment, deductible or coinsurance shall be offset against the Medicare Allowed Amount for Covered Services, without regard to whether the Provider or Group Practice Provider has collected such amounts. Professional Services Reimbursement Rate Adult Primary Care Physicians: 115% of the Medicare Allowed Amount Adult Specialists: 140% of the Medicare Allowed Amount Pediatric Primary Care Physicians: 200% of the Medicare Allowed Amount Pediatric Specialists: 225% of the Medicare Allowed Amount Injectable medications will generally be paid at 105% of the Medicare Fce Schedule, as defined below, except for those drugs that may be available through 8 specialty pharmacy benefits manager. In the event there is no Medicare Allowed Amount Plan will price using the above percentages of the CMS RVU values | 21 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 100 | 2017-01-01 SJHS-St. Joseph Heritage Healthcare AMD | training-data/contract-text-file/To Be Reorganized Upon Completion/HealthFirst of Cali - Professional/2017-01-01 SJHS-St. Joseph Heritage Healthcare AMD_MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 33-0185031 | 33-0185031 | c=US Date: :2017 10 31 15:05:00-07'00 Ginny Ripslinger Signature Interim Senior Vice President Network Development and Contracting Thomas D Hamilton Print Name 10-26-17 Date Regional Health Plan Officer Title 33-0185031 Federal Tax Identification Number PPG Provider Type Date St Joseph Heritage Healthcare Amendment Effective 1/1/17 Page 4 | 4 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||
| 101 | Custom_2018-09-15 COMM Agmt FE - Bandon Community Health Center dba Coast Community Health Center | training-data/contract-text-file/To Be Reorganized Upon Completion/Moda - Professional/Custom_2018-09-15 COMM Agmt FE - Bandon Community Health Center dba Coast Community Health Center.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 943455260 | 94-3455260 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | False | ||||
| 102 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/To Be Reorganized Upon Completion/Molina - Professional/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 103 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/To Be Reorganized Upon Completion/Molina - Professional/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True | ||||
| 104 | CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 | training-data/contract-text-file/To Be Reorganized Upon Completion/Molina - Professional/CustomFac_AMD - AMD - UNIVERSITY MEDICAL CENTER OF EL PASO - 74-6000756 MU.txt | Group Provider Taxpayer Identification Number per Signatory | PROV_GROUP_TIN_SIGNATORY | 74-6000756 | 74-6000756 | What is the Group provider's taxpayer identification number stated on the signatory page? This is a 9 digit long number typically with a hyphen after the first 2 digits. It will be around the following keywords: tax identification number, TIN or IRS number. Return only this 9 digit number with a hyphen after the first 2 digits. Do not elaborate or add context. | True |