query-orchestration/assets/sampleOne/tx_01-66.txt

Document Index
MANAGED BEHAVIORAL HEALTH PRACTITIONER   1
FEE FOR SERVICE AGREEMENT   1
ARTICLE I   1DEFINITIONS   1



Start of Page No. = 1
MANAGED BEHAVIORAL HEALTH PRACTITIONER
FEE FOR SERVICE AGREEMENT
THIS
MANAGED
BEHAVIORAL
HEALTH
PRACTITIONER
AGREEMENT
("Agreement") is made and entered into this October 1st 2005 'Effective Date") (to be
completed by ABCD), by and between
Jake Ball
("Practitioner")
(insert contracting Practitioner's name), operating in accordance with the laws of the State,
and Best Healthcare Provider
Services ("ABCD "), a Texas not-for-profit medical corporation
(Practitioner and ABCD to be collectively referred to herein as the "Parties").
WHEREAS, Practitioner is a behavioral health care practitioner duly licensed under the laws of
the State; and
WHEREAS, ABCD wishes to contract with Practitioner to provide certain Covered Behavioral
Health Services to Covered Persons (as hereinafter defined); and
WHEREAS, Practitioner desires to provide or arrange for the provision of the Covered
Behavioral Health Services specified in this Agreement to Covered Persons for the
consideration, and under the terms and conditions, set forth in this Agreement; and
NOW, THEREFORE, in consideration of the premises and mutual promises herein stated, the
Parties hereby agree as follows:
ARTICLE I
DEFINITIONS
As used in this Agreement and each of its Attachments, each of the following terms (and the
plural thereof, when appropriate) shall have the meaning set forth herein, except where the
context makes it clear that such meaning is not intended.
1.1
Attachment(s) means any attachments, amendments, exhibits and schedules to this
Agreement, including any Product Attachments, incorporated herein by reference.
1.2
Clean Claim means an electronic submission that is compliant with the federal standard
transactions provisions of the Health Insurance Portability and Accountability Act of
1996 ("HIPAA"), Pub. L. 104-191, or a CMS 1500 claim form, or its successor,
submitted by Practitioner for Covered Behavioral Health Services provided to a Covered
Person which accurately reflects such information as is required by this Agreement and
the Provider Manual, and which has no defect or impropriety (including any lack of any
required substantiating documentation) or particular circumstance requiring special
treatment that prevents timely payment from being made on the claim.
1.3
Copayment means the amount (expressed as either a percentage of the cost of a specific
service or a specific dollar amount) that a Covered Person is obligated to pay for a
specific health care service pursuant to his or her Plan.
CONFIDENTIAL & PROPRIETARY
1
ABCD TX Practitioner Agreement
07/28/06

Start of Page No. = 2
1.4
Covered Behavioral Health Services means those Medically Necessary health care
services covered under the terms of the applicable Plan, subject to the limitations and
exclusions of such Plan, that Practitioner agrees to provide pursuant to this Agreement
and as described in the relevant Product Attachment.
1.5
Covered Person means a person entitled under the terms of a Plan to have health care
services provided through Participating Health Care Providers of ABCD
1.6
DOI, as referenced in this Agreement, means the State Department of Insurance.
1.7
Emergency Care has, as to each particular Product, the meaning set forth in the Product
Attachment pertaining to each such Product or, if no such meaning is specified in a
Product Attachment, the meaning set forth in the Provider Manual.
1.8
Medically Necessary means, unless otherwise defined in the applicable Plan, any
behavioral health care services determined by ABCD's medical director or his/her
designee to be required to preserve and maintain a Covered Person's behavioral health,
provided in the most appropriate setting and in a manner consistent with the most
appropriate type, level, and length of service, which can be effectively and safely
provided to the Covered Person, as determined by acceptable standards of behavioral
health care practice and not solely for the convenience of the Covered Person, his/her
Practitioner, or other health care provider. A determination that a service is Medically
Necessary does not mean that a particular service is a Covered Service if the service is
otherwise excluded under the Covered Person's Plan.
1.9
Negotiated Payments means the amount designated as the maximum amount payable by
ABCD to Practitioner for any particular Covered Service provided to any particular
Covered Person, pursuant to this Agreement or its Attachments for Covered Behavioral
Health Services.
1.10
Participating Health Care Provider means any physician, hospital, skilled nursing
facility, home health agency, or other health care provider, including institutional
providers and ancillary services providers, and also Practitioner, which has contracted
with, or on whose behalf a contract has been entered into with, ABCD to participate in
one or more Products.
1.11
Plan a health benefits plan, or federal or State health benefits program, with which
ABCD has contracted to provide or arrange the Covered Behavioral Services
contemplated by this Agreement.
1.12 Preauthorization means verbal or written approval by ABCD, Plan, or other authorized
person or entity, including a corresponding approval number obtained prior to admitting
a Covered Person to a behavioral health care facility or to providing certain other
Covered Behavioral Health Services to a Covered Person, when approval is required
under the utilization management program of the applicable Plan.
CONFIDENTIAL & PROPRIETARY
2
ABCD TX Practitioner Agreement
07/28/06