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108 lines
7.1 KiB
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108 lines
7.1 KiB
Plaintext
Document Index
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PARTICIPATING PROVIDER AGREEMENT 1
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ARTICLE I - DEFINITIONS 1
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Start of Page No. = 1
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PARTICIPATING PROVIDER AGREEMENT
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This Participating Provider Agreement (together with all Attachments and amendments, this "Agreement")
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is made and entered by and between Trinity HealtCare
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LLC ("Provider") and WellBeing HealthPlan, Inc. ("Health
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Plan" or "MCO") (each a "Party" and collectively the "Parties"). This Agreement is effective as of the date designated
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by Health Plan on the signature page of this Agreement ("Effective Date").
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WHEREAS, Provider desires to provide certain health care services to individuals in products offered by or
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available from or through a Company or Payor (as hereafter defined), and Provider desires to participate in such
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products as a Participating Provider (as defined herein), all as hereinafter set forth.
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WHEREAS, Health Plan desires for Provider to provide such health care services to individuals in such
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products, and Health Plan desires to have Provider participate in certain of such products as a Participating Provider,
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all as hereinafter set forth.
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NOW, THEREFORE, in consideration of the recitals and mutual promises herein stated, the Parties hereby
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agree to the provisions set forth below.
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ARTICLE I - DEFINITIONS
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When appearing with initial capital letters in this Agreement (including an Attachment(s)), the following
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quoted and underlined terms (and the plural thereof, when appropriate) have the meanings set forth below.
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1.1.
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"Affiliate" means a person or entity directly or indirectly controlling, controlled by, or under
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common control with Health Plan.
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1.2.
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"Attachment" means any document, including an addendum, schedule or exhibit, attached to this
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Agreement as of the Effective Date or that becomes attached pursuant to Section 2.2 or Section 8.7, all of which are
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incorporated herein by reference and may be amended from time to time as provided in this Agreement.
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1.3.
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"Clean Claim" has, as to each particular Product, the meaning set forth in the applicable Product
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Attachment or, if no such definition exists, the Provider Manual.
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1.4.
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"Company" means, as appropriate in the context, Health Plan and/or one of or more of its Affiliates,
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except those specifically excluded by Health Plan.
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1.5.
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"Compensation Schedule" means at any given time the then effective schedule(s) of maximum rates
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applicable to a particular Product under which Provider and Contracted Providers will be compensated for the
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provision of Covered Services to Covered Persons. Such Compensation Schedule(s) will be set forth or described in
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one or more Attachments to this Agreement, and may be included within a Product Attachment.
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1.6.
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"Contracted Provider" means a physician, hospital, health care professional or any other provider of
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items or services that is employed by or has a contractual relationship with Provider. The term "Contracted Provider"
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includes Provider for those Covered Services provided by Provider.
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1.7.
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"Coverage Agreement" means any agreement, program or certificate entered into, issued or agreed
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to by Company or Payor, under which Company or Payor furnishes administrative services or other services in
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support of a health care program for an individual or group of individuals, and which may include access to one or
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more of Company's provider networks or vendor arrangements, except those excluded by Health Plan.
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1.8.
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"Covered Person" means any individual entitled to receive Covered Services pursuant to the terms
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of a Coverage Agreement.
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PPA_TX_Jan2018
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Page 1 of 74
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Start of Page No. = 2
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1.9.
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"Covered Services" means those services and items for which benefits are available and payable
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under the applicable Coverage Agreement and which are determined, if applicable, to be Medically Necessary.
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1.10.
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"Managed Care Organization" or "MCO" will have the same meaning as Health Plan.
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1.11.
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"Negative Balance" means an account balance in which Provider or Contracted Provider debits
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exceed credits as a result of Health Plan or Payor overpayments or payments made in error.
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1.12.
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"Medically Necessary" or "Medical Necessity" shall have the meaning defined in the applicable
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Coverage Agreement and/or applicable Regulatory Requirements.
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1.13. "Participating Provider" means, with respect to a particular Product, any physician, hospital,
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ancillary, or other health care provider that has contracted, directly or indirectly, with Health Plan to provide Covered
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Services to Covered Persons, that has been approved for participation by Company, and that is designated by
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Company as a "participating provider" in such Product.
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1.14. "Payor" means the entity (including Company where applicable) that bears direct financial
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responsibility for paying from its own funds, without reimbursement from another entity, the cost of Covered Services
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rendered to Covered Persons under a Coverage Agreement and, if such entity is not Company, such entity contracts,
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directly or indirectly, with Company for the provision of certain administrative or other services with respect to such
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Coverage Agreement.
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1.15.
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"Payor Contract" means the contract with a Payor, pursuant to which Company furnishes
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administrative services or other services in support of the Coverage Agreements entered into, issued or agreed to by
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a Payor, which services may include access to one or more of Company's provider networks or vendor arrangements,
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except those excluded by Health Plan. The term "Payor Contract" includes Company's or other Payor's contract
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with a governmental authority (also referred to herein as a "Governmental Contract") under which Company or Payor
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arranges for the provision of Covered Services to Covered Persons.
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1.16.
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"Product" means any program or health benefit arrangement designated as a "product" by Health
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Plan (e.g., Health Plan Product, Medicaid Product, PPO Product, Payor-specific Product, etc.) that is now or hereafter
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offered by or available from or through Company (and includes the Coverage Agreements that access, or are issued
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or entered into in connection with such product, except those excluded by Health Plan).
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1.17.
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"Product Attachment" means an Attachment setting forth requirements, terms and conditions specific
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or applicable to one or more Products, including certain provisions that must be included in a provider agreement
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under the Regulatory Requirements, which may be alternatives to, or in addition to, the requirements, terms and
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conditions set forth in this Agreement or the Provider Manual.
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1.18.
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"Provider Manual" means the provider manual and any billing manuals, adopted by Company or
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Payor which include, without limitation, requirements relating to utilization management, quality management,
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grievances and appeals, and Product-specific, Payor-specific and State-specific requirements, as may be amended
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from time to time by Company or Payor.
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1.19. "Regulatory Requirements" means all applicable federal and state statutes, regulations, regulatory
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guidance, judicial or administrative rulings, requirements of Governmental Contracts and standards and requirements
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of any accrediting or certifying organization, including, but not limited to, the requirements set forth in a Product
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Attachment.
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1.20.
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"State" is defined as the state identified in the applicable Attachment.
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PPA_TX_Jan2018
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Page 2 of 74 |