query-orchestration/assets/text/hn_23-70.txt

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14001190
Pages: 5
1) TODAY'S DATE: 2010-01-29
2) DOCUMENT TYPE
XCONTRACT OCORRESPONDENCE TERM SHEET
3) PROVIDER TYPE
HOSP XPPG CANCILLARY
POP
CLINIC
FQHC
4) PROVIDER SYSTEM:
5) PROVIDER NAME: UDCC Medical Group
6) FOR AGREEMENTS INCLUDING ALL FORMS OF CONTRACTS:
AGREEMENT - DOCUMENT TYPE
PPA
AGR XAMD
LOA
UAAD
SET
CDM
EFFECTIVE DATE: 2005-01-01
7) FOR SUPPORTING DOCUMENTS (ALL NON CONTRACTS):
DOCUMENT TYPE
ITS
REI
SRS
COR
FND
OTHER:
YEAR RANGE:
8) TAX ID NUMBER: 12-3456789
POST SCANNING
Scanned Electronic Document Verified
(initial please)
Placed in Electronic Provider Contract Files folder
(initial please)
Original Files removed and placed in Original Files Room
(initial please)
Conversion to Digital Files Completed
(initial please)


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AMENDMENT
to the
PROVIDER SERVICES AGREEMENT
between
ALL HEALTH INC. AFFILIATES
and
THE REGENTS OF THE SCHOOL
OF CALIFORNIA UCDD HEALTHCARE NETWORK
The Provider Services Agreement ("Agreement") effective January 1. 2000. between The Regents of the School
of California a Constitutional Corporation: on behalf of the UCDD Medical Group a Participating Physician Council
("PPC"),
and All Health, Inc. Affiliates ("AHI"), as subsequently amended, is hereby further amended effective
January 1, 2005.
IAHI and PPC hereby agree to amend the Agreement as follows:
1.
Section 4.3 Billing and Payment subsections (a), (c), and (d) only are hereby deleted and replaced as follows:
(a)
Billing Provider shall submit to AHI or Payor via AHI's electronic claims submission
program or by hard copy, clean, complete and accurate claims for Contracted Services in accordance
with the Operations Manual and the applicable Benefit Program Provider shall submit claims within
ninety (90) days of rendering Contracted Services Where AHI is the secondary payor under
Coordination of Benefits, such ninety (90) day period shall commence immediately after the primary
payor has paid or denied the claim. If |AHI does not receive the requested information from
Provider within said ninety (90) days, claim (s) shall be denied without recourse to resubmit and
AHI shall have no liability for such claim
IAHI shall not be under any obligation to pay Provider for any claim not timely submitted as set
forth above Provider shall not seek payment from any Member in the event AHI does not pay
Provider for a claim not timely submitted
(c)
Adjustments and Appeals Provider shall submit requests for adjustments and/or
appeals regarding claim payments to AHI within three hundred sixty-five days (365) calendar days
after the date of the payment of such claim to Provider. In the event Provider fails to appeal a
claim within such time period. Provider shall not have the right to appeal such claim
(d)
Offsetting AHI shall have the right to offset any amounts owed to AHI by PPG.
including but not limited to. amounts owed by PPG under loans guaranteed by AHI, errors, or AHI
interim payment for Contracted Services, including Capitation payments Notwithstanding any
other provision of this Agreement or any other contract to the contrary, only deficits in the shared
risk programs which provide financial incentives for the control or management of Shared Risk
Services' expenses or utilization will neither be collected from PPG by AHI nor offset against
PPG Capitation: provided however, that AHI shall not be restricted from (i) offsetting such
deficits against payments to PPG including but not limited to, surpluses from other shared risk
programs, stop loss payments, bonus or other incentive program payments; (ii) establishing
reasonable withholds from Capitation approved by DMHC as set forth in the applicable
Addendum to offset PPG liability when the cost of Shared Risk Services exceed the Shared Risk
Budget (Withhold Fund): or (iii) carrying forward such shared risk program deficits to be applied
against future year's program surpluses and Withhold Fund Each PPG numbered site shall be
calculatEd as a separate entity and any payments to or from PPG with multiple sites shall be net
amount duelowed from all sites. In no event shall PPG be required to make any cash payment to
AHI for any deficit in a shared risk program for institutional services
To the extent AHI identifies financial liabilities including overpayments owed to AHI by PPG
under this Agreement, the intent to collect such financial liabilities shall be communicated to PPG
Proof of such liabilities and the methodology used to make such determination shall be subject to
UCDD 2005 Amd doc
Effective January 1. 2005


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external actuarial review. with PPG bearing the cost of such review. No collection of such
liabilities shall occur until PPG has a reasonable opportunity to conduct such review. provided that
such review occurs within ten (10) business days of communication to PPG by AHI
Concurrently, to the extent that PPG identifies financial liabilities owed to PPG by AHI under this
Agreement the intent to collect such financial liabilities shall be communicated to AHI. Proof of
such liability, and the methodology used to make such determination shall be subject to external
actuarial review, with AHI bearing the cost of such review No collection of such liability shall
occur until AHI has a reasonable opportunity to conduct such review. provided that such review
occurs within ten (10) days of communication to AHI by PPG
2.
Addendum B, Section B.I.I. Capitation Rates, is hereby deleted in its entirety and replaced with the
following:
1.1
Capitation Rates, PPG Capitation for Standard HMO Members shall be determined on a
monthly basis by multiplying the following normalized PMPM rates by the age, sex and benefit
plan factors set forth in Addendum B for each assigned Member Normalized rates represent the
PMPM prior to the adjustment for PPG's assigned Members' age, sex and benefit plan. Actual
PPG gross Capitation shall fluctuate from month to month to the extent that PPG's age, sex and
benefit plan mix fluctuates
-------Table Start--------
[["Effective Period","Standard HMO"],["January 1. 2005","$75.15 PMPM"]]
-------Table End--------
3.
Addendum B. Section C.1.1. Capitation Rates, is hereby deleted in its entirety and replaced with the
following:
1.1
Capitation Rates, PPG Capitation for Small Group HMO Members shall be determined
on a monthly basis by multiplying the following normalized PMPM rates by the age, sex and
benefit plan factors set forth in Addendum B for each assigned Member Normalized PMPM rates
represent the PMPM prior to the adjustment for PPG's assigned Members' age, sex and benefit
plan. Actual PPG gross Capitation shall fluctuate from month to month to the extent that PPG's
age, sex and benefit plan mix fluctuates
-------Table Start--------
[["Effective Period","Small Group HMO"],["January 1, 2005","$67.59 PMPM"]]
-------Table End--------
4.
Addendum C. Section B.2.1, Compensation for PPG Capitated Services is deleted and replaced with the
following:
2.1
Compensation for PPG Capitated Services. As compensation for rendering PPG
Capitated Services as defined herein, HMO shall pay PPG Capitation at forty one and fifty eight
hundreds percent (41.58%) of Monthly Revenue as set forth below for each Medicare HMO Member
eligible to receive such services from PPG during any particular month
Capitation shall be computed on the basis of the most current information available and shall be
paid by HMO by wire transfer on or before the fifteenth (15th) day of each month or the first
business day following the fifteenth if the fifteenth is a holiday or on a weekend or within two (2)
days of CMS's payment to HMO: whichever is later. Each Capitation payment shall be
accompanied by a remittance summary. The remittance summary identifies the total Capitation
payable and those Medicare HMO Members for whom Capitation is being paid. In the event of a
Capitation error, resulting in an overpayment or underpayment to PPG, HMO shall adjust
subsequent Capitation to offset such error.
UCDD Amendment 1/1/05
2


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Per PPG's request and upon receipt of reconciliation report from PPG, AHI agrees to reevaluate
the withhold amount of $1.57 PMPM for the mental health and substance abuse services as set
forth in section 6 of this Amendment for the period of January 1. 2005-December 31,2005. Based
upon audit result AHI will adjust the capitation accordingly to ensure that the equivalent withhold
against Monthly Revenue does not exceed $1.57 PMPM for this period only.
AHI agrees to offer PPG's participating providers for Mental Health and substance abuse services
and will make best effort to direct Medicare HMO members to these providers.
5.
Addendum C. Section B.3.1. Shared Risk Budget is deleted in its entirety and is replaced with the
following>
3.1
Shared Risk Budget. At the final settlement upon the event of a deficit, as a
contingency for any PPG liability. HMO shall deduct two percent (2 %) of PPG's Capitation and
place such amount in the Withhold Fund as described in this Agreement Each month, HMO shall
fund the Shared Risk Budget for each eligible Medicare HMO Member at forty-three and forty
three hundredths percent (43.43%) of Monthly Revenue
6
Addendum C.2. DIVISION OF FINANCIAL RESPONSIBILITY MATRIX OF HMO AND PPG
CAPITATED SERVICES MEDICARE BENEFIT PROGRAM of the Agreement shall be amended only for the
following Service categories as indicated below:
-------Table Start--------
[["","PPG CAPITATED SERVICES","HMO RISK SERVICES","SHARED RISK/HOSPITAL CAPITATED SERVICES"],["CHEMICAL DEPENDENCE","","",""],["(Rehabilitation Services)","","",""],["MENTAL HEALTH - Inpatient","","",""],["MENTAL HEALTH - Outpatient","","",""]]
-------Table End--------
7.
Addendum E is deleted in its entirety and is replaced with a new Addendum E attached
8.
Addendum F.1 Fee-For-Service Compensation Schedule is amended by adding the following:
Injectables As to injectables for which HMO is responsible for reimbursement, HMO shall
compensate PPG at one hundred ten percent (110%) of the State of California Medi-Cal Fee
Schedule rates in effect at the time of service If such medication is not listed on the Medi-Cal Fee
Schedule, the value will be determined by the Average Wholesale Price (AWP) as calculated by
HNI in accordance with the Medi-Cal methodology
Such rates shall be payment-in-full, except for applicable copayments HMO shall reimburse PPG
at such rates, less applicable copayment HMO shall not be responsible for reimbursing the
Member Physicians for such injectables PPG shall seek reimbursement from HMO for such
injectables and shall submit claims for such services to HMO using the CMS 1500 Form and the
appropriate CPT-4, HCPCS and NDC codes
UCDD Amendment 1/1/05


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9.
AHI I shall pay PPG eighty-five thousand dollars ($85,000) as a lump sum payment for PPG to use to fund
a
twenty four month e-visit program with Relay Health ("E-Visit Program"). PPG shall use such monies to implement
the E-Visit Program for Commercial Members from January 1; 2005 through December 31 2006. PPG shall provide
information regarding the usage and benefits of the E-Visit Program to AHI upon request. In the event that PPG and
Relay Health do not execute am agreement by July 1, 2005, PPG shall pay AHI eighty-five thousand dollars,
($85,000) within thirty (30) days of such date
In consideration for all of the payment terms set forth herein, including but not limited to the increase in the
Commercial rates, PPG understands and agrees that HNI shall he the exclusive Medicare Advantage payor
contracted with Provider, for any and all Medicare Advantage products including, but not limited to. HMO products.
PPO products or demonstration projects, from January 1, 2005 through December 31. 2006.
10.
Except as otherwise provided in this Amendment all other terms and conditions of the Agreement remain
unchanged and is full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this Amendment on the dates indicated below.
UDCC Medical Group
Signature
Tom Pete
CFO. UDCC Health Sciences
1/20/05
Date
All Health, Inc. Affiliates
Peanth
Signature
Kinjal Dave
Network Management & Development Officer
2-2-05
Date
Provider Tax Identification Number 12-3456789
UDCC Amendment 1/1/05

This page has 2 signature.


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ADDENDUM E
FEE-FOR-FER-SERVICE COMPENSATION SCHEDULE
PPG or Member Physician shall be compensated for non-capitated Contracted Services, less applicable Copayments, in
an amount equal to the lesser of (a) one hundred ten percent (110%) of the Medicare allowable charges based on the
Medicare Resource Based Relative Value Scale (RBRVS) unit values and CMS Geographical Practice Cost Indices as
published in the most current published edition of the Federal Register: or (b) seventy-five percent (75%) of PPG's
allowable billed charges
For "by report".procedures procedures not listed. or procedures with relativities not established in RBRVS, PPG shall
be compensated at sixty percent (60%) of PPG or the Participating Provider's billed charges. less any applicable
Copayment
Injectables and HMO Designated Vendor As to injectables for which HMO is responsible for reimbursement
PPG shall obtain such injectables from the HMO designated vendors as described in the Operations Manual If such
injectables are not available from the HMO designated vendor, PPG shall be compensated at the lesser of: a) the
PPG's billed charges b) the CMS Single Drug Pricer c) the Average Wholesale Price (AWP) as established by First
Databank, Medispan. MDX and as reflected in HMO's database which is updated semi-annually, less ten percent
(10%); or d) the lowest acquisition cost provided through services made available by HMO AWP reimbursement is
based on the lowest AWP for the specific antigen. Multi-dose vials shall be reimbursed on a per dose basis
Assistant Surgeons
PPG or Participating Provider shall be compensated for Contracted Services at twenty percent (20%) of the surgeon's
reimbursement as determined above
For Obstetrical Care:
Compensation for obstetrical services shall be at the lesser of the PPG's billed charges, or
-------Table Start--------
[["CPT 59400-Global Obstetric care with vaginal delivery","$1700.00"],["CPT 59510 Global Obstetric care with Cesarean delivery","$1700.00"]]
-------Table End--------
For Anesthesiology Services:
PPG shall be compensated for anesthesiology services which are Covered Services at the lesser of (a) $34. 00 per unit
value in accordance with the American Society of Anesthesiology (ASA) unit scale, or (b) 75% of the PPG's usual
billed charges
OB Epidural shall be compensated under the unit value conversion factor stated above for Anesthesiology and applied
to the ASA Base Units and Time Units as set forth below:
BASE UNITS:
-------Table Start--------
[["00955 - Continuous epidural, labor and vaginal delivery","5 units"],["00857 - Continuous epidural, labor and C-Section","7 units"],["00850 - Planned C-Section","7 units"]]
-------Table End--------
TIME UNITS
Start up time:
up to three units for first hour of labor time plus
Labor time:
two units for each additional hour of labor, plus
Surgery time:
one unit for each fifteen minute interval of surgical time if labor goes
into C-Section or of planned C-Section
CONFIDENTIAL PROPRIETARY AND TRADE SECRET
UCDD Amendment 1/1/05
.5.