query-orchestration/assets/sampleOne/hn_24-83.txt

Document Index
06/15/2016 04:18 FAX   1
002/003   1
06/30/2016 23:54 FAX   2
003/005   2
BENEFIT PROGRAMS AND AFFILIATES   2
I.   2BENEFIT PROGRAMS   2
II. Affiliates.   2
ADDENDUM B   3
PREFFERRED PROVIDER ORGANIZATION (PPO)   3EXCLUSIVE PROVIDER ORGANIZATION (EPO)   3BENEFIT PROGRAMS   3Fee For Service Compensation Schedule   3
Compensation for Covered Services:   3
For Anesthesiology Services:   3



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002/003
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the effective date set forth on this
signature page.
All Health Inc. Affiliates
PHYSICIAN
Smith
Leslie K. Meser
(PRINT NAME)
Mashi 6.00m
All Health
Signature
Signature
Effective Date
11/19/04
Date
Physician Specialty
Internal Medicine
Physician Federal Tax Identification Number:
123-45-6789
Primary Office
Address:
456 Oak Avenue, Greenville County,
CA, 92222
Billing Address:
some
Telephone Number: 123-456-7890
Facsimile Number: 123-456-7890
Medicare Certified:
YES
NO
CHDP Certified:
YES
NO
Medical License # B99999
K00001
UPIN #
PPO/EPO I
All Products April 2004
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This page has 2 signature.

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ADDENDUM A
BENEFIT PROGRAMS AND AFFILIATES
I.
BENEFIT PROGRAMS
Benefit Program participation included under this Agreement is as follows:
II. Affiliates.
Upon execution of this Agreement, the Affiliates primarily using this Agreement include, but are
not limited to, the following: All Health of California, Inc; All Health Life Insurance Company;
Health Foundation Systems Life and Health Insurance Company: All Health Federal Services;
FFD Managed Care Services, Inc.; FFD Claims Services, Inc. The Affiliates are defined in
Section 1.1 of this Agreement.
Notwithstanding the foregoing, Physician agrees that any other Affiliate of HNI not listed above may access
the rates set forth in this Agreement and Addenda. This would include Members of non-California based affiliates
who may be treated by Physician.
PPO/EPO
All Products April 2004
14


-------Table Start--------
c832aecc-a2f3-4c61-a810-271937dabb25
[['BENEFIT PROGRAM', 'ADDENDUM', 'Physician PARTICIPATION Yes/No', 'Effective Date of Benefit Program'], ['PPO/EPO', 'B', 'Yes', 'Upon Execution of Agreement'], ['Commercial HMO/ Commercial POS', 'C', 'Yes -', 'Upon Written Notice from HNI'], ['Medicare HM0/ Medicare POS Medicare Select', 'C', 'Yes', 'Upon Written Notice From HNI'], ['Medi-Cal', 'D', 'Yes', 'Upon Written Notice from HNI'], ['CHAMPUS/TRICARE', 'E', 'NA', 'NA'], ['Occupational Medicine', 'F', 'Yes', 'Upon Written Notice from HNI'], ['Healthy Families', 'G', 'Yes', 'Upon Written Notice from HNI']]
 Benefit Program participation included under this Agreement is as follows:
-------Table End--------

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ADDENDUM B
PREFFERRED PROVIDER ORGANIZATION (PPO)
EXCLUSIVE PROVIDER ORGANIZATION (EPO)
BENEFIT PROGRAMS
Fee For Service Compensation Schedule
This Addendum shall take effect on the Effective Date set forth on the signature page of this Agreement.
Compensation for Covered Services:
Compensation shall be based on the Resource Based Relative Value Scale (RBRVS), the Conversion Factors (CF) and
the Geographic Practice Cost Indices (GPCI) adjustment factors promulgated by the Centers for Medicare and Medicaid
Services (CMS).
Physician shall be compensated for Covered Services in an amount, less applicable Copayments and/or coinsurance, that
is equal to the lesser of: (a) 90% of the HCFA participating provider fee schedule for Physician's locality, or (b) for "by
report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75%
of billed charges not to exceed usual, reasonable and customary charges, or (c) Physicians usual billed charges.
Medications: Medications provided or administered by Physician shall be billed using HCPC codes if
available and shall be compensated at the lesser of (a) 90% of the HCFA participating provider fee schedule
for Physician's locality, or (b) for medications for which a HCPC code has not been established Physician shall
bill using the NDC code, drug and manufacturer name and shall be compensated at the Average Wholesale
Price, or (c) Physician's billed charge amount not to exceed usual, reasonable and customary charges.
Immunizations: Immunization administered by Physician shall be billed using CPT-4 codes and shall be
compensated at the lesser of a) the Physician's billed charges, or b) the Average Wholesale Price (AWP) as
established by MediSpan less ten percent (10%). This AWP fee schedule is reviewed and subject to
adjustment on a semi annual basis.
Laboratory Procedures: Compensation for laboratory procedures provided and administered by Physician
shall be at the lesser of 90% of the HCFA participating provider fee schedule for Physician locality, or
Physician's usual billed charge amount not to exceed usual, reasonable and customary charges.
For Obstetrical Care: Compensation for obstetrical services shall be at the lesser of the Physician's billed charges, or:
CPT 59400-Global Obstetric care with vaginal delivery.
$1700.00
CPT 59510-Global Obstetric care with Cesarean delivery
$1700.00
For Anesthesiology Services:
Physician shall be compensated for anesthesiology services which are Covered Services at the lesser of (a) $39.00 per
unit value in accordance with the American Society of Anesthesiology (ASA) unit scale, or (b) 75% of the Physician's
usual billed charges.
PPO/EPO
All Products April 2004
15