query-orchestration/assets/sampleOne/chc_1.txt

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Sample Company Name, Inc.
ANCILLARY AGREEMENT
This Agreement is entered into and effective as of the date shown on the signature page ("Effective
Date"), by and between Sample Company Name, Inc
a Texas non-profit 501(c)(4) corporation licensed by
the Texas Department of Insurance as a health maintenance organization in the State of Texas and its Affiliates
(collectively "Community") and ABC Center
("Contracted Provider").
(Legal Name and DBA as a appears on W-9)
WITNESSETH:
WHEREAS, Community has its certificate of authority to operate as a health maintenance organization
under Chapter 843 of the Texas insurance Code, as amended;
WHEREAS, Contracted Provider is licensed or otherwise authorized to provide a health care service in
this State, and qualified to provide Covered Services and
WHEREAS, Community wishes to enter into an agreement with Contracted Provider to provide or arrange
for the provision of Covered Services to Members, and Contracted Provider wishes to enter into an agreement with
Community to provide or arrange for the provision of Covered Services to Members
NOW, THEREFORE for and in consideration of the premises and the mutual covenants and agreements
herein contained it is understood and agreed by and between the parties hereto as follows:
SECTION 1 - DEFINITIONS
Many words and terms are capitalized throughout this Agreement to indicate that they are defined as set forth in this
Section 1.
1.1
Accreditation Organization Any organization including but not limited to, URAC. the National
Committee for Quality Assurance ("NCQA") or the Joint Commission engaged in accrediting or certifying
Community or any Participating Provider
1.2
Affiliate A corporation partnership or other legal entity (including without limitation any Payor)
directly or indirectly owned or controlled by, or which owns or controls, or which is under common ownership or
control with Community.
1.3
Benefit Plan/Program A certificate of coverage, summary plan description, or other document or
program under which Community or other Payor undertakes to provide arrange for, pay for, or reimburse any part
of the cost of health care services for eligible Members Community may also enter into administrative agreements
with other Payors, governmental, public or private employers, or other entities to provide administrative services
related to providing, arranging for, paying for or reimbursing for the cost of health care services, including self-funded
employer sponsored plans. Benefit Plan/Program will include self-funded employee benefit plans for which
Community provides administrative services.
1.4
Billed Charges. The usual and customary fee charged by Provider that does not exceed the fee
Provider would ordinarily charge regardless of expected payment source
1.5
Capitation A method of compensating a Provider for arranging for or providing a defined set of
covered health care services to certain enrollees for a specified period that is based on a predetermined payment
per enrollee for the specified period, without regard to the quantity of services actually provided.
1.6 CMS The federal agency, Center for Medicare and Medicaid Services, responsible for
administering the Medicare, Medicaid and Children Health Insurance Programs.


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1.7
Clean Claim. An electronic claim or paper claim for payment for services that meets the Texas
and/or federal statutory and regulatory requirements for "clean claim."
1.8
Community Protocols. The rules, procedures, policies, protocols, and other conditions to be followed
by Participating Physicians, Providers and Members with respect to providing Covered Services under a particular
Benefit Plan/Program generally defined in Community's Provider Manual
1.9
Coinsurance A component of Member Expense, generally reflected as a percentage, in an
amount identified in Member's Benefit Plan/Program paid to a Provider or a Physician for Covered Services by
Member.
1.10 Copayment A component of Member Expense, generally reflected as a flat or fixed dollar amount
either per Covered Service or per encounter, identified in Member's Benefit Plan/Program and collected by
Provider or Physician at the time Member receives Covered Services
1.11 Coordination of Benefits. The allocation of financial responsibility between two or more Payors of
health care services, each with a legal duty to pay for or provide Covered Services to a Member at the same time.
1.12 Covered Services. The Medically Necessary health care services, products or supplies for which a
Member is entitled to receive coverage from Community or other Payor, pursuant to the terms of the Member's
Benefit Plan/Program
1.13 Deductible A component of Member Expense, generally reflected as fixed dollar amount during
a
specific benefit period, typically one year, identified in Member's Benefit Plan/Program; payable by a Member
prior to Community's or Payor's obligation to make payment for Covered Services Deductibles may apply to a
Member or to a Member's eligible dependents
1.14 Emergency Behavioral-Health Condition. Any condition, without regard to the nature or cause of the
condition, which requires immediate intervention and/or medical attention without which an individual would present
an immediate danger to himself/herself or others or which renders the individual incapable of controlling. knowing
or understanding the consequences of his/her actions.
1.15 Emergency Services. The health care services provided in a hospital emergency facility,
freestanding emergency medical facility or comparable facility to screen for emergency medical conditions and/or to
evaluate and stabilize medical conditions, including but not limited to severe pain, that would lead a prudent
layperson possessing an average knowledge of medicine in health to believe that the person's condition, sickness,
or injury is of such a nature that failure to get immediate medical care could result in: (1) placing the patient's health
in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part;
(4) serious disfigurement; (5) in the case of a pregnant woman, serious jeopardy to the health of the fetus; or (6) an
Emergency Behavioral Health Condition. in no event will "Emergency Services" be interpreted under this Agreement
so as to conflict with emergency service or emergency screening obligations under federal or State law.
1.16 Encounter Data. A record that sets forth those Covered Services a Provider or Healthcare
Professional renders to Members in accordance with the Member's Benefit Plan/Program and Community
Protocols.
1.17
Excluded Provider. A healthcare Provider that has been prohibited, debarred or excluded from
participation in a State or federal healthcare program by operation of law or an edict by a regulatory agency.
1.18
Excluded Services. Those health care services and supplies that are determined not to be Medically
Necessary or that otherwise are not Covered Services under a Member's Benefit Plan/Program.
1,19 Healthcare Professional. The Physicians, healthcare professionals, practitioners, and/or Providers
licensed and/or authorized under the laws of the State, who are employed by or contracted with Contracted Provider
to provide Covered Services under the terms of this Agreement.
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1.20 Medically Necessary/Medical Necessity. Those Covered Services that Community determines
under the applicable Utilization Management Program to be: (i) appropriate and necessary for the symptoms,
diagnosis, or treatment of a medical condition; (ii) provided for the diagnosis or direct care and treatment of a medical
condition; (iii) within standards of good medical practice within the organized medical community of the treating
provider including Texas Medicaid policies and procedures (where applicable) and the Texas Resilience and
Recovery model of service delivery; (iv) not primarily for the custodial convenience of the Member or the treating
provider; (v) consistent with sound medical policy, the Utilization Management Program, the Quality Improvement
Program, and the requirements of the Benefit Plan/Program under which the Covered Services are rendered; and
(vi) an appropriate and cost-effective service or supply consistent with generally accepted medical standards of care.
For inpatient stays, this means that acute care as an inpatient is necessary due to the kind of services the Member
is receiving or the severity of the Member's condition, and that safe, cost-effective, and adequate care cannot be
received as an outpatient or in a less acute, alternative medical setting.
1.21
Member. A person who is eligible for and enrolled in a covered Benefit Plan/Program.
1.22
Member Expense. The out-of-pocket expense, or cost-sharing amounts, such as Copayments,
Coinsurance or deductibles, a Member must pay to a Physician or Provider for Covered Services, identified in
the Member's Benefit Plan/Program,
1.23 Participating Physician. A Physician with a direct or indirect contractual relationship with
Community to provide certain Covered Services to Members.
1.24
Participating Provider. A Provider with a direct or indirect contractual relationship with Community
or another Payor to provide certain Covered Services.
1.25 Payor. Community, or any other public or private entity (including, but not limited to, the federal
government, the State, employers, insurance carriers, self-funded plans, associations, trust funds, and health
maintenance organizations), which provides, administers, funds, insures, or is responsible for paying Participating
Physicians or Participating Providers for Covered Services rendered to Members.
1,26 Physician. Physician is an individual licensed to practice medicine in this State; a professional
association organized under the Texas Professional Association Act (Article 1528f, Vernon's Texas Civil Statutes);
an approved nonprofit health corporation certified under Chapter 162, Occupations Code; a medical school or
medical and dental unit, as defined or described by Section 61.003, 61.501, or 74.601, Education Code, that
employs or contracts with physicians to teach or provide medical services or employs physicians and contracts with
physicians in a practice plan; or another person wholly owned by physicians that is qualified to provide or arrange
for the provision of primary care and/or specialty care professional services.
1,27
Primary Care Physician (PCP). A Physician who (i) is contracted with Community; (ii) holds an
unrestricted license to practice allopathic or osteopathic medicine in the State of Texas; (iii) (a) is engaged primarily
in family practice, general practice, geriatrics, internal medicine, pediatrics, obstetrics/gynecology, (b) is a Specialty
Care Physician who at the request of a Member with a chronic, disabling or life-threatening illness and, upon the
approval of Community, has agreed to accept the coordination of all of the Member's health care needs, or (c) is an
Advanced Practice Nurse (APNs) or physician assistant who practices under the supervision of a Physician
specializing in family practice, internal medicine, pediatrics or obstetrics/gynecology who also qualifies as a PCP,
Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or similar community clinics; and (iv)
is responsible pursuant to the applicable Benefit Plan/Program for coordinating and managing the delivery of
Covered Services to Members selected or assigned to such PCP,
1,28
Prior Authorization. The written or confirmed electronic determination by the Community, a Payor or
other permitted person or entity that health care services proposed to be provided by a Physician or Provider are
medically necessary and appropriate before such services are provided.
1.29 Provider. A person or entity, other than a Physician, who is licensed or otherwise authorized to
provide a health care service in this State, including, but not limited to: (i) a chiropractor, registered nurse,
pharmacist, optometrist, registered optician, or acupuncturist; or (ii) a pharmacy, hospital, or other institution or
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organization; a person who is wholly owned or controlled by a provider or by a group of providers who are
licensed or otherwise authorized to provide the same health care service; or a person who is wholly owned or
controlled by one or more hospitals and physicians, including a physician-hospital organization.
1.30 Provider Manual. The Community document, incorporated in its entirety by this reference,
containing administrative policies and procedures relating to issues such as credentialing, utilization
management, claims payment, provider complaints or appeals and quality improvement.
1.31
Quality Improvement Program. The functions including, but not limited to, credentialing and
certification of providers, review and audit of medical and other records, clinical outcomes, peer review, and provider
appeals and grievance procedures performed or required by Community, or any other permitted person or entity, to
review the quality of Covered Services rendered to Members.
1,32 Referral. Consultation for evaluation and/or treatment of a Member, requested by one Physician or
Provider to another Physician or Provider, usually for a specified number of visits, treatments or period of time.
1.33
Specialty Care Physician. A Physician who (i) is a Participating Physician: (ii) holds an unrestricted
license to practice allopathic or osteopathic medicine in the State of Texas; (iii) is engaged in a specialty medical
practice; (iv) accepts Referrals from Primary Care Physicians for the purpose of providing Covered Services to
Members in the Specialty Care Physician's designated specialty; and (v) is not a Specialty Care Physician who
meets the criteria of Section 1.27 above.
1.34
State. The State of Texas.
1.35 TDI. The Texas Department of Insurance,
1.36
Utilization Management Program. A system of prospective, concurrent or retrospective review of the
medical necessity and appropriateness of health care services and a system for prospective, concurrent, or
retrospective review to determine the experimental or investigational nature of health care services. The term does
not include a review in response to an elective request for clarification of coverage or information regarding Member
eligibility.
SECTION 2 - OBLIGATIONS OF COMMUNITY
2.1
Marketing. Contracted Provider acknowledges that Community shall market or arrange for the
marketing of its Benefit Plans/Programs as well as Contracted Provider's and its Healthcare Professional's
participation in such Benefit Plans/Programs
2.2
Timely Assignment of Members. Community shall require a Member to select a specified
Participating Primary Care Physician or Participating Primary Care Provider at the time of enrollment. In the event
a Member does not select a Participating Primary Care Physician or Participating Primary Care Provider within sixty
(60) days, Community shall automatically assign the Member. Upon automatic assignment of a Participating
Primary Care Physician or Participating Primary Care Provider, the Member may change to another Participating
Primary Care Physician or Participating Primary Care Provider.
2.3
Member Volume. Contracted Provider understands that no guarantees are afforded by Community
as to the number of Members who enroll in Community's Benefit Plans/Programs. Community does not, by this
Agreement or otherwise, promise, warrant or guarantee that any minimum number of Members will select or be
assigned to Contracted Provider or Healthcare Professional.
2.4
Identification Cards. For each Member, Community shall issue, or shall ensure the issuance, of a
Member identification card or similar item setting forth, at a minimum, the Member's name, the Member's unique
identification number, the first date on which the Member became enrolled or the toll-free number a Physician or
Provider can use to obtain the date, and the Member's Primary Care Physician or Primary Care Provider.
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2.5
Regulatory Compliance. Community agrees that it shall comply with all applicable requirements of
State and federal authorities, all municipal ordinances and regulations, and all State and federal statutes and
regulations now or hereafter in force and effect which bear upon the subject matter of this Agreement.
SECTION 3 - OBLIGATIONS OF PROVIDER
3.1
Changes in Contracted Provider Information. Contracted Provider shall provide Community thirty
(30) calendar days advanced written notice of any of the following changes, as applicable to Contracted Provider or
any Healthcare Professional rendering services under the terms of this Agreement:
a.
termination of any Healthcare Professional from Contracted Provider's office;
b.
the addition of any Healthcare Professional to Contracted Provider's office;
C.
the addition of another Covered Service after the Effective Date of this Agreement to be
provided to Members by Contracted Provider and;
d.
the discontinuation of delivery of any Covered Service currently offered as of the Effective
Date of this Agreement, which thereby results in Members having to receive such Covered
Services from another non-Participating Provider or Participating Provider;
e.
any change in address(es) or contact information where Contracted Provider renders
Covered Services, including the addition or closure of a location;
f.
any change in billing information, including but not limited to, a. change in Contracted
Provider's legal structure, payment remit address, or change in Tax Identification Number;
g.
any change in other demographic or information necessary to ensure access and availability
of Covered Services to Member by Contracted Provider or that may be required for
Community to meet Community's obligations defined in this Agreement.
Contracted Provider acknowledges that the addition of any Healthcare Professional shall be subject to
Community's credentialing policies and payment guidelines defined herein and in accordance with Section 5.14.
Contracted Provider further acknowledges that if any fines or sanctions are levied against Community by
applicable State or federal agencies or are imposed by Community resulting from non-compliance by Contracted
Provider of this Section 3.1, Community shall have the right to withhold from future payments to Contracted Provider:
(a) the entire amount of such fine or sanction if Contracted Provider is the sole cause of such a fine or sanction
levied or imposed; or (b) a pro rata share of such fine or sanction amount if Contracted Provider is not the sole cause
of the fine or sanction levied or imposed.
3.2
Authority. Contracted Provider attests that it has the authority to bind all Healthcare Professionals
rendering Covered Services under the terms of this Agreement to the obligations defined herein. Further,
Contracted Provider represents that the terms of this Agreement do not conflict with the terms of its agreements with
Healthcare Professionals and that the terms of this Agreement shall control and apply in any situation where there
is an inconsistency or conflict with the terms such agreements or with respect to any matter that is not addressed in
any such agreements. Contracted Provider shall be responsible to Community for any such inconsistency or conflict
in terms. This provision shall supersede any similar provision in any agreement between Contracted Provider and
Healthcare Professionals, Upon request, Contracted Provider agrees to forward to Community: (i) a copy of any
template contracts Contracted Provider maintains with Healthcare Professionals, (ii) a copy of any written policy and
procedure pursuant to such agreements, (iii) Contracted Provider's bylaws and Articles of Incorporation, as well as,
(iv) any subsequent modifications thereto. Contracted Provider will notify Healthcare Professionals of their rights
and duties under this Agreement, and of all amendments, exhibits, and modifications thereto. Contracted Provider
is responsible for the compliance of its Healthcare Professionals of all the terms and conditions in this Agreement.
References to "Contracted Provider" also include Healthcare Professionals.
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3.3
Contracted Provider Representations and Warranties. Contracted Provider represents and warrants
that Contracted Provider and Healthcare Professionals, now and for the duration of this Agreement shall remain: (i)
in compliance with all laws and licensing requirements applicable to serviced rendered, (ii) accredited by The Joint
Commission, or similar state or nationally recognized Accreditation Organization (where applicable), and (iii) a
Medicare certified provider under the Federal Medicare Program and a Medicaid provider under applicable State
and federal law. Contracted Provider warrants that all employees of Contracted Provider and Healthcare
Professionals will perform their duties in accordance with all applicable local, State, and federal licensing
requirements, as well as applicable national, State, and county, and local standards of professional ethics and
practices. Evidence of satisfaction of the requirements set forth in this Section 3,3 shall be submitted to Community
upon request.
3.4
Services Rendered by Excluded Providers. Contracted Provider warrants that neither Contracted
Provider nor any Healthcare Professional is, or has ever been, an Excluded Provider. Contracted Provider agrees
to assure that Contracted Provider and its Healthcare Professionals shall refrain from the provision of any
Covered Services to a Member if said Contracted Provider or Healthcare Professional becomes an Excluded
Provider. Notwithstanding any provision to the contrary, Contracted Provider understands and agrees that
Contracted Provider and/or its Healthcare Professionals shall not bill and Payor shall not pay for any services or
goods furnished under this Agreement by an Excluded Provider.
3.5
Eligibility. Except where Emergency Services, including screening for emergency medical
conditions, are required, Contracted Provider shall verify Member's eligibility for the services requested prior to the
rendering of such services. Community shall make reasonable business efforts to timely confirm the eligibility of
any Member when such is in question. Contracted Provider recognizes that a Member's eligibility may retroactively
change, which may change Community's responsibility for payment. If Community makes payment to Contracted
Provider and retroactively discovers a change in the Member's eligibility, Community may adjust or recoup such
payment in accordance with Section 5,5 of this Agreement.
3,6
Provision of Services. Contracted Provider, for itself and on behalf of its Healthcare Professionals,
agrees to render Covered Services to Members in accordance with: (i) the terms and conditions of this Agreement
and the applicable Benefit Plan/Program; (ii) all laws, rules, and regulations applicable to Contracted Provider and
its Healthcare Professionals; (iii) the Utilization Management Program, Quality Improvement Program, Community
Protocols, and grievance, appeals, and other policies and procedures of the particular Benefit Plan/Program under
which the Covered Services are rendered; (iv) at least the minimum clinical quality of care and performance
standards that are professionally recognized and/or adopted, accepted, or established by Community; (v) the
customary rules of ethics and conduct of applicable State and professional licensure boards and agencies; and (vi)
the prevailing standards of care of similar providers in the same community.
3.7
Non-Discrimination. Except as necessitated by Member's medical condition, Contracted Provider
agrees not to differentiate or discriminate in the treatment of Members. Provider further agrees to provide
Covered Services to Members in accordance with the same standards and within the same time availability as
provided to Contracted Provider's other patients. Contracted Provider agrees not to discriminate against
Members on the basis of race, color, national origin, gender, sexual orientation, age, religion, marital status,
health status or health insurance coverage. Contracted Provider and/or Healthcare Professional shall treat
Members promptly, fairly, and courteously.
3.8
Ancillary Services. Contracted Provider agrees: (i) to provide to Members Covered Services within
the
scope of its licensure, expertise, and usual and customary range of facilities and/or personnel, and (ii) as
applicable, to provide Members with access 24 hour-per-day, 7 days-per-week.
3,9
Subcontracting. Contracted Provider shall not subcontract for the performance of Covered Services
under this Agreement without the prior written consent of Community.
3.10 Prior Authorization and Referrals, When required under a Benefit Plan/Program, Community or
applicable Payor protocols, or the Utilization Management Program, Contracted Provider agrees to obtain Prior
Authorization or Referral in advance of providing Covered Services, except for Emergency Services. Contracted
Provider acknowledges that failure to obtain required Prior Authorization or Referral will impact Contracted Provider's
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compensation for said Covered Services. For a situation involving Emergency Services, Contracted Provider agrees
to ensure that Community or Payor is notified as soon as possible, but no later than twenty-four (24) hours after the
provision of Covered Services or the ordering of the other Covered Services, or on the next business day.
3.11
Referrals to Non-Participating Providers. Referral to a non-Participating Physician or non-
Participating Provider requires Prior Authorization.
3.12 Certification and Regulatory Compliances. Contracted Provider and its Healthcare Professionals
shall, at all times during the term of this Agreement, satisfy all State and federal certifications, regulations, or
licensure requirements and shall render Covered Services under this Agreement in compliance with all applicable
statutes, regulations, standards, rules, and directives of State, federal, and other governmental and regulatory
bodies having jurisdiction over Contracted Provider. Evidence of such licensing, if applicable, shall be submitted
to
Community upon request. Contracted Provider agrees to give immediate notice to Community in the case of a
disciplinary action, modification, limitation, suspension or revocation, or initiation of any proceeding that could result
in a disciplinary action, modification, limitation, suspension or revocation. of such licensure.
3,13 Non-Participating Provider. Contracted Provider agrees to notify Community within twenty-four (24)
hours if Contracted Provider has knowledge that a non-Participating Provider is rendering Covered Services to a
Member in a situation involving Emergency Services.
3.14
New or Additional Benefit Plans/Programs. Contracted Provider acknowledges that Community may
administer and/or offer new or additional Benefit Plans/Programs, and Contracted Provider, if requested by
Community, agrees to negotiate with Community in good faith to amend this Agreement to include such new or
additional Benefit Plans/Programs,
3,15
Payment of Applicable Taxes. Subject to the provisions of Section 5,10 ("No Surcharges") hereof,
Contracted Provider shall be solely responsible for the payment of any sales, use, or other applicable taxes on the
sale or delivery of medical services.
3.16
Adherence to Community Protocols. Contracted Provider shall comply with all Community Protocols
without limitation, notification and Prior Authorizations as may be required for (i) medical services, hospital
admissions, and elective outpatient diagnostic or procedural Covered Services; (ii) concurrent and retrospective
review; and (iii) Referral procedures; provided, however, in no event shall such policies and procedures be less than
the standard of care for the provision of medical services to patients in the geographic area where medical services
are being provided by Contracted Provider hereunder. Nothing in this Section 3.16, however, shall be construed to
authorize Community or any of Community's officers or employees to exercise any control over the practice of
medicine by Contracted Provider or the manner in which Contracted Providers provide medical services. Contracted
Provider acknowledges that Community may consider the failure of Contracted Provider or Healthcare Professional
to abide by Benefit Plan/Program, Community Protocols, and/or Utilization Management Program a material breach
of Agreement subject to termination as defined in Section 10.3.
3.17
Electronic
Connectivity.
Contracted Provider agrees to communicate with Community
electronically according to standard HIPAA transactions, including, but not limited to, verification of eligibility,
claims status check, electronic claims submission, electronic payment remittance advice, and electronic funds
transfer. In the event of a system(s) failure or a catastrophic event that substantially interferes with the Contracted
Provider's business operations, Contracted Provider may submit paper claims to Community at the address in
the signature block below with "Attention to Technical Support Manager" for the days during which a substantial
interference with business operations occurs as a result of the catastrophic event or systems failure. Contracted
Provider shall provide written notice of Contracted Provider's intent to submit non-electronic claims to Community
within five (5) calendar days of the catastrophic event or systems failure. Contracted Provider may request that
Community waive this requirement to communicate electronically under circumstances in which: no method is
available for the submission of claims in electronic form; there would be undue hardship, including fiscal or
operational hardship; or any other special circumstance that would justify a waiver. Community in its sole
discretion will determine whether to agree to waive the requirement.
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3.18
Credentialing of Contracted Provider and/or Healthcare Professional, Contracted Provider shall
submit to Community a credentials application, as modified from time to time by Community, TDI or other regulatory
entity (as applicable), the current form of which will be provided by Community upon request. Contracted Provider
shall be responsible for completing the credentials application in its entirety for Contracted Provider and every
Healthcare Professional rendering Covered Services to Members. In no event will this Agreement become effective,
non will Contracted Provider or Healthcare Professional render Covered Services to a Member until Contracted
Provider's or Healthcare Professionals' credential applications have been accepted and approved in writing by
Community; provided, however, this Agreement may be executed prior to acceptance by Community of all
Healthcare Professionals' credential applications.
3,19 Access to Premises. Contracted Provider agrees to permit Community and any Payor, or their
designated representatives, and the designated representatives of State and federal regulatory agencies having
jurisdiction over Community, Payor, or any Benefit Plan/Program, to conduct site evaluations and inspections of
Contracted Provider's offices and service locations as necessary under applicable laws, rules, or regulations or as
may be needed to assure quality of care rendered to Members. In the event the right of access is requested under
this Section 3.19, Contracted Provider shall, upon request, provide and make available its staff to assist in the audit
or inspection effort, and provide adequate space on the premises to reasonably accommodate the State or federal
personnel conducting the audit or inspection effort. All inspections or audits shall be conducted in a manner that will
not unduly interfere with the performance of Contracted Provider's and its Healthcare Professionals" activities. All
information obtained during such audit or inspection shall be accorded confidential treatment as provided under
applicable law.
3.20 Complaint Resolution Notice. Contracted Provider shall post a notice, in Contracted Provider's office
or other location reasonably certain to be seen by all Members, of the process for resolving complaints with
Community, including the Texas Department of Insurance's toll-free telephone number for filing complaints.
3.21
Laboratory Compliance. If Contracted Provider performs clinical laboratory services, Contracted
Provider shall comply with all requirements of the Clinical Laboratory Improvement Act ("CLIA"), and implementing
regulations. Contracted Provider agrees to furnish written verification to Community that Contracted Provider's
laboratory(ies), if any, and those with which it conducts business related to Members have a CLIA certificate of
registration or a waiver, and CLIA identification number. Contracted Provider shall furnish, annually to Community,
a written list of diagnostic tests performed in its laboratory(ies), if any, and those with which it conducts business
related to Members. Contracted Provider shall notify Community of changes in the CLIA status of its laboratory(ies),
and those with which it conducts business related to Members, in writing within five (5) days of such changes.
3.22 Encounter Data Submission. If Contracted Provider's compensation is based on Capitation,
Contracted Provider must submit to Community, no later than the fifteenth (15th) day of each month, a record of
all Covered Services rendered during the prior month to each Member for which Contracted Provider receives
Capitation under this Agreement. Additionally, Contracted Provider shall promptly provide Community with all
corrections to and revisions of such Encounter Data. Contracted Provider shall submit such Encounter Data based
on Community's established requirements for Encounter Data submission.
3,23 Provider Manual. Contracted Provider shall comply with all policies and procedures identified in the
Provider Manual. Community reserves the right to revise the Provider Manual in its sole discretion from time to time.
Community will use best efforts to inform Provider at least ninety (90) calendar days prior to the effective date of
changes that materially affect the rights or responsibilities of Provider under this Agreement. Revisions to the
Provider Manual shall not constitute amendments to this Agreement for purposes of Section 11.10.
SECTION 4 - MAINTENANCE, RELEASE & ACCESS TO RECORDS
4.1
Administrative Records. Contracted Provider shall retain for a minimum of ten (10) years, or as
otherwise maybe required by law whichever is shorter, such financial, administrative, and other records as may be
necessary for compliance by Community and with other applicable local, State, and federal laws, rules, and
regulations. Contracted Provider shall make such records or documents available to Community, Payors and their
authorized agents, and appropriate representatives of any State and/or Federal regulatory agency during normal
business hours for review, inspection, and/or audit.
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4.2
Medical Records. Contracted Provider shall maintain a complete medical record for each Member
for which Contracted Provider or Healthcare Professional renders Covered Services hereunder. Such medical
records shall include the recording of a Contracted Provider's services and such other records as may be required
by law. Such records shall be maintained in accordance with all applicable present and future local, State, and
federal laws, rules, and regulations and shall be safeguarded against loss, destruction, and unauthorized use. All
medical records shall be treated as confidential so as to comply with all State and federal laws, rules, and regulations
regarding the confidentiality of patient records. Contracted Provider shall retain such medical records for a period
of ten (10) years following termination of this Agreement or as mandated by any applicable State or federal law.
4.3
Member Consent to Release of Medical Record Information. Contracted Provider will obtain
Member consent required in order to authorize Contracted Provider to provide access to the requested
information or records as contemplated in this Section 4 of this Agreement, including copies of the Contracted
Provider's medical records relating to the care provided to Member.
4.4
Access to Records, The records referred to in Section 4.2 above shall be and remain the property
of Contracted Provider and shall not be removed or transferred from Contracted Provider except in accordance with
applicable local, State or federal laws, rules, and regulations. Subject to applicable State or federal confidentiality
laws and pursuant to written authorization by Members, Community or its designated representative and any Payor
shall have access to Contracted Provider's office during normal business hours on request, to inspect, review, and
make copies of such records, Contracted Provider shall provide, at Contracted Provider's expense, copies of such
records to authorized representatives of local, State, or federal regulatory agencies. In no event, shall Contracted
Provider charge for records requested for payment of a claim. Notwithstanding the foregoing, but subject to
applicable local, State, or federal laws, rules, or regulations, in the event of (i) termination of this Agreement; (ii) the
selection by a Member of another Participating Provider in accordance with Benefit Plan/Program procedures; or
(iii) the approval by Community Protocols of Contacted Provider's request to transfer a Member to another
Participating Provider, Contracted Provider agrees to transfer copies of the Member's medical records, x-rays,
and/or other data to the Participating Provider when requested to do so by Community or Member, or at no charge
to the Member or Community or transferee Participating Provider.
4.5
Continuing Obligation. The obligations of Contracted Provider under this Section 4 shall not be
terminated upon termination or rescission of this Agreement. After termination of this Agreement, Community and
the applicable Payor shall continue to have access to Contracted Provider's records as necessary to fulfill the
requirements of this Agreement and to comply with all applicable present and future laws, rules, and regulations.
SECTION 5 - COMPENSATION
If applicable, attached regulatory Addendum(s) may supersede certain requirements of this Section, 5-
Compensation.
5.1
Claims Submission. In circumstances in which Contracted Provider is not paid Capitation,
Contracted Provider shall submit Clean Claims to Payor within ninety-five (95) calendar days of the provision of the
Covered Services. Failure to submit a Clean Claim within this 95-day period may result in non-payment. When
submitting Claims and/or Encounter Data to Payor, Contracted Provider shall: (i) use the most current coding
methodologies on all forms; (ii) abide by all applicable coding rules and associated guidelines, including without
limitation inclusive code sets; and (iii) in the event a code is formally retired or replaced, regardless of any
provision or term in this Agreement, discontinue use of such code and begin use of the new or replacement code
following the effective date published by the appropriate coding entity or government agency. Should Contracted
Provider submit claims using retired or replaced codes, Contracted Provider understands and agrees that Payor
may deny such claims until appropriately coded and resubmitted.
5.2
Adjudication of Claims. In circumstances in which Contracted Provider is not paid Capitation, Payor
shall adjudicate all Clean Claims submitted by Contracted Provider within forty-five (45) calendar days for claims
received by Contracted Provider vía non-electronic submission, and within thirty (30) calendar days for claims
received by Contracted Provider via electronic submission. When adjudicating Contracted Provider's claim(s),
Payor shall: (i) pay the total amount of the claim in accordance with Exhibit B; (II) notify Contracted Provider in
writing why the claim will not be paid; or (iii) pay the portion of the claim that is not in dispute and notify Contracted
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Provider in writing why the remaining portion of the claim was not paid. When medical information is requested to
support payment, Contracted Provider shall have twenty-one (21) calendar days to provide information to Payor.
Not later than fifteen (15) days following receipt of Contracted Provider's response to Payor's request for additional
information, Payor shall make a final adjudication decision. Payor will adjudicate all Clean Claims received in
according with the terms and conditions of this Agreement, Texas Insurance Code Section 843 and, TDI rules
promulgated thereto, governing claim payment for Covered Services provided under a health maintenance
organization's benefit plan, and/or federal laws, rules, and regulations and federal laws, rules and regulations
related to ERISA claims payment for self-funded plans or for Medicare Advantage plans, regarding timeliness of
claims payments.
5.3
Claims Coding/Editing Determinations. Payor shall utilize CMS, state Medicaid and/or other
nationally recognized claims and payment processing policies, procedures, and guidelines, which may include
claim and code audit and edit determinations and other claims logic as may be implemented by Payor. Upon
request by Contracted Provider, Payor shall forward to Contracted Provider a description and copy of Payor's
coding guidelines, including any underlying bundling, recoding, or other payment process and fee schedules
applicable to specific Covered Services rendered by Contracted Provider, Payor shall forward such coding
guidelines and fee schedules not later than the thirtieth (30th) day after receipt of Contracted Provider's request.
Payor shall include the name, edition, and model version of the software that Payor uses to determine bundling
and unbundling of claims. Further, Payor shall forward to Contracted Provider a notice of changes to Payor's
coding guidelines and fee schedules that will result in a change of payment to Contracted Provider. Such notice
of changes shall not later than the ninetieth (90th) day before said changes take effect, unless such changes are
required by CMS, TDI, or other regulatory entity, in which Payor shall provide as much notice as reasonably
possible. Payor shall not make retroactive revisions to the coding guidelines and fee schedules. On or before
the thirtieth (30th) day after the date after receipt of requested information and/or notice of future changes,
Contracted Provider may terminate this Agreement by providing written notice to Payor without penalty or
discrimination in participation in other health care products or plans. Contracted Provider shall use or disclose
any information received by Payor solely for the purpose of practice management, billing activities. and other
business operations and shall disclose such information only to a governmental agency involved in the regulation
of health care or insurance.
5.4
Claims/Payment Disputes. Should Contracted Provider request reconsideration of or dispute
payment or payments made by Payor under this Agreement, Contracted Provider must notify Payor in writing of
the dispute within one hundred and eighty (180) calendar days of the date of the original claim adjudication.
Contracted Provider acknowledges that Payor may consider Contracted Provider's failure to submit such
disputes within the above referenced time period as Contracted Provider's waiver of any such dispute and
Payor's original adjudication may be considered final without further appeal options.
5.5
Correction of Claim Overpayments. In the event Payor determines that a claim was overpaid, Payor
may seek correction of the payment within one hundred and eighty (180) calendar days from the overpayment.
Contracted Provider may appeal the refund request within forty-five (45) calendar days of receipt of refund request.
If after appeal, the overpayment determination is maintained, Contracted Provider will repay Payor the overpayment
amount within ten (10) calendar days of notice of the outcome of the appeal. If Contracted Provider fails to refund
overpayments, Contracted Provider agrees that Payor may recover overpayments through offsets against future
payments. Contracted Provider will report promptly any credit balance that it maintains with regard to any claim
overpayment under this Agreement, and will return such overpayment to Payor within forty-five (45) calendar days
after posting it as a credit balance. Contracted Provider must refund an overpayment from an enrollee in the amount
of the overpayment to the enrollee not later than the 30th day after the date the Contracted Provider determines that
an overpayment has been made.
5.6
Payor Solely Responsible for Payment. Unless otherwise provided by the Member's Benefit
Plan/Program, Contracted Provider shall collect Member Expenses for Covered Services directly from Member, and
shall not waive, discount or rebate any such Member Expenses. Contracted Provider understands and agrees that,
except for any applicable Member Expense, Payor has the sole responsibility for payment of covered services
rendered by provider under this Agreement. In the event of the insolvency of Payor or cessation of operations by
Payor, Contracted Provider's sole recourse shall be against Payor through the bankruptcy or receivership estate of
Payor.
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5.7
Benefit Plan/Program Participation and Compensation Rates. The parties agree that Exhibit B shall
outline: (1) the Benefit Plan(s)/Program(s) in which Provider participates; and (2) the applicable compensation to
Provider for each Benefit Plan/Program. Contracted Provider agrees to participation in such Benefit
Plan(s)/Program(s) and agrees to receive compensation for Covered Services for such Benefit Plan(s)/Program(s)
as described in the applicable Exhibit B.
For the term of this Agreement, Contracted Provider shall accept as payment in full for Covered Services
and all other services rendered to Members under this Agreement, less any applicable Member Expense, the
agreed compensation set forth in Exhibit B, attached hereto and incorporated by reference into this Agreement.
If Exhibit B outlines Contracted Provider's compensation based on Capitation for any programs in which
Contracted Provider and Healthcare Professionals participate, such Capitation shall exclude any Member
Expense. Payor shall begin payment of capitated amounts to Provider, computed from the date of enrollment,
not later than the sixtieth (60th) calendar day after the date the Member selects or is assigned a PCP.
5.8
Schedule of Benefits and Determination of Covered Services. Upon request, Community will
provide or make available to Contracted Provider with a summary of Covered Services for each applicable Benefit
Plan/Program. Payor shall be solely responsible for the determination of the extent of Member's coverage. Any
action by Payor pursuant to a Member's Benefit Plan/Program, or Community or Community Protocols or Payor
protocols or Utilization Management Program in no way releases Contracted Provider or Healthcare
Professional(s) of the responsibility to provide appropriate care to Members.
5.9
Member Hold Harmless. Contracted Provider agrees that in no event, including but not limited to,
non-payment by Payor, the insolvency of Payor, or breach of this Agreement, shall Contracted Provider bill, charge,
collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any other recourse
against any Members or persons other than Payor acting on the Member's behalf for services provided under this
Agreement. This section shall not prohibit collection of Member Expense made in accordance with the terms of the
applicable Benefit Plan/Program. Contracted Provider further agrees that the terms of this section shall: (i) survive
termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the
benefit of Members; and (ii) supersede any oral or written contrary agreement now existing or hereafter entered into
between Contracted Provider or a Healthcare Professional and Members or persons acting on their behalf. Any
modification, addition, or deletion of or to the provisions of this Section 5,9 shall be effective on a date no earlier
than fifteen (15) calendar days after the Texas Commissioner of Insurance has received written notice of such
proposed change.
5.10
No Surcharges. Contracted Provider shall not charge Member any fees or surcharges for provision
of Covered Services rendered pursuant to this Agreement, with the exception of any applicable Member Expense.
In addition, Contracted Provider shall not collect a sales, use, or other applicable tax from Members for the sale or
delivery of medical services. If Community receives notice of any additional charge for the provision of Covered
Services, Provider shall fully cooperate with Community to investigate such allegations, and shall promptly refund
any payment deemed improper by Community to the party who made the payment.
5.11
Member Payment of Excluded Services. Prior to the provision of any Excluded Service to a Member,
Contracted Provider or Healthcare Professional(s) shall obtain written confirmation with Member's signature
indicating that: (i) Member has been informed of the services to be provided; (ii) the services to be provided are not
covered under the Member's Benefit Plan/Program; (iii) Payor will not pay for or be liable for said services; (iv)
Member requests that Contracted Provider or Healthcare Professional(s) renders the Excluded Services; and (v)
Member will be financially liable for such services.
5.12
Coordination of Benefits. Payment for Covered Services provided to each Member may be subject
to subrogation and/or coordination with other benefits paid or payable to or on behalf of the Member, and to Payor's
right of recovery in other third party liability situations. Contracted Provider and Healthcare Professionals shall retain
in Member's records updated information concerning other health benefit plan coverage and to provide the
information Payor. Contracted Provider and Healthcare Professionals who submit a claim for particular health care
services to more than one Payor shall provide written notice on the claim submitted to each Payor of the identity of
the each other Payor with which the same claim is being filed. Payor will coordinate payment for Covered Services
in accordance with the terms of the Member's Benefit Plan/Program and applicable State and federal laws, rules,
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and regulations. If a Member has coverage from more than one payment source, Payor will coordinate benefits with
such other payment source in accordance with the Member's Benefit Plan/Program. Contracted Provider agrees to
share information obtained or documentation required by Payor to facilitate Payor's coordinate of such other
benefits. If Contracted Provider has knowledge of an alternative primary Payor, Contracted Provider shall bill such
other Payor(s) with the primary liability based on such information prior to submitting claims for the same services
to Payor. If Payor is a secondary Payor and pays a portion of a claim that should have been paid by the primary
Payor, Payor may recover the overpayment only from the Payor that is primarily responsible for that amount. If the
portion of the claim overpaid by Payor was also paid by the primary Payor, Payor may recover the amount of the
overpayment from Contracted Provider or Healthcare Professional that received the payment. To the extent
permitted by law, if Payor is not Member's primary Payor, payment for Covered Services from Payor shall be no
more than the difference between the amount paid by the primary Payor(s) and the applicable rate under this
Agreement, less any applicable Member Expense. Payor may share information with another Payor to the extent
necessary to coordinate appropriate payment obligations on a specific claim.
5.13 Failure to Obtain Prior Authorization or Referral. For any Covered Services rendered to, prescribed,
or authorized for Members by Contracted Provider in a non-emergent situation for which Payor requires Prior
Authorization in advance of the delivery of service, which Prior Authorization was not obtained by Contracted
Provider in advance, Contracted Provider acknowledges that Payor will deny Provider's claim for said Covered
Services. Contracted Provider agrees that in no event will Member be financially responsibility for payments arising
for such services, except for applicable Member Expenses as may be required under a Benefit Plan/Program.
5.14
Services Locations/New Services. This Agreement applies to Covered Services rendered at
Contracted Provider's service locations set forth in Exhibit A. In the event Contracted Provider begins providing
services at other locations, new types of facilities, or under other tax identification number(s), (either by operating
such locations itself, or by acquiring, merging, or affiliating with an existing provider that was not already under
contract as a participant in Community's network of providers), such additional tax identification number(s), new
types of facilities, or locations, will be subject to this Agreement only upon written agreement between the parties.
For the purposes of this paragraph, types of facilities shall include, but not be limited to; inpatient hospital,
hospital emergency room, outpatient hospital, physician office, ambulatory surgery centers, skilled nursing
facilities, durable medical equipment, home health, home infusion, dialysis, specialty pharmacy, etc.
In the event Contracted Provider acquires or is acquired by, merges with, or otherwise becomes affiliated
with another provider of Covered Services that is already under contract with Community, the compensation
defined herein shall remain in effect for each of the Contracted Provider's locations specified in Exhibit A, and
the compensation for the acquired provider shall be the lesser of: (1) the rates set forth in the acquired entity's
agreement with Community, or (2) the rates set forth in this Exhibit B of this Agreement.
Contracted Provider shall not transfer all or some of its assets to any entity during the term of this
Agreement, which the result that all or some of the Covered Services subject to this Agreement will be rendered
by the other entity rather than by Provider, without the express written agreement of Community.
SECTION 6 - UTILIZATION MANAGEMENT AND QUALITY IMPROVEMENT PROGRAMS
6.1
Utilization Management Program. Contracted Provider shall participate in, cooperate with, and
comply with all decisions rendered in connection with Community's Utilization Management Program. Contracted
Provider shall (i) provide such records and other information as may be required or requested under such Utilization
Management Program; and (ii) comply with all confidentiality requirements regarding a Utilization Management
Program.
6,2
Quality Improvement Program. Contracted Provider shall be solely responsible for the quality of
such Covered Services rendered to Members, The quality of Covered Services rendered to Members shall be
monitored under the Quality Improvement Program applicable to the particular Benefit Plan/Program. Contracted
Provider shall: (i) participate in, cooperate with, and comply with all decisions rendered by Community or the
applicable Payor in connection with a Quality Improvement Program; (ii) provide such medical records, and such
review data and other information as may be required or requested under a Quality Improvement Program; and (iii)
comply with all confidentiality requirements regarding a Quality Improvement Program. In the event that the
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standard or quality of care furnished by a Contracted Provider is found to be unacceptable under any Quality
Improvement Program, Community shall give written notice to Contracted Provider and/or Healthcare Professional
to correct the specified deficiencies within the time period specified in the notice, Such Contracted Provider shall
correct such deficiencies within that time period. Contracted Provider shall perform such quality management in
accordance with the performance standards and criteria of Community.
6,3
Limitation. In no event, however, shall the requirements of such Utilization Management Program
or Quality Improvement Program be less than the standard of care for the provision of medical services to patients
in the geographic area where medical services are being provided by Contracted Providers under this Agreement.
Further, nothing in this Agreement shall be construed to authorize Community or any of Community's officers or
employees to exercise any control over the practice of medicine by Contracted Providers or the manner in which
Providers provide medical services.
SECTION 7 - INSURANCE, INDEMNIFICATION & RELEASE
7.1
Professional and General Liability. Contracted Provider agrees to purchase and maintain during the
term of this Agreement, at its sole cost and expense, policies of general liability, professional liability, and other
insurance as shall be necessary to adequately insure Contracted Provider and Healthcare Professionals, agents,
and employees against any claim or claims for damage arising by reason of personal injury or death occasioned
directly or indirectly in connection with the performance of any procedure or service provided hereunder, the use of
any property and facilities provided by Contracted Provider, and activities performed by Contracted Provider and
Healthcare Professionals in connection with this Agreement. Such policies shall provide coverage in the amounts
acceptable to Community, but in no event shall professional liability insurance be less than One Hundred Thousand
Dollars ($100,000) for each person and Three Hundred Thousand Dollars ($300,000) for each single occurrence for
bodily injury or death and One Hundred Thousand Dollars ($100,000) for each single occurrence for injury to or
destruction of property, unless a lesser amount is determined sufficient by Community in writing. Such professional
liability coverage shall include "tail" coverage of the same limits as stated above for any "claims-made" policy as
necessary to continue coverage until any applicable statute of limitations has expired. Contracted Provider shall
require of Contracted Provider's professional liability insurance carrier that Community be named as a party entitled
to thirty (30) calendar days prior written notice of an intent to cancel or terminate such insurance. Upon execution
of this Agreement, Contracted Provider shall provide to Community written proof from Contracted Provider's
carrier(s) of the coverages required under this Section.
7.2
Notice of Adverse Action. Contracted Provider shall notify Community in writing, within forty-eight
(48) hours or such lesser period of time as required by the applicable federal or State statute, of receiving any written
or oral notice of any adverse action, including without limitation, any malpractice suit or arbitration action, or other
suit or arbitration action naming or otherwise involving Contracted Provider, a Healthcare Professional, Community,
or any Payor, and of any other event, occurrence, or situation that might materially interfere with, modify, or alter
performance of any of Contracted Provider's duties or obligations under this Agreement. Contracted Provider also
shall notify Community promptly of any action against Contracted Provider or any Healthcare Professional's license
or certification under Title XVIII or Title XIX or other applicable statute of the Social Security Act or other State law,
and of any material change in the ownership or business operations. Failure to notify Community of any adverse
action shall be a material breach of this Agreement and may include termination under section 10.
7.3
Indemnification by Contracted Provider and Subcontractors. Contracted Provider will at all times
hereafter indemnify, defend, and hold harmless Community and its representatives, officers, directors, employees,
and agents individually and collectively from any and all causes of action, liabilities, claims, or other expenses
(including, without limitation, costs of suit and attorney's fees, and mediation expenses) which might be asserted
against Community and its representatives, officers, directors, employees, and agents, individually and collectively
arising from, or pertaining to, any acts or omissions of Contracted Provider or Healthcare Professionals under this
Agreement; provided, however, that to the extent that any such causes of action, costs, or fees are compensated
for by insurance purchased by Community, Contracted Provider shall not be required to reimburse Community
or
insure for same.
Contracted Provider shall further indemnify, defend, and hold harmless Community, and as applicable, any
Payor, and their representatives, officers, directors, employees, and agents individually and/or collectively from any
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and all causes of action, liabilities, claims, or other expenses (including, without limitation, costs of suit, attorney's
fees, and/or mediation expenses) that might be asserted against Community and its representatives, officers,
directors, employees, and agents individually arising from, or pertaining to, the failure or refusal of Contracted
Provider to pay its subcontractors and/or the members of its provider network for services and/or goods and
equipment provided to Members. Contracted Provider agrees that all Healthcare Professionals" contracts related
to the provision of services under this agreements, Contracted Provider will require that the Healthcare Professionals
providing such service hold harmless Community and any Payor as applicable, and their representatives, officers,
director, employees, and agents in the event of Healthcare Professional's failure or refusal to make payment for any
reason and whether due to Healthcare Professional's insolvency or otherwise.
7.4
Release. Contracted Provider and Healthcare Professionals hereby release from liability
Community, and its affiliates, directors, committees, officers, employees, or agents, and agrees to waive all legal
claims that Contracted Provider or Healthcare Professionals may now or may hereafter have against such
individuals or entities related to any and all actions taken in good faith in connection with evaluating Contracted
Provider's or Healthcare Professional's professional qualifications. Contracted Provider hereby releases and shall
cause Contracted Provider's Healthcare Professionals to further release from liability any individual or entity who
may have information bearing on Contracted Provider's or Healthcare Professional's professional qualifications who
discloses in good faith such information in connection with evaluation by the above entities and individuals of
Contracted Provider's or Healthcare Professional's professional qualifications. Contracted Provider and Healthcare
Professionals further agree/s that any act, communication, report, recommendation or disclosure made in
connection with the evaluation of professional qualifications, shall be privileged and confidential and shall not be
subject to discovery, subpoena, or other means of legal compulsion for their release.
SECTION 8 - DISPUTE RESOLUTION
8,1
Dispute Resolution. The parties agree to meet promptly in good faith to resolve any controversy or
dispute that may arise out of or relating to this Agreement that cannot be resolved informally. Neither party shall
unreasonably refuse or delay the other party's request for such meeting. If the parties are unsuccessful in resolving
such controversy or dispute, the dissatisfied party shall submit a written complaint (the "Complaint") to the other
party (the "Responding Party"), which complaint shall set forth with specificity the basis of the complaint and the
proposed resolution. The Responding Party shall respond in writing to the Complaint within thirty (30) calendar days
of receiving the Complaint. The Responding Party's written acceptance, rejection or modification of the proposed
resolution will constitute the Responding Party's final determination. If the parties are unable to resolve the dispute
within ten (10) calendar days from the date that the Responding Party responds to the Complaint, the controversy
or dispute may be submitted to non-binding mediation in Harris County, Texas, at the request of any party, and
the parties shall attempt to resolve the matter, in good faith, prior to the institution of any litigation or other legal
action. The parties agree to select an individual qualified under the requirements of Chapter 154, Texas Civil
Practice and Remedies Code, as amended, to serve as mediator. Failing agreement to name a mediator, the
Parties agree to have a mediator appointed by a court of competent jurisdiction. Nothing in this paragraph shall
preclude either party from seeking remedies in law or equity. Either Party may impose shortened time limits in
this section if the dispute is subject to the time limits in Section 843 of the Texas Insurance Code.
SECTION 9 - CONFIDENTIALITY
9,1
Member-Related Information. Community, Contracted Provider and/or Healthcare Professionals
understand and agree that all information and records related to Members are privileged and confidential. Any
Member-related information, records, or reports that may be disclosed to Community pursuant to the express terms
of this Agreement shall not be disclosed nor divulged by Community in whole or in part to any other third person,
other than as allowed by applicable law or as expressly provided for in this Agreement, without the prior written
consent of the Member; if required, except that information required for the Utilization Management Program, the
Quality Improvement Program, and claims adjudication will be released to Community or other appropriate Payor
or designee without Member consent as a healthcare operation.
9.2
Business Activities. Contracted Provider agrees to maintain the confidentiality of all information
related to fees, charges, expenses and utilization derived from or through, or provided by Community and/or a Payor.
Except as required by law and for the purposes of carrying out this Agreement, Community and Contracted Provider
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agree to keep confidential any information regarding the other's business activities that is not otherwise available to
the general public, unless prior written consent for disclosure is obtained from the other party.
9,3
Proprietary Information. All information and materials provided by Community to Contracted Provider
shall remain proprietary to Community including, but not limited to, contracts, fee schedules, reimbursement rates
and methodology, handbooks, and any other operations manuals. Contracted Provider shall not disclose any of
such information or materials or use them except as may be required to perform Contracted Provider's obligations
hereunder.
9,4
Survival of Obligations. The obligations of the parties under this Section 9 shall survive termination
of this Agreement,
9.5
HIPAA Provisions. Contracted Provider and Community are Covered Entities. Therefore,
Contracted Community and Provider agree to comply with the requirements of the Health Insurance Portability
and Accountability Act of 1996, Pub. L. No. 104-191 (codified at 45 C.F.R. Parts 160 and 164), as amended
("HIPAA"); privacy and security regulations promulgated by the United States Department of Health and Human
Services ("DHHS"); Title XIII, Subtitle D of the American Recovery and Reinvestment Act of 2009, Pub. L. No.
111-5, as amended ("HITECH Act"); provisions regarding Confidentiality of Alcohol and Drug Abuse Patient
Records (codified at 42 C.F.R. Part 2), as amended; and TEX, HEALTH & SAFETY CODE ANN. §§ 81.046, as
amended, 181.001 et seq., as amended, 241.151 et seq., as amended, and 611.001 et seq., as amended
(collectively referred to herein as the "Privacy and Security Requirements").
SECTION 10 - TERM AND TERMINATION
10.1
Term. Unless otherwise agreed upon by the parties, this Agreement shall commence on the
Effective Date as indicated on the signature page of this Agreement, and shall continue for an initial term of one (1)
year. The Agreement shall automatically renew for periods of one (1) year, unless either party terminates
the
Agreement as allowed in any of the following circumstances:
a. either party terminates the Agreement as allowed herein; or
b. the parties terminate this Agreement by mutual agreement in writing effective on a mutually agreed upon
date, subject to any applicable laws, rules and/or regulations.
Regardless of the Effective Date or any renewal date of this Agreement, Contracted Provider acknowledges
that neither Community nor a Member shall have any obligation to pay for Covered Services rendered by Contracted
Provider or Healthcare Professional, until such time as Contracted Provider completes Community's credentialing
process and receives approval from Community's credentialing body.
10.2
Termination Without Cause, Following the initial term as defined in 10.1, either party may terminate
this Agreement at any time, without cause, upon ninety (90) calendar days' notice to the other party.
10.3
Termination With Cause. Either party may terminate this Agreement for material breach of any of
the terms or provisions of this Agreement by providing the other party with at least ninety (90) calendar days'
advance written notice specifying the nature of the alleged material breach. During the first sixty (60) calendar days
of the above referenced notice period, if the breaching party cures the breach to the reasonable satisfaction of the
non-breaching party, in the non-breaching party's sole discretion, and upon mutual agreement between the Parties,
the Agreement shall not terminate at such time.
10.4 Immediate Termination. Community, at its sole election, may terminate this Agreement, and/or
participation of any Healthcare Professional rendering services under the terms of this Agreement, immediately
upon written notice to Contracted Provider in the event of any of the following: (I) suspension, revocation, condition,
expiration, or other restriction of Contracted Provider's or its Healthcare Professionals" licensure, certification, and/or
accreditation; (ii) failure to meet or maintain Community credentialing/re-credentialing standards, as determined by
the Community in its sole discretion; (iii) suspension, limitation or bar of Contracted Provider or its Healthcare
Professionals from participation in any government healthcare program; (iv) Contracted Provider's or its Healthcare
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Professionals breach of Section 5,9 ("Member Hold Harmless"); (v) determination by a government agency or any
judicial or administrative review body that Contracted Provider or its Healthcare Professionals have engaged or are
engaging in fraud; (vi) failure by Contracted Provider or its Healthcare Professionals to maintain the general and/or
professional liability insurance coverage requirements of this Agreement; (vii) Community's reasonable
determination that termination of Agreement or Contracted Provider or its Healthcare Professional is necessary for
health and safety of Member(s); or (viii) any other grounds that are not in bad faith.
10.5 Pre-Termination Review. Upon request of Contracted Provider, prior to terminating this Agreement,
Community shall provide a written explanation to Contracted Provider of the reason or reasons for termination. On
request and before the effective date of the termination, but within a period not to exceed sixty (60) calendar days,
Contracted Provider shall be entitled to a review of Community's proposed termination by an advisory review panel
appointed by Community, except in a case in which there is imminent harm to patient health, as determined solely
by Community, or an action by a state medical or dental board, other medical or dental licensing board, or other
licensing board or other government agency, that effectively impairs Contracted Provider's ability to practice
medicine, dentistry, or another profession, or in a case of fraud or malfeasance, as determined solely by Community.
The advisory review panel shall be composed of physicians and providers, including at least one representative in
Contracted Provider's specialty or a similar specialty, if available, appointed to serve on the standing Quality
Improvement Committee or Utilization Review Committee of Community. The décision of the advisory review panel
must be considered but is not binding on Community. Community shall provide to Contracted Provider, on request,
a copy of the recommendation of the advisory review panel and Community's determination. Contracted Provider
shall be entitled, on request, to an expedited review process by Community. Contracted Provider shall have no
cause of action against any member of the advisory review panel or against any person who supplies information
to the advisory review panel.
10.6 Continuation of Care. Community shall give reasonable advance notice of the impending termination
of Contracted Provider or a Healthcare Professionals to each Member receiving treatment from such Provider.
Except for any Immediate Termination as defined above, nothing herein shall be construed to release Community
from the obligation to reimburse Contracted Provider for the Covered Services of a Contracted Provider or a
Healthcare Professional who is rendering ongoing Medically Necessary treatment in accordance with the dictates
of medical prudence to a Member of special circumstance at no less than the compensation rate provided for under
this Agreement in exchange for the ongoing treatment of the Member. Special circumstance means a condition
such that the treating Contracted Provider or the Healthcare Professional reasonably believes that discontinuing
care by the treating Contracted Provider or Healthcare Professional could cause harm to the patient, such as a
person who has a disability, acute condition, life threatening illness, or is past the twenty-fourth (24th) week of
pregnancy. Special circumstance) shall be identified by the treating Contracted Provider or the Healthcare
Professional who must make a written request to Community asking that the Member be permitted to continue
treatment under the treating Contracted Provider's or the Healthcare Professional's care and Contracted Provider
and Healthcare Professional must agree not to seek payment from the Member of any amounts for which the
Member would not be responsible if the Contracted Provider was still on the Community network. In the event
Contracted Provider or a Healthcare Professional is deselected for a reason other than by a request from the Facility
or a Healthcare Professional, Community may not notify Members until the effective date of the deselection or
Community's advisory review panel makes a formal recommendation.
Any dispute between Community and Contracted Provider or a Healthcare Professional with respect to
coverage for continued care to Members with special circumstance shall be resolved in accordance with the
procedures set forth in the Community Provider Manual or this Agreement, as it may be amended from time to time.
This Section 10.6 does not extend the obligation of Community to reimburse Contracted Provider for ongoing
treatment of a Member beyond ninety (90) days from the effective date of termination or beyond nine (9) months in
the case of a Member who at the time of termination has been diagnosed with a terminal illness. However, the
obligation of Community to reimburse the terminated Contracted Provider for services rendered to a Member who
at the time of termination is past the twenty-fourth (24th) week of pregnancy, extends through delivery of the child,
immediate postpartum care, and the follow up checkup within the first six (6) weeks of delivery.
10,7 Post-Termination Continuation of Care. Upon termination of this Agreement for any reason,
Contracted Provider, upon Community's written request and at Community's sole discretion, shall continue to
provide or arrange for the provision of Covered Services to enrolled Members for a period not to exceed ninety (90)
Page 16 of 38

Start of Page No. = 17
calendar days following receipt of written notice of termination. Such extension of obligation shall not require
Contracted Provider to arrange for the provision of care for Members not enrolled as of the date of termination or
cases where the Member has not begun active treatment with Provider. Except as may be required by the obligation
of Contracted Provider to continue care in the event of special circumstances herein, Contracted Provider shall be
compensated by Community for all Covered Services provided to Members after the effective date of termination of
this Agreement as follows: if Capitation is being paid to Contracted Provider as of the date of termination, Contracted
Provider shall be financially responsible for Covered Services until the conclusion of the course of treatment;
otherwise Contracted Provider will be compensated until conclusion of the course of treatment; according to the
rates defined in this Agreement for all dates of service following the termination's effective date. Contracted Provider
agrees to cooperate with Community's efforts to arrange for the prompt, medically appropriate transfer of Members
to Participating Providers following termination notice of this Agreement.
10.8 Member Notification. Community shall provide notification of the termination of Contracted
Provider or its Healthcare Professional(s) to its Members receiving care from Contracted Provider or at least
thirty (30) days before the effective date of the termination. Community may notify Members at the time
Community terminates Contracted Provider or a Healthcare Professional if such termination is immediate as
allowed in this Agreement. Upon a final determination of a date that Agreement will terminate, Contracted Provider
shall notify any Member attempting to schedule Covered Services, or any Member already scheduled, beyond the
termination date, that Contracted Provider or the Healthcare Professional will no longer be a Participating Provider
as of the termination date, and will incur a greater Member Expense that Contracted Provider's non-participation
status with Community. Contracted Provider shall comply with Community's policy and procedures related to any
Immediate Termination of Agreement, to include immediate cessation of scheduling further Members, prompt
notification to all Members with scheduled appointments, as well as immediate notification to Community of any and
all Members in active treatment or with scheduled procedures as well as identification and prioritization of Members
whose health may be in jeopardy without immediate transfer to another or other Participating Providers.
10.9 Retaliation. Community shall not engage in any retaliatory action, including terminating or refusing
to renew this Agreement, against Contracted Provider because Contracted Provider has, on behalf of a Member,
reasonably filed a complaint against Community or appealed a decision of Community.
SECTION 11 - MISCELLANEOUS
11.1 Advance Directives. Contracted Provider acknowledges and agrees to comply with all federal and
State laws with respect to advance directives as defined in the Patient Self-Determination Act (P.L. 101-508), as
amended). An advance directive is, for example, a Directive to Physician (formerly known as a living will) or a
Medical Power of Attorney (formerly known as a durable power of attorney for health care) pursuant to TEX,
HEALTH & SAFETY CODE ANN. §§ 166.001 et seq., as amended, in which an individual makes decisions
concerning medical care, including the right to accept or refuse medical or surgical treatment. or a Declaration
for Mental Health Treatment pursuant to TEX. Civ. PRAC. & REM. CODE ANN. §§ 137.001 et seq., as amended,
11.2
Independent Medical Judgment. Nothing contained in this Agreement shall be construed to require
a Contracted Provider to recommend or withhold any procedure or course of treatment that is not consistent with
such Provider's best medical judgment. Eligibility, Prior Authorization, case management, and Utilization
Management Program activities are performed for the purpose of clearly defining financial responsibility and
encouraging efficient use of resources and network services. A Contracted Provider is free to make independent
medical recommendations and Members are free to choose to accept or reject any treatment course.
11.3
Communications with Patients. Community shall not impose any restrictions upon Contracted
Provider's free communications with Members about a Member's medical conditions, treatment options, Community
referral policies, and other Community policies, including financial incentives or arrangements. Further, Community
shall not, as a condition of this Agreement with Contracted Provider, or in any other manner, prohibit, attempt to
prohibit, or discourage Contracted Provider from, or in any way penalize, terminate, or refuse to compensate
Contracted Provider for Covered Services for: (i) discussing with or communicating to a current, prospective or
former patient, or a party designated by a patient, information or opinions regarding the patient's health care,
including, but not limited to, the patient's medical condition or treatment options; or (ii) discussing with or
communicating in good faith to a current, prospective or former patient, or a party designated by a patient,
Page 17 of 38

Start of Page No. = 18
information or opinions regarding the provisions, terms, requirements or services of the Benefit Plan/Program as
they relate to the medical needs of the patient.
11.4 Non-Exclusivity, This Agreement shall not be an exclusive agreement between Community and
Contracted Provider. Nothing herein shall be construed to restrict the rights of Contracted Provider (and any
Healthcare Professionals) or Community to participate in other preferred provider plans, health maintenance
organizations, or other managed care systems.
11.5
Entire Agreement. This Agreement, the Community Protocols, and the Exhibits constitute the sole
and only agreement of the parties with respect to the subject matter hereof and supersedes any and all prior
agreements or understandings, either oral or in writing, between the parties hereto with respect to the subject matter
hereof, and no other agreement, statement, or promise relating to the subject matter of this Agreement that is not
contained or incorporated by reference herein shall be valid or binding. Provided, however, the Covered Services
provided hereunder must be provided in accordance with the terms and conditions of the particular Benefit
Plan/Program.
11.6 Assignment. Neither this Agreement nor the duties or obligations hereunder shall be assignable by
either party without the prior written consent of the other party hereto, except as may expressly be permitted under
this Agreement. Community shall have the right in its sole discretion to assign this Agreement to any affiliated entity,
parent or subsidiary of Community.
11.7 Successors and Assigns. Subject to the provisions of Section 11.6 hereof ("Assignment"), this
Agreement shall be binding on the heirs, executors, administrators, legal representatives, successors, and assigns
of the respective parties hereto.
11.8
Governing Law. The validity of any of the terms and provisions of this Agreement as well as the
rights and duties of the parties hereunder, shall be governed by the laws of the State of Texas, except to the extent
such laws conflict with or are preempted by any federal law, in which case such federal law shall govern. Federal
law shall also govern with respect to Benefit Plans/Programs of federal government Payors.
11.9 Venue, The sole venue for any dispute arising hereunder shall be in the court of appropriate
jurisdiction in Harris County, Texas, exclusively.
11.10 Amendment. This Agreement may be amended by the mutual agreement of the parties hereto in
writing or by Community upon written notice to Contracted Provider if necessary in order to comply with applicable
law or regulation. Mandatory modifications, additions or deletions required by any change in State or federal law or
regulation shall be effective immediately and shall not require mutual signature.
11.11 Severability. In case any one or more of the provisions contained in this Agreement shall for any
reason be held to be invalid, illegal, or unenforceable in any respect, such invalidity, illegality, or unenforceability
shall not affect any other provision hereof, and this Agreement shall be construed as if such invalid, illegal. or
unenforceable provision had never been contained herein.
11.12 Notices. Any notices to be given hereunder by either party to the other may be effected by personal
delivery in writing or by mail, registered or certified, postage prepaid, return receipt requested, to Community at its
principal place of business or to Contracted Provider at Contracted Provider's principal place of business according
to the address(es) provided on the signature page of this Agreement. Notices are deemed received when personally
delivered or three (3) business days after being placed in the mail.
11.13 Waiver. The waiver by either party of a breach or violation of any provision of this Agreement shall
not operate as or be construed to be a waiver of any subsequent breach hereof. The failure of either party to insist
upon the strict observation or performance of any provision of this Agreement or to exercise any right or remedy
Page 18 of 38

Start of Page No. = 19
shall not impair or waive any such right or remedy. Every right and remedy given by this Agreement to the parties
may be exercised from time to time and as often as appropriate.
11.14 No Third-Party Member. Except as set forth in Section 5.9 hereof ("Member Hold Harmless"), or as
may be required by law, nothing in this Agreement is intended to, or shall be deemed or construed to, create any
rights or remedies in any third party, including a Member. Nothing contained herein shall operate (or be construed
to operate) in any manner whatsoever to increase the rights of any such Member or the duties or responsibilities of
Provider or Community with respect to such Members.
11.15 Regulations. Community is subject to the requirements of various local, State, and federal laws,
rules, and regulations. Any provision required to be in this Agreement by any of the above shall bind Provider and
Community whether or not provided herein and shall supercede requirements in this contract.
11.16 Status as Independent Entities. None of the provisions of this Agreement are intended to create or
shall be deemed or construed to create any relationship between Contracted Provider and Community other than
that of independent entities contracting with each other solely for the purpose of effecting the provisions of this
Agreement. Neither Contracted Provider nor Community, nor any of their respective agents, employees, or
representatives shall be construed to be the agent, employee, or representative of the other.
11.17 Exhibits. Each Exhibit to this Agreement is made a part of this Agreement as though set forth fully
herein. Any provision of an Amendment that is in conflict with any provision of this Agreement and its Exhibit shall
take precedence and supersede the conflicting provision of this Agreement and Exhibit. Any provision of this
Agreement that is in conflict with any provision of an Exhibit, other than an Amendment, or that is in conflict with any
provision of the Provider Manual shall take precedence and supersede the conflicting provision of the Exhibit or the
Provider Manual.
11.18 Headings. The headings contained in this Agreement are for the convenience of the parties only
and shall not be deemed to affect the meaning of the provisions hereof.
11.19 Authority. The provisions of this Agreement required to be approved by the governing board of
Community or Contracted Provider have been so approved and authorized.
11.20 Non-Assumption of Liabilities. Unless specifically provided by this Agreement, Contracted Provider
does not assume or become liable for any of the existing or future obligations, liabilities, or debts of Community, and
Community does not assume or become liable for any of the existing or future obligations, liabilities, or debts of
Contracted Provider.
11,21 Costs Associated with this Agreement. Except as otherwise provided herein, each party shall bear
the costs of its own legal, accounting, and other services necessary to comply with its duties and obligations under
this Agreement.
11.22 No Waiver of Rights. The failure of either party to insist upon the strict observation or performance
of any provision of this Agreement or to exercise any right or remedy shall not impair or waive any such right or
remedy. Every right and remedy given by this Agreement to the parties may be exercised from time to time and as
often as appropriate.
11.23 Impossibility of Performance. Neither Contracted Provider nor Community shall be deemed to be in
default of this Agreement if prevented from performing for reasons beyond its control including, without limitation.
governmental laws, rules and regulations, acts of God, war, and strikes. In such cases, the parties shall negotiate
in good faith with the goal and intent of preserving this Agreement and the respective rights and obligations of the
parties.
11.24 No Personal Liability. Nothing in this agreement is construed as creating any personal liability on
the part of any officer, director, employee, or agent or any public body that may be a party to this Agreement, and
the parties expressly agree that the execution of this Agreement does not create any personal liability on the part of
any officer, director, employee, or agent of Community.
Page 19 of 38

Start of Page No. = 20
11.25 Use of Name. Neither Community nor Contracted Provider shall use each other's trademarks, name,
or symbols without the prior written consent of the other, provided, however, Contracted Provider agrees that
Community and Benefit Plans/Programs may use Provider's and each Healthcare Professional's name, office
address, telephone number, and specialty, and a factual description of the practice in directories and other
promotional materials.
IN WITNESS WHEREOF, the parties have and caused this Agreement to be effective on the later day and
year written below by execution on behalf of Sample Company Name, Inc
by a duly authorized representative
of Sample Company Name, Inc
and by execution on behalf of Contracted Provider and Healthcare Professional
by a duly authorized representative.
Sample Company Name, Inc
ABC Center
456 Oak Avenue
123 Maple Street
Coppell, TX 77054
Springfield,
TX 77471
Phone: 123-456-7890
Phone: 123-456-7890
Facsimile: 123-456-7890
Facsimile: 123-456-7890
Smoke
Community Signature
Contracted Provider Signature
lan Smith
George Clone
Printed Name
Printed Name
Director - Contracting
CEO
Title
Title
8/30/19
8-28-19
Date
Date
123456789
TO BE COMPLETED BY COMMUNITY ONLY:
TIN
Effective Date:
SEP 01 2019
1234567890
NPI
Page 20 of 38

This page has 2 signature.

Start of Page No. = 21
EXHIBIT A
CONTRACTED PROVIDER DEMOGRAPHICS & LIST OF HEALTHCARE PROFESSIONALS
Complete list of each service location where Contracted Provider will render Covered Services, including all of the
following data elements listed below.
A. In accordance with Sections 3.1 and 3.18 of this Agreement, Contracted Provider shall provide Community with thirty (30)
calendar days prior written notice of any proposed changes in the locations or the proposed closing by Contracted
Provider of any affiliated Contracted Provider location(s) listed below.
B. In the event that a particular service or type of service that was provided previously at one of the affiliated facilities owned
and/or managed and operated by Contracted Provider listed below, is discontinued, but then offered as a new service or
type of service by one of the other affiliated facilities listed below, Contracted Provider acknowledges and agrees that
such service or services shall be included under this Agreement, at Community's discretion, at the rate(s) included under
this Agreement for such service or services.
Page 21 of 38


-------Table Start--------

[['Legal Name', "'ABC Center"], ['DBA Name I If applicable', None], ['Website', 'www.abccenter.com'], ['Tax Identification Number', '12-3456789'], ['NPI Number', '1234567890'], ['Medicare Participation Number', '12C83M'], ['Medicaid Number', '001122334'], ['Specialty / Type of Service', 'Local Mental Health Authority (LMHA), Early Childhood Intervention (ECI) Provider, Mental Health Rehabilitative Services, Mental Health Targeted Case Management, Multispecialty Clinic'], ['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '123 Maple Street, Springfield, TX 77471 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish'], ['Remit Address Address: / City / State/ ZIP: Phone: / Fax:', '123 Maple Street, Springfield, TX 77471 123-456-7890/123-456-7890']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '123 Maple Street, Springfield, 77471 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon I Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '123 Maple Street, Springfield, TX 77414 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------

Start of Page No. = 22
Page 22 of 38


-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 77423 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 78934 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 77488 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 77471 123-456-7890/123-456-7890'], ['Hours of operation', '24 Hours - 7 days a week'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 77479 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 77478 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 77471 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '456 Oak Avenue, Coppell, TX 77406 , 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon - Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------

Start of Page No. = 23
Facility active provider roster of healthcare professionals to be submitted by Texana Center including all
data elements above.
Page 23 of 38


-------Table Start--------

[['Practice or Business Location Address: / City / State/ ZIP: Phone: / Fax:', '123 Maple Street, Springfield, TX 77471 123-456-7890/123-456-7890'], ['Hours of operation', 'Mon 1 Fri: 8:00AM - 5:00PM'], ['Language(s) spoken', 'English, Spanish']]
None
-------Table End--------
-------Table Start--------

[['Physician or Mid-Level Practitioner Last Name, First Name, MI and Degree', 'SEE ROSTER'], ['Specialty / Type of Service', 'SEE ROSTER'], ['Individual NPI Number', 'SEE ROSTER'], ['Medicare Participation Number', 'SEE ROSTER'], ['Medicaid Number', 'SEE ROSTER'], ['Individual THSteps TPI', 'SEE ROSTER'], ['Practice or Business Location Address: City / State/ ZIP: Phone: Fax:', 'SEE ROSTER'], ['Hours of operation', 'SEE ROSTER'], ['Language(s) spoken', 'SEE ROSTER']]
 Facility active provider roster of healthcare professionals to be submitted by Texana Center including all data elements above.
-------Table End--------

Start of Page No. = 24
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
Local Mental Health Authority (LMHA)
Chemical Dependency (CD) Treatment Facility
Provider Type:
Early Childhood Intervention (ECI) Provider
Mental Health Targeted Case Management
Non- Local Mental Health Authority (LMHA)
Behavioral Health Services
Services:
Mental Health Targeted Case Management
Mental Health Rehabilitative 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 except those listed below: one hundred fifteen percent (115%) of the then current 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.
If applicable, 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.
Physician/Provider Signature:
Date:
8.28-19
Page 24 of 38


-------Table Start--------
5f0dfb9d-2f05-4285-8351-7a217bbae755
[['Procedure Code', 'Description', 'Rate', 'Provider Type'], ['90792', 'Psychiatric diagnostic evaluation with medical services', '$ 155,00', 'MD / DO'], ['99212', 'Office / outpatient visit for evaluation and management; established patient', '$ 45.20', 'MD / DO'], ['99213', 'Office / outpatient visit for evaluation and management; established patient', '$ 75,14', 'MD / DO'], ['99214', 'Office / outpatient visit for evaluation and management; established patient', '$ 110,91', 'MD / DO'], ['99215', 'Office / outpatient visit for evaluation and management; established patient', '$ 149.57', 'MD / DO']]
 All Covered Services except those listed below: one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule.
-------Table End--------

Start of Page No. = 25
EXHIBIT B-2
COMPENSATION
Applicable
Health Insurance Marketplace (HIM)
Does not participate in Marketplace
Benefit
Plan(s):
Limited Network Plan (Kelsey Marketplace)
Does not participate in Kelsey Marketplace
Local Mental Health Authority (LMHA)
Chemical Dependency (CD) Treatment Facility
Provider
Early Childhood Intervention (ECI) Provider
Type:
Mental Health Targeted Case Management
Non- Local Mental Health Authority (LMHA)
Applied Behavior Analysis (ABA)
Behavioral Health Services
Mental Health Targeted Case Management
Services:
Mental Health Rehabilitative Services
Applied Behavior Analysis
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 except those listed below: one hundred fifteen percent (115%) of the then current Texas Medicaid
Fee Schedule.
Applied Behavior Analysis (ABA) Services and Rates
Page 25 of 38


-------Table Start--------
1fb7fa14-3176-4bac-85ed-6bb3c8d5bd71
[['Procedure Code', 'Description', 'Rate Per Unit (15 minutes)'], ['97151', "Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or other QHP's time face-to-face with patient, and/or guardian(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan", '$ 40.00'], ['97152', 'Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face to face with the patient, each 15 minutes.', '$ 15,50'], ['0362T', 'Behavior identification supporting assessment, each 15 minutes of technician\'s time face-to- face with a patient requiring the following components: "administered by the physician or other qualified healthcare professional who is on-site, w with the assistance of two or more technicians, *for a patient who exhibits destructive behavior, "completed in an environment that is customized to a patient\'s behavior', '$ 45.00'], ['97153', 'Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP, face-to-face with one patient. each 15 minutes', '$ 15.50']]
 Applied Behavior Analysis (ABA) Services and Rates
-------Table End--------

Start of Page No. = 26
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,
If applicable, 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.
Physician/Provider Signature:
fat
Date:
8-28-19
Page 26 of 38


-------Table Start--------

[['Procedure Code', 'Description', 'Rate Per Unit (15 minutes)'], ['97154', 'Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP, face-to-face with 2 or more patients, each 15 minutes', '$ $11.00'], ['97155', 'Adaptive behavior treatment, with protocol modification, administered by physician or other QHP, which includes simultaneous direction of technician, face-to-face with one patient, each 15 minutes', '$ 30.00'], ['97156', 'Family adaptive behavior treatment guidance administered by physician or other QHP (with or without the patient present). face-to-face with guardians(s)/caregiver(s), each 15 minutes', '$ 30.00'], ['97157', 'Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified healthcare professional (without the patient present) face-to-face with multiple sets of guardians(s)/ caregiver(s)', '$ 22.00'], ['97158', "Group adaptive behavior treatment with protocol modifications, administered by a physician or other QHP, face to face with multiple patents', each 15 minutes", '$ 22.00'], ['0373T', 'Adaptive behavior treatment with protocol modification, each 15 minutes of technician\'s time face-to-face with a patient requiring the following components: *administered by the physician or other qualified healthcare professional who is on site, * with the assistance of two or more technicians, *for a patient who exhibits destructive behavior, "completed in an environment that is customized to a patient\'s behavior', '$ 45.00'], ['H0032', 'Mental health service plan development by a non-physician', '$ 25.00']]
None
-------Table End--------

Start of Page No. = 27
EXHIBIT B-3
COMPENSATION
Physician/Provider.c does not participate in above plan/program.
clat
Physician/Provider Signature
Date
8.28.19
Page 27 of 38


-------Table Start--------
bd69c793-ac60-4fa7-8866-5d1bac378b44
[['Applicable Benefit Plan(s): Provider Type: Services:', 'Dual Special Needs Plan (D-SNP) Does not participate in D-SNP [ ]'], ['Applicable Benefit Plan(s): Provider Type: Services:', 'Local Mental Health Authority (LMHA) Chemical Dependency (CD) Treatment Facility Early Childhood Intervention (ECI) Provider Mental Health Targeted Case Management Non- Local Mental Health Authority (LMHA) [ ]'], ['Applicable Benefit Plan(s): Provider Type: Services:', 'Behavioral Health Services Mental Health Targeted Case Management Mental Health Rehabilitative Services [ ]']]
 EXHIBIT B-3 COMPENSATION Physician/Provider.c does not participate in above plan/program.
-------Table End--------

Start of Page No. = 28
TEXAS MEDICAID COMPLIANCE ADDENDUM - PROVIDER
This Texas Medicaid Provider Addendum ("Addendum") is incorporated by reference into the Agreement and applies to
Medicaid and CHIP products ("Medicaid Program(s)") and the eligible populations covered by the State Contract(s), between
Sample Company Name, Inc
("Community," "Company" or generally referred to in the State Contract as an MCO)
and
the Texas Health & Human Services Commission ("HHSC"), which can be found at
https://hhs.texas.gov/services/health/medicaid-chip/provider-information/managed-care-contracts-manuals.
This Addendum may be updated and amended unilaterally at any time in order to comply with any local, state, or federal
laws, rules, or regulations. If Community has delegated administrative functions to any Subcontractor under the Agreement,
Community shall notify Subcontractor and Subcontractor shall notify its Participating Providers regarding these changes as
soon as practicable after changes have been announced. If there is any conflict between the terms of this Addendum and
any of the other terms of the Agreement, the terms of this Addendum will govern and control; provided, however, if there is
any conflict between any of the terms of the Agreement, including this Addendum, and the State Contract (as defined below),
then the terms of the State Contract will govern and control.
SECTION 1 - DEFINITIONS
Many words and terms are capitalized throughout this Addendum to indicate that they are defined in Section 1. Capitalized
terms used and not otherwise defined in this Addendum shall have the meanings set forth in the Agreement or, if not defined
in the Agreement, in the State Contract(s) or under Texas Law.
For purposes of this Addendum, the term "Provider" means Participating Provider as defined in the Agreement. As
applicable, the term "Community" includes any Subcontractor delegated administrative functions by Community under the
Agreement or otherwise providing or arranging for the provision of Covered Services.
1.1
Acute Care. Preventative care, primary care, and other medical care provided under the direction of a physician
for a condition having a relatively short duration.
1.2
Behavioral Health Services. Covered Services for the treatment of mental, emotional, or chemical dependency
disorders.
1.3
Covered Services. Health Care Services Community must arrange to provide to Members, including all services
required by the State Contract, state and federal law, and all value added services required under the State Contract.
1,4
Children's Health Insurance Program or "CHIP". The health insurance program authorized and funded pursuant to
Title XXI, Social Security Act (42 U.S.C. §§ 1397aa-1397jj) and administered by Texas Health and Human Services
Commission ("HHSC").
1.5
CHIP Program. The State of Texas program in which HHSC contracts with managed care organizations to provide,
arrange for, and coordinate Covered Services for enrolled CHIP Members.
1,6
CHIP Perinatal Program. The State of Texas program in which HHSC contracts with managed care organizations
to provide, arrange for, and coordinate Covered Services for enrolled CHIP Perinate and CHIP Perinate Newborn Members.
Although the CHIP Perinatal Program is part of the CHIP Program, for administrative purposes, it is sometimes identified
independently in the State Contract.
1.7
Clean Claim. As set forth in subsection 4.2, a claim submitted by physician or provider for medical care or Health
Care Services rendered to a Member, with the data necessary for Community or subcontracted claims processors to
adjudicate and accurately report the claim. A Clean Claim other than a nursing facility services clean claim must meet all
requirements for accurate and complete data as defined in the appropriate 837-(claim type) encounter guides as follows:
(1) 837 Professional Combined Implementation Guide; (2) 837 Institutional Combined Implementation Guide; (3) 837
Professional Companion Guide; (4) 837 Institutional Companion Guide; or (5) National Council for Prescription Drug
Programs (NCPDP) Companion Guide.
1.8
Health Care Services. Acute Care, Behavioral Health care, and health-related services that an enrolled population
might reasonably require in order to be maintained in good health.
1.9
Material Subcontract." Any contract, Subcontract, or agreement between Community and another entity that meets
any of the following criteria:
(a) the other entity is an Affiliate of the MCO;
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(b) the Subcontract is considered by HHSC to be for a key type of service or function, including Administrative
Services (including, but not limited to, third party administrator, Network administration, and claims processing);
delegated Networks (including, but not limited to, behavioral health, dental, pharmacy, and vision); management
services (including management agreements with parent): reinsurance; Disease Management: pharmacy
benefit management ("PBM") or pharmacy administrative services; call lines (including nurse and medical
consultation); or
(c) any other Subcontract that exceeds, or is reasonably expected to exceed, the lesser of:
a. $500,000 per year, or
b. 1% of Company's annual Revenues under the State Contract.
(d) Any Subcontracts between Company and a single entity that are split into separate agreements by time period,
Program, or SDA, etc., will be consolidated for the purpose of this definition. For the purposes of the Agreement,
Material Subcontracts do not include contracts with any non-Affiliates for any of the following, regardless of the
value of the contract: utilities (e.g., water, electricity, telephone, Internet, trash), mail/shipping, office space,
maintenance, security, or computer hardware.
1.10 Medicaid. The medical assistance entitlement program authorized and funded pursuant to Title XIX, Social Security
Act (42 U.S.C. § 1396, et seq.) and administered by HHSC.
1.11
Medical Home. A patient-centered medical home as described in Texas Government Code § 533.0029(a).
1.12
Primary Care Physician or Primary Care Provider ("PCP"). A physician or provider who has agreed with Community
to provide a Medical Home to Members and who is responsible for providing initial and primary care to patients, maintaining
the continuity of patient care, and initiating referral for care.
1.13
State Contract. The HHSC Uniform Managed Care Contract ("UMCC") for Medicaid, CHIP and STAR+PLUS
Contract(s) where applicable.
1.14
Subcontractor. Any entity with a Material Subcontract with Community.
1.15
Texas Health Steps or THSteps. The name adopted by the State of Texas for the federally mandated Early and
Periodic Screening, Diagnosis and Treatment ("EPSDT") program. It includes the State's Comprehensive Care Program
extension to EPSDT, which adds benefits to the federal EPSDT requirements contained in 42 U.S.C. § 1396 and defined
and codified at 42 C.F.R. §§ 440.40 and 441.56-62. HHSC's rules are contained in 25 T.A.C., Chapter 33 (relating to Early
and Periodic Screening, Diagnosis and Treatment).
SECTION 2 - OBLIGATIONS OF COMMUNITY
2.1
Community will Initiate and maintain any action necessary to stop Provider or employee, agent, assign, trustee, or
successor-in-interest from maintaining an action against HHSC, an HHS Agency, or any Member to collect payment from
HHSC, an HHS Agency, or any Member, excluding payment for non-covered services. This provision does not restrict a
CHIP Provider from collecting allowable copayment and deductible amounts from CHIP Members. Additionally, this
provision does not restrict a CHIP Dental Network Provider from collecting payment for services that exceed a CHIP
Member's benefit cap.
SECTION 3 - OBLIGATIONS OF PROVIDER
3.1
Provider acknowledges that HHSC does not assume liability for the actions of, or judgments rendered against,
Community, its employees, agents or subcontractors or Subcontractors. Further, Provider understands and agrees that
there is no right of subrogation, contribution, or indemnification against HHSC for any duty owed to Provider by Community
or any judgment rendered against Community. HHSC's liability to Provider, if any, will be governed by the Texas Tort
Claims Act, as amended or modified (TEX, Civ. PRAC. & REM. CODE § 101.001, et seq.).
3.2
Pharmacy. If prior authorization for a medication is not immediately available, a 72-hour emergency supply may be
dispensed when the pharmacist on duty recommends it as clinically appropriate and when the medication is needed without
delay. Please consult the Vendor Drug Program Pharmacy Provider Procedures Manual, the Texas Medicaid Provider
Procedures Manual, and Community's Provider Manual (page 48) for information regarding reimbursement for 72-hour
emergency supplies of prescription claims. It is important that pharmacies understand the 72-hour emergency supply policy
and procedure to assist Medicaid clients.
3.3
Access to Records.
a.
Provider agrees to provide at no cost to HHSC: all information required under Community's managed care
contract with HHSC, including, but not limited to, the reporting requirements and other information related to Provider's
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performance of its obligations under that contract; and any information in its possession sufficient to permit HHSC to comply
with the federal Balanced Budget Act of 1997 or other federal or state laws, rules and regulations. All information must be
provided in accordance with the timelines, definitions, formats and instructions specified by HHSC.
b.
Provider agrees that upon receipt of a record review request from HHSC's Office of Inspector General
("OIG"), Special Investigative Units (SIUs) or another state or federal agency authorized to conduct compliance, regulatory,
or program integrity functions, Provider shall provide, at no cost to requesting agency. the records requested within 3
business days of the request. If the OIG, SIUs or another state or federal agency representative believes that the requested
records are about to be altered or destroyed or that the request may be completed at the time of the request and/or in less
than 24 hours, Provider shall provide the requested records at the time of the request and/or in less than 24 hours.
The request for records review may include, but is not limited to, clinical, medical or dental Member records, other records
pertaining to Member: any other records of services provided to Medicaid or other health and human services program
recipients and payments made for those services; documents related to diagriosis, treatment, service, lab results, charting,
billing records, invoices, documentation of delivery items, equipment, or supplies; radiographs and study models related to
orthodontia services; business and accounting records with backup support documentation; statistical documentation;
computer records and data; and/or contracts with providers and subcontractors.
Provider's failure to produce the records or make the records available for the purpose of reviewing, examining, and securing
custody of the records may result in the OIG imposing sanctions against Provider as described in 1 TEX. ADMIN. CODE,
Chapter 371, Subchapter G.
C.
Provider agrees to provide at no cost to the following entities or their designees with prompt, reasonable
and adequate access to this Agreement any records, books, documents, and papers that are related to this Agreement
and/or Provider's performance of its responsibilities under this Agreement:
(1) HHSC and MCO Program personnel from HHSC;
(2) U.S. Department of Health and Human Services;
(3) Office of Inspector General and/or the Texas Medicaid Fraud Control Unit;
(4) an independent verification and validation contractor or quality assurance contractor acting on behalf
of HHSC;
(5) state or federal law enforcement agency;
(6) special or general investigation committee of the Texas Legislature;
(7) the U.S. Comptroller General;
(8) the Office of the State Auditor of Texas; and
(9) any other state or federal entity identified by HHSC or any other entity engaged by HHSC.
Provider must provide access wherever it maintains such records, books, documents and papers. Provider must provide
such access in reasonable comfort and provide any furnishings, equipment and other conveniences deemed reasonably
necessary to fulfill the purposes described herein. Requests for access may be for, but are not limited to: examination,
audit, investigation, contract administration, the making of copies, excerpts or transcripts, or any other purpose HHSC
deems necessary for contract enforcement or to perform its regulatory functions.
d.
Provider understands and agrees that the acceptance of funds under this Agreement acts as acceptance
of the authority of the State Auditor's Office ("SAO"), or any successor agency, to conduct an investigation in connection
with those funds. Provider further agrees to cooperate fully with the SAO or its successor in the conduct of the audit or
investigation, including providing all records requested at no cost.
3.4
NPI and TPI. Providers serving Medicaid Members must enter into and maintain a Medicaid provider agreement
with HHSC or its agent to participate in the Medicaid Program, and must have a Texas Provider Identification Number
("TPI"). Provider shall have a National Provider Identifier ("NPI") in accordance with the timelines established in 45 C.F.R.
Part 162, Subpart D. For purposes of this section, "national provider identifier" means the national provider identifier required
under Section 1128J(e), Social Security Act (42 U.S.C. Section 1320a-7k(e)).
3.5
Administrative Requirements. Provider must inform Community and HHSC's administrative services contractor of
any change to Provider's address, telephone number, group affiliation, etc.
3.6
Professional Conduct. While performing the services described in this Agreement, Provider agrees to comply with
applicable state laws, rules, and regulations and HHSC's requests regarding personal and professional conduct generally
applicable to the service locations; and otherwise conduct themselves in a businesslike and professional manner.
3.7
Quality Assessment and Performance and Improvement ("QAPI"). Provider agrees to comply with Community's
QAPI Program requirements.
3.8
Early Childhood Intervention ("ECI"), Provider must cooperate and coordinate with local ECI programs to comply
with federal and state requirements relating to the development, review and evaluation of Individual Family Service Plans
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("IFSP"). Provider understands and agrees that any Medically Necessary Health and Behavioral Health Services contained
in an IFSP must be provided to the Member in the amount, duration, scope and setting established in the IFSP.
3,9
Women, Infants and Children ("WIC"). Provider must coordinate with the WIC Special Supplemental Nutrition
Program to provide medical information necessary for WIC eligibility determinations, such as height, weight, hematocrit or
hemoglobin.
3.10
Tuberculosis ("TB"), Provider must coordinate with the local TB control program to ensure that all Members with
confirmed or suspected TB have a contact investigation and receive Directly Observed Therapy (DOT). The Network
Providers must report to the Texas Department of State Health Services (DSHS) or the local TB control program any
Member who is non-compliant, drug resistant, or who is or may be posing a public health threat.
3.11
Lead Screening. Provider agrees (1) report all blood lead results to the Childhood Lead Poisoning Program (if
not performed at the DSHS state laboratory) and, (2) follow-up on suspected or confirmed cases of Childhood lead exposure
with the Childhood Lead Poisoning Prevention. Program, and follow the Centers for Disease Control and Prevention
guidelines for testing children for lead and follow-up actions for children with elevated lead levels located at
http://www.dshs.state.tx.us/lead/pdf_files/pb_109_physician reference.pdf.
3.12
Waiting Times for Appointments. Provider must provide:
(a) Emergency Services upon Member presentation at the service delivery site, including at non-network and out-
of-area facilities (where applicable);
(b) Treatment for an Urgent condition, including urgent specialty care, within 24 hours (where applicable);;
(c) Routine primary care within 14 days;
(d) Specially routine care within 21 days;
(e) initial outpatient behavioral health visits within 14 days (this requirement does not apply to CHIP Perinate
Members):
(f) Non-urgent specialty care within 60 days (this requirement applies to STAR Health only);
(g) Pre-natal care within 14 days, except for high-risk pregnancies or new Members in the third trimester, for whom
an appointment must be offered within 5 days, or immediately, if an emergency exists (where applicable); and
(h) Preventive health services including annual adult well checks for Members 21 years of age or older must be
offered within 90 Days (where applicable);
(i) Preventive health services for Members less than 6 month of age must be provided within 14 days. Preventive
health services for Members 6 months through age 20 must be provided within 60 Days. CHIP Members should
receive preventive care in accordance with the American Academy. of Pediatrics (AAP) periodicity schedule.
Medicaid Members should receive preventive care in accordance with the Texas Health Steps periodicity
schedule.
In addition, PCPs must make referrals for specialty care on a timely basis, based on the urgency of the Member's medical
condition, but no later than 30 days.
3.13 Cancellation of Product Orders. Provider that offers delivery services for covered products, such as durable medical
equipment (DME), limited home health supplies (LHHS), or outpatient drugs or biological products must reduce, cancel, or
stop delivery if the Member or the Member's authorized representative submits an oral or written request. Provider must
maintain records documenting the request.
SECTION 4 - COMPENSATION
4.1
Claims Payment. The method of payment applicable to this Agreement is described in the applicable Compensation
Addendum, If Provider is reimbursed based on the Texas Medicaid Fee Schedule, the rates are set by the State Medicaid
Program and are available at http://www.tmhp.com.
4.2
Claims Submission. Provider must file a Clean Claim with Community within 95 days from the date of service. The
required data elements for Medicaid claims must be present for a claim to be considered a Clean Claim and can be-found
in the Section 8 "Managed Care" of the Texas Medicaid Provider Procedures Manual.
Community will notify Provider at least 90 days prior to implementing a change in the above-referenced claims guidelines,
unless the change is required by statute or regulation in a shorter timeframe.
Provider must submit claims for processing and/or adjudication to the following entity/entities or as set forth in the Provider
Manual:
Page 31 of 38


-------Table Start--------
bb09cfe5-352b-45e5-b0c9-a0ea849d6018
[['Electronic submission', 'Payer ID 12345'], ['Paper Claims', 'Sample Company Name P.O. Box 123456']]
 Provider must submit claims for processing and/or adjudication to the following entity/entities or as set forth in the Provider Manual:
-------Table End--------

Start of Page No. = 32
Provider may call 123-456-7890
for all claims inquiries.
Community will notify Provider in writing of any changes in the list of claims processing and adjudication entities at least 30
days prior to the effective date of change. If Community is unable to provide 30 days' notice, Community will give Provider
a 30-day extension on its claims filing deadline to ensure claims are routed to the correct processing center.
4.3
Corrected Claims. A Corrected Claim is a claim that has already been adjudicated, whether paid or denied, Provider
must submit a Corrected Claim if the original claim adjudicated needs to be changed. A Corrected Claim could be'a result
of:
a) Errors were found involving diagnosis, procedure, date or modifier.
b) Claims contained missing, incorrect, or incomplete data according to our claims submission requirements.
c) Services were missed in an original claim.
d) Original claim billed with incorrect number of units or billed amount.
When submitting a corrected claim on a CMS 1500, Provider must clearly mark the claim as "Corrected Claim" along with
the original claim number in box 22 form along with resubmission code of 7. When submitting a corrected claim on a UB
04, Provider must clearly mark the claim as "Corrected Claim" along with the third digit of Type. of Bill indicated as Frequency
code 7.
Corrected Claims must be sent within 120 days of initial claim disposition. Failure to mark the claim as "corrected" could
result in a duplicate claim and be denied for exceeding the 95 days timely-filing deadline
4,4
Supervised Providers. If Provider, including a nurse practitioner or physician assistant, provides a referral for or
orders health care services for a recipient or enrollee, as applicable, at the direction or under the supervision of another
provider, and the referral or order is based on the supervised provider's evaluation of the recipient or enrollee, the names
and associated national provider identifier numbers of the supervised provider and the supervising provider must be included
on any claim for reimbursement submitted by a provider based on the referral or order as required by TEX. Gov. CODE
§
531.024161.
4.5
Adjudication of Claims. Community shall adjudicate (finalize as paid or denied adjudicated) Clean Claims for:
(a) healthcare services within 30 days from the date the claim is received by the MCO;
(b) pharmacy services no later than 18 days of receipt if submitted electronically, or 21 days of receipt if submitted
non-electronically; and
(c) Community will pay Providers interest at a rate of 18% per annum on all clean claims that are not adjudicated
within 30 days.
Community must withhold all or part of payment for any claim submitted by a Provider for any of the following reasons:
a) excluded or suspended from the Medicare, Medicaid, or CHIP programs for Fraud, Abuse, or Waste;
b) on payment hold under the authority of HHSC or its authorized agent(s);
c)
with debts, settlements, or pending payments due to HHSC, or the state or federal government;
d) for neonatal services provided on or after September 1, 2017, if submitted by a Hospital that doès not have
neonatal level of care designation from HHSC;
e) for maternal services provided on or after September 1, 2019, if submitted by a Hospital that does not have a
maternal level of care designation from HHSC,
In accordance with Texas Health and Safety Code § 241.186, the restrictions on payment identified in items (d) and (e)
above do not apply to emergency services that must be provided or reimbursed under state or federal law.
4.6
Claim Audits. With the following exceptions, Community must complete all audits of a Provider claim no later than
2 years after receipt of a Clean Claim, regardless of whether the Provider participates in the Community's network:
a) in cases of provider Fraud, Waste, or Abuse that Community did not discover within the 2-year period following
receipt of a claim;
b) when regulatory officials or entities conclude an examination, audit, or inspection of a Provider more than 2
years after Community received the claim;
c) when HHSC has recovered a capitation from Community based on a Member's ineligibility.
Page 32 of 38


-------Table Start--------

[[None, 'Coppell, TX 77230-1404'], ['Certified Mail', 'Sample Company Name 123 Maple Street, Springfield, Coppell, TX 77054']]
None
-------Table End--------

Start of Page No. = 33
If an exception to the 2-year limitation applies, then Community may recoup related payments from providers.
If an additional payment is due to Provider as a result of an audit, Community must make the payment no later than 30 days
after it completes the audit. If the audit indicates that Community is due a refund from Provider, except for retroactive
changes to a Member's Medicaid eligibility, Community must send Provider written notice of the basis and specific reasons
for the recovery no later than 30 days after it completes the audit. If the provider disagrees with Community's request,
Community must give Provider an opportunity to appeal, and may not attempt to recover the payment until the provider has
exhausted all appeal rights.
4.7
Co-payments and Deductibles. Co-payments are the only amounts that Provider may collect from CHIP Members,
except for costs associated with unauthorized non-emergency services provided to a Member by out-of-network providers
for non-covered services.
Provider is responsible for collecting at the time of service any applicable CHIP co-payments or deductibles in accordance
with CHIP cost-sharing limitations.
Providers shall not charge: (a) cost-sharing or deductibles to CHIP Members of Native American Tribes or Alaskan Natives;
(b) co-payments or deductibles to the CHIP Member with an ID card that indicates the Member has met his or her cost-
sharing obligation for the balance of their term of coverage; (c) co-payments for well-child or well-baby visits or
immunizations; or (d) co-payments for routine preventive and diagnostic dental services (CHIP Dental).
4.8
Liability for Payment of Services. Provider understands and agrees that HHSC is not liable or responsible for
payment for Covered Services rendered pursuant to the Agreement. In no event, including, but not limited to, nonpayment
by Community, Community's insolvency or breach of this Agreement, shall Provider bill, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any recourse against a Member or persons other than
Community acting on their behalf for Covered Services provided pursuant to this Agreement. Provider further understands
and agrees that Community's Members may not be held liable for Community's debts in the event of Community's
insolvency. This provision shall not prohibit collection from a Member for any non-covered service and/or Copayment
amounts in accordance with the terms of the applicable Member's health benefits and this Agreement. Provider further
agrees that: (1) this provision shall survive the termination of this Agreement regardless of the cause giving rise to
termination and shall be construed to be for the benefit of the Member; and (2) this provision supersedes any oral or written
contrary agreement now existing or hereafter entered into between Provider and Member, or persons acting on their behalf.
In the event Community becomes insolvent or ceases operations, Provider understands and agrees that its sole recourse
against Community will be through the Community's bankruptcy, conservatorship, or receivership estate.
4.9
Third Party Recovery. Provider understands and agrees that it may not interfere with or place any liens upon the
State's right or Community's right, acting as the State's agent, to recovery from third-party resources.
After 120 days from the date of adjudication (on any claim, encounter, or other Medicaid related payment made by
Community, wherein the claim, encounter, or payment is subject to Third Party Recovery), HHSC may attempt recovery,
independent of any action by Community. HHSC will retain, in full, all funds received as a result of any state-initiated
recovery or subrogation action.
4.10
Costs of Non-Covered Services. Provider must inform Members of the cost for non-covered services prior to
rendering such services and must obtain a signed Private Pay form from such Member.
4.11 Claims Payment. Violations of the Medicaid program arising out of performance of the Agreement are subject to
administrative enforcement by the OIG as specified in 1 TEX. ADMIN. CODE, Chapter 371, Subchapter G.
4.12 Overpayments. An overpayment can be identified by the Provider or Community. If Provider identifies the
overpayment, Provider must submit a refund check all with an explanation of refund and/or Explanation of Payment (EOP)
to Community or call Provider Services at 713-295-2295 and approve a recoupment from any future payments to Provider.
If Community identifies the overpayment, a recovery letter will be sent to Provider, Provider has 45 days to submit a refund
check or appeal the refund request. If Provider does not respond within 45 days from the date of the recovery letter, then
Community will begin the recoupment on any future payments. In the event Members retroactively dis-enroll from
Community as a result of changes in their eligibility, Community reserves the right to automatically recover payments made
to Provider for services rendered to those Members.
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SECTION 5 - DISPUTE RESOLUTION
5.1
Complaints and Appeals. Community's complaint and appeal processes applicable to Provider under the terms of
this Agreement are set forth in the Provider Manual. Specifically, a Provider may file a complaint at any time with
Community. Send Complaints to:
Sample Company Name
Attn: Services Improvement Team
123 Maple Street, Springfield,
Houston. TX 77054
Fax: 123.456.7890
Email: Servicelmprovement@companyname.org
Complaints may also be submitted online at the Community Web site https://www.companyname.org
Community
shall acknowledge all written complaints within five business days. If a Provider's complaint is oral, Community's
acknowledgement letter shall include a one-page Complaint Form. Community shall acknowledge, investigate and resolve
all complaints no later than the 30th calendar day after the date Community receives written complaint or one-page complaint
form from the complainant. Community will retain all Provider complaint documentation, including fax cover sheets, emails
to and from Community, and a telephone log of communication related to the complaint.
Provider understands and agrees that HHSC reserves the right and retains the authority to make reasonable inquiry and to
conduct investigations into Provider and Member complaints.
5.2
Claim Appeals. An appealed claim is a claim that has been previously adjudicated as a Clean Claim and the Provider
is appealing the disposition through written notification to Community. Provider must request Claim Appeals within 120
days from the date of remittance of the Explanation of Payment (EOP).
SECTION 6 - CONFIDENTIALITY
6.1
Provider agrees to treat all information that is obtained through the performance of the services included in this
Agreement as confidential information to the extent that confidential treatment is provided under state and federal laws,
rules and regulations. This includes, but is not limited to, information relating to applicants or recipients of HHSC Programs.
6.2
Provider agrees it shall not use information obtained through the performance of this Agreement in any manner
except as is necessary for the proper discharge of obligations and securing of rights under this contract.
6.3
Provider agrees to protect the confidentiality of Member Protected Health Information ("PHI"), including patient
records. Provider must comply with all applicable federal and state laws, including the HIPAA Privacy and Security Rule
governing the use and disclosure of PHI.
SECTION 7 - FRAUD AND ABUSE
7.1 Provider acknowledges and agrees to the following:
(1) HHSC Office of Inspector General ("OIG") and/or the Texas Medicaid Fraud Control Unit must be allowed to
conduct private interviews of Network Providers and their employees, agents, contractors, and patients;
requests for information from such entities must be complied with, in the form and language requested;
Providers and their employees, agents, and contractors must cooperate fully with such entities in making
themselves available in person for interviews, consultation, grand jury proceedings, pre-trial conference,
hearings, trials at the Network Provider's own expense; and compliance with these requirements will be at the
Provider's own expense.
(2) Providers are subject to all state and federal laws and regulations relating to fraud, abuse or waste in health
care or dental care and the Medicaid and/or CHIP Programs, as applicable.
(3) Providers must cooperate and assist HHSC and any state or federal agency that is charged with the duty of
identifying, investigating, sanctioning or prosecuting suspected fraud, abuse or waste.
(4) Providers must provide originals and/or copies of any and all information as requested by HHSC or the state or
federal agency, allow access to premises, and provide records to the Office of Inspector General, HHSC, the
Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Health and Human Services, FBI,
TDI, the Texas Attorney General's Medicaid Fraud Control Unit or other unit of state or federal government,
upon request, and free-of-charge.
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(5) If the Provider places required records in another legal entity's records, such as a hospital, the Network Provider
is responsible for obtaining a copy of these records for use by the above-named entities or their representatives.
(6) Network Providers must report any suspected fraud or abuse including any suspected fraud and abuse
committed by the MCO or a Member to the HHSC Office of Inspector General.
SECTION 8 - INSURANCE
8.1
Provider shall maintain, during the term of the Provider contract, Professional Liability Insurance of at least $100,000
per occurrence and $300,000 in the aggregate, or, where applicable, the limits required by the hospital at which Provider
has admitting privileges.
8.2
Subsection 8.1 does not apply if Provider is a state or federal unit of government, or a municipality, that is required
to comply with, and is subject to, the provisions of the Texas and/or Federal Tort Claims Act.
SECTION 9 - LAWS, RULES AND REGULATIONS
9.1
Liability for Violation of Applicable Laws. Provider understands and agrees that it is subject to all state and federal
laws, rules, regulations, waivers, policies and guidelines, and court-ordered consent decrees, settlement agreements or
other court orders that apply to this Agreement and Community's managed care contract with HHSC, the Community
Program, and all persons or entities receiving state and federal funds. Provider understands and agrees that any violation
by a provider of a state or federal law relating to the delivery of services pursuant to this Provider Agreement, or any violation
of Community's contract with HHSC could result in liability for money damages, and/or civil or criminal penalties and
sanctions under state and/or federal law.
9.2
Applicable Laws. Provider further understands and agrees that the following laws that apply to the Agreement
include, but are not limited to, the following laws, rules, regulations and all amendments or modifications thereto, apply to
this Agreement:
a.
environmental protection laws:
(1)
Pro-Children Act of 1994 (20 U.S.C. § 6081, et seq.) regarding the provision of a smoke-free
workplace and promoting the non-use of all tobacco products;
(2)
National Environmental Policy Act of 1969 (42 U.S.C. § 4321, et seq.) and Executive Order 11514
("Protection and Enhancement of Environmental Quality") relating to the institution of environmental
quality control measures;
(3)
Clean Air Act and Water Pollution Control Act regulations (Executive Order 11738, "Providing for
Administration of the Clean Air Act and Federal Water Pollution Control Act with Respect to Federal
Contracts, Grants, and Loans");
(4)
State Clean Air Implementation Plan (42 U.S.C. § 740, et seq.) regarding conformity of federal
actions to State Implementation Plans under § 176(c) of the Clean Air Act; and
(5)
Safe Drinking Water Act of 1974 (21 U.S.C. § 349; 42 U.S.C. § 300f to 300j-9) relating to the
protection of underground sources of drinking water.
b.
state and federal anti-discrimination laws:
(1)
Title VI of the Civil Rights Act of 1964, (42 U.S.C. § 200d, et seq.) and as applicable 45 C.F.R. Part
80 or 7 C.F.R. Part 15;
(2)
Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794));
(3)
Americans with Disabilities Act of 1990 (42 U.S.C. § 12101, et seq.);
(4)
Age Discrimination Act of 1975 (42 U.S.C. §§ 1681-1688);
(5)
Title IX of the Education Amendments of 1972 (20 U.S.C. §§ 1681-1688);
(6)
Food Stamp Act of 1977 (7 U.S.C. § 1101, et seq.);
(7)
Executive Order 13279, and its implementing regulations at 45 C.F.R. Part 87 or 7 C.F.R. Part 16;
and
(8)
the HHS agency's administrative rules, as set forth in the Texas Administrative Code, to the extent
applicable to this Agreement.
C.
the Immigration Reform and Control Act of 1986 (8 U.S.C. § 1101, et seq.) and the Immigration Act of 1990
(8 U.S.C. § 1101, et seq.) regarding employment verification and retention of verification forms;
d.
the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191); and
e.
the Health Information Technology for Economic and Clinical Health Act (HITECH Act) at 42 U.S.C. §
17931, et seq.
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9.3
Marketing. Provider agrees to comply with state and federal laws, rules and regulations governing marketing.
Provider agrees to comply with HHSC's marketing policies and procedures, as set forth in HHSC's Uniform Managed Care
Manual. Provider is prohibited from engaging in direct marketing to Members that is designed to increase enrollment in a
particular health plan. The prohibition should not constrain Provider from engaging in permissible marketing activities
consistent with broad outreach objectives and application assistance.
9.4.
Member Protections.
Provider must inform Community of any reports of abuse, neglect or exploitation made
regarding a Member. This includes self-reports and reports made by others that Provider becomes aware of.
SECTION 10 - MEMBER COMMUNICATIONS
10.1
Nothing contained in this Agreement is intended to interfere with or hinder communications between Provider and
Member regarding a patient's medical condition and/or treatment options; Community's referral policies, and other
Community policies, including financial incentives or arrangements and all managed care plans with whom the Provider
contracts.
SECTION 11 - PRIMARY CARE PHYSICIANS AND PRIMARY CARE PROVIDERS
11.1
Accessibility. If Provider is a PCP, it must be accessible to Members 24 hours per day, 7 days per week.
11.2
Preventative Care. If Provider is a PCP, it must provide preventative care to children under age 21 in accordance
with AAP recommendations for CHIP Members and CHIP Perinatal Newborns; the THSteps periodicity schedule published
in the THSteps Manual for Medicaid Members; and to adults in accordance with the U.S. Preventative Task Force
requirements.
11.3
Referral and Coordination of Care. If Provider is a PCP, it must assess the medical needs and behavioral health
needs of Members for referral to specialty care providers and provide referrals as needed; coordinate Members' care with
specialty care providers after referral; and serve as a Medical Home to Members.
SECTION 12 - TERMINATION
12.1
Termination. Community shall follow the procedures outlined in $843.306 of the Texas Insurance Code and 28
Tex. Admin. Code § 11.901 when terminating the Agreement with Provider.
In addition to the Termination section of the Agreement, the following provisions apply:
Community must notify HHSC within five Days after termination of (1) a Primary Care Provider (PCP) contract that impacts
more than 10 percent of its Members or (2) any Provider contract that impacts more than 10 percent of its Network for a
provider type by Service Area and Program. Community must make a good faith effort to give written notice of termination
of a Provider to each Member who receives his or her primary care, or who is seen on a regular basis by, the Provider as
follows:
(1) For involuntary terminations of a Provider (terminations initiated by Community), Community must provide notice to
the Member of the Provider's termination from the network within 15 Days of either expiration of the provider's
advance notice period or once the provider has exhausted rights to appeal. In cases of imminent harm to Member
health, the MCO must give the Member notice immediately that the Provider will be terminated even if a final
termination notice to the Provider has not been issued.
(2) For voluntary terminations of a Provider (terminations initiated by the Provider), Community must provide notice to
the Member 30 Days prior to the termination effective date. In the event that the Provider sends untimely notice of
termination to Community making it impossible for Community to send Member notice within the required timeframe,
Community must provide notice as soon as practical but no more than 15 days after Community receives notice to
terminate from the Provider. Community must send notice to: (1) all its Members in a PCP's panel, and (2) all its
Members who have had two or more visits with the Provider for home-based or office-based care in the past 12
months.
12.2
Termination for Gifts or Gratuities. Provider may not offer or give anything of value to an officer or employee of
HHSC or the State of Texas in violation of state law. A "thing of value" means any item of tangible or intangible property
that has a monetary value of more than $50.00 and includes, but is not limited to, cash, food, lodging, entertainment and
charitable contributions. The term does not include contributions to public office holders or candidates for public office that
are paid and reported in accordance with state and/or federal law. Community may terminate this Provider contract at any
time for violation of this requirement.
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SECTION 13 - BEHAVIORAL HEALTH
13.1
If Provider is a PCP, it must have screening and evaluation procedures for detection and treatment of, or referral
for, any known or suspected behavioral health problems and disorders.
13.2 Providers who provide inpatient psychiatric services to a Member must schedule the Member for outpatient follow-
up and/or continuing treatment prior to discharge. The outpatient treatment must occur within 7 days from the date of
discharge. Behavioral Health providers must contact Members who have missed appointments within 24 hours to
reschedule appointments.
13.3
All behavioral and physical health providers (including PCPs, OB/GYNs, internists, and other relevant provider
types) must share amongst each other clinical information regarding Members with co-occurring behavioral and
physical health conditions, to the extent allowed by federal law.
ADDITIONAL PROVISIONS SPECIFIC TO MEDICAID
1.
Durable Medical Equipment. Please consult the Texas Medicaid Provider Procedures Manual, Durable Medical
Equipment (DME) and Comprehensive Care Program (CCP) sections, and Community's Provider Manual
(Pharmacy and Benefits sections) for information regarding the scope of coverage of durable medical equipment
(DME) and other products commonly found in a pharmacy. For qualified children, this includes medically necessary
over-the-counter drugs, diapers, disposable/expendable medical supplies, and some nutritional products. It also
includes medically necessary nebulizers, ostomy supplies or bed pans, and other supplies and equipment for all
qualified Members. Community encourages your pharmacy's participation in providing these items to Medicaid
clients.
2.
Family Planning. If a Member requests contraceptive services or family planning services, Provider must provide
Member counseling and education about family planning and available family planning services. Provider shall not
require parental consent for Members who are minors to receive family planning services. Provider must comply
with state and federal laws and regulations governing Member confidentiality (including minors) when providing
information on family planning services to Members.
3.
THSteps. Provider must send all THSteps newborn screens to the Texas Department of State Health Services
("DSHS") or a DSHS-certified laboratory. Providers must include detailed identifying information for all screened
newborn Members and each Member's mother to allow HHSC to link the screens performed at hospitals with
screens performed at the 2-week follow-up visit.
PCPs must:
a. either be enrolled as THSteps providers or refer Members due for a THSteps check-up to a THSteps
provider;
b.
refer Members for follow-up assessments or interventions clinically indicated as a result of the THSteps
check-up, including the developmental and behavioral components of the screening;
C.
submit information from the THSteps forms and documents to the Health Passport.
4.
Provider Fraud and Abuse Policy. If Provider receives annual Medicaid payments of at least $5 million dollars
(cumulative, from all sources), Provider must:
a.
Establish written policies for all employees, managers, officers, contractors, subcontractors and agents of
Provider. The policies must provide detailed information about the False Claims Act, administrative
remedies for false claims and statements, any state laws about civil or criminal penalties for false claims,
and whistleblower protections under such laws, as described in Section 1902(a)(68)(A) of the Social
Security Act.
b.
Include as part of such written policies detailed provisions regarding Provider's policies and policies and
procedures for detecting and preventing fraud, waste and abuse.
C.
Include in any employee handbook a specific discussion of the laws described in Section 1902(a)(68)(A) of
the Social Security Act, the rights of employees to be protected as whistleblowers, and Provider's policies
and procedures for detecting and preventing fraud, waste and abuse.
5.
Advance Directives. Provider must comply with requirements of state and federal laws, rules and regulations
relating to advance directives.
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Referral and Coordination of Care. If Provider is a PCP, it must assess the medical needs and behavioral health
needs of Members for referral to specialty care providers and provide referrals as needed; coordinate Members'
care with specialty care providers after referral; and serve as a Medical Home to Members.
6.
Payment for Services. Provider is prohibited from billing or collecting from a Medicaid Member for health care
services provided pursuant to the Agreement. Federal and state laws provide severe penalties for any provider to
bill or collect any payment from a Medicaid recipient for a Covered Service.
7.
Mental Health. Provider must comply with 25 Tex. Adm. Code, Part 1, Chapter 415, Subchapter F, "Interventions
in Mental Health Services," when providing mental health rehabilitation services and mental health targeted case
management.
8.
Electronic Visit Verification. Network Providers using the EVV system must maintain compliance with HHSC
minimum standards detailed in UMCM, Chapter 8.7, Section IX.
9.
Service Coordination. All Home and Community Support Services Agency (HCSSA) providers, adult day care
providers, and residential care facility providers must notify the MCO if a Member experiences any of the following:
a) a significant change in the Member's physical or mental condition or environment; b) hospitalization; c) an
emergency room visit; or d) two or more missed appointments.
10.
Waiting Times for Appointments. In addition to the requirements in 3.12 of this Addendum, Community Long-Term
Services and Supports for Members must be initiated within 7 days from the start date on the Individual Service
Plan or the eligibility effective date for non-waiver LTSS unless the referring provider, Member, or STAR+PLUS
Handbook states otherwise.
[END OF PAGE]
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