query-orchestration/assets/sampleOne/cnc_01-06.txt

Document Index
AMENDMENT NUMBER ONE   1PARTICIPATING PROVIDER AGREEMENT   1
Attachment A: Medicaid   3
EXHIBIT 2   3COMPENSATION SCHEDULE   3PROFESSIONAL SERVICES   3
Additional Provisions:   3
Definitions:   4



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AMENDMENT NUMBER ONE
PARTICIPATING PROVIDER AGREEMENT
This Amendment Number One ("Amendment") is entered into as of December 1. 2019 by and between Dummy
HealthCare Inc. ("Health Plan") and Picture, LLC Novelty Pharmacy
("Provider"), collectively reterred to
herein as the "Parties".
WHEREAS, Health Plan and Provider have previously entered into a Participating Provider Agreement (the
"Agreement") effective as of January 1. 2017 (defined in the Agreement as the "Effective Date"); and
WITEREAS, the Parties desire to amend the Agreement;
NOW THEREFORE, in consideration of the promises and mutual covenants herein contained. the Parties agree as
follows:
1.
Attachment A: Medicaid Exhibit 2 Compensation Schedule Professional Services shall be added
and
incorporated into the Agreement as shown by the attached.
2. All other terms and conditions of the Agreement and any amendments thereto, if any, shall remain in full
force and effect. If the terms of this Amendment conflict with any of the terms of the Agreement. the terms
of this Amendment shall prevail.
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IN WITNESS WHEREOF. the Parties hereto have executed and delivered this
Amendment as of the date first set forth above.
HEALTH PLAN:
PROVIDER:
Dummy HealthCare Inc.
LLC Novelty Pharmacy
Authorized Signature
Authorized Signature
Bank
Mark Chappman
Jake Parelta
Printed Name:
Printed Name:
Title: PRocedent
Title: RPinCharge
Date: 11/19/9
Date: 11/15/19
ECM #: 112233
Tax ID Number: 12-3456789
State Medicaid Number: 0123456789
National Provider Identifier: 123456789
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Attachment A: Medicaid
EXHIBIT 2
COMPENSATION SCHEDULE
PROFESSIONAL SERVICES
Picture,
LLC Novelty Pharmacy
This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for
Covered Services provided by Contracted Providers to Covered Persons enrolled in a Medicaid Product. Where the
Contracted Provider's tax identification number ("TIN") has been designated by the Payor as subject to this
Compensation Schedule. Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by
the Contracted Provider according to the terms of, and subject to the requirements set forth in, the Agreement and
this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set
forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule
shall have the meanings set forth in the Agreement, the applicable Product Attachment. or the Definitions section set
forth at the end of this Compensation Schedule.
The maximum compensation for professional Covered Services rendered to a Covered Person shall be the "Allowed
Amount." Except as otherwise provided in this Compensation Schedule. the Allowed Amount for professional
Covered Services is the lesser of: (i) Allowable Charges; or (ii) one hundred percent (100%) of the Payor's Medicaid
fee schedule.
Additional Provisions:
1.
Code Change Updates. Payor utilizes nationally recognized coding structures (including. without limitation,
revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or their
successors) for basic coding and descriptions of the services rendered. Updates to billing-related codes shall
become effective on the date ("Code Change Effective Date") that is the later of: (i) the first day of the month
following sixty (60) days after publication by the governmental agency having authority over the applicable
Product of such governmental agency's acceptance of such code updates, (ii) the effective date of such code
updates as determined by such governmental agency or (iii) if a date is not established by such governmental
agency or the applicable Product is not regulated by such governmental agency. the date that changes are made
to nationally recognized codes. Such updates may include changes to service groupings. Claims processed prior
to the Code Change Effective Date shall not be reprocessed to reflect any such code updates.
2.
Fee Change Updates. Updates to the fee schedule shall become effective on the effective date of such fee
schedule updates. as determined by the Payor ("Fee Change Effective Date"). The date of implementation of any
fee schedule updates. i.e. the date on which such fee change is first used for reimbursement ("Fee Change
Implementation Date"). shall be the later of: (i) the first date on which Payor is reasonably able to implement the
update in the claims payment system; or (ii) the Fee Change Effective Date. Claims processed prior to the Fee
Change implementation Date shall not be reprocessed to reflect any updates to such fee schedule. even if service
was provided after the Fee Change Effective Date.
3.
Modifier, Unless specifically indicated otherwise, fee amounts listed in the fee schedule represent global fees
and may be subject to reductions based on appropriate Modifier (for example, professional and technical
modifiers). As used in the previous sentence, "global fees" refers to services billed without a Modifier, for which
the fee amount includes both the professional component and the technical component. Any Cost-Sharing
Amounts that the Covered Person is responsible to pay under the Coverage Agreement will be subtracted from
the Allowed Amount in determining the amount to be paid.
4.
Anesthesia Modifier Pricing Rules. The dollar amount that will be used in the calculation of time-based and non-
time based anesthesia management fees in accordance with the anesthesia payment policy. Unless specifically
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stated otherwise, the anesthesia conversion factor indicated is fixed and will not change. The anesthesia
conversion factor is based on an anesthesia time unit value of 15 minutes.
5. Payment for Multiple Procedures. Where multiple outpatient surgical or scope procedures performed on a
Covered Person during a single occasion of surgery, reimbursement will be as follows: i) the procedure for which
the Allowed Amount under this Compensation Schedule is greatest will be reimbursed at one hundred percent
(100%) of such Allowed Amount; and ii) the other procedures under this Compensation Schedule will each be
reimbursed at fifty percent (50%) of such Allowed Amounts..
6. Place of Service Pricing Rules. This fee schedule follows CMS guidelines for determining when services are
priced at the facility or non-facility fee schedule (with the exception of services performed at Ambulatory Surgery
Centers. POS 24, which will be priced at the facility fee schedule).
7. Payment under this Compensation Schedule. All payments under this Compensation Schedule are subject to the
terms and conditions set forth in the Agreement. the Provider Manual and any applicable billing manual.
Definitions:
1. Allowed Amount means the amount designated in this Compensation Schedule as the maximum amount payable
to a Contracted Provider for any particular Covered Service provided to any particular Covered Person, pursuant
to this Agreement or its Attachments.
2. Allowable Charges means a Contracted Provider's billed charges for services that qualify as Covered Services.
3. Cost-Sharing Amounts means any amounts payable by a Covered Person. such as copayments. cost-sharing,
coinsurance, deductibles or other amounts that are the Covered Person's financial responsibility under the
applicable Coverage Agreement. if applicable.
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