Michael McGuinness
752fb2e2c0
Text Extraction Clean Up + Parallelization * merged_Call * directchildren * bitofimprovements * go * parallel * fixfullsuite * pondforconcurrency * comments * muchdone * bitsofclean * stabilisedtests * snappy * threadpooltests * childelements * testspassed
78 KiB
78 KiB
| 1 | Contract Name | Parent Agreement Code | Pages | Page_Num | Attachment/Exhibit | Line of Business | Provider Type | Provider Type - Level 2 | IP/OP | Service Type | Plan Type | Lesser of Logic language, included (Y/N) | Lesser of Rate | Reimb. Methodology | Reimb. Methodology_Short | If rate is % of Payor or MCR [STANDARD] | If rate is % of Payor or MCR [STANDARD]_Short | FLAT FEE | Default Term | Default Rate | Medical Necessity Language (Language) | Medical Necessity Language (Y/N) | Inclusion of essential RBRVS "Fee Source" Language (Y/N) | CDM Neutralization Language, included (Y/N) | CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE | Add On Reimbursement (Language) | Add On Reimbursement (Y/N) | IP - DSH/IME/UC, included (Y/N) | IP - Stoploss Catastrophic Threshold | Exclusions | Not to Exceed | Escalator or COLA (Y/N) | Escalator I, Eff. Date | Single Code Multiple Rates (Y/N) | Single Code Multiple Rates (Language) | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 | 0 | Filename: chc_1.txt | 1 | 38 | 24 | EXHIBIT B-1 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | STAR | N | All Covered Services except those listed below: one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 3 | 1 | Filename: chc_1.txt | 1 | 38 | 24 | EXHIBIT B-1 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | STAR+PLUS | N | All Covered Services except those listed below: one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 4 | 2 | Filename: chc_1.txt | 1 | 38 | 24 | EXHIBIT B-1 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | CHIP Perinatal | N | All Covered Services except those listed below: one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 5 | 3 | Filename: chc_1.txt | 1 | 38 | 25 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Medicaid | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 6 | 4 | Filename: chc_1.txt | 1 | 38 | 25 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services | Medicaid | Y | 100% of AC | 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: Applied Behavior Analysis (ABA) Services and Rates | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||||
| 7 | 5 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | All Covered Services except those listed below | Medicaid | N | one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 8 | 6 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - 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 | Medicaid | N | Procedure Code : 97154 | Description : 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 | Rate Per Unit (15 minutes) : $ $11.00 | Flat Fee | $11.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 9 | 7 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - 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 | Medicaid | N | Procedure Code : 97155 | Description : 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 | Rate Per Unit (15 minutes) : $ 30.00 | Flat Fee | $30.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 10 | 8 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Health Insurance Marketplace (HIM) | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 11 | 9 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Limited Network Plan (Kelsey Marketplace) | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 12 | 10 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Local Mental Health Authority (LMHA) | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 13 | 11 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Chemical Dependency (CD) Treatment Facility | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 14 | 12 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Early Childhood Intervention (ECI) Provider | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 15 | 13 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Mental Health Targeted Case Management | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 16 | 14 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Non- Local Mental Health Authority (LMHA) | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 17 | 15 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Covered Services | Applied Behavior Analysis (ABA) | Y | 100% of BC | 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. | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||
| 18 | 16 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - 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 | Applied Behavior Analysis (ABA) | N | Procedure Code : 97156 | Description : 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 | Rate Per Unit (15 minutes) : $ 30.00 | Flat Fee | $30.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 19 | 17 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - 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) | Applied Behavior Analysis (ABA) | N | Procedure Code : 97157 | Description : 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) | Rate Per Unit (15 minutes) : $ 22.00 | Flat Fee | $22.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 20 | 18 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - Group adaptive behavior treatment with protocol modifications, administered by a physician or other QHP, face to face with multiple patents', each 15 minutes | Medicaid | N | Procedure Code : 97158 | Description : Group adaptive behavior treatment with protocol modifications, administered by a physician or other QHP, face to face with multiple patents', each 15 minutes | Rate Per Unit (15 minutes) : $ 22.00 | Flat Fee | $22.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 21 | 19 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - 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 | Medicaid | N | Procedure Code : 0373T | Description : 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 | Rate Per Unit (15 minutes) : $ 45.00 | Flat Fee | $45.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 22 | 20 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | All Covered Services except those listed below | Local Mental Health Authority (LMHA) | N | one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 23 | 21 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | All Covered Services except those listed below | Chemical Dependency (CD) Treatment Facility | N | one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 24 | 22 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | All Covered Services except those listed below | Early Childhood Intervention (ECI) Provider | N | one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 25 | 23 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | All Covered Services except those listed below | Non- Local Mental Health Authority (LMHA) | N | one hundred fifteen percent (115%) of the then current Texas Medicaid Fee Schedule | % of MCD | 115% of MCD | 1.15 | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | ||||||||||||
| 26 | 24 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - Mental health service plan development by a non-physician | Local Mental Health Authority (LMHA) | N | Procedure Code : H0032 | Description : Mental health service plan development by a non-physician | Rate Per Unit (15 minutes) : $ 25.00 | Flat Fee | $25.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 27 | 25 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - Mental health service plan development by a non-physician | Chemical Dependency (CD) Treatment Facility | N | Procedure Code : H0032 | Description : Mental health service plan development by a non-physician | Rate Per Unit (15 minutes) : $ 25.00 | Flat Fee | $25.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 28 | 26 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - Mental health service plan development by a non-physician | Early Childhood Intervention (ECI) Provider | N | Procedure Code : H0032 | Description : Mental health service plan development by a non-physician | Rate Per Unit (15 minutes) : $ 25.00 | Flat Fee | $25.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 29 | 27 | Filename: chc_1.txt | 1 | 38 | 26 | EXHIBIT B-2 COMPENSATION | MEDICAID | Professional | Behavioral Health | Applied Behavior Analysis (ABA) Services and Rates - Mental health service plan development by a non-physician | Non- Local Mental Health Authority (LMHA) | N | Procedure Code : H0032 | Description : Mental health service plan development by a non-physician | Rate Per Unit (15 minutes) : $ 25.00 | Flat Fee | $25.00 Per Unit (15 minutes) | 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. | 30% of Physician/Provider's BC | 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. | N | N | N | N | N | |||||||||||||
| 30 | 28 | Filename: hn_23-70.txt | 23-70 | 6 | 3 | AMENDMENT to the PROVIDER SERVICES AGREEMENT between ALL HEALTH, INC. AFFILIATES and THE REGENTS OF THE SCHOOL OF CALIFORNIA UCDD HEALTHCARE NETWORK | MEDICARE | Professional | Medicare HMO | Medicare HMO | N | As compensation for rendering PPG Capitated Services as defined herein, HMO shall pay PPG Capitation at forty one and fifty eight hundreds percent (41.58%) of Monthly Revenue as set forth below for each Medicare HMO Member eligible to receive such services from PPG during any particular month. | % of Monthly Revenue | 41.58% of Monthly Revenue | 0.4158 | N | N | N | N | N | ||||||||||||||||
| 31 | 29 | Filename: hn_23-70.txt | 23-70 | 6 | 3 | AMENDMENT to the PROVIDER SERVICES AGREEMENT between ALL HEALTH, INC. AFFILIATES and THE REGENTS OF THE SCHOOL OF CALIFORNIA UCDD HEALTHCARE NETWORK | MEDICARE | Professional | PPG Capitated Services | Medicare HMO | N | As compensation for rendering PPG Capitated Services as defined herein, HMO shall pay PPG Capitation at forty one and fifty eight hundreds percent (41.58%) of Monthly Revenue as set forth below for each Medicare HMO Member eligible to receive such services from PPG during any particular month. | % of Monthly Revenue | 41.58% of Monthly Revenue | 0.4158 | N | N | N | N | N | ||||||||||||||||
| 32 | 30 | Filename: cnc_50-16.txt | 50-16 | 33 | 31 | Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE PRACTITIONER SERVICES BEHAVIORAL HEALTH Sample Name1, PhD | MEDICAID | Professional | Behavioral Health | Covered Services | Medicaid | Y | 100% of AC | The maximum compensation for practitioner Covered Services rendered to a Medicaid Managed Care Member, shall be the "Allowed Amount." Except as otherwise provided in this Compensation Schedule, the Allowed Amount for practitioner Covered Services is the lesser of: (i) Allowable Charges; or (ii) one hundred percent (100%) of the Payor's Medicaid fee schedule. | % of Payor's Medicaid fee schedule | 100% of Payor's Medicaid fee schedule | 1 | If there is no established payment amount on the Payor's Medicaid fee schedule for a Covered Service provided to a Medicaid Managed Care Member, Payor may establish a payment amount to apply in determining the Allowed Amount. Until such time as Payor establishes such a payment amount, the maximum compensation shall be twenty five percent (25%) of Allowable Charges. | 25% of AC | 2.2.4 No Subcontract shall not contain any provision that provides incentives, monetary or otherwise, for the withholding of Medically Necessary Services. | N | N | N | N | N | |||||||||||
| 33 | 31 | Filename: cnc_50-16.txt | 50-16 | 33 | 32 | Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE PRACTITIONER SERVICES BEHAVIORAL HEALTH Sample Name1, PhD | MEDICAID | Professional | Behavioral Health | Covered Services | Medicaid | Y | 100% of AC | The maximum compensation for practitioner Covered Services rendered to a Medicaid Managed Care Member, shall be the "Allowed Amount." Except as otherwise provided in this Compensation Schedule, the Allowed Amount for practitioner Covered Services is the lesser of: (i) Allowable Charges; or (ii) one hundred percent (100%) of the Payor's Medicaid fee schedule. | % of Payor's Medicaid fee schedule | 100% of Payor's Medicaid fee schedule | 1 | If there is no established payment amount on the Payor's Medicaid fee schedule for a Covered Service provided to a Medicaid Managed Care Member, Payor may establish a payment amount to apply in determining the Allowed Amount. Until such time as Payor establishes such a payment amount, the maximum compensation shall be twenty five percent (25%) of Allowable Charges. | 25% of AC | 2.2.4 No Subcontract shall not contain any provision that provides incentives, monetary or otherwise, for the withholding of Medically Necessary Services. | N | N | N | N | N | |||||||||||
| 34 | 32 | Filename: cnc_50-16.txt | 50-16 | 33 | 33 | Attachment A: Medicaid EXHIBIT 1 COMPENSATION SCHEDULE PRACTITIONER SERVICES BEHAVIORAL HEALTH Sample Name1, PhD | MEDICAID | Professional | Behavioral Health | Covered Services | Medicaid | Y | 100% of AC | The maximum compensation for practitioner Covered Services rendered to a Medicaid Managed Care Member, shall be the "Allowed Amount." Except as otherwise provided in this Compensation Schedule, the Allowed Amount for practitioner Covered Services is the lesser of: (i) Allowable Charges; or (ii) one hundred percent (100%) of the Payor's Medicaid fee schedule. | % of Payor's Medicaid fee schedule | 100% of Payor's Medicaid fee schedule | 1 | If there is no established payment amount on the Payor's Medicaid fee schedule for a Covered Service provided to a Medicaid Managed Care Member, Payor may establish a payment amount to apply in determining the Allowed Amount. Until such time as Payor establishes such a payment amount, the maximum compensation shall be twenty five percent (25%) of Allowable Charges. | 25% of AC | 2.2.4 No Subcontract shall not contain any provision that provides incentives, monetary or otherwise, for the withholding of Medically Necessary Services. | N | N | N | N | N | |||||||||||
| 35 | 33 | Filename: hn_0109.txt | 109 | 4 | 2 | EXHIBIT A-1 COMMERCIAL BENEFIT PROGRAMS DIRECT NETWORK FEE-FOR-SERVICE RATE EXHIBIT | COMMERCIAL | Facility | Covered Services | Commercial | Y | 100% of BC | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health or Payor shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. | % of BC | 100% of BC | 1.0 | By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established | 75% of billed charges for Covered Services | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health or Payor shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under commercial Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. | N | N | N | N | N | ||||||||||||
| 36 | 34 | Filename: hn_0109.txt | 109 | 4 | 3 | EXHIBIT B-1 MEDICARE ADVANTAGE PROGRAM DIRECT NETWORK FEE-FOR-SERVICE RATE EXHIBIT | MEDICARE ADVANTAGE | Professional | Covered Services delivered or arranged by Provider | Medicare Advantage | Y | 100% of BC | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under Medicare Advantage Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. Category of Service : Covered Services delivered or arranged by Provider | Compensation : 100% of CMS Allowable | % of CMS Allowable | 100% of CMS Allowable | 1.0 | By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established | 75% of billed charges for Covered Services | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under Medicare Advantage Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. | N | N | N | N | N | ||||||||||||
| 37 | 35 | Filename: hn_0109.txt | 109 | 4 | 3 | EXHIBIT B-1 MEDICARE ADVANTAGE PROGRAM DIRECT NETWORK FEE-FOR-SERVICE RATE EXHIBIT | MEDICARE ADVANTAGE | Professional | General Health Panel - CPT 80050 | Medicare Advantage | Y | 100% of BC | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under Medicare Advantage Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. Category of Service : General Health Panel - CPT 80050 | Compensation : $20.00 | Flat Fee | $20.00 | By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established | 75% of billed charges for Covered Services | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under Medicare Advantage Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. | N | N | N | N | N | |||||||||||||
| 38 | 36 | Filename: hn_0109.txt | 109 | 4 | 3 | EXHIBIT B-1 MEDICARE ADVANTAGE PROGRAM DIRECT NETWORK FEE-FOR-SERVICE RATE EXHIBIT | MEDICARE ADVANTAGE | Professional | General Health Panel - CPT 80055: Obstetric Panel | Medicare Advantage | Y | 100% of BC | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under Medicare Advantage Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. Category of Service : General Health Panel - CPT 80055: Obstetric Panel | Compensation : $15.00 | Flat Fee | $15.00 | By Report (BR) Procedures, Procedures not Listed and Procedures with Relativities not Established | 75% of billed charges for Covered Services | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered under Medicare Advantage Benefit Programs pursuant to this Addendum, the lesser of: (i) the rates listed below, or (ii) 100% of Provider's billed charges. | N | N | N | N | N | |||||||||||||
| 39 | 37 | Filename: hn_0109.txt | 109 | 4 | 4 | EXHIBIT C-1 MEDI-CAL BENEFIT PROGRAM DIRECT NETWORK FEE-FOR-SERVICE RATE EXHIBIT | MEDICAID | Professional | Covered Services | Medi-Cal | Y | 100% of BC | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered pursuant to this Addendum, the lesser of: 100% of the State of California Medi-Cal Fee Schedule rates in effect at the time of service, subject to any adjustments made by the State of California under the applicable Medi-Cal Fee-For-Service Program; (ii) Fee-for-service rates for the commercial Benefit Program set forth in Addendum A, Exhibit A-1; or (iii) Provider's billed charges. | % of MCD | 100% of MCD | 1.0 | Subject to the terms of this Agreement, including without limitation the Payment Conditions set forth in Addendum E, All Health shall pay and Provider shall accept as payment in full for non-capitated Medically Necessary Covered Services delivered pursuant to this Addendum, the lesser of: 100% of the State of California Medi-Cal Fee Schedule rates in effect at the time of service, subject to any adjustments made by the State of California under the applicable Medi-Cal Fee-For-Service Program; (ii) Fee-for-service rates for the commercial Benefit Program set forth in Addendum A, Exhibit A-1; or (iii) Provider's billed charges. | N | N | N | N | N | ||||||||||||||
| 40 | 38 | Filename: molina_2016.txt | 2016 | 27 | 24 | ATTACHMENT B-1 Alternate Compensation Schedule | MARKETPLACE | Facility | Hospital | NICU Level 2 | Marketplace | N | Rev Code 172 with MS DRG 789 - 794 | Per Diem $5,658 | Flat Fee | $5,658 Per Diem | Notwithstanding any provision in this Agreement to the contrary, Provider may appeal and Health Plan shall review claims that were totally or partially denied for Provider's failure to (i) provide a notice required by this Agreement; (ii) follow Health Plan's policies; (iii) determine eligibility; or (iv) obtain an authorization required by this Agreement, to determine if the services rendered were Covered Services and were Medically Necessary. If in its evaluation of Provider's reconsideration request, Health Plan reasonably determines that the services provided by Provider, including but not limited to outpatient diagnostic imaging services, were Covered Services, were Medically Necessary and appropriate for the Member's condition, then Health Plan shall reverse its denial and reimburse Provider in accordance with Attachment B within ten (10) days of such determination. If, in its evaluation of Provider's appeal, Plan reasonably determines that the services in question were not Covered Services, and/or were not Medically Necessary and appropriate for the Member's condition, and or would not have been paid even had Provider not failed to comply with Health Plan's policies, then Health Plan may uphold its denial, subject to Provider's right to pursue whatever additional remedies may be available to it. | N | N | Provider agrees that if in any given calendar year the aggregate increases of the rates in its ChargeMaster(s) are in excess of eight percent (8%) of the prior year's rates, then the percentage of charges reimbursement rates will be discounted so that no higher payment shall be paid by Molina than it would have paid had such percentage increase in rates above the maximum level set out herein not been implemented. All adjusted rates will be rounded. (For example, if ChargeMaster increase is 12% and existing rate is 50%: (1.08/1.12)*.50=.4821. New rate would equal 48%) | N | N | N | ||||||||||||||
| 41 | 39 | Filename: molina_2016.txt | 2016 | 27 | 24 | ATTACHMENT B-1 Alternate Compensation Schedule | MARKETPLACE | Facility | Hospital | NICU Level 2 - Effective Date 2018 | Marketplace | N | Rev Code 172 with MS DRG 789 - 794 | Per Diem $5,792 | Flat Fee | $5,792 Per Diem | Notwithstanding any provision in this Agreement to the contrary, Provider may appeal and Health Plan shall review claims that were totally or partially denied for Provider's failure to (i) provide a notice required by this Agreement; (ii) follow Health Plan's policies; (iii) determine eligibility; or (iv) obtain an authorization required by this Agreement, to determine if the services rendered were Covered Services and were Medically Necessary. If in its evaluation of Provider's reconsideration request, Health Plan reasonably determines that the services provided by Provider, including but not limited to outpatient diagnostic imaging services, were Covered Services, were Medically Necessary and appropriate for the Member's condition, then Health Plan shall reverse its denial and reimburse Provider in accordance with Attachment B within ten (10) days of such determination. If, in its evaluation of Provider's appeal, Plan reasonably determines that the services in question were not Covered Services, and/or were not Medically Necessary and appropriate for the Member's condition, and or would not have been paid even had Provider not failed to comply with Health Plan's policies, then Health Plan may uphold its denial, subject to Provider's right to pursue whatever additional remedies may be available to it. | N | N | Provider agrees that if in any given calendar year the aggregate increases of the rates in its ChargeMaster(s) are in excess of eight percent (8%) of the prior year's rates, then the percentage of charges reimbursement rates will be discounted so that no higher payment shall be paid by Molina than it would have paid had such percentage increase in rates above the maximum level set out herein not been implemented. All adjusted rates will be rounded. (For example, if ChargeMaster increase is 12% and existing rate is 50%: (1.08/1.12)*.50=.4821. New rate would equal 48%) | N | N | N | ||||||||||||||
| 42 | 40 | Filename: molina_2016.txt | 2016 | 27 | 24 | ATTACHMENT B-1 Alternate Compensation Schedule | MARKETPLACE | Facility | Hospital | All Inpatient Services | Marketplace | N | Reimbursement for all Medicare Inpatient services shall be at the applicable percent (%) of the Provider-specific inpatient Rate Sheet rates. These rates shall consist of the Medicare Base DRG Rates, PLUS Disproportionate Share (DSH), PLUS Uncompensated Care payment or other naming convention, PLUS Outlier, PLUS Technology Add-on, PLUS Capital Pass-Through Base, PLUS Capital DSH, PLUS Capital IME, PLUS VBP, and PLUS Readmission Factor. Plan agrees that use of the penalty associated with readmissions in adjudication of claims "Readmission Factor", whether or not an individual hospital is assessed that penalty, precludes Plan from applying any other readmission policies or adjustments to Provider payments either retrospectively or prospectively. | % of MCR | 100% of MCR | 1.0 | Notwithstanding any provision in this Agreement to the contrary, Provider may appeal and Health Plan shall review claims that were totally or partially denied for Provider's failure to (i) provide a notice required by this Agreement; (ii) follow Health Plan's policies; (iii) determine eligibility; or (iv) obtain an authorization required by this Agreement, to determine if the services rendered were Covered Services and were Medically Necessary. If in its evaluation of Provider's reconsideration request, Health Plan reasonably determines that the services provided by Provider, including but not limited to outpatient diagnostic imaging services, were Covered Services, were Medically Necessary and appropriate for the Member's condition, then Health Plan shall reverse its denial and reimburse Provider in accordance with Attachment B within ten (10) days of such determination. If, in its evaluation of Provider's appeal, Plan reasonably determines that the services in question were not Covered Services, and/or were not Medically Necessary and appropriate for the Member's condition, and or would not have been paid even had Provider not failed to comply with Health Plan's policies, then Health Plan may uphold its denial, subject to Provider's right to pursue whatever additional remedies may be available to it. | N | N | Provider agrees that if in any given calendar year the aggregate increases of the rates in its ChargeMaster(s) are in excess of eight percent (8%) of the prior year's rates, then the percentage of charges reimbursement rates will be discounted so that no higher payment shall be paid by Molina than it would have paid had such percentage increase in rates above the maximum level set out herein not been implemented. All adjusted rates will be rounded. (For example, if ChargeMaster increase is 12% and existing rate is 50%: (1.08/1.12)*.50=.4821. New rate would equal 48%) | N | N | N | |||||||||||||
| 43 | 41 | Filename: molina_2016.txt | 2016 | 27 | 24 | ATTACHMENT B-1 Alternate Compensation Schedule | MARKETPLACE | Facility | Hospital | Outpatient Default Rate | Marketplace | N | Covered Services rendered in which there is not a reimbursement amount addressed in Table 2 for Outpatient Services shall be reimbursed at twenty-five percent (25%) of Provider's billed charges. | % of BC | 25% of BC | 0.25 | Notwithstanding any provision in this Agreement to the contrary, Provider may appeal and Health Plan shall review claims that were totally or partially denied for Provider's failure to (i) provide a notice required by this Agreement; (ii) follow Health Plan's policies; (iii) determine eligibility; or (iv) obtain an authorization required by this Agreement, to determine if the services rendered were Covered Services and were Medically Necessary. If in its evaluation of Provider's reconsideration request, Health Plan reasonably determines that the services provided by Provider, including but not limited to outpatient diagnostic imaging services, were Covered Services, were Medically Necessary and appropriate for the Member's condition, then Health Plan shall reverse its denial and reimburse Provider in accordance with Attachment B within ten (10) days of such determination. If, in its evaluation of Provider's appeal, Plan reasonably determines that the services in question were not Covered Services, and/or were not Medically Necessary and appropriate for the Member's condition, and or would not have been paid even had Provider not failed to comply with Health Plan's policies, then Health Plan may uphold its denial, subject to Provider's right to pursue whatever additional remedies may be available to it. | N | N | Provider agrees that if in any given calendar year the aggregate increases of the rates in its ChargeMaster(s) are in excess of eight percent (8%) of the prior year's rates, then the percentage of charges reimbursement rates will be discounted so that no higher payment shall be paid by Molina than it would have paid had such percentage increase in rates above the maximum level set out herein not been implemented. All adjusted rates will be rounded. (For example, if ChargeMaster increase is 12% and existing rate is 50%: (1.08/1.12)*.50=.4821. New rate would equal 48%) | N | N | N | |||||||||||||
| 44 | 42 | Filename: molina_2016.txt | 2016 | 27 | 24 | ATTACHMENT B-1 Alternate Compensation Schedule | MARKETPLACE | Facility | Hospital | All Outpatient Services - Effective Date 2016 - 2017 | Marketplace | N | 215% of Current Year Medicare rate Allowable*. | % of MCR | 215% of MCR | 2.15 | Notwithstanding any provision in this Agreement to the contrary, Provider may appeal and Health Plan shall review claims that were totally or partially denied for Provider's failure to (i) provide a notice required by this Agreement; (ii) follow Health Plan's policies; (iii) determine eligibility; or (iv) obtain an authorization required by this Agreement, to determine if the services rendered were Covered Services and were Medically Necessary. If in its evaluation of Provider's reconsideration request, Health Plan reasonably determines that the services provided by Provider, including but not limited to outpatient diagnostic imaging services, were Covered Services, were Medically Necessary and appropriate for the Member's condition, then Health Plan shall reverse its denial and reimburse Provider in accordance with Attachment B within ten (10) days of such determination. If, in its evaluation of Provider's appeal, Plan reasonably determines that the services in question were not Covered Services, and/or were not Medically Necessary and appropriate for the Member's condition, and or would not have been paid even had Provider not failed to comply with Health Plan's policies, then Health Plan may uphold its denial, subject to Provider's right to pursue whatever additional remedies may be available to it. | N | N | Provider agrees that if in any given calendar year the aggregate increases of the rates in its ChargeMaster(s) are in excess of eight percent (8%) of the prior year's rates, then the percentage of charges reimbursement rates will be discounted so that no higher payment shall be paid by Molina than it would have paid had such percentage increase in rates above the maximum level set out herein not been implemented. All adjusted rates will be rounded. (For example, if ChargeMaster increase is 12% and existing rate is 50%: (1.08/1.12)*.50=.4821. New rate would equal 48%) | N | Y | 2018.0 | N | ||||||||||||
| 45 | 43 | Filename: molina_2016.txt | 2016 | 27 | 24 | ATTACHMENT B-1 Alternate Compensation Schedule | MARKETPLACE | Facility | Hospital | All Outpatient Services - Effective Date 2018 | Marketplace | N | 220% of Current Year Medicare rate Allowable* | % of MCR | 220% of MCR | 2.2 | Notwithstanding any provision in this Agreement to the contrary, Provider may appeal and Health Plan shall review claims that were totally or partially denied for Provider's failure to (i) provide a notice required by this Agreement; (ii) follow Health Plan's policies; (iii) determine eligibility; or (iv) obtain an authorization required by this Agreement, to determine if the services rendered were Covered Services and were Medically Necessary. If in its evaluation of Provider's reconsideration request, Health Plan reasonably determines that the services provided by Provider, including but not limited to outpatient diagnostic imaging services, were Covered Services, were Medically Necessary and appropriate for the Member's condition, then Health Plan shall reverse its denial and reimburse Provider in accordance with Attachment B within ten (10) days of such determination. If, in its evaluation of Provider's appeal, Plan reasonably determines that the services in question were not Covered Services, and/or were not Medically Necessary and appropriate for the Member's condition, and or would not have been paid even had Provider not failed to comply with Health Plan's policies, then Health Plan may uphold its denial, subject to Provider's right to pursue whatever additional remedies may be available to it. | N | N | Provider agrees that if in any given calendar year the aggregate increases of the rates in its ChargeMaster(s) are in excess of eight percent (8%) of the prior year's rates, then the percentage of charges reimbursement rates will be discounted so that no higher payment shall be paid by Molina than it would have paid had such percentage increase in rates above the maximum level set out herein not been implemented. All adjusted rates will be rounded. (For example, if ChargeMaster increase is 12% and existing rate is 50%: (1.08/1.12)*.50=.4821. New rate would equal 48%) | N | N | N | |||||||||||||
| 46 | 44 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Covered Services | PPO | Y | 100% of BC | Compensation shall be based on the Resource Based Relative Value Scale (RBRVS), the Conversion Factors (CF) and the Geographic Practice Cost Indices (GPCI) adjustment factors promulgated by the Centers for Medicare and Medicaid Services (CMS). Physician shall be compensated for Covered Services in an amount, less applicable Copayments and/or coinsurance, that is equal to the lesser of: (a) 90% of the HCFA participating provider fee schedule for Physician's locality, or (b) for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges, or (c) Physicians usual billed charges. | % of MCR | 90% of MCR | 0.9 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | ||||||||||||
| 47 | 45 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Covered Services | EPO | Y | 100% of BC | Compensation shall be based on the Resource Based Relative Value Scale (RBRVS), the Conversion Factors (CF) and the Geographic Practice Cost Indices (GPCI) adjustment factors promulgated by the Centers for Medicare and Medicaid Services (CMS). Physician shall be compensated for Covered Services in an amount, less applicable Copayments and/or coinsurance, that is equal to the lesser of: (a) 90% of the HCFA participating provider fee schedule for Physician's locality, or (b) for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges, or (c) Physicians usual billed charges. | % of MCR | 90% of MCR | 0.9 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | ||||||||||||
| 48 | 46 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Medications | PPO | Y | 100% of BC | Medications provided or administered by Physician shall be billed using HCPC codes if available and shall be compensated at the lesser of (a) 90% of the HCFA participating provider fee schedule for Physician's locality, or (b) for medications for which a HCPC code has not been established Physician shall bill using the NDC code, drug and manufacturer name and shall be compensated at the Average Wholesale Price, or (c) Physician's billed charge amount not to exceed usual, reasonable and customary charges. | % of HCFA participating provider fee schedule | 90% of HCFA participating provider fee schedule | 0.9 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | ||||||||||||
| 49 | 47 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Medications | EPO | Y | 100% of BC | Medications provided or administered by Physician shall be billed using HCPC codes if available and shall be compensated at the lesser of (a) 90% of the HCFA participating provider fee schedule for Physician's locality, or (b) for medications for which a HCPC code has not been established Physician shall bill using the NDC code, drug and manufacturer name and shall be compensated at the Average Wholesale Price, or (c) Physician's billed charge amount not to exceed usual, reasonable and customary charges. | % of MCR | 90% of MCR | 0.9 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | ||||||||||||
| 50 | 48 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Immunizations | PPO | Y | 100% of BC | Immunization administered by Physician shall be billed using CPT-4 codes and shall be compensated at the lesser of a) the Physician's billed charges, or b) the Average Wholesale Price (AWP) as established by MediSpan less ten percent (10%). This AWP fee schedule is reviewed and subject to adjustment on a semi annual basis. | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | 90% of AWP | Y | semi annual basis | N | |||||||||||||
| 51 | 49 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Immunizations | EPO | Y | 100% of BC | Immunization administered by Physician shall be billed using CPT-4 codes and shall be compensated at the lesser of a) the Physician's billed charges, or b) the Average Wholesale Price (AWP) as established by MediSpan less ten percent (10%). This AWP fee schedule is reviewed and subject to adjustment on a semi annual basis. | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | 90% of AWP | Y | semi annual basis | N | |||||||||||||
| 52 | 50 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Laboratory Procedures | PPO | Y | 100% of BC | Compensation for laboratory procedures provided and administered by Physician shall be at the lesser of 90% of the HCFA participating provider fee schedule for Physician locality, or Physician's usual billed charge amount not to exceed usual, reasonable and customary charges. | % of HCFA participating provider fee schedule | 90% of HCFA participating provider fee schedule | 0.9 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | ||||||||||||
| 53 | 51 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | Laboratory Procedures | EPO | Y | 100% of BC | Compensation for laboratory procedures provided and administered by Physician shall be at the lesser of 90% of the HCFA participating provider fee schedule for Physician locality, or Physician's usual billed charge amount not to exceed usual, reasonable and customary charges. | % of HCFA participating provider fee schedule | 90% of HCFA participating provider fee schedule | 0.9 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | ||||||||||||
| 54 | 52 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | For Obstetrical Care - Global Obstetric care with vaginal delivery | PPO | Y | 100% of BC | Compensation for obstetrical services shall be at the lesser of the Physician's billed charges, or: CPT 59400-Global Obstetric care with vaginal delivery. $1700.00 | Flat Fee | $1700.00 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | |||||||||||||
| 55 | 53 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | For Obstetrical Care - Global Obstetric care with vaginal delivery | EPO | Y | 100% of BC | Compensation for obstetrical services shall be at the lesser of the Physician's billed charges, or: CPT 59400-Global Obstetric care with vaginal delivery. $1700.00 | Flat Fee | $1700.00 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | |||||||||||||
| 56 | 54 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | For Obstetrical Care - Global Obstetric care with Cesarean delivery | PPO | Y | 100% of BC | Compensation for obstetrical services shall be at the lesser of the Physician's billed charges, or: CPT 59510-Global Obstetric care with Cesarean delivery $1700.00 | Flat Fee | $1700.00 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | |||||||||||||
| 57 | 55 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | For Obstetrical Care - Global Obstetric care with Cesarean delivery | EPO | Y | 100% of BC | Compensation for obstetrical services shall be at the lesser of the Physician's billed charges, or: CPT 59510-Global Obstetric care with Cesarean delivery $1700.00 | Flat Fee | $1700.00 | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | |||||||||||||
| 58 | 56 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | For Anesthesiology Services - Anesthesiology Services | PPO | Y | 75% of BC | Physician shall be compensated for anesthesiology services which are Covered Services at the lesser of (a) $39.00 per unit value in accordance with the American Society of Anesthesiology (ASA) unit scale, or (b) 75% of the Physician's usual billed charges. | Flat Fee | $39.00 per unit value | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | |||||||||||||
| 59 | 57 | Filename: hn_24-83.txt | 24-83 | 3 | 3 | ADDENDUM B PREFERRRED PROVIDER ORGANIZATION (PPO) EXCLUSIVE PROVIDER ORGANIZATION (EPO) BENEFIT PROGRAMS Fee For Service Compensation Schedule | COMMERCIAL | Professional | Physician | For Anesthesiology Services - Anesthesiology Services | EPO | Y | 75% of BC | Physician shall be compensated for anesthesiology services which are Covered Services at the lesser of (a) $39.00 per unit value in accordance with the American Society of Anesthesiology (ASA) unit scale, or (b) 75% of the Physician's usual billed charges. | Flat Fee | $39.00 per unit value | for "by report" procedures, unlisted procedures and relativities not established in RBRVS, Physician shall be reimbursed at 75% of billed charges not to exceed usual, reasonable and customary charges | 75% of billed charges | N | N | N | N | N | |||||||||||||
| 60 | 58 | Filename: sga_01.txt | 1 | 16 | 15 | EXHIBIT B VENDOR TRAVEL REIMBURSEMENT POLICY | Ancillary | Reimbursable Expenses - Airfare | XYZ Corporation | N | Airfare (no first class, business class allowed upon pre-approval and requires two week advance booking) | N | N | N | N | N | ||||||||||||||||||||
| 61 | 59 | Filename: sga_01.txt | 1 | 16 | 15 | EXHIBIT B VENDOR TRAVEL REIMBURSEMENT POLICY | Ancillary | Reimbursable Expenses - Lodging | XYZ Corporation | Lodging | N | N | N | N | N | |||||||||||||||||||||
| 62 | 60 | Filename: sga_01.txt | 1 | 16 | 15 | EXHIBIT B VENDOR TRAVEL REIMBURSEMENT POLICY | Ancillary | Reimbursable Expenses - Food and beverages | XYZ Corporation | N | Food and beverages (capped per GSA per diem rate) | N | N | N | N | N | ||||||||||||||||||||
| 63 | 61 | Filename: sga_01.txt | 1 | 16 | 15 | EXHIBIT B VENDOR TRAVEL REIMBURSEMENT POLICY | Ancillary | Reimbursable Expenses - Ground transportation | XYZ Corporation | N | Ground transportation (taxi, bus, rental car or Uber) | N | N | N | N | N | ||||||||||||||||||||
| 64 | 62 | Filename: sga_01.txt | 1 | 16 | 15 | EXHIBIT B VENDOR TRAVEL REIMBURSEMENT POLICY | Ancillary | Reimbursable Expenses - Self-Parking | XYZ Corporation | N | Self-Parking | Flat Fee | $5 Per Parking Session | N | N | N | N | N | ||||||||||||||||||
| 65 | 63 | Filename: sga_01.txt | 1 | 16 | 15 | EXHIBIT B VENDOR TRAVEL REIMBURSEMENT POLICY | Ancillary | Reimbursable Expenses - Tolls | XYZ Corporation | N | Tolls | N | N | N | N | N | ||||||||||||||||||||
| 66 | 64 | Filename: sga_01.txt | 1 | 16 | 15 | EXHIBIT B VENDOR TRAVEL REIMBURSEMENT POLICY | Ancillary | Covered Services | XYZ Corporation | Y | Reimbursable Expenses (require pre-approval by XYZ and shall not exceed 12% of the specific engagement) | N | N | N | 12% of engagement | N | N | |||||||||||||||||||
| 67 | 65 | Filename: cnc_01-06.txt | 01-06 | 4 | 3 | Attachment A: Medicaid EXHIBIT 2 COMPENSATION SCHEDULE PROFESSIONAL SERVICES Picture, LLC Novelty Pharmacy | MEDICAID | Professional | Covered Services | Medicaid | Y | 100% of AC | 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. | % of Payor's Medicaid fee schedule | 100% of Payor's Medicaid fee schedule | 1 | N | N | N | N | N | |||||||||||||||
| 68 | 66 | Filename: cnc_01-06.txt | 01-06 | 4 | 4 | Attachment A: Medicaid EXHIBIT 2 COMPENSATION SCHEDULE PROFESSIONAL SERVICES Picture, LLC Novelty Pharmacy | MEDICAID | Professional | Covered Services | Medicaid | Y | 100% of AC | 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. | % of Payor's Medicaid fee schedule | 100% of Payor's Medicaid fee schedule | 1 | N | N | N | N | N | |||||||||||||||
| 69 | 67 | Filename: cnc_01-06.txt | 01-06 | 4 | 4 | Attachment A: Medicaid EXHIBIT 2 COMPENSATION SCHEDULE PROFESSIONAL SERVICES Picture, LLC Novelty Pharmacy | MEDICAID | Professional | OP | Payment for Multiple Procedures - Multiple Outpatient Surgical or Scope Procedures | Medicaid | Y | 100% of AC | 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. | % of AA / % of AA | 100% of AA / 50% of AA | 1 / 0.5 | N | N | N | N | N | ||||||||||||||
| 70 | 68 | Filename: cnc_arch.txt | 12 | 11 | EXHIBIT 2 of the INDIVIDUAL PRODUCT ATTACHMENT PROVIDER COMPENSATION SCHEDULE COMMERCIAL-EXCHANGE PRODUCT PROFESSIONAL SERVICES | COMMERCIAL-EXCHANGE | Professional | Covered Services | Commercial-Exchange | Y | 100% of AC | For Covered Services provided to Covered Persons, Payor shall pay Provider the lesser of: (i) the Provider's Allowable Charges; or (ii) one hundred percent (100%) of the Payor Medicare fee schedule in effect on the date of service and specific to the services rendered, less any applicable coinsurance or deductible. This fee schedule is based on the CMS/Medicare RBRVS relative values and for certain codes alternative fee sources may be used. | % of MCR | 100% of MCR | 1 | In the event CMS contains no published fee amount, alternate (or "gap fill") Fee Sources may be used to supply the Fee Basis amount for deriving the Fee Amount. At such time in the future as CMS publishes its own RBRVS value for that CPT/HCPCS code, Payor will use the CMS fee amount for that code and no longer use the alternate Fee Source. | 100% of alternate (or "gap fill") Fee Sources | Each Participating Provider shall continue to provide Covered Services to patients that were Covered Persons under the Agreement in the event of HMO's or the Payor's insolvency or discontinuance of operations. Each Participating Provider shall continue to provide Covered Services to patients that were Covered Persons under the Agreement as needed to complete any Medically Necessary procedures commenced but unfinished at the time of HMO's or the Payor's insolvency or discontinuance of operations. The completion of a Medically Necessary procedure shall include the rendering of all Covered Services that constitute Medically Necessary follow-up care for that procedure. The foregoing | N | N | N | N | N | |||||||||||||
| 71 | 69 | Filename: cnc_arch.txt | 12 | 12 | EXHIBIT 2 of the INDIVIDUAL PRODUCT ATTACHMENT PROVIDER COMPENSATION SCHEDULE COMMERCIAL-EXCHANGE PRODUCT PROFESSIONAL SERVICES | COMMERCIAL-EXCHANGE | Professional | Covered Services | Commercial-Exchange | Y | 100% of AC | For Covered Services provided to Covered Persons, Payor shall pay Provider the lesser of: (i) the Provider's Allowable Charges; or (ii) one hundred percent (100%) of the Payor Medicare fee schedule in effect on the date of service and specific to the services rendered, less any applicable coinsurance or deductible. This fee schedule is based on the CMS/Medicare RBRVS relative values and for certain codes alternative fee sources may be used. | % of MCR | 100% of MCR | 1 | In the event CMS contains no published fee amount, alternate (or "gap fill") Fee Sources may be used to supply the Fee Basis amount for deriving the Fee Amount. At such time in the future as CMS publishes its own RBRVS value for that CPT/HCPCS code, Payor will use the CMS fee amount for that code and no longer use the alternate Fee Source. | 100% of alternate (or "gap fill") Fee Sources | Each Participating Provider shall continue to provide Covered Services to patients that were Covered Persons under the Agreement in the event of HMO's or the Payor's insolvency or discontinuance of operations. Each Participating Provider shall continue to provide Covered Services to patients that were Covered Persons under the Agreement as needed to complete any Medically Necessary procedures commenced but unfinished at the time of HMO's or the Payor's insolvency or discontinuance of operations. The completion of a Medically Necessary procedure shall include the rendering of all Covered Services that constitute Medically Necessary follow-up care for that procedure. The foregoing | N | N | N | N | N | |||||||||||||
| 72 | 70 | Filename: cnc_arch.txt | 12 | 12 | EXHIBIT 2 of the INDIVIDUAL PRODUCT ATTACHMENT PROVIDER COMPENSATION SCHEDULE COMMERCIAL-EXCHANGE PRODUCT PROFESSIONAL SERVICES | COMMERCIAL-EXCHANGE | Professional | Multiple Procedures | Commercial-Exchange | Y | 100% of AC | Multiple procedures performed during the same day will be reimbursed at 100% for the primary procedure, 50% for the second procedure, and 50% for the third procedure, subsequent procedures shall not be eligible for reimbursement. | % of MCR / % of MCR / % of MCR | 100% of MCR / 50% of MCR / 50% of MCR | 1 / 0.5 / 0.5 | In the event CMS contains no published fee amount, alternate (or "gap fill") Fee Sources may be used to supply the Fee Basis amount for deriving the Fee Amount. At such time in the future as CMS publishes its own RBRVS value for that CPT/HCPCS code, Payor will use the CMS fee amount for that code and no longer use the alternate Fee Source. | 100% of alternate (or "gap fill") Fee Sources | Each Participating Provider shall continue to provide Covered Services to patients that were Covered Persons under the Agreement in the event of HMO's or the Payor's insolvency or discontinuance of operations. Each Participating Provider shall continue to provide Covered Services to patients that were Covered Persons under the Agreement as needed to complete any Medically Necessary procedures commenced but unfinished at the time of HMO's or the Payor's insolvency or discontinuance of operations. The completion of a Medically Necessary procedure shall include the rendering of all Covered Services that constitute Medically Necessary follow-up care for that procedure. The foregoing | N | N | N | N | N |