HomeMy WebLinkAboutContract 47186-P3 CITY SECRETARY , r
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ADDENDUM
To
Blacl(Stone 504 Program
Provider Agreement
This Addendum is entered into by and among Preferred Imaging of Grapevine/Colleyville ("Member
Provider"), Rockport. Healthcare Grou ("Rockport"), and the City of Fort Worth ("City") 011 this
day of—:� X20 '.
WHEREAS,Rockport and Member Provider entered into a Provider Agreement,effective June 20,2014,
("Provider Agreement"), and desire that this Addendum apply to covered services that are governed by
the Texas Insurance Code,Texas Labor Code,and Texas Administrative Code.
WHEREAS, Rockport has contracted with Member Provider on behalf of the City in the process of
setting up a direct contracted 504 provider panel pursuant to Texas Labor Code Section 504.053.
WHEREAS, the City has determined that a workers' compensation health care network certified under
Texas Insurance Code Chapter 1305 is not available or practical for its self-insured workers'
compensation program needs and, as such, have elected to provide medical benefits to injUred workers by
directly contracting with health care providers.
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504.053(b)(2).
WHEREAS, Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
Agreement to be the same terms and conditions that apply to the direct contract between Member
Provider and the City that make available covered services for Qualified Participants' needs to the injured
workers of the City.
NOW,THEREFORE, for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
1. All terms and conditions of the Provider Agreement are hereby adopted by both Member Provider
and the City, with Rill consent and agreement of Rockport, to apply as a direct contractual
agreement between Member Provider and the City.All references to certified networks as well as
the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413.041 of the
Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set tip tinder
section 504.053 of the Texas Labor Code. The City's Provider Manual (under the name of
B1ackStone) shall instead apply to matters of notice, billing, dispute resolution, complaints,
preauthorization,and related matters.
2. The parties agree that the City will bear the financial responsibility for payment to Member Provider
under (lie terms of the Provider Agreement subject to the applicable Provider Manual and the
provisions of the Texas Labor Code and applicable rules under the Texas Administrative Code.
Rockport will continue to provide applicable network administrative services.
3. When used in this Addendum,unless the content otherwise clearly requires,the following words and
terms shall have the meaning set forth.below. All other defined terms shall have the meaning
ascribed to them in the Provider Agreement.
FOFFICUALAIECORDTARY, TX
Preferred Imaging of Grapevine/ColleyviIle Provider Agreement
"Payors" will be the City as they are responsible for payment of medical benefits for
compensable injuries and or illnesses sustained by its injured workers according to the
Texas`Yorkers Compensation Act.
"BlackStone" is the 504 Provider Panel established by the City of Tort Worth through
this and other direct contracts using Rockport as its contracting agent
"Provider Manual"means the BlackStone Provider Manual as amended from time to time
and available upon request to the Member Provider.
"Provider Panels" are those direct contracted panels formed by political subdivisions or
public pool entities authorized by Section 504.053 of the Texas Labor Code.
4. Member Provider agrees to participate in the BlackStone provider panel for the benefit of the City
and Qualified Participants.
5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a
new cause of action.
r 6. All other terms of the Provider Agreement shall remain in force and unchanged. Any conflicts
between this Addendum and the Provider Agreement shall be superseded by the terms provided
herein.
IN WITNESS WH1;REOF,the parties hereto have executed this Addendum effective on the day and year
first written above.
For ai>d on belialf of:
City of Fort Worth
BlackStone
Signatur
�&an anis
Title: Assistant City Manager
Date: I I ty
AH1RC VUJ AS'M t Oftcrl AND LEGALITY,
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Preferred Tmagitig ofGrapeviite/Colleyvilie Provider Agreement
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ROCKPORTTM
FACILITY/ANCILLARY AGREEMENT
ROCKPORT UNITED NETWORK
ROCKPORT SELECTHEALTH NETWORK
This Facility/Ancillary Agreement("Agreement"), is I. DEFINITIONS
entered into by and between Rockport Community
Network, Inc., a Nevada Corporation, dba Rockport When used in this Agreement and unless the content
Healthcare Group ("RHG"), dba Rockport United otherwise clearly requires, the following words and
Network (a preferred provider network for terms shall mean:
Occupational Injuries and IIlnesses), dba Rockport
SelectHealth Network (an exclusive provider 1.1 "Ph ssician" means a licensed Medical Doctor or
network) and Preferred Imaging, Inc. ("Member Doctor of Osteopathic Medicine, or group of same
Provider"), and will become effective as of the date who desire to become a Member Provider with
the provider is fully credentialed by RHG, RHO,
WHEREAS, RHG is engaged in the business of Pursuant to §10.42 of Texas Insurance Code 1305
developing and acting in an administrative capacity regarding Network Contracts with Providers seeking
in providing Occupational Injury and health provider to participate in Texas Certified Workers'
networks that offer direction of care white providing Compensation Networks,
savings to RHO clients and/or Payors. These
petworks will offer greater coverage of services and I,2 "Oualifted Participant" means an "employee" as
savings;and defined and used in the Texas Labor Code, the
Network Act Section 1.305 and the implementing
WHEREAS, RHO has networks of contracted rules who sustained a work-related injury/illness that
physicians, physician groups, hospitals and is determined compensable by an employer and that
providers of ancillary healthcare services participates in the Rockport United Network or
(collectively, the "Member Providers") to provide a Rockport SelectHealth Network through Rockport's
full-range of healthcare services. These services are Client. Unless in an emergency or after business
available for use by "Qualified Participants" as hours, initial services provided for the work-related
defined in I,2 of this Agreement;and injury/illness require authorization by the Employer
and/or network either in writing or by teleplione.
WHEREAS, Member Provider desires to provide
medical care services to "Qualified Participants" 1.3 "Client" means an insurance company, certified
who are covered by Payor Agreements at the rates in self-insured or governmental entity as those terms
ExhibitB and in locations listed in Exhibit C:and are defined and used in. the Texas Labor Code, the
Network Act Section 1305 and the .implementing
WHEREAS, Rl-IG has entered into Agreements rules. These Clients have entered into a Client
and/or services with one or more Payors who Agreement with RHO for the provision of healthcare
provide payment of claims for medical care rendered services to Qualified Participants.
to Qualified Participants,
1.4 "Payor" means an insurance carrier or network
NOW, THEREFORE, in consideration of the certified by an insurance carrier for its own benefit,
promises,the mutual promises contained herein, and certified self-insured or governmental entity as those
other good and valuable consideration, the receipt terms are defined and used in the Texas Labor Code,
and sufficiency of which are hereby acknowledged, the Network Act Section 1305 and the implementing
it is mutually agreed as follows: rules 'who is responsible for payment of medical
benefits for on the job injuries and or illnesses
according to State and/or Federal Rules and
Regulations,
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I.5 "Client Aameement" means the agreement specialty to maintain their RHG classification as
between RHG and a Client, which agreement is such.
made before, on or after the effective date of this
Agreement and which expresses the agreed upon 1.9 "Emergency Medical or Mental Condition" is
contractual rights and obligations of the patties. defined as tine sudden onset of a medical condition
Such Client Agreements will require Payors to pay manifested by aoute symptoms of sufficient severity,
Member Provider for Covered Services rendered to including severe pain,that the absence of immediate
Qualified Participants pursuant to this Agreement medical attention could reasonably be expected to
Furthermore,such Client Agreements shall authorize result in;
RHG to enter this Agreement and contractually bind (a)placing the patient's health or bodily functions in
Payors to the terms hereof unless there is a conflict serious jeopardy;or
with State and/or Federal rules and regulations, (b)serious dysfunction of any body organ or part as
defined in TIC 1305.004(13);and
I,6 "Member Provider" means any physician; (c) in the case of a mental health condition, one that
physician group;hospital; surgery center; diagnostic could reasonably present danger to the person
imaging center, laboratory; clinic; chiropractor; experiencing the mental health Condition or another
dentist; podiatrist; psychologist; social ,vorker; person as defined in T1C 1305.004(15).
physical, occupational and speech therapist; etc,
licensed or certified to practice a healthcare 1.10 "Covered Services" are those healthcare and
profession or licensed as a facility to offer healthcare health-related services provided to Qualified
services,in the state where services are rendered and Participants for treatment of a compensable, work-
who has executed a contract with RHG. related injury/illness as defined by either nationally
recognized treatment guidelines and/or individual
1.7 "Primary Treatiniz Phvsielan/Clinic" means treatment protocols that do not conflict with any
a Member Provider who is a Medical Doctor(MD) state and/or federal rules and regulations,
or a Doctor of Osteopathic Medicine(DO)that
specializes in Family Practice,General Practice, I,11 "Bill and/or Clairn Form" UB-92 (or other
Occupational Medicine or Internal Medicine as well appropriate claim form or their successors)
as a physician that provides initial and/or follow-up completed in accordance with the guidelines
care in Oce-Med or Urgent Care Clinics whose established by the National Uniform Billing
practice is largely dedicated to oaring for work Committee or UB-92 billing guidelines, and//or state
related injuries and illnesses is designated by RHG rules and regulations.
as a Primary Treating Physician/Clinic (PTP). PTP
agrees to render medical care to Qualified Il, MEMBER PROVIDER OBLIGATIONS
Participants 'Without a scheduled appointment and
must be, available and aceesible to employees 11.1 Services. Member Provider agrees to provide or
twenty-four(24) hours-per-day, seven (7) days-per- arrange for all medically necessary medical care for
week as per 28 TAC I0.80(b)(1). Should a Qualified Qualified Participants who present themselves to
Participant need medical attention outside of Member Provider. Member Provider agrees to
Member Provider's normal business hours, Member perform such services Nvith the same standard of
Provider will be available and/or make arrangements care, skill and diligence for all Qualified
to have another Member Provider render care to Participants. Member Provider agrees that it is their
Qualified Partioipant. Both parties agree that sole responsibility to verify that the individual
Member Provider is a health care facility or other presenting for care is a Qualified Participant
ancillary provider, and as such, the requirements of Member Provider agrees to render healthcare
28 Texas Administrative Code § 10,42(b)(12)do not services to Qualified Participants at any and all
apply regarding Treating Doctors, facility or practice locations listed in Exhibit "C".
Member Provider shall make best efforts to ensure
1.8 "Specialist Physician" means a Member Provider that services provided are consistent with nationally
who has met the credentialing requirements of RHG recognized treatment guidelines (i.e. Official
to be a Specialist Physician, and to whom Primary Disability Guidelines (OD(a), American
Treating Physicians/Clinics may refer for necessary Occupational- and Environmental Medicine's
and authorized care other than primary treating (ACOEM) and /or state rules and regulations.
services. Specialists will need to maintain their Member Provider agrees to comply with and be j
current board certifications £or their particular bound by all State/Federal Rules and Regulations,
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11.2 Treatment Guidelines, Member Provider agrees Member Provider shall report such encounter on an
to follow the treatment guidelines, return-to-work appropriate form and shall include statistical,
guidelines and individual treatment protocols descriptive inedical and patient data and identifying
outlined in Exhibit A of this Agreement, provided in information, if and to the extent that reports are
RHO's Provider Handbook and/or Clients' specified by RHG, Client or its designated
Utilization Review Programs.RHO agrees to furnish representative, and requested information is not
Member Provider or cause Payor to furnish to prohibited by state and/or federal rules and
Member Provider, and Member Provider agrees to regulations.
abide by,the list of any treatments and services that
require preauthorization and by any procedures to 11.7 Professional Requirements,
obtain preauthorization. Unless in an emergency or
after business hours, initial services provided for the 11.7.1 Licensure&Accreditation. Member Provider
work-related injury/illness require authorization by shall comply with all applicable federal, state and
the Employer and/or Network either in writing or by local laws, rules and regulations governing like
telephone. The Client and/or Payor may not deny providers and their provision of services. Evidence
treatment solely on the basis that a treatment for a of such current licensing, certification and/or
compensable fiI ury in question is not specifically accreditation shall be submitted promptly to RHO
addressed by the treatment guidelines used by the upon request, Member Provider represents and
Client and/or Payor. However, Member Provider warrants that it and each of its employees and
must demonstrate medical necessity to support contracted service providers has obtained, and shall
services rendered to Qualified Participants that are maintain throughout the term of this Agreement, all
outside of treatment guidelines. necessary registrations, certifications, Iicenses,
permits and approvals as are required for the lawful
II.3 Non-Discrimination.Member Provider shall not provision of Member Provider services to Qualified
differentiate or discriminate in the treatment of its Participants, Member Provider shall immediately
patients as to the quality of services delivered to notify RHG of any revocation, suspension or
Qualified Participants because of race, sex, age, restrictions, that would affect any certifications,
religion, national origin, place of residence, source licenses or accreditation's, Member Provider
of payment or health status, Member Provider shall warrants that it is currently accredited.by the Agency
observe, protect and promote the nights of Qualified that governs Iike. providers and is certified as a
Participants. provider under Title XVHI (Medicare) and when
appropriate, Title XIX (Medicaid) of the Social
1I.4 Medical Staff Participation. Member Provider Security Act and that it shalt maintain such
shall cooperate to the fullest extent possible in accreditation and certification during the term of this
obtaining staff privileges for Participating Primary Agreement, Member Provider shall immediately
Treating and Specialist Physicians/Clinics who notify RHO of any action, investigation or
meet Member Provider's credentiaiing standards and proceeding to revoke, suspend,restrict, or otherwise
agree to comply with the rules and regulations, affect such accreditation or certifications.
policies and procedures as may exist from time to !
time governing Member Provider and its medical 11.7.2 Qrganization's Requirements. Member i
staff. Member provider shall grant staff privileges Provider shall use best efforts to comply with RHG's
only to competent qualified physicians and criteria for provider participation, including
healthcare professionals and shall exercise ongoing credentialing policies and procedures. Member
peer review of the members of its medical staff. Provider shall cooperate with RHG's periodic
Upon request, Member Provider shall provide RHO evaluation of qualifications. In addition, Member
with a current copy of its medical staff roster, Provider shall use best efforts to cooperate with
RHG's and/or state rules and regulations for the ;
11.5 Referrals. Except in a medical emergency or expeditious resolution of any grievance or f
when authorized by RHO, Client, or its designated complaint.
representative, Member Provider agrees to refer
Qualified Participants only to other Member 11.8 Notification to RHO, Member Provider
Providers,as defined in 1.6, represents and warrants that information provided
herein and in the RHO application is true and
! il.fi Ve arts. For each encounter where Member accurate in all respects and acknowledges that RHO
Provider provides services to a Qualified Participant, is relying on the accuracy of such information in ,
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Preferred Imaging 10/62013 RUNPAC TX 01-2012
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entering into and continuing the term of this RHO Qualified Participants, services provided to
agreement. In addition Member Provider shall use Qualified Participants, and to Member Provider's
best efforts to provide written notice to RHO of any performance under this Agreement. Member
(i)suspension,reduction or loss of license to provide Provider flrther agrees to allow RHO, Payor or a
healthcare services; (ii) denial, suspension, designated representative thereof, including the
restriction, reduction or termination of designated utilization review, quality management,
accreditation/certification; (iii) changes in Federal case management or peer review staff, to have
Tax Identification Number(s), (iv) other information reasonable access to medical records and
provided in its application or Exhibit C for Information of Qualified Participants for services
participation, (v) Member Provider's professional provided under the terms of this Agreement as
liability insurance if such insurance falls below the necessary to enable such party to perform li ilization
requirements of state law and (vi) Member Review and Quality Assurance activities in
Provider's billing or facility address. A failure to accordance with the applicable Utilization Review
give any notice required by this Section shall be a and Quality Assurance Program, In addition,
material breach of Member Providers obligations Physician agrees that in the event an examination
and responsibilities hereunder, regardless of the concerning the quality of healthcare services is
status,pendency or outcome of the event giving rise conducted by appropriate officials, as required .by
to the obligation to give that notice, and may be federal,state, and/or local law,RHO shall submit,in
grounds for termination of this Agreement. a timely fashion,any required books and records and
shall facilitate such examination, RHO and
II.9 Medical Records, Member Provider shall Member Provider agree to assist one another with
maintain complete and timely medical records for on-site inspection of facilities and records by
Qualified Participants treated by Member Provider representatives of authorized federal, state and local
and its medical staff. Such records shall be prepared regulatory agencies
in accordance with accepted principles of practice,
shall document all services performed for Qualified 11.11 Relationship of Parties. Member Provider and
Participants and shall comply with all applicable RHO understands and agrees that they are each an
state and federal laws. Member Provider shall Independent legal entity. Nothing in this agreement
maintain such records for the length of time required shall be construed or deemed to create a relationship
by applicable state or federal law, Subject to all of employer and employee, principal and agent,
applicable privacy and confidentiality requirements, partnership or joint venture or any relationship other
stuch medical records shall be made available to each than that of independent parties contracting with
Member Provider and other health professionals each other solely to carry out the provisions of this
treating the Qualified Participant, and upon request, Agreement for the purposes recited in this
to the Payor, RHO or its designated representative Agreement, With regard to the provision of
for review at the rates approved by State law and as healthcare services, Member Provider acts as an
set forth in the current State Workers Compensation independent entity and the Member Provider-patient
Reimbursement Manual for Hospitals, if applicable, relationship shall in no way be affected.
Member Provider shall obtain a valid consent for the
release of the Qualified Participant's medical records 11.12 Standards of Care, Member Provider agrees
to other providers, RHO, Payor, or• its designated that all duties performed hereunder shall be
representative, RHO agrees that medical records of consistent with the proper practice of their
Qualified Participants shall be treated as confidential healthcare profession, and that such duties shall be
so as to comply with all federal and state laws and performed in accordance with the customary rules of
regulations regarding the confidentiality of patient ethics and conduct of the appropriate and applicable
records. The Member Provider's obligations under professional organizations and/or associations,as the
this Section 11.9 shall survive the termination of this case may be, and suelu other bodies, formal or
Agreement, informal state <
> government or otherwise, or b}
which they are subject to licensing/certification and
11.10 Inspection of Records and Operations, RHO, control. Additionally, Member Provider shall
Payor or a designated representative shall have the perform all medical and healthcare services in
right to inspect and audit, at all reasonable times conformance with the standards for their facilities as
during normal business hours, upon prior five (5) established by the local/regional professional
business days, any of Member Provider's medical healthcare community and applicable
records and operations reasonably pertaining to accrediting/licensing agencies. Member Provider ;
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j Preferred Imaging 10162013 RUNFAGTX 01 2012
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agrees that, to the extent feasible, it shall utilize such Panels (iv) Customized Local Networks and (v)
additional allied health and other qualified personnel Client Service Provider Referral Service.
as are available and appropriate for effective and
efficient delivery of care. Member Provider shall III.2 Credentialing. RHO will perforin and/or
ensure that all such personnel are properly licensed delegate to qualified organizations credentialing of
and/or possess the necessary credentials to render cacti Member Provider. Credentialing may include
the services that they perform, verification of all information and documents
provided it) the application for participation and
11.13 Right to Use Member Provider's or Network's investigation, including but not limited to
Naine. Member Provider agrees to allow R140 to verification with all state and national licensing and
list Member Provider's name, specialty, address, certifying bodies that apply to the services rendered
telephone number, and hours of operation in a by the Member Provider;such as JCAHO,AAAHC,
Member Provider directory, Provider Search, RIIG NCQA, CLIA, URAC, etc. Inquiries inay also be
Site-Specific Provider Panel(s), RHO website and/ made to current and previous professional liability
or other materials to help promote and assist Clients carriers, Medicate and Medicaid. R140's
with Qualified Participants needing medical care for credentialing policies and procedures follow the
injuries/illnesses sustained. RHO agrees to allow American Accreditation Healthcare Commission
Member Provider to list RIIG's name, address, and (URAL) and//or NCQA standards for Workers'
telephone number on Member Provider's website or Compensation provider networks.
in other publications listing the health plans accepted
by Member Provider. In addition, Member Provider I11.3 Operational Functions, RHO shall utilize
agrees to post in waiting roam and make available to systems to respond to Member Providers requests
Qualified Participant notice of Member Provider's for information and will provide clarification of
participation with RHO with name, address and policies concerning the operation of RHG's
telephone number and process for Qualified programs. Member Provider agrees to work in
Participants to resolve complaints. The Member cooperation with RHG to market the services of the
Provider is required to post, in Member Provider's Member Provider to Clients and/or Payors.
office, notice to employees on the process for
resolving workers' compensation health care RHO shalt act as a liaison with the Member
network complaints. The notice must include the Providers and Clients and/or Payors to devote
Texas Department of Insurance's toil-free phone necessary time and effort to perform RHG's
number for filing a complaint and must list all responsibilities hereunder.
workers' compensation health care networks with
which the Member Provider contracts. 111.4 Retaliatory Action. RHG agrees not to engage
in any retaliatory action including termination of
11.14 Noncompliance.Member Provider understands contract or refusal to renew a contract against
that failure to comply with any of the requirements Member Provider, because Member Provider, on
imposed pursuant to this Agreennent may result in behalf of an Qualified Participant,reasonably filed a
termination of this Agreement by RHG. complaint against, or appealed a decision of RHO or
Payor, or requested reconsideration or independent
11.15 Antitrust Guidelines. Member Provider agrees review of an adverse determination.
to comply with all antitrust guidelines and
procedures promulgated by Federal and State 111.5 Antitrust Guidelines. RHO agrees to comply
entities. with all antitrust guidelines and procedure
promulgated by Federal and State entities.
III. RHG's OBLIGAI'1ONS
1I1.6 Audit Policy and Procedure Compliance. All
111,1 Marketing to Clients/Payors. RHG shall enter bill audit requests by Payor shall be done in
into agreements with Clients and/or Payors as accordance with the State Law and/or Federal Rules
defined in 1.3 and 1.4 for their access to R1.1G quality and Regulations.
Member Providers through specific referral
processes. RHG will market Member Providers for f
referral; including but not limited to the following;
(i) Provider Search Provider Locator System (ii)
Provider Directories (iii) Site-Specific Provider
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IV. REIMBURSEMENT,CLAIMS will be subject to the reimbursement rates
SUBMISSION AND PAYMENT established in the Exhibit B of this Agreement.
IV,l Reimbursement. RHG shall arrange and All billing and re€riburseinent will be made in
provide the Member Provider, locations and/or any accordance with Labor Code 408.027 and all other
additional Tax Identification Numbers as listed in applicable state rules and regulations.
Exhibit C for Payors to pay Member Provider the
reimbursement rates for Covered Services rendered IV.3 Bill and/or Claim Forms, Claim fbi ns are
to Qualified Participants pursuant to Exhibit B, required for all services. All claims must be
Member Provider agrees and acknowledges that submitted complete and accurate on UB-92(or other
RHG is acting solely in an administrative capacity in appropriate claim form or their successors) and must
providing a network of quality health services,RHO include Member Provider's usual and customary
is not the claims paying agent and will not be liable billed charges(not discounted rates) and appropriate
for the payinent of any amount owed by a Payor to codes, consistent with policies established or
Member Provider in the event that Member Provider approved by applicable state and/or federal
is unable to collect such amount of money up to and m•eguiations.Member Provider must submit claims to
including the insolvency of the Payor, Under no Payor not later than the 950' day after the date on
circumstance will a Member Provider attempt to which services are provided to the Qualified
collect payment from a Qualified Participant for Participant, or as specified by state law. In
medical services rendered for a compensable, work- accordance with Labor Code §408,027 and other
related injury/illness. applicable statutes and rules, billing and payment to
Member Provider will be made within forty-five
IV,2 Reimbursement Rates, Member Provider is to (45) days of receipt of bills which are accurate and
be paid by the Payor in accordance with State Law complete, and otherwise in accordance with state
and/or rales and regulations at the rates established rules and regulations,
in Exhibit B. Member Provider hereby agrees that
rates in Exhibit 13,which may be amended from time IVA Limited Recourse Against Qualified
to time upon mutual written agreement,represent the Partioipants. Except as otherwise provided in this
total amount to be received and agrees to look solely Agreement (Section 1.10), Member Provider agrees
to the Payor for payment for such Covered Services. to seek payment from. each Payor for Covered
Payinnent will be made for Covered Services actually Services provided to its Qualified Participants, and
rendered. All claims will be paid, when appropriate, agrees that it will not seek additional payments or
only after submission of a complete and accurate reimbursement for compensable injuries from
claim. A complete and accurate claim shall be Qualified Participants, In addition, Member
defined as a clean claim by Medicare.RHG does not Provider agrees that neither RHG,tate Payor nor the
guarantee, represent, warrant or covenant regarding Qualified Participant shall be billed or ultimately
the selection or use of Member Provider's services held responsible for payment of services deemed not
by any Qualified Participant or Payor,or the number to be covered by the Payor or its designee. When
of patients, if any, which may ,result from Qualified Participant is covered by a state or
participation in RHG's provider network. The federally regulated Occupational hiiury and Illness
obligation of a Payor to reimburse Member Provider program, Member Provider agrees to comply with
in accordance with Exhibit B for the provision of state and federal regulations regarding holding
Covered Services to a Qualified Participant shall be Qualified Participants harmless for amounts not paid
conditioned upon a good faith determination by the by Payor for any reason, including Payors
Payor or its designated representative that (i) such insolvency. This provision does not preclude billing
services are medically necessary, whether such a bion-Qualified Participant for a non-compensable
determinations are made before, on or after the injury.
provision of services to such Qualified Participant,
IVA.1 Transfer of Risk. This Agreement and any
All services billed under the Tax Identification subcontract within shall not be interpreted to involve
Number(s) indicated in this Agreement, any a transfer of financial risk for the provision of health
Amendments, Exhibit A, Exhibit B, Exhibit C, care services from Payor to RHO as defined under
Applications or any updates regarding locations Insurance Code §1305.004(a)(26). Member Provider `
and%or a Member Provider as defined in section 1.6 agrees and acknowledges that RHG is acting solely
in an administrative capacity in providing a network i
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of quality health providers. RHG is not the claims intent of RHG to cooperate In the defense of said
paying agent and will not be liable for the payment claim. However, RHG shall have the right to take
of any amount owed by a Payor to Member Provider any and all actions they believe necessary to protect
in the event that Member Provider is unable to their interest.
collect such amount of money up to and including
the insolvency of Payor. V.3 Indemnification of Member Provider. Member
Provider will be responsible fol' its own acts or
IV.5 Payment of Claim Forms, RHG shall omissions and any and all claims,liabilities,injuries,
administratively arrange for the Payor or its suits and demands and expenses of all kinds which
designated representative to pay undisputed claims may result or arise out of any alleged malfeasance or
which are accurate, complete and comply with the neglect caused or alleged to have be caused by its
Agreement within the time period mandated by state employees or representatives, in the performance or
or federal law. omission of any act or responsibility under this
Agreement. In the event that a claim is made against
IV.6 Erroneous Paeitt. In the event that a Payor Member Provider, it is the intent of Member
and/or its designated representative pays the Provider to cooperate in the defense of said claim.
Member provider (i) more than once, or (H) an However, Member Provider shall have the right to
incorrect amount, or(iii) an overpayment, the Payor take any and all actions they believe necessary to
or its designated representative may, at its sole protect their interest.
option and discretion, request the return of such
amount fiom Member Provider The Member W. TERM AND TERMINATION
Provider will not unreasonably withhold
reimbursement. If overpayment has been made VI,l Tera, The term of this Agreement shall be for
Member Provider shall reimburse such overpayment one (1) year fiom the date hereof and shall be
within forty-five (45) days and/or follow State and automatically renewed on an annual basis for
Local Rules and Regulations, The Member Provider successive twelve(12) month periods, unless sooner
may not contest payment of Claims after one terminated in accordance with SectionV1.2.
hundred eighty(180)days from the date of payment.
All claims for overpayment or underpayment shall VI.2 Termination. This Agreement may be
be resolved in accordance with State Law and /or terminated sooner on the first to occur of the
Federal Rules and Regulations. following;
V. INSURANCE AND INDEMNINCATION V1.2.1 Termination by Member Provider. Member
Provider may terminate this Agreement in the event
V.1 Insurance Requirement. Member Provider shall of a material default or breach of RHG's obligations
provide and maintain such policies of professional hereunder,upon ninety (90)days prior written notice
liability insurance or a self-funded program, The and the failure of RHG to cure such breach or
amounts and extent of such insurance coverage or default within sixty (60) days of the notice. In
self-funded program shall be in the amounts addition, in the event of an "emergency situation",
determined by community standards for relevant Member Provider may terminate the Agreement
hospital/facilities. Member Provider shall promptly immediately with acknowledgment by RHG that
demonstrate evidence of insurability or self-funded such an emergency condition does exist.
program and that the required insurance is paid and "Emergency Situation" shall mean an unforeseeable
in force upon request of RHG and/or meet the event, not resulting fronn Member Provider's act or
credentiaiing guidelines of RHG. omission, which materially affects Member
Providers ability to continue the practice of
V.2 Indemnification of RHG. RHG will be medicine or to perform his obligations hereunder,
responsible for its own acts or omissions and any The Network will provide notification to employees
and all claims,liabilities, injuries, snits and demands of the terminating Member Provider immediately
} and expenses of all kinds which may result or• arise upon receipt of the Member Provider's termination
out of any alleged malfeasance or neglect caused or request or as soonr as reasonably possible before the
alleged to have be caused by its employees or effective date of termination as required by 28 TAC
representatives, in the performance or omission of 10.42(b)(6)(G),
any act or responsibility tinder this Agreement, In
the event that a claim is made against RHG, it is the
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VI.2.2 Termination by RHG. A Member Provider the breach within sixty (60) days of the notice, in
i shall automatically be terminated on the date when: which case, the Agreement and applicable rates and
(1) Member Provider's license in the State where terms shall continue in effect. Either party may
services are rendered is suspended or revoked, (ii) terminate this Agreement without cause upon ninety
Member Provider is excluded from participation in (90)days prior written notice.
1
the Medicaid or Medicare programs, (iii) Member
Provider losses their 3CAHO, NCQA, AAAHC, VI.2.5 Unforeseen Events, In the event that either
URAC, CLIA or other applicable license, party's ability to perform their obligations under this
i certification and/or accreditation, (iv) Member Agreement is substantially interrupted by war, fire,
Provider loses or experience a material reduction in insurrection, riots, the elements, earthquake, acts of
liability insurance and such insurance falls below the God, or other similar circumstances beyond the
requirements of State Law (v) Member Provider reasonable control of such party, •the patty shall be
j engages in any act, omission, demeanor or conduct relieved of those obligations for the duration of the
that is reasonably likely to be detrimental to patient interruption upon notice to the other party. In the
safety or to the delivery of quality patient cure,or to event that the interruption is reasonably determined
lead to the provision of healthcare services below likely to persist for at least ninety (90) days, either
applicable standards, or (vi) ninety (90) days patty may terminate this Agreement upon thirty (30)
following written notice by RHO of a material days prior written notice.
default or breach by Member Provider hereunder
and the failure of Member Provider to cure such VI.3 Effects of Termination. Upon termination of
default or breach within sixty(60)days of the notice this Agreement, neither party shall have any further
(vii) Member Provider falls to meet RHG's or the obligation hereunder except for (i) obligations
State's cledentialing requirements, RFIG, however, accruing prior to the date of termination, including
may not terminate this Agreement in direct response without limitation, any obligation by Member
to Physician filing a reasonable complaint, on behalf Provider to continue to provide heattlicare services
of a Qualified Participant against, or appealed a to Qualified Participants, and (H) obligations,
decision of, the network, or requested promises or covenants contained herein which are
reconsideration or independent review of an adverse expressly made to extend beyond the term of this
decision. Agreement.
In the event RHO deems it necessary to terminate VIA Qualified Participant and Payor Notification,If
Member Provider's agreement based on the above applicable, upon the termination of this Agreement,
requirements RHO will notify Member Provider at by either party, Member Provider shall cooperate
least ninety (90) days before the effective date of with RHG to notify Qualified Participants and
termination. Payors of such termination.
Upon written notification from RHO, Member VII, CONTINUATION OF BENE F{'ITS
Provider may request a review by RHG's advisory
review panel, not later than thirty (30) days after VIII Continuation of Benefits. If Member Provider
notification, RHO must then complete the review voluntarily terminates its contract with RHG, upon
before the effective date of termination. Member Provider's request, Payor must continue to
reimburse Member Provider for a period not to
VI.2.3 Termination for Insolvency. This Agreement exceed 90 days at the Member Provider's contracted
shall terminate immediately in the event that either tate set forth in Exhibit B of this Agreement with
RHO or Member Provider voluntarily or RHG,for care of an Qualified Participant with a life-
involuntarily, liquidates, dissolves or becomes threatening condition or an acute condition for
subject to any proceeding for the rehabilitation or which discontinuing or disruption of care would
conservation of their financial affairs with written harm tiie Qualified Participant as per 28 TAC
notification. 10.42(b) (A). Any disputes concerning continuity of
care shall be resolved through the complaint process
VI.2A Termination by Either Party..In case of under Insurance Code §1305.401 - §1305.405 and
material breach of the terms of this Agreement, Subchapter G of Title 28, Part 1 (relating to
either party may terminate the Agreement with at Complaints).
least ninety (90) days prior written notice to the
i
other party; however, the party in breach may cure
{
Preferred ImaPnge 3 of 14 ging 10162010 RUNMC ) 01-20I2 j
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;
VII.2 Surviva. The provisions of this Article VTI IX.1.1 Mediation through RHO, The Member
! shall survive the termination of this Agreement Provider shall notify RHG in writing of the dispute
regardless of the cause - giving 'rise to such or disagreement and shall provide all necessary
termination, as will sections 11.9, V.2, V.3, VD, information to RHG. RIO shall use best efforts to
VIII, and IX. The provisions of this Article VII mediate the dispute within the rules and regulations
supersede any oral or written agreement to the put forth by the State as reference in RHG's
contrary now existing or hereafter entered into Provider Handbook.
between Member Provider and any Qualified
Participant or any person acting on a Qualified IX.1.2 Arbitration. If the dispute cannot be solved
Participant's behalf, by the mediation process described above, either the
Member Provider, RHG or Payor may elect to
VIII, CONFIDENTIALITY submit the dispute to binding arbitration under the
rules of the American Arbitration Association or any
All business, medical and other records relating to other method of arbitration mutually agreed upon by
the operation of RHG or Member Provider, the parties. Arbitration will be conducted in
including but not limited to, books of account, Houston, Texas. Each party will be responsible for
general administrative records, policies and their own legal fees. The cost of the arbitration
procedures, pricing information, terms of this services will be the sole responsibility of the party
Agreement and all information generated and/or requesting the arbitration,
contained in management information systems
owned by or pertaining to RHG or Member 1X.1.3 Provider Appeals.Except for termination due
Provider, and all systems, manuals, computer to contract expiration, Member Provider has the
software and other materials, but excluding patient right to appeal his/her termination from the Network,
charts,shall be and remain the sole property of RHG as follows:
or Member Provider respectively (collectively, the
"Confidential Information"), RHG and Member IX.1.3.1 RHG will provide notice to the Member
Provider acknowledges that the Confidential Provider at least 90 days before the effective date of
Information and all other information regarding a termination by RHG;
RHG or Member Provider that is competitively
sensitive is the property of RHG or Member IX.1,3.2 Upon receipt of the written notification of
Provider and RHG or Member Provider may be termination, a Member Provider may request in
damaged if such information was revealed to a third writing a review by the Network's advisory review
i party. Accordingly, RHG and Member Provider panel no later than 30 days after receipt of the
agrees to keep strictly confidential and to hold in notification;
trust all Confidential Information. Upon termination
of this Agreement by either party for any reason 1X.1.3.3 The Network will provide an advisory
whatsoever, RHG and Member Provider shall review panel that consists of at least three Providers
promptly return to the other all material constituting of the same licensure and the same or similar
Confidential Information or containing Confidential specialty as the Member Provider;
Information, and neither party will not thereafter
use, appropriate, or reproduce such information or IX.1,3.4 The Network inust complete the advisory
disclose such information to any third party. RHG panel review before the effective date of the
and Member Provider specifically agrees that under termination;
no circumstances will either party discuss the terms
and conditions of this Agreement, and in particular 1X.1.3.5 The Client, Payor, or RHO may not notify
the pricing information herein. patients of the termination until the earlier of t11e
effective date of the termination or the date the
IX. MISCELLANEOUS advisory review panel makes a formal
recommendation;
IX.1 Disputes. All disputes and difference between
the Member Provider and RHG upon which an IX.1.3.6 If Member Provider terminates the contract,
amicable understanding cannot be reached are to be the Network or RHO's Client will provide
decided by the following method; notification of the termination to employees
receiving care from the terminating provider. The
Network shall give such notice immediately upon
3
Page 9 of 14 i
Preferred Imaging 10162013 RUNFAC TX 01-2012 E
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i
receipt of the Member Provider's termination
request or as soon as reasonably possible before the IX.8 Severability. The invalidity or un-
effective date of termination, enforceability of any terin or condition hereof shall
in no way affect the validity or enforceability of any
IX.2 Non-Exclusivity. Nothing in this Agreement other term or provision.
shall be construed to restrict Member Provider or
RHG from entering into other contracts or IX.9 Assignment, Member Provider may not assign
agreements to provide healthcare services to Payors or otherwise transfer any right or delegate any duty
or other healthcare delivery plans, patients, and of performance hereunder, in whole or in part
employer groups. without the prior written consent of RHO. A change
Ill ownership will not negate the prior contractual
IX.3 Entire Agreement. This Agreement contains agreement without 'written. notification to RHG.
the entire understanding of the parties and RHO retains the right to assign this Agreement, In
supersedes any prior understandings and agreements, whole or in part,to any entity with which RHO or its
written or oral, respecting the subjects discussed parent company or any of its subsidiaries is
herein, affiliated,or with which it merges or consolidates.
IXA No Waiver. The waiver by either party of a IX.10 Third Partv Beneficiaries. Except for Payors
breach or violation of any provision of this and the agents thereof, there are no third party
Agreement shall not operate as or be construed to be beneficiaries of this Agreement.
a waiver of any subsequent breach hereof.
1X,11 Captions. The captions and headings
IX.S Regulatory Compliance. Member Provider, contained in this Agreement are for reference
sub-contracting providers, and RHG agree that each purposes only and shall not affect in anyway the
small comply with all applicable requirements of meaning or interpretation of this Agreement.
municipal, county, state and federal authorities, all
municipal and county ordinances and regulations, IX,12 Execution of Counter arts. This Agreement
and all applicable state and federal statutes and may be executed in any number of counterparts,
regulations, now or hereafter in force and effect, including facsimiles, each of which shall be deemed
governing RHG, Member Provider, sub-contracting to be an original as against any part whose signature
providers, the provision of services by Member appears thereon, and all of which shall together
Provider or sub-contracting providers, and/or constitute one and the same instrument,
Payors, including but not limited to applicable
requirements under any state or federal fair 1X.13 Partial Invalidity. If any part, clause or
employment practices, equal employment provision of this Agreement is held to be void by a
opportunity, or similar laws declaring discrimination court of competent jurisdiction, the remaining
in employment based upon race, color, creed, provisions of this Agreement shall not be affected
religion,sex, or national origin as illegal, and,Titles and shall be given construction, if possible, as to
VI and VII of the Civil Rights Act of 1964, Section permit it to comply with the minimum requirements
202 of Executive Order 11246 as amended by of any applicable law, and the intent of parties
Executive Order 11375, Sections 503 and 504 or the hereto.
Rehabilitation Act of 1973 and Title IV of the
Vietnam Era Veterans Readjustment Assistance Act IK14 Financial Incentives. Neither a Client, Payor,
of 1974, and Sections 1 and 3 of Executive Order nor RHG may use financial incentive or make a
1.1625, or any applicable rule or regulation payment to a health care provider that acts directly
promulgated pursuant to any such laws or orders. or indirectly as an inducement to limit medically
necessary services. The adoption of treatment and
IX.6 Governing Law. This Agreement shall be return-to-work guidelines and individual treatment
governed by and construed in accordance with protocols by RHG or Network is not in violation of
applicable state law, this section as pursuant -to Insurance Code §1305.
304 and§10,83(a)of Chp 10 of Title 28 Part 1,
IX.7 Amendments, This Agreement may be
amended as agreed to by both parties in writing upon IX.15 Financial Disclosure Requirements, Both
thirty (30) days written notice of such proposed parties agree Member Provider is a facility or
i amendment, consists of facilities aril therefore Member Provider
is not required to file financial disclosures in
Page 10 of 14
Preferred Imaging 10162013 IiUNFAC TX 03-20tZ
accordance with .Labor Code §§408.023 and IX.17 Official Notices. Any notice or
§§413.041. communication required, permitted or desired to be
given hereunder shall be deemed effectively given
IX.16 Econ-omio Pra61111 . Network must provide when personally delivered. or walled, return receipt
written notice to Member .Provider before the requested, or overnight express mail addressed as
Network conduots economic profiling, including follows:
utilization inanagement studies or other profiling of
the provider or group of providers.
Member Provider of Representative/Designee:
' (Please Print)
Name:
0
Organization:Preferred Irnag Tnc.
Address: 7920 Beitline Rd,Ste 410
City/State/Zip:Dallas.TX 75251
Telephone:22�;788-7500
Fax: 972-346-6869
Organization:
Rockport Colx mimity Network,Inc.
dba Rockport healthcare Group
Attn: Network Develop;inent
50 Briar Hollow Lane,Suite 515W
Houston,TX 77027
Telephone:(713)621-9424
Fax:(713)621-9511
IN WITNESS WHEREOF,the undersigned will be, or to such other address, and to the attention of such
deemed to have executed. this Agreement as of the other petson(s) or officer(s) as either party may
date the provider is fully credentialed by RHO. designate by written notice.
For and on behalf of
For and on behalf oh
Rockport Community Network,Ine,
dba Rockport Healthenre Group Member Frovlder or Representativ / esi�rlee
S 1,1xr Hollow Lane,Suite 515W
Hou to77027 Signature: r
Naine.
Douglas rkha6i ��(Print)
FrMde TIN:see Exhibit C s 1t reacflsheet
Date; '��-l`"t Date: � � 1
Pxfcrmd Imaging 10162013 Page 11 of 14 RUNPA.0 TX 01-2012
i
EXHIBIT A
STANDARDS AND GUIDELINES
UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS
RHO and its Clients require Member Providers to follow nationally recognized treatment guidelines (i.e. Official
Disability Guidelines(ODG) and/or American Occupational and Environmental Medicine's (ACOEM)guidelines)
in the treatment of work-related injuries/illnesses for Qualified Participants,
R110's CIients provide utilization review and quality improvement programs for Qualified Participants. RHO shall
review each Clients Utilization Review and Quality Improvement Program in accordance with RHG's Credentialing
Standards and Guidelines as described in this Exhibit, Physician and/or Member Provider agrees to comply and be
bound by such programs and any state or federal rules and regulations.
Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written
notice to Physician and/or Member Provider.
The primary goals of the Utilization Review Programs shall be to:
1) Ensure and certify for the payment of benefits that healthcare services meet the definition of medical necessity
as defined by the network,Payor or the Payors designee;
2) Ensure that healthcare services are provided at the appropriate level of care;and
3) Ensure that healthcare services follow nationally recognized treatment guidelines that are evidenced-based and
outcome-focused,
Treatments and Services that may Require Preauthorization:
1) In-patient hospital admissions including the principal scheduled procedures(s)and the length of stay;
2) Outpatient surgical or ambulatory surgical services;
3) Spinal surgery,as provided by Texas Labor Code§408.026;
4) All psychological testing and psychotherapy, repeat interviews, and biofeedback; except when any service is
part of a preauthorized or exempt rehabilitation program;
5) All external and implantable bone growth stimulators;
6) All chemonucleolysis;
7) All myelograms,discograms,or surface electrornyograins;
8) Unless otherwise specified,repeat individual diagnostic study,with a fee established in the current Medical Fee
Guideline of greater than$350 or documentation of procedure(DOP);
9) Work hardening and work conditioning services provided in a facility that has not been approved for exemption
by the Division;
10) Rehabilitation programs to include (a) outpatient medical rehabilitation and (b) chronic pain management /
interdisciplinary pain rehabilitation;
11) All durable medical equipment (DME) in excess of$500 per item (either purchase or expected cumulative
rental)and all transcutaneous electrical lzerve stimulator(TENS)units,
12) Nursing home,convalescent,residential,and all home health care services and treatments;
13) Chemical dependency or weight loss programs;
14) Any investigational or experimental service or device for which there is early,developing scientific or clinical
evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly
accepted as the prevailing standard of care;and
15) Physical and occupational therapy services;(a)physical and occupational therapy services are those listed in the
Healthcare Common Procedure Coding System (HCPCS) Level I code range for Physical Medicine and
Rehabilitation, but limited to: (i.) modalities, both supervised and constant attendance; (ii) therapeutic
procedures,excluding work hardening and work conditioning;and(iii)other procedures, limited to the unlisted
physical medicine and rehabilitation procedure code.
NOTE; Preauthorization is not required for the first two visits of physical or occupational therapy following the
t evaluation when such treatment is rendered within the first two weeks immediately following: (i)the date of injury,
or(ii)a surgical intervention previously approved by the payor.
i
+
Page 12 of 14
Preferred Inca ing 10162013
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EXHIBIT B
Reimbursement Schedide
I,Rockport United Network/Rockport SeleetHealth Network-Occupational Injury and Illness
Provider fees£oi•the prograins listed above shall be reimbursed at the follotiving:
All fees will be reimburses[ at 80% (eighty percent) of the state's current Workers' Compensation
I
fees,rules and regulations or usual and oustommy allowablos,
Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of
this Agreement,state rules and regulations and/or the applicable Occupational Injury or Tlhiess Benefit
Plan.
I/'We Ampt the fees as outlined in this Exhibit B.
For and on behalf of, For and on behalf of,
(Name,address,ete.)
ROCKPORT COMMUNITY NETWORK,INC.
Preferred Imaging,Inc.
dila,ROC10ORT HEALTHCARE GROUP 7920 Beltline Rd Ste 41.0
qff-Balar Hollow Lane,Suite 5155 Dallas,M 75254
kot:n,M702 "pp
Signature
Douglas kka\1diaxu
Pxlnted Nang
President Title
Office Ad--J.
Date '� TTN see Exhibit C srlreadslieet Date
i
i
Page 13 of 14
i Preferred Waging 10162013 RUNPAC TX 01-2012
EXHIBIT C
Signature Page
Facilties and/or locations where services are to be rendered by Member Provider
The Member Provider agrees thatthe following facllity locations and/or practice locations listed on attached
Exhibit C Spreadsheet andtor an equivalent spreadsheet provided by Member Provider;shall be Inclusive of the
signed agreement and the signed rates in Exhibit B. By signing below Member Provider or its
Representative/Designee allows Rockport Healthcare Group(RHO)and its representatives to use any and all of
the aftaohed information as agreed to in this sighed agreement.
See Exhibit C spreadsheet
For and on behalf oh For anti on behalf ob
Rockport Community Network,Inc. Member Provider or Represen-tative/Designee
dba Rockport Healthcare Group
riar Hollow Lane,Suite 515W f yx/1 `1
�79
ort 771327 Signature; $ �
n N�f`. 1
Nanze: u t 1
Dougla rRham (print)
Preside
Date: Date:
i
t
S
t
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