HomeMy WebLinkAboutContract 47186-P6 CITY SECKJARY
CONTRACT NO.
i
A DDE1\7DUM
d To
o BlackStone 504 Program
c� Provider Agreement
This Addendum is entered into by and among Peter E. Grays, MD ("Member Pro ' "�, Rockport
H alt Group ('4o kport"), and the City of Fort Worth ("City") on this day of
WHEREAS, Rockport and Member Provider entered into a Provider Agreement, effective March 15,
2007. ("Provider Agreement"), and desire that this Addendum apply to covered services that are
i 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 S ection 504.053.
i
WHEREAS, the City has determined that a workers' compensation health care network certified tinder
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.
I
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 full 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
t Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under
section 504,0.53 of the Texas Labor Code. The City's Provider Manual (under the name of
Blackstone) 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 the terms of the Provider Agreement subject to the applicable Provider Manual and the
provisions of the Texas Labor Code and applicable rules under the Texcas Administrative Code.
Rockport will continue to provide applicable network administrative services_
3. When used in this Addendum,unless the content otherwise clearly requh es,the following words and
i terms shall have the meaning set forth below. All other defined terms shat have the meaning
' ascribed to them in the Provider Agreement.
4
Peter E. Grays,MD 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 Workers Compensation Act.
"BlackStone?' is the 504 Provider Panel established by the City of Fort 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.
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 WfIEREOF,the parties hereto have executed this Addendum effective on the day and year
first written above.
For and on behalf of:
City of Fort Worth
BlackStone
n. 0
Signatur .
Name: san A nis
Title: Assistant City Manager
C1)
Dater (
APPROVED AST(J.PURN MID LEGALITY:
LI
FOP
Assistant Cit<j Atio;neyC�u�
OFFICIAL RECORD 2
CITY SECRETARY
y
FT.WORTH,TXmd'yXeir, dtysomt'-
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Peter E.Grays,ND Provider Agreement
ROCK ORT DFA.LTHCARE GROUP
,�►/e- -
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Signature: :•�
Name., ji, C.L'
altTe:
Date: C)4 I `x-11 P
MEMBER PROVMF,R or
Representative/Designee
Name' ��. �Fr �c rGctgS
.Date:
TTN:
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IPA/PHO/MSO AGREEMENT 106
ROCKPORT COMMUNITY NETWORK,INC.
This Agreement ("Agreement") is entered into by I. DEFINITIONS
and between Rockport Community Network, Inc.,
("RCN"), a Nevada Corporation and T.I.O.P.A., Inc. When used in this Agreement and unless the content
("Provider"), on behalf of its member physicians otherwise clearly requires, the following words and
("Physician"), a corporation composed of physicians terms shall mean:
licensed to practice medicine in the state where
services are rendered, and will become effective as I.1 "Physician' means a licensed Medical Doctor or
of the date the Agreement is executed by RCN. Doctor of Osteopathic Medicine, or group of same
who desire to become a Member Provider with
WHEREAS, RCN is engaged in the business of RCN
developing and acting in an administrative capacity
in providing individual and group accident and 1.2 "Qualified Participant" means: (a) an employee,
health; industrial and occupational; personal injury member and/or dependent of an RCN payor/client
protection; and Medical Access Savings Card who is eligible to receive certain healthcare benefits
provider networks that offer a new integrated under an.individual or group accident and health
continuum of healthcare services. These networks benefit plan, personal injury protection plan, or any f
will offer greater efficiency, economy, quality and other insurance program; (b) a person who presents
availability of healthcare services; and with authorization from the Employer prior to the
initiation of treatment that the worker is currently
WHEREAS, RCN has networks of contracted employed and that the presenting problem was job
physicians, physician groups, hospitals and related, either in writing or by telephone; and (c)
providers of ancillary healthcare services individuals and/or families eligible to receive
(collectively, the "Member Providers") to provide a contracted rates as described in Exhibit B by virtue
full-range of healthcare services. These services are of their verified participation in the Medical Access
available for use by "Qualified Participants" as Savings Card Program, which is neither an insurance
defined later in this document;and or benefit plan.
WHEREAS, Physician desires to provide 1.3 "Payor" means an individual, organization, firm
appropriate and cost-effective healthcare services to or governmental entity, including but not limited to
"Qualified Participants" who are covered by Payor an employer, self-insured employer, employer
Agreements at the rates in Exhibit B; and coalition, health insurance purchasing cooperative,
insurer, third party administrator, or a Qualified
WHEREAS, RCN has entered into Agreements with Participant in a Medical Access Savings Card
one or more insurance carriers, self insured groups, Program. These Payors have entered into a Payor
and third party administrators to provide for Agreement with RCN for the provision of
healthcare review, medical service, and other healthcare services to Qualified Participants and
medical utilization "services for employers which have agreed to pay for such services, pursuant to
maintain self-insured funds, third party such Payor Agreement.
administrators, insurance carriers and individuals
who have contracted with RCN. 1.4 'Payor Arbreement" means the . agreement
between RCN and a Payor, which is made before,
NOW, THEREFORE, in consideration of the on or after the effective date of this Agreement and
premises, the mutual promises contained herein, and which expresses the agreed upon contractual rights .
other good and valuable consideration, the receipt and obligations of the parties.
and sufficiency of which are hereby acknowledged,
it is mutually agreed as follows: 1.5 "Member Provider" means any physician;
physician group; hospital- surgery center; diagnostic
imaging center; laboratory; -clinic; chiropractor;
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rRocKPORT COMMUNPCY NETWORK.INC:."' - 01/03/00
dentist; podiatrist; psychologist; social worker; resources is sought and utilization and practice
physical, occupational and speech therapist; etc. patterns are monitored in order to identify and, as
licensed or certified to practice a healthcare appropriate, to correct deviations from established
profession or licensed as a facility to offer healthcare norms. Medical necessity and medically necessary
services, in the state where services are rendered, determinations are established and administered by
who has met the credentialing requirements of RCN, the Payor or the Payor's designee, in accordance
and who has been accepted by RCN as a Member with Exhibit A, with the exception of Qualified
Provider and who has executed a contract with RCN. Participants in the Medical Access Savings Card
Program.
I.6 "Primark Care Physician" means a Member
Provider who has met the credentialing requirements I.1 I "Claim and/or Claim Form" means a HCFA
of RCN to be a Primary Care Physician.and is 1500 and/or UB 92 used for billing for all services
designated by RCN as a Primary Care Physician. with regard to Accident and Health, Personal Injury
Protection, and Workers' Compensation Plans. For
1.7 "Specialist Physician" means a Member Provider services rendered to Qualified Participants of the
t who has met the credentialing requirements of RCN Medical Access Savings Card Program, Member
to be a Specialist Physician, and to whom Primary Provider can and should make payment
Care Physicians may refer for necessary and arrangements prior to the delivery of care with the
authorized care other than primary care services. patient or.responsible party. Services provided in
connection with the use of the Medical Access r
I.8 "Emergency" means the sudden and unexpected Savings Card must be documented by a receipt that
onset of a medical condition or accidental injury the Qualified Participant may use for tax purposes or
manifesting itself by acute symptoms of sufficient in conjunction with other coverage. Member
severity (including severe pain) such that the Provider can pursue collection efforts directly with
absence of immediate medical attention could these Qualified Participants if necessary. All others
reasonably be expected to result in any of the will be paid, when appropriate, only after
following: (i) placing the Qualified Participant's submission of a complete and accurate claim.
health in serious jeopardy; (ii) serious impairment to
bodily functions; or (iii) serious dysfunction of any II. PHYSICIAN OBLIGATIONS
bodily, organ or part; and which the Qualified
Participant secures immediately after the onset II.1 Services. Physician agrees to provide or arrange
thereof, or as soon thereafter as practicable,but in no for all medically necessary medical care for
event later than twenty-four (24) hours after onset. Qualified Participants who seek care from Physician.
To the maximum extent permitted by law, the Physician agrees to perform such services with the
determination of whether an Emergency existed at same standard of care, skill and diligence which is
the time covered services were provided shall be customarily used by Physicians in the community in
made exclusively by Payor. which such services are rendered. Physician agrees
that it is his/her sole responsibility to verify that the
1.9 "Covered Services" are those healthcare and individual presenting for care is a Qualified
health-related services as defined by each individual Participant. Physician agrees to render healthcare
Payor. RCN wily communicate Payor specific services to Qualified Participants in the same
Covered Services to each Member Provider. manner, in accordance with the same standards, and
Services covered under the Medical Access Savings with the same time availability as offered to
Card Program are not subject to this definition. Physician's other patients. Physician shall ensure
that services provided are consistent `with RCN's
I.10 "Utilization Review and Quality Assurance programs,policies and procedures and the applicable
Program" means the program or programs, Accident and Health, Personal Injury Protection,
applicable to the Payor, with the exception of Workers' Compensation, Medical Access Savings
Utilization Programs for Qualified Participants in Card programs and plans. Physician agrees to
the Medical Access Savings Card Program, as comply with and be bound by all Utilization Review
amended from time to time, through which and Quality Assurance Programs, including
appropriate, cost-effective utilization of health discharge planning programs, adopted by RCN and
r
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KI'Q72T CQAId)CNITY NL'TIVORK.INC.' Page
the Payor, when approved by RCN, from time to and hold such other licenses, certifications,
time. registrations, permits and approvals as are required.
for the Iawful conduct of Physician's practice.
II.2 Non-Discrimination. Physician shall not Evidence of such current licensing and/or
differentiate or discriminate in the treatment of certifications shall be submitted promptly to RCN
his/her patients as to the quality of services delivered when data changes or renewal occurs and upon
to Qualified Participants because of race, sex, age, request. Physician will have, where appropriate, a
religion, national origin, place of residence, source current narcotics number issued by the appropriate
of payment or health status. Physician shall observe, authority, currently the United States Drug
protect and promote the rights of Qualified Enforcement Administration("DEA")and/or various
Participants as patients. State Controlled Substance Registration Authorities.
I1.3 Continuity of Care,Covering Physician. II.6.2 Medical Staff Privileges. Certain medical
Physician agrees to devote such time as is necessary specialties may not require hospital privileges such
to the performafice of his/her obligations under this as Industrial and Occupational Medicine, Pathology,
Agreement, including maintaining reasonable office Dermatology, Allergy, etc. Where appropriate,
hours. Physician agrees to maintain accessibility Physicians must maintain active, unrestricted staff
either personally or by covering arrangements with privileges with at least one RCN Member Provider
another Member Provider of like specialty or other hospital or Surgery Center. Physician hereby
qualified physician approved by RCN, on a twenty consents to discl-osu're by such facility to RCN of all
four (24) hour-per-day, seven (7) day-per-week data collected with respect to Physician in
basis. Physician shall ensure that such Member connection with Physician's medical staff
Provider or other physician shall comply with RCN's membership, including without limitation all
and each Payors Utilization Review and Quality applications for staff privileges and any renewals
Assurance Programs and will comply with Article thereof.
IV of this Agreement.
11.6.3 Organization's Requirements. Physician shall
IIA Referrals. Except in a medical emergency or comply with and be bound by RCN's criteria for
when authorized by RCN or its designated provider participation, including RCN's
representative, Physician agrees to refer Qualified credentialing and administrative policies and
Participants only to other Member Providers, as procedures, as adopted and amended from time to
defined in I.5, when medically necessary and time by RCN. Physician shall cooperate with RCN's
appropriate.All referrals must be in accordance with periodic evaluation of professional qualifications
the applicable Utilization Review and Quality which shall include, but not be limited to, Physician
Assurance Program unless specifically directed by giving consent to the release of infonnation from
RCN. In addition,Physician agrees to use RCN's or any facility at which Physician has medical staff
the applicable Payors pharmaceutical formularies, if privileges. In addition, Physician shall cooperate
any, when prescribing medications for Qualified with RCN's and each Payor's programs and
Participants. procedures, as approved by RCN,for the expeditious
resolution of any grievance or complaint.
11.5 Reports. For each encounter where Physician
provides services to a Qualified Participant, 11.7 Notification to RCN. Provider represents and
Physician shall report such encounter on an warrants that information provided herein and in the
appropriate form and shall include statistical, RCN provider application is true and accurate in all
descriptive medical and patient data and identifying respects and acknowledges that RCN is .relying on
information, if and to the extent that reports are the accuracy of such.information in entering into and
specified by RCN or its designated representative. continuing the term of this agreement.Provider shall
notify RCN within two or three business days upon
II.6 Professional Requirements, becoming aware of the initiation of any
investigation, disciplinary action, sanction, or peer
11.6.1 Licenses. Physician shall be duly licensed to review action against Physician that could result in
practice medicine in the state where care is rendered (i) suspension, reduction or loss of license to.
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Roci(po T Co11DJuwry NETWORK.INC.' 0I/03/00
.practice Physician's profession or to provide inspect and audit, at all reasonable times during
healthcare services;. (ii) denial, suspension, normal business hours, upon prior notice, any of.
restriction, reduction or termination of privileges or Physician's accounting, administrative, medical
staff membership at any health facility or by any records and operations reasonably pertaining to
peer review body; (iii) impairment of Physician's RCN, to services provided to Qualified Participants,
ability to provide healthcare services safely; or (iv) and to Physician's performance under this
imposition of any sanction under the Medicare Agreement. Physician further agrees to allow RCN,
program or Medicaid program. In addition, Provider Payor (with the exception of.Qualified Participants
shall provide prior written notice to RCN of any in the Medical Access Savings Card Program), or a
changes in (i) Federal Tax Identification Number, designated representative thereof, including the
(ii) other information provided in his/her application designated utilization review, quality management,
for participation, (iii) Physician's professional case management or peer review staff, to have
liability insurance, (iv) Physician's billing or office reasonable access to treatment records and
address, and (v) services provided by Physician. A information of Qualified Participants for services
failure to give any notice required by this Section provided under the terns of this Agreement as
shall be a material breach of Provider's obligations necessary to enable such party to perform Utilization
and responsibilities hereunder, regardless of the Review 'and Quality Assurance activities in
status, pendency or outcome of the event giving rise accordance with the applicable Utilization Review
to the obligation to give that notice, and may be and Quality Assurance Program. In addition,
grounds for delay in payment, claim denial and/or Physician agrees that in the event an examination r
immediate termination of this Agreement. concerning the quality of healthcare services is
conducted by appropriate officials, as required by
11.8 Medical Records. Physician shall maintain federal, state, and/or local law,RCN shall submit, in
complete and timely medical records for Qualified a timely fashion, any required books and records and
Participants treated by Physician. Such records shall shall facilitate such examination. RCN and
be prepared in accordance with accepted principles Physician agree to assist one another with on-site
of practice, shall document all services performed inspection of facilities and records by representatives
for Qualified Participants and shall comply with all of authorized federal, state and local regulatory
applicable state and federal laws. Physician shall agencies.
maintaip such records for the length of time required
by applicable state or federal law. Subject to all 11.10 Relationship of Parties. Provider understands
applicable privacy and confidentiality requirements, and agrees that he/she is an independent legal entity.
such medical records shall be made available to each Nothing in this agreement shall be construed or
physician and other health professionals treating the deemed to create a relationship of employer and
Qualified Participant, and upon request,to the Payor, employee, principal and agent, partnership or joint
RCN or its designated representative for review at venture or any relationship other than that of
the guidelines as established by the TMA. Physician independent parties contracting with each other
shall obtain a valid consent for the release of the solely to carry out the provisions of this Agreement
Qualified Participant's medical records to other for the purposes recited in this Agreement. With
providers, RCN, Payor, or its designated regard to the provision of medical and healthcare
representative. RCN agrees that medical records of services,Physician acts as an independent entity and
Qualified Participants shall be treated as confidential the Physician-patient relationship shall in no way be
so as to comply with.all federal and state laws and affected.
regulations regarding the confidentiality of patient
records. The Physician's obligations under this II.11 Standards of Care. Physician agrees that all
Section 11.8 shall survive the termination of this duties performed hereunder shall be consistent with
Agreement. the proper practice of medicine, and that such duties. .
shall be performed in accordance with the customary
11.9 Inspection of Records and Operations. RCN, rules of ethics and conduct of the American Medical
Payor, with the exception of Qualified Participants Association or American Osteopathic Association,
in the Medical Access Savings Card Program or a as the case may be, and such other bodies,formal or
designated representative, shall have the right to informal, government or otherwise, from which
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nROC.KPORT COMMUNIrry NETWORK,ING" - - 01/03/00
_physicians seek advise and guidance or by which III.2 Utilization Review and Quality .Assurance
they are subject to licensing/certification and Programs. Payor with the exception of Qualified
control. Additionally, Physician shall perform all Participants in the Medical Access Savings Card
medical and healthcare services in conformance with Program or RCN may establish Utilization Review
the standards for his/her specialty as established by and Quality Assurance Programs. Such programs
the applicable specialty board and the local/regional shall be in accordance with 'the Standards and
medical community. Physician agrees that he/she Guidelines established by RCN as outlined in
shall not engage in any acts of moral turpitude, as Exhibit A, which may be amended from time to time
determined by RCN in good faith. Physician agrees upon written notice to Physician.
that, to the extent feasible, he/she shall utilize such
additional allied health and other qualified personnel 111.3 Credentialina. RCN or Provider will perform
as are available and appropriate for the effective and credentialing of each Physician to be included under
efficient delivery of care. Physician shall ensure that this Agreement. Credentialing may include
all such personnel are properly Iicensed and/or verification of all information and documents
possess the necessary credentials to render the provided in the application for participation and
services that they perform. investigation of Physicians education, training and
practice history, including but not limited to queries
II.12 Ri-,ht to Use Physician's Name. Provider to the National Practitioners Data Bank and current
agrees to allow RCN to list Physician's name, and previous professional liability carriers,Medicare
specialty, address and, telephone number and other and Medicaid.
relevant information in a Member.Provider directory
or other materials to help promote and solicit IIIA Operational Functions. RCN shall assign a
contracts with Payors. Provider agrees not to use designated representative to be a liaison with the
RCN's trademarks or trade names without RCN's Providers and Payors, with the exception of
prior written consent. Qualified Participants in the Medical Access Savings
Card Program, to devote reasonable time and effort
II.13 Noncompliance. Physician understands that to perform RCN's responsibilities hereunder. RCN
his/her failure to comply with any of the shall arrange for claims processing except for
requirements imposed on him/her pursuant to this Qualified Participants in the Medical Access Savings
Agreement may result in corrective action, Card Program.
adjustments to Physician's reimbursement, or
termination of this Agreement by RCN. IV. REIMBURSEMENT, CLAIMS
SUBMISSION AND PAYMENT
11.14 Antitrust Guidelines. Physician agrees to
comply with all antitrust guidelines and procedures IV.I Reimbursement. RCN shall arrange for Payors
promulgated by Federal and State entities and RCN to pay Physician the reimbursement rates for
from time to time. services rendered to Qualified Participants pursuant
to Exhibit B. Physician agrees and acknowledges
III. RCN's OBLIGATIONS that RCN is acting solely in an administrative
capacity in providing a network of quality health
III.1 Marketing to Payors. RCN shall enter into services. RCN is not the claims paying agent and
agreements with Payors; implement systems to will not be liable for the payment of any amount
respond to Payors, Customers and Member owed by a Payor to Physician in the event that
Providers requests for information; provide Physician is unable to collect such amount of
clarification of policies concerning the operation of money.
Plans or Programs,as defined by Payor Agreements;
and assist Member Providers to obtain information IV.2 Reimbursement Rates. Physician is to be paid
or clarification regarding the Plans or Programs. by the Payor according to the rates established in
Physician agrees to work in cooperation with RCN Exhibit B. Physician hereby agrees that rates in
to market the services of the Member Providers to Exhibit B, which may be amended from time to time
Payors. upon mutual agreement, represent the total amount
to be received and agrees to look solely to the Payor
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CONINJCNrrY NETWORK.INC:" 01/03/00
for payment for such services. Payment will be IVA Limited Recourse Against .Qualified
made for healthcare services actually rendered. For Participants. Except as otherwise provided in this
services rendered to Qualified Participants of the Agreement (Section I.9),. Physician agrees to seek
Medical Access Savings Card Program, Physician payment from each Payor for services provided to its
can and should make payment arrangements prior to Qualified Participants, and agrees that he/she will
the delivery of care directly with the patient or not seek additional payments or reimbursement from
responsible party. Services provided under the Qualified Participants. In addition,Physician agrees
provisions of the Medical Access Savings Card that neither RCN, the Payor nor the Qualified
Program must be documented by a receipt that the Participant shall be billed or ultimately held-
Qualified Participant may use for tax purposes or in responsible for payment for services deemed not to
conjunction with other coverage. Physician can be a covered service by RCN or its designee unless,
pursue collection efforts directly with Qualified prior to providing such services, the Qualified
Participants of the Medical Access Savings Card Participant has been informed that (i) the services(s)
Program, if necessary. All others will be paid, when to be provided are not covered, and (ii) that the
appropriate, onl j after submission of a complete and Payor with the exception of Qualified Participants in
accurate claim. RCN does not guarantee and makes the Medical Access Savings Card Program, will not
no guarantees, representations, warranties or pay for such services, and (iii) that the Qualified
covenants -regarding the selection or use of Participant will be financially liable for such
Physician's services by any Qualified Participant or services, and (iv) the Qualified Participant
Payor, or the number of patients, if any, which may voluntarily agrees, in writing, to pay for such
result from participation in RCN's provider network. services. When Qualified Participant is covered by a
The obligation of a Payor to reimburse Physician in state or federally regulated workers' compensation
accordance with Exhibit- B for the provision of program, Physician agrees to comply with state and
services to a Qualified Participant shall be federal regulations regarding holding Qualified .
conditioned upon a good faith determination by the Participants harmless for amounts not paid by Payor
Payor or its designated representative that (i) for any reason,including Payors insolvency.
Physician is in compliance with the Payor's
utilization management program, and (ii) such IV.5 Payment of Claims. RCN shall
services are medically necessary, whether such administratively arrange for the Payor or its
determinations are made before, on or after the designated representative to pay undisputed claims
provision of services to such Qualified Participant. which are accurate,complete and comply with the
Agreement within the shorter of (i) the time period
IV.3 Claim Forms. Claim forms are required for all mandated by state law as it relates to workers'
services with the exception of services provided compensation, or (ii) the time period established by
under the provisions of the Medical Access Savings the applicable Payor Agreement,thirty(30)days.
Card Program. All claims must be submitted
complete and accurate on HCFA 1500 and in the IV.6 Erroneous Payment. In the event that a Payor,
manner designated by RCN and must include billed and/or its designated representative pays the
charges(not discounted rates)and appropriate codes, Physician (i) more than once, or (ii) an incorrect
consistent with policies established or approved by amount, or (iii) an overpayment, the Payor or its
RCN or the applicable state regulations. All claims designated representative may, at its sole option and
must be submitted within nine! 90 days, or within discretion, request the return of such amount from
such time period from the date of service, or as Physician or off set the amount of such overpayment
specified by RCN or its designee. In the event that against. any amounts owed to Physician by the
Physician is unable to submit a claim in accordance Payor.
with this Section IV.3, as a result of factors not
within Physician's reasonable control, Physician IV.7 Claims Appeal. The claims appeal process
shall notify RCN in writing of the cause of shall be for a period of no less than one hundred
Physician's inability to submit the claim and RCN eighty(180)days from the date of claim processing.
may, but shall not be required to, waive the
provisions of this Section IV.3.
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V. HOSPITAL/FACILITY ADMISSIONS (ii) medical malpractice liability arising during
periods in which Physician has failed to maintain the
If a Qualified Participant requires a non-emergency malpractice coverage required by Section VI.L
hospital/facility.admission by Physician, Physician
shall verify the patient's status as a Qualified VI.3 Indemnification of Physician. RCN hereby
Participant, arrange for admission with a Member indemnifies and holds harmless Physician from and
Provider and, if required by RCN or the Payor, against any claim, loss, damage, cost, expense or
secure authorization for such admission prior to the liability arising out of or related to the performance
admission in accordance with the applicable or nonperformance by RCN,. or RCN's officers,
Utilization Review and Quality Assurance Program. directors, employees, or independent contractors, of
Medical Access Savings Card Program Participants any service to be performed or provided by RCN
do not require pre-certification, authorization or under this Agreement.
utilization management for hospital/facility
admission. For all other Qualified Participants a VII..TERM AND TERMINATION
Physician wha=does not secure the required prior
authorization or comply with continuing stay review VII.1 Term. The term of this Agreement shall be
processes under the applicable Utilization Review for one (1)year from the date hereof and shall be
and Quality Assurance Program, may be denied automatically renewed on an annual basis for
payment for professional services associated with successive twelve (12) month periods, unless sooner
the Qualified Participant's admission. Finally, terminated in accordance with Section VII.2.
Physician agrees to cooperate and participate in a
coordinated discharge planning program as may be VII.2 Termination. This Agreement may be
established by RCN or applicable Payor. terminated sooner on the first to occur of the
following:
VI. INSURANCE AND INDEMNIFICATION
VII.2.1 Termination by Physician. Physician may
VI.1 Insurance Requirement.Physician shall provide terminate this Agreement in.the event of a material
and maintain such policies of professional liability default or breach of RCN's obligations hereunder,
insurance, in a form and with insurance carriers upon thirty (30) days prior written notice and the
acceptable to RCN. The amounts and extent of such failure of RCN to cure such breach or default within
insurance coverage shall be in the amounts such thirty (30) day period. In addition, in the event
determined by state requirements or community of an "emergency situation", Physician may
standards for relevant specialties and shall be subject terminate the Agreement upon thirty (30) days prior
to the approval from time to time of RCN. If such written notice and the acknowledgment by RCN that
coverage is under a "claims-made policy,Physician such an emergency condition does exist.
agrees to provide and maintain such insurance "Emergency Situation" shall mean an unforeseeable
coverage or a "tail" policy in the same amounts event,not resulting from:Physician's act or omission,
following the termination of this Agreement. which materially .affects Physician's ability to
Physician shall promptly demonstrate evidence of continue the practice of medicine or to perform his
insurability and that the required insurance is paid obligations hereunder.
and in force upon request of RCN.
VII.2.2 Termination by RCN. This Agreement shall
VI.2 Indemnification of RCN. Physician hereby automatically terminate on the date when: (i)
indemnifies and holds harmless RCN from and Physician's license to practice medicine_ or other
against any claim, loss, damage, cost, expense or licensed healthcare profession in the'state where
liability arising out of or related to the performance services are rendered, is suspended or revoked, (ii)
or nonperformance by Physician, or Physician's Physician's medical staff privileges at a participating
partners, employees or independent contractors, of facility are revoked or suspended, unless such
any services to be performed or provided by Physician's privileges are reinstated within twenty
Physician under this Agreement, including but not (20) days of such suspension, (iii) Physician's DEA
limited to (i) liabilities unrelated to the practice of or applicable State Controlled Substance
the profession of medicine by Physician, or Registration number required by Section 11.6 above
Page 7 or I I TIOPA.doe
rR,,,KP01t1' COMMUNPCy Ni.-my)RK,INC.' - 01/03/00
Js suspended 4r revoked, unless such Physician can covenants contained herein which are, expressly
arrange for other Member Providers to prescribe made to extend beyond the term of this Agreement,
regulated drugs for Qualified Participants under the
care of Physician within ten(10)days of such loss of VII.4 Oualified Participant and Pa or•Notification. .
such Registration number(s) and gives RCN notice Upon the termination of this Agreement, by either
of the same, (iv) Physician is excluded from party, Physician shall cooperate with RCN to notify
participation in the Medicaid or Medicare programs, Payors and Qualified Participants of such
(v) Physician loses or experiences a material termination.
reduction in malpractice insurance, (vi) Physician
engages in any act, omission, demeanor or conduct VIII. CONTINUATION OF BENEFITS
that is reasonably likely to be detrimental to patient
safety or to the delivery of quality patient care, or to VHI.1 Continuation of Benefits. Except for Medical
lead to the provision of professional services below Access Savings Card Program Participants, upon
applicable professional standards, or (vii) Physician termination of this Agreement, Physician shall
is convicted.of a Felony, (viii) Physician is found in continue to provide services in accordance with this
violation of professional conduct, or(ix) thirty (30) Agreement to any Qualified Participant currently
days following written notice by RCN of a material undergoing treatment by Physician until a medically
default or breach by Physician hereunder and the appropriate transfer of care has been accomplished
failure of Physician to cure such default or breach provided, however, that Physician shall exercise best
during such thirty (30) day period. efforts to accomplish such transfer within thirty (30) `
days after the date this Agreement terminates.
VII.2.3 Termination for Insolvency. This Agreement Physician shall be reimbursed for any such services
shall terminate immediately in the event that.either in accordance with the terms of this Agreement.
RCN or Physician voluntarily or involuntarily,
liquidates, dissolves or becomes subject to any VM.2 Survival. The provisions of this Article VIII
proceeding for the rehabilitation or conservation of shall survive the termination of this Agreement
their financial affairs, regardless of the cause giving rise to such
termination, as will sections II.8, VI.2, VI.3, VH.3,
VH.2.4 Termination by Either Party. Either party IX, and X. . The provisions of this Article VIII
may terminate this Agreement without cause upon supersede any oral or written agreement to the .
ninety (90)days prior written notice. contrary now existing or hereafter entered into .
between Physician and any Qualified Participant or
VII.2.5 Unforeseen Events. In the event that either any person acting on a Qualified Participant's behalf.
party's ability to perform their obligations under this
Agreement is substantially interrupted by war, fire, IX. CONFIDENTIALITY
insurrection, riots, the elements, earthquake, acts of
God, or other similar circumstances beyond the All business, medical and other records relating to
reasonable control of such party, the party shall be the operation of RCN, including, but not limited to,
relieved of those obligations for the duration of the books of account, general administrative records,
interruption upon notice to the other party. In the policies and procedures, pricing information, terms
event that the interruption is reasonably determined of this Agreement and all information generated
likely to persist for at least one hundred twenty(120) and/or contained in management information
days, either party may terminate this Agreement systems owned by or pertaining to RCN,. and all
upon thirty(30)days prior written notice. systems, manuals, computer software and other
materials, but excluding patient charts, shall be and
VH.3 Effects of Termination. Upon termination of remain the sole property of RCN (collectively, the
this Agreement, neither party shall have any further "Confidential Information"). Physician .
obligation hereunder except for (i) obligations acknowledges that the Confidential Information and.
accruing prior to the date of termination, including all other information regarding RCN, that is
without limitation, any obligation by Physician to competitively sensitive, is.the property of RCN and
continue to provide healthcare services to Qualified RCN may be damaged if such information was
Participants, and (ii) obligations, promises or revealed to a third party. Accordingly, Physician
Page 8 of i I TIOPA.doc
rRocKPORT COMMUNLTy NETWORK.INC.' _ - 01/03/00
.agrees- to keep strictly confidential and to hold in (1) neutral arbitrator to be selected in accordance
trust all Confidential Information. Upon termination with the Commercial Rules of AAA. Neither,party .
of this Agreement by either party for any reason nor the arbitrator may disclose the existence,
whatsoever, Physician shall promptly return to RCN content, or results of any arbitration hereunder
all material constituting Confidential Information or without the prior written consent of both parties
containing Confidential Information, and Physician Each party will be responsible for theirown legal .
will not thereafter use, appropriate, or reproduce fees. The cost of the arbitration services will be the
such information or disclose such information to any sole responsibility of the -party requesting the
third party. Physician specifically agrees that under arbitration.
no circumstances will Physician discuss the terms
and conditions of this Agreement, and in particular X.2 'Non-Exclusivity, Nothing in this Agreement
the pricing information herein, with any Member shall be construed to restrict Physician or RCN from
Provider, healthcare provider or purchaser of entering into other contracts or agreements to
healthcare services. The Agreement prohibits RCN provide healthcare services to Payors or other
from disclosin any information provided by or healthcare delivery plans, patients, employer groups,
about the provider in connection with any provided Physician uses his/her best efforts to bring
credentialing or peer review deliberations, unless opportunities for contracting and other new ventures
such disclosure is otherwise required bylaw. to RCN for consideration and to have the right of
first refusal. The Physician agrees to provide RCN
X. MISCELLANEOUS with ninety (90)-days to consider and have the right
of first refusal before he/she enters into negotiations
X.1 Disputes. All disputes and differences between with such entity on his/her sole behalf,
- the Physician and RCN upon which an amicable
understanding cannot be reached are to be decided X.3 Entire Agreement. This Agreement contains
by mutual agreement in Houston, Texas by the the. entire understanding of the parties and
following method: supersedes any prior understandings and agreements,
written or oral., respecting, the subjects discussed
X.1.1 Mediation through RCN. The Physician,shall herein,
notify RCN in writing of the dispute or
disagrepment, he/she shall supply RCN with all X.4 No Waiver. The waiver by either party of a
pertinent information and state his/her position on breach or violation of any provision of this
the dispute. Upon receipt of this information,RCN Agreement shall not operate as or be construed to be
will immediately contact Payor and require the same a waiver of any subsequent breach hereof.
information. RCN will then attempt to mediate the
dispute to the mutual satisfaction of all parties. If X.5 Regulatory Compliance. Physician and RCN
mediation is not possible within a reasonable time, agree that each shall comply with all applicable
not to exceed thirty (30) days from the time of first requirements of municipal, county, state and federal
notice,the following procedure will apply: authorities, all municipal and county ordinances and
regulations, and all applicable state and federal
X.1.2 Arbitration. Any controversy, claim or statutes and regulations, now or hereafter in force
dispute arising out of or relating to this Agreement, and effect, governing RCN, Physician the provision
or the breach thereof, shall be settled by binding of services of by a Physician, and/or Payors,
arbitration in accordance with the Commercial including but not limited to applicable requirements
Arbitration Rules of the American Arbitration under any-state or federal fair employment,practices,
Association (AAA) and judgment upon any award equal employment opportunity, or similar laws
rendered by the arbitrator may be entered in any declaring.discrimination in employment based upon
court having jurisdiction thereof. Any provisional race, color, creed,religion, sex, or national origin as
remedy which would be available from a court of illegal, and,Titles VI and VII of the Civil Rights Act
law, shall be available from the arbitrator, to the of 1964, Section 202 of Executive Order 11246 as
parties to this Agreement pending arbitration. The amended by Executive Order 11375, Sections 503
arbitrationshall be conducted in Fort Worth Tarrant and 504 or the Rehabilitation Act of 1973 and Title
County, Texas, The arbitration shall be before one IV of the Vietnam Era Veterans Readjustment
Page 9 of I 1 TIOPA.doo
rRo,Kpoia
Communery NBrwon,otic." 01/03/00
Assistance Act of 1974, and Sections 1 and 3 of X.13 Partial Invalidity. If any part, ,clause or
Executive Order 11625, or any applicable rule or provision of this Agreement is held to be void by a
regulation promulgated pursuant to any such laws or court of competent jurisdiction, the remaining
orders. provisions of this Agreement shall not,be affected
and shall be given construction, if possible, as to
X.6 Governing Law, This Agreement shall be permit it to comply with the minimum requirements
governed by and construed in accordance with of any applicable law, and the intent of parties
applicable Texas State law. hereto.
Not withstanding any other provision in this X.14 Assistance in Litigation. Physician and
Agreement, the parties hereto shall comply with the Physician's personnel, shall be available to RCN and
minimum requirements of the preferred provider Payors, at no cost to RCN or Payors, to testify as
organization regulations of the Texas Department of expert witness, or otherwise, in the event of
Insurance as those regulations currently exist and as litigation being brought against RCN and/or Payors,
they a_y adopted and amended from time to time. or their respective directors, officers, employees,
agents or other representatives, based upon a claim
X.7 Amendments. This Agreement may be of negligence, malpractice or any other cause of
amended by RCN upon thirty (30) days written action arising out of, or related to, Physician's
notice of such proposed amendment. Failure of performance of services,except where Physician is a
Physician to provide written objection to such named adverse party. RCN and Payors shall provide
amendment within the sixty (60 day period shall similar assistance to Physician, except where RCN
constitute Physician's objection of such amendment. and/or Payors are named as adverse parties.
X.8 Severability. The invalidity or un-enforceability X.15 Official Notices. Any notice or
of any term or condition hereof shall in no way communication required, permitted or desired to be
affect the validity or enforceability of any other term given hereunder shall be deemed effectively given
or provision. when personally delivered or mailed, return receipt
requested, or overnight express mail addressed as
X.9 Assignment. Physician may not assign or follows:
otherwise transfer any right or delegate any duty of
performance hereunder, in whole or in part without Physician or Representative/Designee:(Please Print)
the prior written consent of RCN. RCN retains the
right to assign this Agreement,in whole or in part, to Name:
any entity with which RCN or its parent company or
any of its subsidiaries is affiliated, or with which it Organization: .
merges or consolidates.
Address:
X.10 Third Party Beneficiaries. Except for Payors
and the. agents thereof, there are no third party City/State/ZIP:
beneficiaries of this Agreement.
Telephone:
X.11 Ca tp ions. The captions and headings
contained in this Agreement are for reference FAX:
purposes only and shall not affect in anyway the
meaning or interpretation of this Agreement. Organization:
Rockport Community Network,Inc.
X.12 Execution of Counterparts. This Agreement Attn: Director of Provider Relations
may be executed in any number of counterparts, 50 Briar Hollow Lane,Suite 515W
including facsimiles, each of which shall be deemed Houston,TX 77027
to be an original as against any part whose signature Telephone: (713)621-9424
appears thereon, and all of which shall together FAX(713)621-9511
constitute one and the same instrument.
�"�— Page 10 of i l TIOPA.doc
ROCKPORT C0,11MUNrrY NETWORK,ItiC," 01/03/00
or to such other address, and to the attention of such
other person(s) or officer(s) as either party may
designate by written notice.
X.16 Silent PPO. RCN agrees not to offer
discounted services to any Payor who sells or leases
RCN's list of contract providers, either directly or
indirectly to other Payor type entity or to a broker.
who then sell the list to other Payor type entities.
This does not apply to access network agreements.
IN WITNESS WHEREOF, the undersigned will be
deemed to have executed this Agreement as of the
date this Agreement is signed by RCN.
For and on behalf of: For and on behalf of.-
Rockport
f:Rockport Commu ' etwork,.Inc. Physician or Representative/Designee
50 Briar'Hollow a 't1I5W . ��
Houston TX 7 2 / Signature �.f
Name_ Tro Aye, &,,, )C)
William W. le erg (Prinkt)
President TIN `Z .S "' 5 ~n q-
Date• _ _2� 7��a Date
rRu
Page 11 of 11 TIOPA.doe
CNFU1iT CONUMUNrrY Nimvom 1Nr:.' 01/03/00
EXHIBIT A
STANDARDS AND GUIDELINES FOR PAYORS'
UTILIZATION REVIEW AND QUALITY ASSURANCE PROGRAMS
ROCKPORT COMMUNITY NETWORK,INC.(RCN)
Each Accident and Health, Workers'Compensation, Personal Injury Protection Payor or RCN may have or may
establish a Utilization Review and Quality Assurance Program for its Qualified Participants. Medical Access
Savings Card Program Participants do not fall under any Utilization Guidelines. All other Payors or RCN may
designate a utilization review organization to conduct the utilization review and case management of healthcare-
services under such Utilization Review and Quality Assurance Program.
RCN shall review each Payor's, with the exception of Qualified Participants in the Medical Access Savings Card
Program,Utilization Review and Quality Assurance Program in accordance with RCN's Standards and Guidelines
for Payors' Utilization Review and Quality Assurance Programs as described in this Exhibit. Physician and/or
Member Provider agrees to comply and be bound by such program in accordance with Article II of this
Agreement.
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 Payor or the Payors designee;
2) Ensure that healthcare services are provided at the appropriate level of care; and
3) Ensure that healthcare services meet local community standards for quality of care.
Utilization Review Programs may include one or more of the following components:
1) Pre-Admission/Prospective Review of elective admissions for all inpatient and ambulatory surgical
services.
2) Post-Admission Review of emergency and urgent inpatient admissions.
3) Admission and/or Concurrent Review of all inpatient stays. Concurrent reviews may include periodic
reviews and certification of treatment plans.
4) Continued Stay Review of all inpatient cases-when the proposed length-of-stay exceeds that which was
initially certified by reviewers of the applicable Utilization Review Program.
5) Retrospective Review of inpatient and ambulatory surgical cases.
6) Outpatient Certification of certain outpatient services prior to rendering such services, as determined by
the applicable Plan.
(continued on next page)
A— __
I I Roc m,ox'r Comm m� y Nc;rwoiw,enc,` Page 1 of 2 RCNEXA0798.doc
EXHIBIT A
(continued)
PREADMISSION/PROSPECTIVE REVIEW The Physician and/or Member Provider shall notify the designated -
utilization review organization for all elective hospital inpatient, day surgery (hospital, free standing facility,
office-based), and short stay admissions. The Physician and/or Member Provider is responsiblefor providing the
designated utilization review organization with the necessary pre-admission information. Whenever possible
Physician and/o'r Member Provider will do, or cause to have done, pre-admission testing when Qualified
Participant is to be hospitalized. Unless otherwise approved in writing by RCN or Payor any Qualified
Participant requiring any elective surgical procedure shall have such surgery performed on day of admission to
the facility(hospital or surgery center). The following information is required:
(a) Patient's name, age, sex, and date of birth;
(b) Qualified Participant's name,address,social security number;
(c) Name of Payor;
(d) Diagnosis(ICD-9 code) and Procedure (CPT code)if applicable;
(e) Name, address, and telephone number of the Admitting Physician and/or Member Provider;
(f) Name, address, telephone number of the Hospital or Facility-,
(g) Date of service(admission and/or procedure date);and
(h) Admit type: Emergency, Scheduled,Urgent,Psychiatric.
After obtaining the information and determining that the admission is medically necessary, the designated
utilization review organization shall provide the admitting Physician and/or Member Provider with a
certification/authorization and/or case number:
If the Physician and/or Member Provider has not received notice of a pre-admission determination at the time of a.
scheduled admission, including ambulatory surgery, the Physician and/or Member Provider shall contact the
designated utilization review organization to request the determination.
Claims/Cases which are subject to retrospective review and potential denial of payment include but are not
limited to the following:
• Any admission that was not pre-certified prior to admission or within the Payor specified time frame
for emergency admissions;
• Any service that required pre-certification prior to the provision of such service which was not pre-
certified; and
0 Services which are determined not to be medically necessary.
SECOND OPINION When a second opinion is required, the Physician and/or Member Provider shall provide the
second opinion Physician and/or Member Provider with the necessary information to evaluate the patient and to
minimize duplication of services.
CONCURRENT REVIEW Throughout the hospital stay, the attending Physician and/or Member Provider shall
provide the necessary information to substantiate the need for treatment and continued stay.
The Member Provider, Physician or Qualified Participant may appeal a utilization review determination by
notifying the utilization review organization that did the initial review. Such requests shall be made in accordance
with the Payor's Utilization Review Program's appeal process and shall contain documentation justifying a
reconsideration. Final decisions on payment determination shall reside with the Payor.
rRocKPORT
COMMUNITY Nz,Twom,INC." Page 2 of 2 RCNEXA0798.doc
EXHIBIT B
Amended Reimbursement Schedule (FS )
The parties hereby agree that this Amendment be incorporated into the existing agreement entered
into by and between Texas Independent Osteopathic Physicians Association (TIOPA) and
Rockport Healthcare Group,Inc. (RHG).
I. Accident&Health, Personal Injury Protection (PIP), & Medical Access Savings Card
Provider fees for the programs listed above shall be based on the following percentage of RBRVS:
Surgery(10040-69979) 145%
Medicine(98925-99499) 145%
Medicine(90700-96999) 145%
Radiology(70010-79999) 145%
Pathology(80002-89399) 145%
Physical Medicine(?7001-97799)' 145%
Anesthesia* (00100-01999) 43.00
*Based on the American Society of Anesthesiologists 15-minute increments. Reimbursement for Anesthesiologists billing
with codes listed in the Relative Value Guide as published by ASA, will be determined by adding a Basic Value, which is
related to the complexity of the service,plus Modifying Units (if any)plus Time Units, if applicable, The sum of which will
be multiplied by the anesthesia unit value listed above. Time increments,as defined by ASA Guide, is 1 unit per 15 minutes
up to 4 hours,after 4 hours, 1 unit per 10 minutes.
"BR" (By Report), "RNE',' (Relativity Not Established), HCPCS (Health Care Financing Administrations
Common Procedure Coding System), Immunizations and any Unlisted Procedure Code will be paid at
90% (ninety percent) of reasonable and customary charges..
Coverage: Coverage for all procedures on the fee schedule are subject to the terms and conditions of the
applicable Benefit Plans and/or the provisions of the Medical Access Savings Card Program.
Schedule: Schedule shall apply to St. Anthony's Complete RBRVS, Relative Value Studies, Inc.,
published by *St. Anthony Publishing Company, copyright 2001 and will update accordingly in
conjunction with the Tarrant,County St. Anthony's Complete RBRVS.
II. Workers' Compensation
Provider fees for the program listed above shall be based on the following:
States with mandated fee schedwles -All fees will be reimbursed at 85%a (eighty five percent)of.
each state's mandated fees,.the fee schedule provided in I.., or covered charges,whichever is less.
RECEIVED
JUN 0 6 2001
Page 1 of 2 FS71
Roc po r CoAUIUNITY NETWORK, INC,` 05/11/01
EXHIBIT B
Reimbursement Schedule (FS )
(Continued) c2,—:U
"BR" (By Report), "RNE" (Relativity Not Established), "HCPCS" (Health Care Financing
Administrations Common Procedure Coding System) and "DOP" (Documentation of
Procedure) and any unlisted procedure code will be paid at 90% (ninety percent) of reasonable and
customary charges.
Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions-of
the applicable Workers' Compensation Benefit Plan.
Schedule:. Schedule II shall apply to the state mandated fee schedule in the state where services were
rendered and will update accordingly in conjunction with the same.
r
I/We accept the fees as outlined in this Amended Exhibit B.
For and on behalf of: For and on behalf of-
PHYSICIAN/DESIGNEE
(Practice name,address,etc.)
ROCKPORT HE, GROUP,INC. T.I.O.P.A,Inc.
50 Briar Hollow Lane,Suite 515W 3632 Tulsa Way
Houst ,T x 77027 Fort Worth,Texas 76107
Signature �(
Harry eer Printed Name b)onA-e.' 1 K-ottiTmct 0 �U
President Title e.lea <q . T• P-O• . A• ��--
Date TIN Date 2 U
_• Page 2 of PS71
ROCKPORT COMMUNITY Nnwon, INC.' 05/11/01
EXHIBIT B
Reimbursement Schedule (171)
I. Accident & Health, Personal Injury Protection (PIP), & Medical Access Savings.Card
Provider fees for the programs listed above shall be based on the following percentage of RBRVS:
Surgery (10040-69979) 135%
Medicine (98925-99499) 135%
Medicine (90700-96999) 135%
Radiology(70010-79999) 135%
Pathology(80002-89399) 135%
Physical Medicine (97001-97799) 135%
Anesthesia* (00100-01999) 42.00
*Based on the American Society of Anesthesiologists 15-minute increments. Reimbursement for Anesthesiologists billing,
with codes listed in the Relative Value Guide as published by ASA, will be determined by adding a.Basic Value, which is
related to the complexity of the service,plus Modifying Units (if any)plus Time Units, if applicable. The sum of which will
be multiplied by the anesthesia unit value listed above. Time increments, as defined by ASA Guide, is 1 unit per 15 minutes
up to 4 hours,after 4 hours, 1 unit per 10 minutes. '
Standard Professional Discount: If fee schedule reimbursement rate meets or exceeds billed charges, a
10% (ten percent)standard professional discount will be applied to billed charges.
"BR" (By Report), "RNE" (Relativity Not Established), HCPCS (Health Care Financing
Administrations Common Procedure Coding System)and any unlisted procedure code will be paid at
80% (eighty percent) of reasonable and customary charges.
Coverage: Coverage for all procedures on the fee schedule are subject to the terms and conditions of the
applicable Benefit Plans and/or the provisions of the Medical Access Savings Card Program.
Schedule: Schedule shall apply to St. Anthony's Complete RBRVS, Relative Value Studies, Inc.,
published by St., Anthony, Publishing Company, copyright 1998 and will update accordingly in
conjunction with the St. Anthony's Complete RBRVS.
II. Workers' Compensation
Provider fees for the program listed above shall be based on the following:
States with mandated fee schedules -All fees will be reimbursed at 85% (eighty five percent) of
each state's mandated fees, the fee schedule provided in I., or billed charges, whichever is less. If fee
schedule reimbursement rate meets or exceeds billed charges, a 10% (ten percent) standard
professional discount will be applied to billed charges.
"BR" (By Report), "RNE" (Relativity Not Established), "HCPCS" (Health Care Financing
Administrations .Common Procedure Coding System) and "DOP (Documentation of
Procedure) and any unlisted procedure code will be paid at 80% (eighty percent) of reasonable and
customary charges.
rRo,101ORT CoNnn:NI[Tv NKMORK.INC." Page 1 of 2 171.doe
EXHIBIT B
Reimbursement Schedule (7.71)
(Continued)
Coverage: Coverage for all procedures on the fee schedule is subject to the terms and'conditions of
the applicable Workers'Compensation Benefit Plan.
Schedule: Schedule II shall apply to Texas Workers Compensation Commission Medical Fee
Guidelines, copyright 1996 and will update accordingly in conjunction with the same.
nVe accept the fees as outlined in this Exhibit B.
For and on behalf of: For and on behalf of.
PHYSICIAN/DESIGNEE
(Practice name,address,etc.)
ROCKPORT COM UN Y NETWORK,INC. `�/r ( L ,laT -
50 Briar Hollow S ite 515W
Houston,Texas
Signature--&
William W.- le erg Printed Name 01 . �,. Tro��"� v1L ct;,� L)
President Title Ckq� i r ) . 0
Date -2,-'7,00 TIN '7 5-'16 V& tl3-IL Date 6 At
rRoc%VORT CoNiairwry Nn-rwon,im.,." Page 2 of 2 171.doc