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HomeMy WebLinkAboutContract 47186-P14 SECRETARY ADDENDUM To BIackStone 504 Program Provider Agreement This Addendum is entered into by and among Kyle Babick, PhD &Associates ("Member ovider"), =4 Healthcare Group ("Rockport"), and the City of Fort Worth ("City") on this ay of 20�( WHEREAS, Rockport and Member Provider entered into a Provider Agreement, effective February 1, 2013, ("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 tip a direct contracted 504 provider panel pursuant to Texas Labor Code S ection 504.053. I WHEREAS, the City has deteradned 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 Stibsection 504.053(b)(2). WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions ofthe 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 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 403.023, 403.027, and 413.041 of the Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under section 504.053 of the Texas Labor Code. The City's Provider Manual (under the name of Black-Stone) 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 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 terns shall have the meaning set forth below. All other defined terms shall have the meaning ascribed to them in the Provider Agreement. �i ci i I i Kyle Babick PhD&Associates 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 North through Us and other direct contracts using Rockport as its contracting agent i "Provider Manual"means the Blackstone Provider Manual as amended from time to time and available upon request to the Member Provider. i "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. i 4. Member Provider agrees to participate in the B1ackStone provider panel for the benefit of the City and Qualified Participants. I 5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a � g� b g t3' new cause of action. 6. All other terms of the Provider Agreement shall remain in farce and unchanged.Any conflicts between this Addendum and the Provider Agreement shall be superseded by the terms provided herein. IN WITNESS WHEREOF,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 Signature- - i Name, $ Sa anlS Title: Assistant ON Manager c Date: A?, -,'PROAS TO FORD{AND LEGALITY: -SlstTnt CQ0M.e FO 0000 -- 2 °M OFFICIAL RECORD A CITY SECRETARY 00 a� <� FT.WORTH,TX Mary �. s , pity Se Kyle Babick PhD&Associates Provider Agreement ROCIOORT T CA.RD'GROUP Signature, Name- Title: Date: O' 1 2 a 111 a I I MEMBER PRO MER or Representative/Designee Signature: Name.-Kyle Babick.PhD Title: OW h-/-r tt Date. TIN:75-2457807 I i I 3 ROCKPORT .,n PHYSICIAN AGREEMENT ROCKPORT UNITED NETWORK ROCKPORT SELECTHEALTH NETWORK This Physician Agreement("Agreement"),is entered I. DEFINITIONS 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>equires, the following words and Network (a preferred provider network for terms shall mean: Occupational injuries and Illnesses), dba Rockport SeleetHealth Network (an exclusive provider I.1 "Physician"means a licensed Medical Doctor or network)and Kyle Babfek. PhD &Associates,PC Doctor of Osteopathic Medicine, or group of same ("Member Provider"), and will become effective as who desire to become a Member Provider with of the date the provider is fully credentialed by RHG. RHO. Pursuant to §10,42 of Texas Insurance Code 1305 WHEREAS, RHG is engaged in the business of regarding Network Contracts with Providers seeking developing and acting in an administrative capacity to participate in Texas Certified Workers' in providing Occupational Injury and health provider Compensation Networks, networks that offer direction of care while providing savings to RHG clients and/or Payors. These 1.2 "Qualified Participant" means an"employee" as networks will offer greater coverage of services and defined and used in the Texas Labor Code, the savings;and Network Act Section 1305 and the implementing rules who sustained a work-related injury/illness that WHEREAS, RHG has networks of contracted is determined compensible by an employer and that physicians, physician groups, hospitals and participates in the Rockport United Network or providers of ancillary healthcare services Rockport SelectHealth Network through Rockport's (collectively, the "Member Providers") to provide a Client. Unless in ail emergency or after business full-range of healthcare services. These services are hours, initial services provided for the work-related available for use by "Qualified Participants" as injury/illness require authorization by the Employer defined in 1.2 of this Agreement;and and/or network either in writing or by telephone. WHEREAS, Member Provider desires to provide 1.3 "Client" means an insurance company, certified medical care services to "Qualified Participants" self-insured or governmental entity as those terms who are covered by Payor Agreements at the rates in are defined and used in the Texas Labor Code, the Exhibit B and in locations listed in Exhibit C:and Network Act Section 1305 and the implementing rules. These Clients have entered into a Client WHEREAS, RHG has entered into Agreements Agreement with RHG for the provision of healthcare and/or services with one or more Payors who services to Qualified Participants. provide payment of claims for medical care rendered to Qualified Participants. I.4 "favor" means an insurance carrier or network certified by an insurance carrier for its own benefit, NOW, THEREFORE, in consideration of the certified self-insured or governmental entity as those premises,the mutual promises contained herein, and terms are defined and used in the Texas Labor Code, other good and valuable consideration, the receipt the Network Act Section 1305 and the implementing and sufficiency of which are hereby acknowledged, rules who is responsible for payment of medical j it is mutually agreed as follows: benefits for on the job injuries and or illnesses according to State and/or Federal Rules and Regulations. Page,1 of 14 Ky1cBabickP10&Assocs I21212 RUNPHY T3:01-2012 I I 1.5 "Client Agreement" means the agreement specialty to maintain their RUG classification as between RHG and a Client, which agreement is such and be willing and able to treat Qualified made before, on or after the effective date of this Participants as needed or required.. Agreement and which expresses the agreed upon contractual rights and obligations of the parties, 1.9 "Emergency Medical or Mental Condition" is Such Client Agreements will require Payors to pay defined as the sudden onset of a medical condition Member Provider for Covered Services rendered to manifested by acute symptoms of sufficient severity, Qualified Participants pursuant to this Agreement. including severe pain,that the absence of immediate Furthermore,such Client Agreements shall authorize medical attention could reasonably be expected to RHG to enter this Agreement and contractually bind result in: Payors to the terms hereof unless there is a conflict (a)placing the patient's health or bodily functions in with State and/or Federal rules and regulations. serious jeopardy;or (b)serious dysfunction of any body organ or part as 1.6 "Member Provider" means any physician; defined in TIC 1305.004(13);and physician group;hospital; surgery center; diagnostic (c) in the case of a mental health condition,one that imaging center; laboratory; clinic; chiropractor; could reasonably present danger to the person dentist; podiatrist; psychologist; social worker; experiencing the mental health condition or another physical, occupational and speech therapist; etc. person as defined in TIC 1305,004(15). licensed or certified to practice a healthcare profession or licensed as a facility to offer healthcare I.10 "Covered Services" are those healthcare and services,in the state where services are rendered and health-related services provided to Qualified who has executed a contract with RHO. Participants for treatment of a compensible, work- related injury/illness as defined by either nationally I.7 "Primary Treating Physician/Clinic" According recognized treatment guidelines and/or individual to Texas law for certified workers' compensation treatment protocols that do not conflict with any networks, the Network decides who will be a state and/or federal rules and.regulations. Treating Doctor.Therefore,a Member Provider who is a Medical Doctor (MD) or a Doctor of I.11 "Bill and/or Claim Form" CMS 1500 (or other Osteopathic Medicine (DO) that specializes in appropriate claim form or their successors) Family Practice, General Practice, Occupational completed in accordance with the guidelines Medicine or Internal Medicine as well as a physician established by the National Uniform Billing That provides initial and/or follow-up care in Occ- Committee or CMS 1500 billing guidelines, and/or Med or Urgent Care Clinics whose practice is state rules and regulations. largely dedicated to caring for work related injuries and illnesses is designated by RHG as a Primary H. MEMBER PROVIDER OBLIGATIONS Treating Physician/Clinic (PTP). PTP agrees to render medical care to Qualified Participants without H.1 Services. Member Provider agrees to provide or a scheduled appointment and must be available and arrange for all medically necessary medical care for accesible to employees twenty-four (24) boors-per- Qualified Participants who present themselves to day, seven (7) days-per-week as per 28 TAC Member Provider. Member Provider agrees to 10.80(b)(1). Should a Qualified Participant need perform such services with the sante standard of medical attention outside of Member Provider's care, skill and diligence for all Qualified normal business hours, Member Provider will be Participants. Member Provider agrees that it is their available and/or make arrangements to have another sole responsibility to verify that the individual Member Provider render care to Qualified presenting for care is a Qualified Participant. Participant twenty-four(24)hours-per-day,seven(7) Member Provider agrees to render healthcare days-per-week. services to Qualified Participants at any and all facility or practice locations listed in Exhibit "C". I 1.8"S ecialist Ph sici " means a Member Provider Member Provider shall make best efforts to ensure who has met the credentialing requirements of RHG that services provided are consistent with nationally to be a Specialist Physician, and to whom Primary recognized treatment guidelines (i.e. Official Treating Physicians/Clinics may refer for necessary Disability Guidelines (ODG), American and authorized care other than primary treating Occupational and Environmental Medicine's services. Specialists will need to maintain their (ACOEM) and /or state rules and regulations. current board certifications for their particular f Pap 2 of 14 Kyle Babi&PLD&Assocs 121212 RUNPHY_TX_01-2412 f Member Provider agrees to comply with and be 1.6 Reports. For each encounter where Member bound by all State/Federal Rules and Regulations. Provider provides services to a Qualified Participant, 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 medical and patient data and identifying outlined in Exhibit A of this Agreement,provided in information, if and to the extent that reports are RHG's Provider Handbook and/or Clients' specified by RHO, 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 sent ices provided for the 113.1 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 compensible injury in question is not specifically accreditation shall be submitted promptly to RHG 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, licenses, 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 o;its Participants. Member Provider shall immediately patients as to the quality of services delivered to notify RHO 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 rights of Qualified that governs like providers and is certified as a Participants. provider under Title XV'IR (Medicare) and when appropriate, Title XIX (Medicaid) of the Social II.4 Medical StaffParticipation. Certain medical Security Act and that it shall maintain such specialties may not require hospital privileges such accreditation and certification during the term of this as Occupational Medicine,Pathology,Dermatology, Agreement. Member Provider shall immediately Allergy, and those Primary Treating notify RHO of any action, investigation or Physicians/Clinics whose practice is dedicated to proceeding to revoke,suspend,restrict, or otherwise treating work-related injuries and illnesses. Where affect such accreditation or certifications. appropriate, Physicians must maintain active, unrestricted staff privileges with at least one RHO 11.7.2 Org_nization's Requirements. Member Member Provider hospital or Surgery Center. Provider shall use best efforts to comply with R.HG's Physician hereby consents to disclosure by such criteria for provider participation, including facility to RHO of all data collected with respect to credentialing policies and procedures. Member Physician in connection with Physician's medical Provider shall cooperate with RHG's periodic staff membership, including without limitation all evaluation of qualifications. In addition, Member applications for staff' privileges and any renewals Provider shall use best efforts to cooperate with thereof. RHG's and/pr state rules and regulations for the expeditious resolution of any grievance or 11.5 Referrals Except in a medical emergency or complaint. when authorized by RHO, Client, or its designated representative, Member Provider agrees to refer 11.8 Notification to RHO. Member Provider Qualified Participants only to other Member represents and warrants that information provided Providers,as defined in 1.6. herein and in the RHG application is true and Page 3 of 14 ( Kyle Babick PhD&Assocs 221212 RUNPHY TX 01-2012 !i f I accurate in all respects and acknowledges that RICO business days, any of Member Provider's medical is relying on the accuracy of such information in records and operations reasonably pertaining to entering into and continuing the term of this RING 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 Ru*cr agrees to allow RHG, Payor or a healthcare services; (ii) denial, suspension, designated representative thereof, including the restriction, reduction or termination of designated utilization review, quality management, accreditation/certificatiou; (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 Utilization 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. RHG and 11.9 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 II.11 Relationship of Parties. Member Provider and Participants and shall comply with all applicable RHG 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 such 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 H.9 shall survive the termination of this case may be, and such other bodies, formal or Agreement. informal, state, government or otherwise, or by which they are subject to licensing/certification and I1.10 Inspection of Records and_Operations. RHO, control. Additionally, Member Provider shall i 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 Iocallrogional professional Page 4 of l4 Ryle Babick PhD&Assm 121212 RUNPHY_rk of 2012 i healthcare community and applicable (i) Provider Search Provider Locator System (ii) accrediting/licensing agencies. Member Provider Provider Directories (iii) Site-Specific Provider 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. RHG will perform and/or ensure that all such personnel are properly licensed delegate to qualified organizations credentialing of and/or possess the necessary credentials to render each Member Provider. Credentialing may include the services that they perform. verification of all information and documents provided in the application for participation and 11.13 Right to Use Member Provider's or Network's investigation, including but not limited to Name. Member Provider agrees to allow RHG 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, RHG NCQA, CLIA, URAC, etc. Inquiries may also be Site-Specific Provider Panel(s), RHG website and/ made to current and previous professional liability or other materials to help promote and assist Clients carriers, Medicare and Medicaid. RHG's with Qualified Participants needing medical care for credentialing policies and procedures follow the injuries/illnesses sustained. RHG agrees to allow American Accreditation Healthcare Commission Member Provides to list RHG'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 Qnerational Functions. RHG shall utilize agrees to post in waiting room 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 RHG 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 RHG shall 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 toll-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. IIIA 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 Agreement may result in behalf of an Qualified Participant,reasonably filed a termination of this Agreement by RHG, complaint against,or appealed a decision of RHG 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 ITIS Antitrust Guidelines. RHG agrees to comply entities. with all antitrust guidelines and procedure promulgated by Federal and State entities. 1H. RHG's OBLIGATIONS 111.6 Audit Policv and Procedure Compliance. All 111.1 Marketing to Clients/Pavors. 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 RHG quality and Regulations. i Member Providers through specific referral processes. RHG will market Member Providers for referral; including but not limited to the following: Page 5 of 14 Kyle liable PhD&Assoos 1212I2 RUNPITY_TX_Ol 2012 I i V. R)EEVIBURSEAMENT,CLAMS will be subject to the reimbursement rates SUBMISSION AND PAYMENT established in the Exhibit B of this Agreement. IV.1 Reimbursement, RHG shall arrwge and All billing and reimbursement 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 forms are to Qualified Participants pursuant to Exhibit B. required for all services. All claims must be Member Provider agrees and aclmowledges that submitted complete and accurate on CMS 1500 (or R.14G is acting solely in an administrative capacity in other appropriate claim form or their successors)and providing a network of quality health services.RHG must include Member Provider's usual and is not the claims paying agent and will not be liable customary billed charges (not discounted rates) and for the payment of any amount owed by a Payor to appropriate codes, consistent with policies Member Provider in the event that Member Provider established or approved by applicable state and/or is unable to collect such amount of money up to and federal regulations. Member Provider must submit including the insolvency of the Payor. Under no claims to Payor not later than the 95`h day after the circumstance will a Member Provider attempt to date on 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 rules and regulations at the rates established rules and regulations. in Exhibit B. Member provider hereby agrees that rates in Exhibit I3,which may be amended from time IVA Limited Recourse Against pualified to time upon mutual written agreement,represent the Participants. 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 Payment 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,the 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 Injury 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 l Payor or its designated representative that (i) such insolvency. This provision does not preclude billing services are medically necessary, whether such a Non-Qualified Participant for a non-compensible determinations are made before, on or after the injury. provision of services to such Qualified Participant. j IVA.1 Transfer of Risk. This Agreement and any All services billed under the Tax Identification subcontract within shall not be interpreted to involve Numbers) 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 RHG 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 I.6 agrees and acknowledges that RHG is acting solely in an administrative capacity in providing a network Page 6 of id Kyle Babi&PLD&Assom 121212 RUNPHY TX Q1-:022 c 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 1;o 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 for its own acts or IV.5 Payment of Claim Forms. RHO shall omissions and any and all claims,liabilities,injuries, i 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 aecurate, 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 j 1V.6 Erroneous Payment. 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 (ii) 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 from Member Provider The Member VL TERM AND TERMINATION Provider will not unreasonably withhold reimbursement. If .overpayment has been made V1.I Term. The term of this Agreement shall be for Member Provider shall reimburse such overpayment one (1) year from 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 atter one terminated in accordance with Section VI.2. hundred eighty(180) days from the date of payment. All claims for overpayment or underpayment shall V1.2 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.INDIEMNMCATION V1.2.1 Terination 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/faoilities. Member Provider shall promptly immediately with the 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 RUG and/or meet the event, not resulting from Member Provider's act or credentialing guidelines of RHG. omission, which materially affects Member Provider's ability to continue the practice of V.2 Indemnification of RHGT. 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,suits 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 soon 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 under this Agreement. In the event that a claim is made against RHG,it is the Page 7 of 14 KyleBabick PhD&Ames 121212 RUNPHY_TX 01-2012 VI.2.2 Termination by RHO. A Member Provider the breach within sixty (60) days of the notice, in shall automatically be terminated on the date when: which case,the Agreement and applicable rates and (i) Member Provider's license in the State where terms shall continue in effect. Either party may services are rendered is suspended or revolted, (ii) terminate this Agreement without cause upon ninety Member Provider is excluded from participation in (90)days prior written notice. the Medicaid or Medicare programs, (iii) Member Provider losses their JCAHO, 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 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 party shall be 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 care,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 party may terminate this Agreement upon thirty(30) following written notice by RHG 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 fails to meet RHG's or the obligation hereunder except for (i) obligations State's credentialing requirements. R-FIG, 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 healthcare services of a Qualified Participant against, or appealed a to Qualified Participants, and (ii) 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 RHG 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 RHG 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 RHG, Member VII.CONTEWATION OF BENEFITS 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 RHO, 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 Insolvenev. This Agreement exceed 90 days at the Member Provider's contracted shall terminate immediately in the event that either rate set forth in Exhibit.B of this Agreement with RHG 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 the Qualified Participant as per 28 TAC notification, 10.42(b) (A). Any disputes concerning continuity of care shall be resolved through the complaint process V1.2.4 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 other party; however, the party in breach may cure Page 8 of 14 Kyle Babiok PbD&Assocs 121212 RUNPHY TX.01-2012 i VII.2 Survival. The provisions of this Article VII IX.I.1 Mediation through RHO. The Member shall survive the termination of this Agreement Provider shall notify RHO in writing of the dispute regardless of the cause - giving rise to such or disagreement and shall provide all necessary termination, as will sections II.9, V.2, V.3, V1.3, information to RHO. RHO shall use best efforts to VIII, and IX. The provisions of this Article VII mediate the dispute within the rules and regulations 1 supersede any oral or written agreement to the put forth by the State as reference in RHO's contrary now existing or hereafter entered into Provider Handbook. i 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, RHO or Payor may elect to Vin. CONFJDENTLALrrY 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 RHO 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 RHO or Member M.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 RHO as follows: or Member Provider respectively (collectively, the "Confidential Information"). RHO and Member IX.1.3.1 RHO 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 RHO; RHO or Member Provider that is competitively sensitive is the property of RHO or Member IX.1.3.2 Upon receipt of the written notification of Provider and RHO 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 party. Accordingly, RHO 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 IX.1.3.3 The Network will provide an advisory whatsoever, RHO 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 must complete the advisory disclose such information to any third party. RHO 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 IX.1.3.5 The Client, Payor, or RHO may not notify the pricing information herein. patients of the termination until the earlier of the effective date of the termination or the date the IX. NBSCELLANE©US advisory review panel makes a formal recommendation; IX.1 Disputes. All disputes and difference between the Member Provider and RHO upon which an 1X.1.3.6 If Member Provider terminates the contract, amicable understanding cannot be reached are to be the Network or RHG'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 Pop 9 of 14 Kyle Bebick PhD&Assoes 121212 RUNPHY k-01-2012 receipt of the Member Provider's termination request or as soon as reasonably possible before the IX.8 Severabilit The invalidity or un- effective date of termination. enforceability of any term 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 RI-IG from entering into other contracts or 1X.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 in ownership will not negate the prior contractual 1X.3 Entire Agreement. This Agreement contains agreement without written notification to RHO. 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. IX.4 No Waiver. The waiver by either party of a IX.10 Third PUU 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. IX.11 C_ ter ions. The captions and headings IX.5 Re atory Compliance. Member Provider, contained in this Agreement are for reference sub-contracting providers, and RHO agree that each purposes only and shall not affect in anyway the shall 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 Counterparts. 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 RHO, 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 a.13 Partial InyWiditv. 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 Ad 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 of 1974, and Sections I and 3 of Executive Order 11625, or any applicable rule or regulation promulgated pursuant to any such laws or orders. 1X.6 Gavernine Law. This Agreement shall be governed by and construed in accordance with applicable state law. IX.7 Amendments. This Agreement may be amended as agreed to by both parties in writing upon thirty (30) days written notice of such proposed amendment. { Page 10 of 14 (it Kyle Babick PhD&Assocs 121212 RUNPHY TX 01-2012 I IX-14 Financial Incentives, Neither a Client, Payor, JX.17 Official Notices. Any notice or nor RHG may use financial incentive or make a communication required, permitted or desired to be payment to a health care provider that acts directly given hereunder shall be deemed effectively given or indirectly as an inducement to limit medically when personally delivered or mailed, return receipt necessary services. The adoption of treatment and requested, or overnight express mail addressed as return-to-work guidelines and individual treatment follows: protocols by RHG or Network is not in violation of this section as pursuant to Insurance Code §1305. 304 and§10.83(a)of Chp 10 of Title 28 Part 1. IX.15 Financial Disclosure Requirements. Member Provider is required to file financial disclosures in accordance with Labor Code §§408.023 and Member Provider or Representative/Designee: §§413.041. (Please Print) IX.16 Economic Pmfilinu. Network must provide Name:Kvie Babick,PhD written notice to Member Provider before the Network conducts economic profiling, including Practice:KvIe Babick.PhD&Associates.PC utilization management studies or other profiling of the provider or group of providers. Address: 8340 Meadow Rd City/State/Zip:Dallas.TX 75231 Telephone:(214)559-5757 Fax: 12141378-7009 Organization: Rockport Community Network,Inc, dba Rockport Healthcare Group Attn: Network Development 50 Briar Hollow bane,Suite 515W Houston,TX 77027 Telephone:(713)621-9424 IN WITNESS WHEREOF, the undersigned will be Fax:(713)621-9511 deemed to have executed this Agreement as of the or to such other address, and to the attention of such date the provider is fully credentialed by RHG. other person(s) or officer(s) as either party may designate by written notice. For and on behalf o£ For and on behalf of: Rockport Community Network,Inc. dba Rockport Healthcare Group Member]Provider or Repres�tiv eslgnee 50 Briar Hollow Lane,Suite 515W Mauston,TX 77027 Signature: , Name:Kyle]Babick,PbD Mark C.Neer Sr.Vice President,Netw rk D velopment TIN: 59 f 0 2 Date: I Date: L 3 Page I 1 of 14 KyleBabi&PbD&Assocs 121272 KUNPHY_TX 02 2012 i 1 Err A STANDARDS AND GUIDELINES UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS i RHG and its Clients require Member Providers to follow nationally recognized treatment guidelines (i.e.Official Disability Guidclines(ODG) and/or American Occupational and Environmental Medicine's (ACOEM)guidelines) in the treatment of work-related injuries/iilnesses for Qualified Participants. RHG's Clients provide utilization review and quality improvement programs for Qualified Participants, RHG shall review each Clients Utilization Review and Quality Improvement Program in accordance with RHG's Credemialing 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; s 4) All psychological testing and psychotherapy, repeat interviews,and blofeedback; 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 electromyograms; 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) &habilitation 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 nerve stimulator('TENS)units; 12) Nursing home,convalescent,residential,and all home health caro 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 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. Page 12 of 14 Kylo Babick PhD&Assocs 121212 RUNPIIIY TX 01-2012 ENMBIT B Reimbursement Schedule I.Rockport United Network/Rockport SelectHealth Network-Occupational Injury and Illness Provider fees for the programs listed above shall be reimbursed at the following: All fees will be reimbursed at 95%(ninety five percent)of the state's current Workers'Compensation fees,rales and regulations or usual and customary allowables. 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 Injtu-y or Illness Benefit Plan. I/We accept the fees as outlined in this Exhibit B. For and on behalf of: For and on behalf of (Name,address,etc.) ROCKPORT COMMUNITY NETWORK,INC. KLe Babick.]PhD&Associates.PC dba Rockport Healthcare Group 8340 gadow Rd 50 Briar Hollow Lane,Suite 515W )Dallas,TX 752:1 .Houston,Texas 7777027 G Signatinre ��1 `1 , Mark C.Neer Printed Name Kyle Babick.PhD Sr.Vice President,Ne ork evelopment Title ( /Date � TIN/��•�G`�r��� Hate i I Page 13 of I? Kyle Habid.PhD&Assoos 121212 R1JNTJIY_TX 01-2012 EXHIBIT C Physicians and/or locations where services are to be rendered by Member Provider The Member Provider agrees that the following physicians and/or practice locations listed on attached Exhibit C, shall be Inclusive of the signed agreement and the signed rates in:C+xIdbit B. By signing below Member Provider or its Representative/Designee allows RockportHealtheare Group(RUG)and its representatives to use any and all of the below information as agreed to In this signed agreement. K'vle Babick,PhD&Associates,PC Me Babick,PhD&.Associates.PC Practice Name(1) Practice Name(1) Kyle Babick,PhD Vincent Tran.PhD Physician Name(if a,�licca�'le) Physician Name(if applicable) jJ 8340 Meadow Rd "tl'�' 259.I.,Par1s, ' F 6 16 t' 1 0 51 t Physical Address Physical Address 3v.,-' Dallas,TX 75231 Fort Worth,TX?648611&1017 City,state Zip City,State Zi��tk r���' t`.�'' 13 y �s� Mailing Address(if different) _ �1 ° IN lag A�ess(if different) L214 559-5757/(214)378-7009 �jv� (214)559-5757 {214)378-7009 Plor}�e Number/Fax Nryumber �;z tVN Phone N ber Fax umber Tax ID Number 01 Tax ID Number Practice Name(3) Practice Name(4) Physician Name(if applicable) Physician Name(if applicable) Physical Address Physical Address City,State Zip City,State Zip Mailing Address(if different) Mailing Address(if different) Phone Number/Fax Number Phone Number/Fax Number Tax ID Number Tax-11)Number For and on behalf of: For and on behalf oh Rock-port Community Network,Inc. Member Provider or Representative/Designee dba Rockport Healthcare Group 50 Briar Hollow Lane,Suite 515W � t Houston,TX 770,7 Signature: / Name: Kyle Babick,PhD Mark C.Nee Sr.Vice Pres dent,Nctwor DevelopmentIt- / Date: / l Date: `�' 7 I Page 14 of 14 (( Kyle Babick,Phil&Assocs 121212 RUNPHY TX 01-2012 i