HomeMy WebLinkAboutContract 47186-P24 CITY SECRETARY�y
R O C K P O R T "' CONTRACT NO. 3A 2 ' - y
A WeXomp company.
ADDENDUM
To
Blackstone 504 Program
Provider Agreement
This Addendum is entered into by and among Al Faigin,DO("Member Provider"),Rockport Community
Network("Rockport"), and the City of Fort Worth ("City") on this day of ,
20
WHEREAS, Rockport and Member Provider entered into a Provider Agreement, effective
11-Z I-2.016 , ("Provider Agreement"),and desire that this Addendum apply to covered services that
are governed by the Texas Insurance Code,Texas Labor Code,and Texas Administrative Code.
WHEREAS, Rockport has contracted with Member Provider on behalf of the City in the process of
setting up a direct contracted 504 provider panel pursuant to Texas Labor Code Section 504.053.
WHEREAS, the City has determined that a workers' compensation health care network certified under
Texas Insurance Code Chapter 1305 is not available or practical for its self-insured workers'
compensation program needs and,as such,have elected to provide medical benefits to injured workers by
directly contracting with health care providers.
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504.053(b)(2).
WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
Agreement to be the same terms and conditions that apply to the direct contract between Member
Provider and the City that make available covered services for Qualified Participants'needs to the injured
workers of the City.
NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
1. All terms and conditions of the Provider Agreement are hereby adopted by both Member Provider
and the City, with 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
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
B1ackStone) shall instead apply to matters of notice, billing, dispute resolution, complaints,
preauthorization,and related matters.
2. The parties agree that the City will bear the financial responsibility for payment to Member Provider
under 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.
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Al Faigin.DO Provider Agreement.
3. When used in this Addendum, unless the content otherwise clearly requires the following words and
terms shall have the meani.ng set forth below. All other defined terms shall have the meaning ascribed
to them in the 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.
'131ackStone" 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. Nothing in this Addendum or the Provider Agreement shall be interpreted to inµre to the benefit
of a third party not a party to this contract. This contract may not be interpreted to waive any
statutory or common law defense, immunity, including governmental and sovereign immunity,
or any limitation of liability, responsibility, or damage of any party to this contract;party's agent;
or party's employee, otherwise provided by law.
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 WHEREOF,the parties hereto have executed this Addendum effective on the day and year
First writtenabove.
For and on behalf of:
City of Fort Worth
Blackstone ProvideLPanel
Signature: ate:
Name: Sus n Al is Assistant Cit ana er TTT
APPROVED AS TO FORM AND LEGALITY:
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As 's t Ci orney pF FORS,
Attest
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