HomeMy WebLinkAboutContract 47186-P34 CITY SECRETARY
01",
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.'�"�, CONTRACT NO.
ROCKPORT
A We11COt-rup Company
ADDENDUM
To
BlackStone 504 Program
Provider Agreement
This Addendum is entered into by and among Nova Healthcare, P.A. a Texas Professional Association
dba Nova Medidal Centers("Member Provider"),Rockport Community Network ("Rockport"), and the
City of Port Worth("City")on this day of 120
WHEREAS,Rockport and Member Provider enterer!into a Provider A;reement,effective May 27.2015,
("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 hAalth 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.
WIMREAS, 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(6)(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 lip under
section 504.053 of the Texas Labor Code, The City's Provider Manual (under the name of
B1ackStoae) 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 wilt continue to provide applicable.network administrative services.
`7
CIT' C , T
Nova Medical Centers Provider Agreement
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 terns shall have the meaning
ascribed to them in the Provider Agreement.
"Payors" will be the City as they are responsible for payment of unedical 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 anent
"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 SO4.053 of the Texas Tabor Code.
4. Nothing in this Addendum or the Provider Agreement shall be interpreted to inure to the
benefit of a third parte not a party to this contract. This contract may not be interpreted
to waive any statutory or corntnon law defense, immunity, including governmental and
sovereign immunity, or any lunitation of liability,responsibility, or damage of any party
to this contract,party's agent,or party's employee.,otherwise provided by law.
S. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a
new Callse 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'W;i.1(RU,OF, the parties hereto have executed this Addendum effective on the day and year
First written above,
For and on behalf of:
BlacicStone -
1('�
Signature Lby; 0
QR7
Name:�ll S� �K•.l �' ''•'p
Title: si-s G o (�54-t, IIald F. Gonzales, st . S
Bate:
APPROVED AS T8
FORM AN EGALITY: - — -
' C ! C M ta,04 ! Ft MY f} ;
AMSTANT&TY ATTOR EY I ,. C'71 T
s
Nova Medical Center's Provider Agreement
ROCKPORT COMMUNIT'YNETWORIC
Signature:
Name: J P acP acci
Title: Sr.Vice Prosiden t
Date:— 53 fJLQ/17`
MEMBER PROYME R ox-
Representative/Designee,
Signature:
Name: 1414 e
Title:
Date: C/
TIN: 76-06 3221
3
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ROCKPORTtrr
PHYSICIANAGREEME,NT.
ROCKPORT UNITED NETWORK
ROCKPORT SELECTIIEALTH NETWORK
This Physician Agreement ("Agreement"), is entered
into by and between Rockport Community Network, I. DEFINITIONS
Inc., a Nevada Corporation, dba Rockport
Healthcare Group ("RHG"), dba Rockport United When used in this Agreement and unless the content
Network (a preferred provider network for otherwise clearly requires, the following words and
Occupational Injuries and Illnesses), dba Rockport terms shall mean:
Selectllealth Network (an exclusive provider
network) and Nova I-Tealthcare. PA, a Texas 1.1 "Physician" means a licensed Medical Doctor or
professional _association. dba Nova Xedical Doctor of Osteopathic Medicine, or group of same
Centers (a "Member Provider"), and will become who is affiliated with a Member Provider and
effective as of the date the provider is fully credentialed with REG under this Agreement.
credentialed by RFIG.
Pursuant to Title 28, Texas Administrative Code
WHEREAS, RIIG is engaged in the business of §10.42 regarding Network Contracts with Providers
developing and acting in an administrative capacity seeking 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 Particiga.nt" 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, RIG has networks of contracted is determined compensable by a Client and that
physicians, physician groups, hospitals and Participates 'in the Rockport United Network or
providers of ancillary healthcare services Rockport Selectllealth Network through Rockport's
(collectively, the "Member Providers") to provide a Client. Unless in an 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 network
defined in 1.2 of this Agreement;and either in writing or by telephone.
WHEREAS, Member Provider desires to provide 13 '_'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
inclusive of the networks included in Exhibit D (the rules. These Clients have entered into a Client
"Networks");and Agreement with RHG for the provision of healthcare
services to Qualified Participants,
WHEREAS, RHG has entered into Agreements
and/or services with one or more Payors who 1.4 "Payor" means an ;nsurance carrier or network
provide payment of claims for medical care rendered certified by an insurance carrier for its own benefit,
to Qualified Participants. certified self-insured or governmental entity as those
ternns aredefined and used in the Texas Labor Code,
NOW, THEREFORE, in consideration of the the Network Act Section 1305 and the implementing
premises, the mutual promises contained herein, and piles who is responsible for payment of medical
other good and valuable consideration, the receipt benefits for on the job injuries and or illnesses
and sufficiency of which are hereby acknowledged;( according to State and/or Fed and
it is mutually agreed as follows: OCr f,/�,Regulations.
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Nova Medical Centers TX 050715 r8 j' RUNPHY_T Osd1i� s" W.
i
physician group; hospital; surgery center; diagnostic as defined in.TIC 1305.004(13);and
imaging center; laboratory; clinic; chiropractor; (c) in the case of a mental health condition, one that
dentist; podiatrist; psychologist; social worker; could reasonably present danger to the person
physical, occupational and speech therapist; etc. experiencing the mental health condition or another
licensed or certified to practice a healthcare person as defined in TIC 1305.004(15).
profession or licensed as a facility to offer healthcare
services, in the state where services are rendered and 1.10 "Covered Services" are those healthcare and
who has executed a contract with RHG. health-related services provided to Qualified
Participants for treatment of a compensable, work-
1.7 "Primary Treating Physician/Clinic" According related in J. as defined by either nationally
to Texas law for certified workers' compensation recognized treatment guidelines and/or individual
networks, the Network decides who will be a treatment protocols that do not conflict with any
Treating Doctor. Therefore, a Member Provider who state and/or federal rules and regulations.
is a Medical Doctor (MD) or a Doctor of
Osteopathic Medicine (DO) that specializes in 1.11 "Bill and/or Claim Form" CMS 1.500 (or other
Family Practice, General Practice, Occupational appropriate claim form or their successors)
Medicine or Internal Medicine as well as a physician completed in accordance with the guidelines
that provides initial and/or follow-up care in Oce- established by the National Uniform Billing
Med or Urgent Care Clinics whose practice is Committee or CMS 1500 billing guidelines, and/or
largely dedicated to caring for work related injuries state rules and regulations.
and illnesses is designated. by RHG as a Primary
Treating Physician/Clinic (PTP). PTP agrees to II. MEKBER PROVIDER OBLIGATIONS
render medical care to Qualified Participants without
a scheduled appointment and must be available and I1.1 Services. Member Provider agrees to provide or
accessible to employees twenty-four (24) hours-per- arrange for a.lI medically necessary medical care for
day, seven (7) days-per-week as per 28 TAC Qualified Participants who present themselves to
10.80(b)(1). Should a Qualified Participant need Member Provider. Member Provider agrees to
I
edical attention outside of Member Provider's perform such services with the same standard of
normal "business hours, Member Provider wilt be care, skill and diligence for all Qualified
available and/or make arrangements to have another Participants. Member Provider agrees that it is their
Member Provider render care to Qualified sole responsibility to verify that the individual
Participant twenty-four(24) hours-per-day,seven(7) presenting for care is a Qualified Participant.
days-per-week. Member Provider agrees to render healthcare
services to Qualified Participants at any and all
j 1.8 "Specialist Physician" means a Member Provider facility or practice locations listed in Exhibit "C".
who has met the credentialing requirements of RHG Member Provider shall make best efforts to ensure
to be a Specialist Physician, and to whom Primary that services provided are consistent with nationally
Treating Physicians/Clinics may refer for necessary recognized treatment guidelines (i.e. Official
and authorized care other than primary treating Disability Guidelines (ODG), American
services. Specialists will need to maintain their Occupational and Environmental Medicine's
current board certifications for their particular (ACOEM) and/or state rules and regulations.
specialty to maintain their RHG classification as
such and be willing and able to treat Qualified Member Provider agrees to comply with and be
Participants as needed or required.. bound by all applicable State/Federal Rules and
Regulations.
1.9 "Emergency Medical or Mental Condition"
is defined as the sudden onset of a medical 11.2 Treatment Guidelines. Member Provider agrees
condition manifested by acute symptoms of to follow the treatment guidelines, return-to-work
sufficient severity, including severe pain, that the guidelines and individual treatment protocols
absence of immediate medical attention could outlined in Exhibit A of this Agreement, provided in
reasonably be expected to result in: RI-10's Provider Handbook and/or Clients'
(a) placing the patient's health or bodily functions Utilization Review Programs. RHG agrees to furnish
j in serious jeopardy;orMember Provider or cause Payor to furnish to
(b) serious dysfunction of any body organ or part Member Provider, and Member Provider agrees to
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Nova Medical Centers TX 050715 RUNPHY_TX_OS0115
abide by, the list of any treatments and services that information is not prohibited by state and/or
require preauthorization and by any procedures`to federal rules and regulations.
obtain preauthorization. Unless in an emergency or
after business hours, initial services provided for the II.7 Professional Requirements.
work-related injury/illness require authorization by
the carrier and/or Network either in writing or by II.7.1 Licensure. & Accreditation. Member Provider
telephone. The Client and/or Payor may not deny shall comply with all applicable federal, state and
treatment solely on the basis that a treatment for a Iocal laws, rules and regulations governing like
compensable injury in questi6n is not specifically providers and their provision of services. Evidence
addressed by the treatment guidelines used by the of such current licensing, certification and/or
Client and/or Payor. However, Member Provider accreditation shall be submitted promptly to RHG
must demonstrate medical necessity to support upon request. Member Provider represents and
services rendered to Qualified Participants that are warrants that it, and each of its employees and
outside of treatment guidelines. contracted service providers has obtained, and shall
maintain throughout the term of this Agreement, all
ILL Non-Discrimination.Member Provider shall not necessary registrations, certifications, licenses,
differentiate or discriminate in the treatment of its permits and approvals as are required for the lawful
patients as to the quality of services delivered to provision of Member Provider services to Qualified
Qualified Participants because of race, sex, age, Participants. Member Provider shall immediately
religion, national origin, place of residence, source notify RHG of any revocation, suspension or
of payment or health status. Member Provider shall restrictions, that would affect any certifications,
observe, protect and promote the rights of Qualified licenses or accreditation. As applicable,
Participants. Member Provider warrants that it is currently
accredited by the Agency that governs like providers
11.4 Medical Stam Participation. Certain medical and is certified as a provider under Title XVIII
specialties may not require hospital privileges such (Medicare) and when appropriate, Title XIX
as Occupational Medicine,Pathology,Dermatology, (Medicaid) of the Sociai Security Act and that it
Allergy, and those Primary Treating shall maintain such accreditation and certification
Physicians/Clinics whose practice is dedicated to during the term of this Agreement. Member
treating work-related injuries and illnesses. Where Provider shall immediately notify RHG of any
appropriate, Physicians must maintain active, action, investigation or proceeding to revoke,
unrestricted staff privileges with at least one RHG suspend, restrict, or otherwise affect such
Member Provider hospital or Surgery Center. accreditation or certifications.
Physician hereby consents to disclosure by such
facility to RIIG of all data collected with respect to 1I.7.2 Organization's Rgquirements. Member
Physician in connection with Physician's medical Provider shall use best efforts to comply with RHG's
staff membership, including without limitation all criteria for provider participation, including
applications for staff privileges and any renewals credentialing policies and procedures. Member
thereof. Provider shall cooperate with RHG's periodic
evaluation of qualifications. In addition, Member
11.5 Refen•als. Except in a medical'emergency or Provider shall use .best efforts to cooperate with
when authorized by RHG, Client, or its RHG's and/or state rules andregulations for the
designated representative, Member Provider expeditious resolution of any grievance or
agrees to refer Qualified Participants only to complaint.
other Member Providers,as defined in I.6.
II.S Notification to RHG. Member Provider
I.6 Reports. For each encounter where Member represents and warrants that information provided
Provider provides services to a Qualified herein. and in the RHG application is true and
Participant, Member Provider shall report such accurate in all respects and acknowledges that RHG
encounter on an appropriate form and shall is relying on the accuracy of such information in
include statistical, descriptive medical and patient entering into and continuing the tern of this
I data and identifying information, if and to the Agreement. In addition Member Provider shall use
extent that reports are specified by RHG, Client best efforts to provide written notice to RHG of any
or its designated representative, and requested (i) suspension, reduction or loss of license to provide
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Nova Medical Centers TX 050715 RUNPHY TX 050115
healthcare services; (ii) denial, suspension,. Qualified Participants, services provided to
restriction, reduction or termination of Qualified Participants, and to Member Provider's
accreditation/certification; (iii) changes in Federal performance under this Agreement. Member
Tax Identification Number(s), (iv) other information Provider further agrees to allow RIIG, Payor or a
provided in its application or Exhibit C for designated representative thereof, including the
participation, (v) Member Provider's professional designated utilization review, quality management,
liability insurance if such insurance falls below the case management or peer review staff, to have
requirements of state law and (vi) Member reasonable access to medical records and
Provider's billing or facility address. A failure to information of Qualified Participants for services
give any notice required by this Section shall be a provided under the terms of this Agreement as
material breach of Member Providers 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 termination of this Agreement. Member Provider agrees that in the event an
examination concerning the quality of healthcare
11'.9 Medical Records. Member Provider shall services is conducted by appropriate officials, as
maintain complete and timely medical records required by federal, state, and/or local law, RHG
for Qualified Participants treated by Member shall submit, in a timely fashion, any required books
Provider and its medical staff. Such records shall be and records and shall facilitate such examination.
prepared in accordance with accepted principles RIIG and Member Provider agree to assist one
of practice, shall document all services performed another with on-site inspection of facilities and
for Qualified Participants and shall comply with all records by representatives of authorized federal,
applicable state and federal laws. Member state and Iocal regulatory agencies
Provider shall maintain such records for the length
of time required by applicable state or federal law. 11.11 Relationship of Parties. Member Provider and
Subject to all applicable privacy and RHG understands and agrees that they are each an
confidentiality requirements, such medical records independent legal entity. Nothing in this agreement
shall be made available to each Member Provider shall be construed or deemed to create a relationship .
and other health professionals treating the of employer and employee, principal and agent,
Qualified Participant, and upon request, to the partnership or joint venture or any relationship other
Payor, RHG or its designated representative for than that of independent parties contracting with
review at the rates approved by State law and as each other solely to carry out the provisions of this
set forth in the current State Workers' Agreement for the purposes recited in this
Agreement. With regard to the provision of
Compensation Reimbursement Manual for
Hospitals, if applicable. Member Provider shall healthcare services, Member Provider acts as an
obtain a valid consent for the release of the independent entity and the Member Provider-patient
Qualified Participant's medical records to other relationship shall in no way be affected.
providers, RHG, Payor, or its designated
representative. RHG agrees that medical records of 11.12 Standards of Care. Member Provider agrees
Qualified Participants shall be treated as that all duties perfonned hereunder shall be
confidential so as to comply with all federal and consistent with the proper practice of their
state laws and regulations regarding the healthcare profession, and that such duties shall be
confidentiality of patient records. The Member performed in accordance withthe customary niles of
Provider's obligations under this Section 11.9 shall ethics and conduct of the appropriate and applicable
survive the termination of this Agreement. Professional organizations and/or associations, as the
case may be, and such other bodies, formal or
1.1.1.0 Inspection of Records and Operations. RHG, informal, state, government or otherwise, or by
Payor or a designated representative shall have which they are subject to licensing/certification and
the right to inspect and audit, at all reasonable control. Additionally, Member Provider shall
times during normal business hours, upon five perform all medical and healthcare services in
(5) business days prior written notice, any of conformance with the standards for their facilities as
Member Provider's medical records and established by the local/regional . professional
operations reasonably pertaining to RHG healthcare community and applicable
i
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Nova Medical Centers TX 050715 RUNPHY TX_050115
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 1I1.2 Credentialing. RIIG 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 Providers 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 naive, specialty, address, certifying bodies that apply to the services rendered
telephone number, and hours of operation in a by the Member Provider, such as JCAIIO, 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. RIIG agrees to allow American Accreditation Healthcare Commission
Member Provider to list UIG's name, address, and (URAC) 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 111.3 Operational functions. RHG shall utilize
agrees to post in waiting room and make available to systems to respond to Member Provider's
Qualified Participant notice of Member Provider's requests for information and will provide
participation with RHG. The Member Provider is clarification of policies concerning the operation .
required to post, in Member Provider's office, of RIIG's programs. Member Provider agrees to
notice to employees on the process for resolving work in cooperation with RHG to market the
workers' compensation health care network services of the Member Provider to Clients and/ or
complaints. The notice must include the Texas Payors.
Department of Insurance's toll-free phone number
for filing a complaint and must list all workers' RIIG shall act as a liaison with the Member
compensation health care networks with whichthe Provider and Clients and/or Payors to devote
Member Provider contracts. necessary time and effort to perform RHG's
respons ibi I ities hereunder.
11.14 Noncom lap 'ance. Member Provider understands
that failure to comply with any of the requirements II1.4 Retaliatory Action. RIIG agrees not to engage
imposed pursuant to this Agreement may result in in any retaliatory action including termination of
tennination of this Agreement by RIIG. contract or refusal to renew a contract against
Member Provider, because Member Provider, on
11.15 Antitrust Guidelines. Member Provider agrees behalf of an Qualified Participant, reasonably fled a
to comply with all -applicable antitrust complaint against, or appealed a decision of RHG or
guidelines and procedures promulgated by Federal Payor, or requested reconsideration or independent
and State entities. review of an adverse determination.
LII. RIIG's OBLIGATIONS 111.5 Antitrust Guidelines. RHG agrees to comply
with all antitrust guidelines and procedure
I11.1 Marketing to Clients/Payors. RIIG shall promulgated by Federal and State entities,
enter into agreements with Clients and/or Payors
as defined in L3 and I.4 for their access to RIIG 1II.6 Audit Policy and Procedure Compliance. All
quality Member Providers through specific bill audit requests by Payor shall be done in
referral processes. RIIG will market Member accordance with the State Law and/or Federal Rules
Provider for referral; including but not limited to and Regulations.
I
the following:
(i) Provider Search Provider Locator System (ii) IV. REIMBURSEMENT,CLAIMS
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Nova Medical Centers TX 050715 RUNPHY_TX_050115
SUBMISSION AND PAYMENT
All billing and reimbursement will be made in
IV.] Reimbursement. RHG shall arrange and accordance with Labor Code 408.027 and all other
provide the Member Provider, locations and/or any applicable state rules and regulations.
additional Tax Identification Numbers as listed in
Exhibit C for Payors to pay Member Provider the IV.3 Bill and/or Claim Forms. Claim forms are
reimbursement rates for Covered Services rendered required for all services. All claims must be
to Qualified Participants pursuant to Exhibit B. submitted complete and accurate on CMS 1500 (or
Member Provider agrees and acknowledges that other appropriate claim form or their successors)and
RI-IG is acting solely in an administrative capacity in must include Member Provider's usual and
providing a network of quality health services. RHG customary billed charges (not discounted rates) and
is not the claims paying agent and will not be liable appropriate codes, consistent with policies
for the payment of any amount owed by a Payor to established or approved by applicable state and/or .
Member Provider in the event that Member Provider federal regulations. Member Provider must submit
is unable to collect such amount of money up to and claims to Payor not later than the 95°i day after the
including the insolvency of the Payor. Under no date on which services are provided to the Qualified
circumstance will a Member Provider attempt to Participant, or as specified by state law. In
collect payment from a Qualified Participant for accordance with Labor Code §408.027 and other
medical services rendered for a compensable, work- applicable statutes and rules, payment to Member
related injury/illness. Provider will be made within forty-five(45) days of
receipt of bills which are accurate and complete,
IV•2 Reimbursement Rates. Member Provider is to and otherwise in accordance with state rules and
be paid by the Payor in accordance with State Law regulations.
and/or rules and regulations at the rates established
in Exhibit B. Member- Provider hereby agrees that 1VA Limited Recourse Against Oualified
rates in Exhibit B, which may be amended from time Participants. Except as otherwise provided in this
to time upon mutual written agreement,represent.the Agreement (Section L 10), Member Provider agrees
total amount to be received and agrees to look solely to seek payment from each Payor for Covered
to the Payor for payment for such Covered Services. Services provided to its Qualified Participants, and
Payment will be made for Covered Services actually agrees that it will not seek additional payments or
rendered. All claims will be paid, when appropriate, reimbursement for compensable injuries from
only after submission of a complete and accurate Qualified Participants. In addition, Member
claim. A complete and accurate claim shall be Provider agrees that neither RHG, the Payor nor the
defined as a clean claim by Medicare. RIIG does not Qualified Participant shall be billed or ultimately
guarantee, represent, warrant or covenant regarding held responsible for payment of services deemed not
the selection or use of Member Provider's services to be covered by the Payor or its designee. When
by any Qualified Participant or Payor, or the number Qualified Participant is covered by a state or
of patients, if any, which may result from federally regulated Occupational Injury and Illness
participation in RHG's provider network. The program, Member Provider agrees to comply with
obligation of a Payor to reimburse Member Provider state and federal regulations regarding holding
in accordance with Exhibit B for the provision of Qualified Participants harmless for amounts not paid
Covered Services to a Qualified Participant shall be by Payor for any reason, including Payor or network
conditioned upon a good faith determination by the insolvency. This provision does not preclude billing
I Payor or its designated representative that such a Non-Qualified Participant for a non-compensable
111 services are medically necessary, whether such injury.
determinations are made before, on or after the
provision of services to such Qualified Participant. IVAJ Transfer of Risk. This Agreement and any
subcontract within shall not be interpreted to involve
All services billed under. the Tax Identification a transfer of financial risk for the provision of health
Number(s) indicated in this Agreement, any care services from Payor to RHG as defined under
Ainendments, Exhibit A. Exhibit B, Exhibit C, Insurance Code§l 305.004(x)(26).Member Provider
Applications or any updates regarding locations agrees and acknowledges that RHG is acting solely
and/or a Member Provider as defined in section 1.6 in an administrative capacity in providing a network
j will be subject to the reimbursement rates of quality health providers. RIIG is not the claims
established in the Exhibit B of this Agreement. paying agent and will not be liable for the payment
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Nova Medical Centers TX 050715 RUNPHY_TX_050115
I -
I of any amount owed by a Payor to Member Provider claim. However, P.HG shall have the right to take
in the event that Member Provider is unable to any and. all actions they believe necessary to protect
collect such amount of money up to and including their interest.
the insolvency of Payor or the Network.
V.3 Indemnification of Member Provider. Member
1V.5 Payment of Claim forms. RHG shall Provider will be responsible for its own acts or
administratively arrange for the Payor or its omissions and any and all claims, liabilities, injuries,
designated representative to pay undisputed claims suits and demands and expenses of all kinds which
which are accurate, complete and comply with the may result or arise out of any alleged malfeasance or
Agreement within the time period mandated by state neglect caused or alleged to have be caused by its
or federal law. employees or representatives, in the performance or
omission of any act or responsibility under this
1V.6 Erroneous Payment. In the event that a Payor Agreement. In the event that a claim is made against
and/or its designated representative pays the Member Provider, it is the intent of Member
Member Provider (i) more than once, or (ii) an Provider to cooperate in the defense of said claim.
incorrect amount, or (iii) an overpayment, the Payor However, Member Provider shall have the right to
or its designated representative may, at its sole take any and all actions they believe necessary to
option and discretion, request the return of such protect their interest.
amount from Member Provider. The Member
Provider will not unreasonably witl-diold VI. TERM AND TERMINATION .
reimbursement. If overpayment has been made
Member Provider shall reimburse such overpayment VI.I Term. The term of this Agreement shall be for
within ninety (90) days and/or follow State and one (1) year from the date hereof and shall be
Local Rules and Regulations. The Member Provider automatically renewed on an annual basis for
may not contest payment. of Claims after one successive twelve (12) month periods, unless sooner
hundred eighty(180) days from the date of payment. terminatedin accordance with Section VI.2.
All claims for overpayment or underpayment shall
be resolved in accordance with State Law and /or VI.2 Termination. This Agreement may be
Federal Rules and Regulations. terminated sooner on the first to occur of the
following:
V. INSURANCE AND INDEMNYMCATION
VL2.1 _Termination by Member Provider. Member
V.1 Insurance Requirement. Member Provider shall Provider may terminate this Agreement in the event
provide and maintain such policies of professional of a material default or breach of RHG's obligations
liability insurance or a self-funded program. The hereunder,upon ninety (90)days prior written notice
amounts and extent of such insurance coverage or and the failure of RIIG to cure such breach or
self-funded program shall be in the amounts default within sixty (60) days of the notice. In
detennined by community standards for relevant addition, in the event of an "emergency situation",
hospital/facilities. Member Provider shall promptly Member Provider may terminate the Agreement
demonstrate evidence of insurability or self-funded immediately with.the acknowledgment by RHG that
program and that the required insurance is paid and such an emergency condition does exist.
j in force upon request of RHG and/or meet the "Emergency Situation" shall mean an unforeseeable
credentialing guidelines of RIIG. event, not resulting from Member Provider's act or
omission, which materially affects Member
V.2 Indemnification of RHG. RHG will be Provider's ability to continue the practice of
responsible for its own acts or omissions and arty medicine or to perform its obligations hereunder.
and all claims, liabilities,injuries,suits and demands The Network will provide notification to employees
and expenses of all kinds which may result or arise of the terminating Member Provider immediately
out of any alleged malfeasance or neglect caused or upon receipt of the Member Provider's tennination
alleged to have be caused by its employees or request or as soon as reasonably possible before the
representatives, in the performance or omission of effective date of termination as required by 28 TAG
i any act or responsibility under this Agreement. In 10.42(b)(6)(G).
j the event that a claim is made against RIIG, it is the
intent of RHG to cooperate in the defense of said V1.2.2 Termination by 1U-1G. A Member Provider
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Nova Medical Centers TX 050715 RUNPHY_TX_050115
shall automatically be terminated on the date when: Agreement with or without cause upon ninety(90)
(i) Member Provider's license in the State where days prior written notice to RHG.
services are rendered is suspended or revoked, (ii)
Member Provider is excluded from participation in V1.2.5 Unforeseen Events. In the event that either
the Medicaid or Medicare programs, (iii) Member party's ability to perform their obligations under this
Provider loses their JCAHO, NCAA, AAAHC, Agreement is substantially interrupted by war, fire,
URAC, CLIA or other applicable license, insurrection, riots, the elements, earthquake, acts of
certification and/or accreditation, (iv) Member God, or other similar circumstances beyond the
Provider loses or experiences a material reduction reasonable control of such party, the party shall be
in liability insurance and such insurance falls below relieved of those obligations for the duration of the
the requirements of State Law (v) Member Provider interruption upon notice to the other party. Ili the
engages in any act, omission, demeanor or conduct event that the interruption is reasonably determined
that is reasonably likely to be detrimental to patient IikeIy to persist for at least ninety (90) days, either
safety or to the delivery of quality patient care ,or to party may terminate this Agreement upon thirty(30)
lead to the provision of healthcare services below days prior written notice,
applicable standards, (vi) ninety (90) days following
written notice by RHG of a material default or VL3 Effects of Tennination. Upon termination of
breach by Member Provider hereunder and the this Agreement, neither party shall have any further
failure of Member Provider to cure such default obligation hereunder except for (i) obligations
or breach within sixty (60) days of the notice, or accruing prior to the date of termination, including
(vii) Member Provider fails to meet RHG's or the without limitation, any obligation by Member
State's credentialing requirements. RHG, however, Provider to continue to provide healthcare services
may not terminate this Agreement in direct response to Qualified Participants, and (ii) obligations,
to Member Provider filing a reasonable complaint, promises or covenants contained herein which are
on behalf of a Qualified Participant against, or expressly made to extend beyond the term of this
appealed a decision of, the Network, or requested Agreement.
reconsideration or independent review of an adverse
decision. VIA Qualified Participant and Payor Notification. If
applicable, upon the termination of this Agreement,
In the event RHG deems it necessary to terminate by either party, Member Provider shall cooperate
this Agreement based on the above requirements with RHG to notify Qualified Participants and
RHG will notify Member Provider at least ninety Payors of such termination.
(90) days before the effective date of termination.
VII. CONTINUATION OF BENEFITS
Upon written notification from RHG, Member
Provider may request a review by RHG's advisory VII.1 Continuation: of Benefits. If Member Provider
review parcel, not later than thirty (30) days after- voluntarily terminates its contract with RHG, upon
notification. RHG must then complete the review Member Provider's request, Payor must continue to
before the effective date of termination. reimburse Member Provider for a period not to
exceed 90 days at the Member Provider's contracted
V1.2.3.Termination for Insolvency. This Agreement rate set forth in Exhibit.B of this Agreement with
shall terminate immediately in the event. that either RHG,for care of an Qualified Participant with a life-
RHG or Member Provider voluntarily or tlueatening condition or an acute condition for
involuntarily, liquidates, dissolves or becomes which discontinuing or disruption of care would
subject to any proceeding for the rehabilitation or harm the Qualified Participant as per 29 TAC
conservation of their financial affairs with written 10.42(b) (5)(A). Any disputes concerning continuity
notification. of care shall be resolved through the complaint
process under Insurance Code §1305.401 -
VI.2.4 Termination by RIIG or Member §1305.405 and Subchapter G of Title 28, Part 1
Provider. In case of material breach of the terms (relating to Complaints).
of this Agreement or CAP (contained in Exhibit
E), RHG may terminate the Agreement VII.2 Survival. The provisions of this Article VII
immediately upon written notice . to Member shall survive the termination of this Agreement
Provider. Member Provider may tenninate this regardless of the cause - giving rise to such
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Nova Medical Centers TX 050715 RUNPHY_TX_050115
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termination, as will sections 11.9, V.2, V.3, VI.3, necessary information to RIIG. RIIG shall use best
VIII, and LX. The provisions of this Article VII efforts to mediate the dispute within the rules and
supersede any oral or written agreement to the regulations put forth by the State as referenced in
contrary now existing or hereafter entered into RIIG's Provider Handbook.
between Member Provider and any Qualified
Participant or any person acting on a Qualified. IX.1.2 Arbitration. If the dispute cannot be solved
Participant's behalf. by the mediation process described above, either the
Member Provider, RIIG or Payor may elect to
VIII. CONIZIDENTIALITY submit the dispute io 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 REG 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 inforniation systems
owned by or pertaining to RHG or Member IX.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 R14G as follows:
or Member Provider respectively (collectively, the
"Confidential Infonnation"). RHG and Member IX.1.3.1 RHG will provide notice to the Member
Provider acknowledges that the Confidential Provider at least 90 days before the effective date of.
Infonnation and all other information regarding a termination by It IG;
RHG or Member Provider that is competitively
sensitive is the property of RHG or Member IX.1.3.2 Upon receipt of the written notification of
! Provider and RHG or Member Provider may be termination, a Member Provider may request in
damaged if such information was revealed to a third writing a review by the Network's advisory review
party. Accordingly, RIIG 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 Infonnation. Upon termination
of this Agreement by either party for any reason 1X.1.3.3 The Network will provide an advisory
whatsoever, RHG and Member Provider shall review panel that consists of at least three Providers
promptly return to the other all material constituting of the same licensure and the same or similar
Confidential .Information or containing Confidential specialty as the Member Provider;
Infonnation, and neither party will 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. RHG panel review before the effective date of the
and Member Provider specifically agree that under termination;
no circumstances will either party discuss the terms
and conditions of this Agreement, in particular the IX.1.3.5 The Client, Payor, or RHG may not notify
pricing information herein, with third parties. patients of the termination until the earlier of the
edeptive date of the termination or the date the
IX. MISCELLANEOUS advisory review panel makes a formal
recommendation;
IX.1 Disputes. All disputes and differences between
the Member Provider and RING upon which an IX.1.3.6 If Member Provider terminates the contract,
amicable understanding cannot be reached are to be the Network or RPIG's Client will provide
decided by the following method: notification of the termination to employees
receiving care from the ternninating provider. The
IX.1.1 Mediation through RHG. The Member , Network shall give such notice immediately upon
Provider shall notify RIIG in writing of the receipt of the Member Provider's tennination request
dispute or disagreement and shall provide all or as soon as reasonably possible before the effective
Page 9 of 17
Nova Medical Centers 7X 050715 RUNPHY_TX_050115
date oftenuination. IX.8 Severability. The invalidity or un-
enforceability of any term or condition hereof shall
1X.2 Non-Exclusivity. Nothing in this Agreement in no way affect the validity or enforceability of any
shall be construed to restrict Member Provider or other term or provision.
1U4G from entering into other contracts or
agreements to provide healthcare services to Payors 1X.9 Assig_nnnent, Member Provider may not assign
or other healthcare delivery plans; patients, and or otherwise transfer any right or delegate any duty
employer groups. of performance hereunder, in whole or in part
without the prior written consent of R1IG. A change
IX.3 Entire Agreement. This Agreement contains . iu ownership will not negate the prior contractual
the entire understanding of the parties and agreement without written notification to R .G.
supersedes any prior understandings and agreements, RHG retains the right to assign this Agreement, in
written or oral, respecting the subjects discussed whole or in part, to any entity with which RHG or its
herein. parent company or - any of its subsidiaries is
affiliated,or with which it merges or consolidates.
1X.4 No Waiver. The waiver- by either party of a
breach or violation of any provision of this 1X.10 Third Party Beneficiaries. Except for Payors
Agreement shall not operate as or be construed to be and the agents thereof, there are no third party
a waiver of any subsequent breach hereof. beneficiaries of this Agreernent.
1.X.5 Regulatory Compliance. Member Provider, IX.I.l Ca ptl ions. The captions and headings
sub-contracting providers, and RHG agree that each contained in this Agreement are for reference
shall comply with all applicable requirements of purposes only and shall not affect in anyway the
municipal, county, state and federal authorities, all meaning or interpretation of flus Agreement.
municipal and county ordinances and regulations,
and all applicable state and federal statutes and IX.12 Execution of Counterparts. This Agreement
regulations, now or hereafter in force and effect, may be executed in any number of counterparts,
governing RHG, Member Provider, sub-contracting including facsimiles, each of which shall be deemed
providers, the provision of services by Member to be an original as against any part whose signature
Provider or sub-contracting providers, and/or appears thereon, and all of which shall together
Payors, including but not limited to applicable constitute one and the same instrument.
requirements under any state or federal .fair
employment practices, equal employment IX.13 Partial Invalidity. If any part, clause or
opportunity, or similar laws declaring discrimination provision of this Agreement is held to be.void by a
in employment based upon race, color, creed, court of competent jurisdiction, the remaining
religion, sex, or national origin as illegal, and, Titles provisions of this Agreement shall not be affected
VI and VII of the Civil Rights Act of 1964, Section and shall be given construction, if possible, as to
202 of Executive Order 11246 as amended by permit it to comply with the minimum requirements
Executive Order 11375, Sections 503 and 504 or the of any applicable law, and the intent of parties
Rehabilitation Act of 1973 and Title IV of the lrerelo.
Vietnam Era Veterans Readjustment Assistance Act
of 1974, and Sections I and 3 of Executive Order 1.X.14 Financial Incentives: Neither a Client, Payor,
11625, or any applicable rule or regulation nor RHG may use financial incentive or make a
promulgated pursuant to any such laws or orders. payment to a health care provider that acts directly
or indirectly as an inducement to limit medically
IX.6 Governing Law. This Agreennent shall be necessary services. The adoption of treatment and
governed by and construed in accordance with return-to-work guidelines and individual treatment
applicable state law. protocols by RHG or Network is not in violation of
this section as pursuant to Insurance Code §1305.
IX.7 Amendments. This Agreement may be 304 and §10.83(x)of Clip 10 of Title 28 Part 1.
amended as agreed to by both parties in writing upon
thirty (30) days written notice of such proposed IX.15 Financial Disclosure Requirements. Member
amendment. Provider is required to file financial disclosures in
accordance with Labor Code §§408.023 and
§§413.041.
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I Nova Medical Centers TX 050715 RUNPHY_TX_050115
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IX.17 Official Notices. Any notice or
IX.16 Economic Profiling. Network must provide communication required, permitted or desired to be
written notice to Member Provider, before the given hereunder shall be deemed effectively given
Network conducts economic profiling, including when personally delivered or mailed, .return receipt
utilization management studies or other profiling of requested, or overnight express mail addressed as
the provider or group of providers. follows:
Member Provider or Representative/Designee:
(Please Print)
Name:Gert Rohde,President
i
Organization: NovaHealtheare,PA
dba Nova Medical Centers
Address: 6213 Skyline Dr.
i
City/State/Zip:Houston,TX 77057
Telephone:X71.3)880-4400
Pax: (713) 333-2900
Organization:
Rockport Community Network,Inc.
dba Rockport Healthcare Group
j Attn: Network Development
50 Briar hollow Lane, Suite 515W
Houston,TX 77027
Telephone:(713)621-9424
j Pax:(71.3)621-9511
IN WITNESS WHEREOF, the undersigned will be
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 RHO. other person(s) or officer(s) as either party may
designate by written notice.
t
For and on behalf of:
For and on behalf of:
Rockport Community Network,Inc.
dba RockportUeaItheare Group Member Yiobde,
or Representative/Designee
U3riar Hollow Lane,Suite 515W
.Houston,TX 77 2T, Signatur
' Name: GPresident
Dougla J 'Markham (Print)
Presi debt � TIN:76-0693221
Date: C%`I'�J� Date:
Page 11 of 17
Nova Medicat Centers TX 050715 RUNPHY TX_050115
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EXHIBIT A
STANDARDS AND GUIDELINES
UTILIZATION REVIEW AND QUALITY BIPROVEMENT PROGRAMS
RHG and its Clients require Member Providers to follow nationally recognized treatment guidelines (i.e. Official Disability
Guidelines(ODG) and/or American Occupational and Environmental. Medicine's (ACOEM) guidelines) in the treatment of
work-related injuries/illnesses for Qualified Participants.
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 Credentialing Standards and
Guidelines as described in this Exhibit. Physician and/or Member Provider agrees to comply and be bound by such programs
and any state or federal rules and regulations.
Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written notice to
Physician and/or Member Provider.
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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 Require Preauthorization;unless otherwise specified by the network:
1) In-patient hospital admissions including the principal scheduled procedures(s)and the length of stay;
21 Outpatient surgical or ambulatory surgical services;
3) Spinal surgery,as provided by Texas Labor Code§408.026;
4) All psychological testing and psychotherapy, repeat interviews,and biofeedback.; except when any service is part of a
preauthorized or exempt rehabilitation program;
5) All external and implantable bone growth stimulators;
6) All chemonucleolysis;
7) All myelograms,discograms,or surface 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) Rehabilitation programs to include (a) outpatient medical rehabilitation and (b) chronic pain management /
interdisciplinary pain rehabilitation;
11) All durable medical equipment(DME) in excess of$500 per item(either purchase or expected cumulative rental) and
all transcutaneous electrical nerve stimulator. (TENS)units;
12) Nursing home,convalescent,residential,and all home health care services and treatments;
13) Chemical dependency or weight loss programs;
14) Any investigational or experimental service or device for which there is early, developing scientific or clinical
j 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
i 15) Physical and occupational therapy services; (a) physical and occupational therapy services are those listed in the
Healthcare Common Procedure Coding System (I-ICPCS) 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.
16) Closed Formulary Drugs,as defined by 28 TAC Chapter 134,Subchapter F.
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 17
Nova Medical Centers TX 050715 RUNPHY_TX_0S0115
(EXHIBIT B
ReimbursementSchedule
I.Rockport United Network/Rockport Selectllealth Network—Occupational Injury and Illness
Provider fees for the programs listed above shall be reimbursed at the following:
Rehab services that fall into CPT codes 97001 - 97662 Physical Medicine will be reimbursed at
90% (ninety percent) of-the state's current Workers' Compensation fees, riles and regulations or
usual and.customary allowables.
All other services or codes will be reimbursed at 92% (ninety two percent) of the state's current
Workers'Compensation fees,rules and.regulations or usual and customary allowables.
Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of
I this Agreement, state rules and regulations and/or the applicable Occupational Injury or Illness
Benefit Plan.
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I/We accept the fees as outlined in this Exhibit B.
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For and on behalf of: For and on behalf of:
(Name,address,etc.) --
ROCKPORT COMMUNITY NETWORK,INC. .. Nova Healthcare PA dba Nova Medical Centers
dba Rockport healthcare Group 6213 Skyline Dr.
$0 Briar hollow Lane,Suite 515W flouston,TX 77057
)=Ioi Ston Texas 77 2
1 Signature
t
Dottgla J.tarlsham Printed N,m��Gjert ohde
President Title:President
Date ^O���1 5 TIN 1.(1-06221 Date
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Page 13 of 17
Nova M edical Centers 050115 RUNPHIY TX_050115
lEX'.IIIBIT C
Physicians and/or locations where services are to be rendered by Member Provider
The Member Provider agrees that the following practitioners and practice locations listed on attached E,xhibit C
spreadsheet or equivalent,shall be inclusive of the signed agreement and the signed rates in Exhibit B. By signing
below Member Provider or its Representative/Designee allows Rockport healthcare Group(RHG)and its
representatives to use any and all of the below information as agreed to in this signed agreement.
4
1,
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Parc 14 or 17
Nova Medical Centers 050115 RUNPEIY TX_050115
EXH1131T D
Workers' Compensation Networks(WCN)
Rockport may make this provider agreement available to other networks through delegation. As defined within the
Physician agreement,Member Providers agree to provide treatment for injured employees who obtain workers'
compensation health care service through these networks. The named networks are listed below:
• Rockport SelectIlegith Network
• Welicomp Managed Care Services,Inc.,Plan Name: CompKey Plus
• Broadspire 1ICN
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Page 15 of 17
Nova Medical Co eters 050115 RUNPH Y_TX_050115
EXYUBIT P
Corrective Action Plan(CAP)
Deficiency:
Failure to follow Medicare staffing guidelines for Texas Physical Therapy Services by Nova IIeaIthcare Management,LLP
("Nova"), the delegated management company,on behalf of Member Provider.
Corrective Action:
Member Provider shall require Nova Healthcare Management,LLP to implement an external and internal compliance
program to insure compliance with all State and Federal laws related to billing and clinical documentation. The program
shall include but not be limited to:101
• Initiate an External Clinical Quality and Compliance Audit by a Nationally Recognized Firm on or before August
1",2015 and annually thereafter.
i
Scope to include documentation sufficient to confirm:
L1Compliance and Quality Program Efficacy
_1Compliance with all applicable State and Federal Laws and Regulations
!:?Completeness of Clinical Documentation
-']Medical Coding&Billing Compliance
i;Wedical Necessity documentation
Development of an Internal Compliance Program tinder the direction of General Counsel/Chief Compliance
Officer
I
Scope to include documentation sufficient to confirm:
■ Evidence sufficient to confutn Nova has developed and deployed an OIG-based Corporate Compliance Program
■ Evidence sufficient to confirm Nova has a Compliance,Risk and Safety Committee to oversee the Compliance
Program
■ Evidence sufficient to confirm Nova has an internal a4dit process,and incident,compliance and ethics reporting
processes in place. A summary of the results of each audit process shall be shared with RHG on a quarterly basis.
:Implementation of routine Risk Management/Safety Audits
Implementation of routine HIPAA Compliance Audits
-Implementation of routine Internal Coding&Billing Audits
■ Development of an audit result review process to ensure continuous quality improvement efforts are in place.
•._.;Implement employee training program and distribute training materials by June 2015,
Physical Therapy Treatment Compliance to include:
Hiring additional licensed Physical Therapy staff to ensure compliance with adopted Direct Care Coding Medicare
requirements
■ Retraining/Educating Physical Therapy Staff on State/Federal Rules and Regulations by May 27,2015.
■ Implementation of the IMS Automated Billing System to ensure billing audit trail,real-time coding analysis to
ensure Fee Schedule Compliance.
■ Development of an audit process by May 27,2015,to ensure complete and thorough documentation on all records.
■ In the event Member Provider initiates group therapy treatment for an injured employee covered under this
Agreement,Member Provider agrees to pre-authorize these services.
Completion Date:Member Provider must provide RHG documentation and progress of CAP to verify(lie above items
,I
are completed and in place at least every 90 days unless requested in writing prior to every 90 days by
Page 16 of 17
RITG shall monitor progress of Member Provider's adherence to the CAP and to notification requirements
i of the progress of the CAP.
Continuing Measures:RITG reserves the right to audit RHG with no less than 5 business days prior notice.
Notice shall include a detailed listing of the items being audited.
Responsible Party:Nova Staff as appropriate to the items listed.
Terni Clause:RITG reserves the right to terminate this CAP and any or all agreements between Member
Provider and WIG should Member Provider or its management company fail to meet the terms of the
CAP as agreed upon within the timeframes outlined herein upon immediate written notification by
IR II G to Member Provider.
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For Ind on behalf of: For and on behalf of:
Rockport Community Network,Inc. Member Provider or
Representative/Designee dbn Rockport Healthcare Group
T3riar Hollow Lane,Suite 515W
Hodsto `TX 7707\1Signature-
Name: e t Rohde President
Douglasarlchain (print)
Presidet t• _
Date: "O �5 Date:-
F!C 11,
ate: F!C11,, R 77R`}.'
Pago 17 of 17