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Contract 47186-P36
0,'10 11 1,;1 '0 °If � 9 h CITY SECRETARY M �o CONTRACT N0._ � o � 0CKP0RT c> A WUellComp company ADDENDUM To BlackStone 504 Program Provider Agreement This Addendum is entered into by and among BIR N. LLP dba Baylor Institute for Rehabilitation — Outpatient Services ("Member Provider'), ckport Community Nvork("Rockport', and the City of Fort Worth("City'j on this day of 20 WHEREAS,Rockport and Member Provider entered into a Provider Agreement,effective Amil 17,2017, ("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 Blackstone) shall instead apply to matters of notice, billing, dispute resolution, complaints, preauthorization,and related matters. 2. The parties agree that the City will bear the financial responsibility for payment to Member Provider under the terms of the Provider Agreement subject to the applicable Provider Manual and the provisions of the Texas Labor Code and applicable rules under the Texas de. Rockport will continue to provide applicable network administrative services. OFFICIAL RECOR® CITY SECRETARY FT. WORTH,TX BIR JV.LLP dba Baylor Institute for Rehabilitation-Outpatient Services 3. When used in this Addendum,unless the content otherwise clearly requires, the following words and terms shall have the meaning set forth below. All other defined terms shall have the meaning ascribed to them in the Provider Agreement. "Payors" will be the City as they are responsible for payment of medical benefits for compensable injuries and or illnesses sustained by its injured workers according to the Texas Workers Compensation Act. `BlackStone" is the 504 Provider Panel established by the City of Fort Worth through this and other direct contracts using Rockport as its contracting agent "Provider Manual"means the BlackStone Provider Manual as amended from time to time and available upon request to the Member Provider. "Provider Panels" are those direct contracted panels formed by political subdivisions or public pool entities authorized by Section 504.053 of the Texas Labor Code. 4. Nothing in this Addendum or the Provider Agreement shall be interpreted to inure 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 written above. For and on behalf of: BlackStone At Signature. Maty J. Kay , C;i S GjiO Name: 0: 2 Title: �`, • (,-4-y cm"LQ Date: APPROVED AS TO M ND LEGALITY: FOFFICIAL ECORD CITCITETARY 1ASSTN CITY ATTORNEY2 FT.WORTH,Tx Big N LLP dba Baylor Mute for Rebabi}itation-Ouivatient Services ROCKPORT COMMUIlITX NETWORK Signature: ~��''''"..'• Name:Jahn Paolacci Title:Sr.Vice President Date• mxMBERPROVIDRR or Repreaentative/Desiguee . S'�gnature: Name: Ian C.Skinner Tim; VP,Operations _ Date: May 16 2017 TXT:27-4586141.29--8077—M i I i 3 ROCKPORT " A 1NehCOMP ComRarw T'ACnATX/ANCaXARY AGREEMENT R0CXP0RT Col+bxrrMTY NETWORK This Fae ty/AndUary Agreement ("Agreement"), who desire to become a Member Provider with is entered into by and between Rockport ROCKPORT. Commtfrity Netwod; Inc., herein ]mown as :Rockport: a Nmda Corporation ROCUORT and Pursuant to Title 28, Texas Administrative Code Big JV, LLP d(b/a B4AQl r. Institate for §10.42 regarding Network Contracts with Providers Rehsbbilita m — Outpatient Services {"Member seeking to participate in Teras Certified Workers' Provider"), and will beco=cffeotive as of the date CompensationNetwodts, the provider is fully credentialed by ROCMRT. 12"Ouaiified Partidp-fiat"means an employee'as VnIEREAS, ROCKPORT is engaged in the defined and used in the 'Texas Labor Code, the business of developing and aching in an NCtw' & Aot Section 1305 and the implementing administrative capacity is providing Occupational rules who sustained a work-related inpmy/iffness that Injury and health provider ndworks that offer 18 determined compensable by a Client and that direction of care while providing simings to partioipates in the Rodp)rt Community Network ROCKPORT clients and/or Payors.These networks through Rockport's Client. Unless In an emergeney an11 offer greater coverage of services and savings; or after business hams, initial services provided for and the work-related injury/illness require authorization by the network either in writing or by telephone. 'WaIEREAS, ROCKPORT has networks of contracted physicians, physician graups, hospitals I.3 'Q rot°means an insurance company, certified and providers of ancillary heatdleare services self insured or goveu meatal entity as those terms (ooReotivcly,the"Member Providers")to provide a are defined and used in the Texas Labor Code, the full-range of healthcare services. These services are Ntt'w'ork Act Section 1305 Sud the implemenrins available for ube by "Qualified Participants"'as rules. These Clients have entered into a Client defined in L 2 of this Agreement;and Agreement with ROCKPORT for the provWon of � bealthoare services to Qualified Participants. 'GVIIERr.�i3, 1Vleraber Provider dashes to provide medical care services to "Qualified Participants" 14 "Pay�neans an insurance carries or network who are covered by payor Agreements at the rates in oWitied by an insurancc carder for its own benefit, Exhibit B and in locations listed in Exhibit C: and certified aeif-insured or governmental entity as those inclusive of the networks included in Exhibit D;and terms art defined and used in the Terms Labor Code, the Network Act Section 1305 and the implementing SEAS, ROCKPORT has enterod into rules who is responsible for payment of medical Agreements and/or services with one or more Payors benefits for on the job igjuries and or illnesses who provide Payment of claims for medical care according to State auftr Federal, Rubs and rendered to Qualified Participants, Regalalions. 1-5 "Clientinem I means the agreement NOW, THEREFORE, in consideration of the between ROWORT and a Client, which premises, the mutual promises contained herein,and agreement is made before,, on or after the elyeotive other good and 'valuable eoi4der+tion, the receipt date of this Agreement and which expresses the and sufficiency of which are hereby aclmawledged, agreed upon contractual rights and obligations of ft it is mutually agreed as follows: parties. Such Client Agreements will require Payors to pay Member provider foT Covered Services L DEF)2%TI0X8 rendered to Qnalified Participants pursuant to this When used in this Agreement and unless the content Agreement. Farthemiore, such Client Agreements otherwise Clearly requires,the following words and shall authorize ROCKPORT to enter this Agreement terms shall mean: and contractually bind Payors to the terms hereof unless there is a conflict with State and/or Federal I.1 "Blysid'meads a licensed Medical Doctor or rales and regulations. Doctor of Oste%athio Medicine, or group of same a , PIkV 1 pf15 BW N.UP 3-9.17 RC1V'<:AC TX 062016 f Mar. 15. 2011 2:32PM No. 2025 P. 2 L6 "Member Provider:" means any physician; (b)serious dysfunction of any body organ or part as physician group;hosppita.1;surgery oenter;diagnostic defined in TIC 1305.004(13);and imaging center; laboratory-, clinic; Chiropractor, (c)in the case of a mental health condition,one that dwtisfi podiatrist; psychologist; social worker; could reaaonaably presarrt danger to the person physical, occupational and speech therapist; etc. experiencing the mental health condition or anatber lioemcd or certified to practice a healthcare person as defined in TIC 1305.004(15). profession or licensed as a facility to off-er healthcare services,in the state where sees arereddered and I.10 "Covered Services" are those healthcare and who has executed a contract with ROCKPORT. health-related services provided to Qualified Participants for treatment of a compensable, work- L? orkI.7"Fdw=TreatingEhyli.d�Clmic"means related iwuryrllneu as defined by eitl=nationally it Member Provider who is a Medical Doctor(MD) recognized treatment guidelines and/or individual or a Doctor of Osteopathic Medic=(DO)that treatment protocols that do not conflict with any specializes in Family Practice,General Procttoc, state and/or federal rules and regulations. Occupational Medicine or Internal Medicine as well as a physician that provides initial and/or follow-up Ill "Bill and/or Claim Form" M-92 (or other ooze in Occ-Mod or Urgent Cam Clinics whose appropriate claim form or their sueoesm) practice is largely dedicated to caring for work omVlete d in accordance with the guidelines related irriu des and illnesses is designated by established by the rational Uniform Billing ROCKPORT as a Primary Treating Physician/Clinic Committee or UB-92 billing guidelines,and/or state (PTl?). PTP agrees to render medical cam to rules and regulations. Qualified Participants without a scheduled appointment and must be available and accesible to II. MBSERPROVIDER OB11GATIONS employees twenty--four(24)hours per-dad,seven(1) days-per-week as per 28 TAC 10.80(b)(1). Should a ILl Services. Member Provider agrees to provide or Qualified Participant need medical attention outside arrange for all medically necessary medical care for of Member Provider's normal business hours, Qualified Participants who present themselves to Member Provider will be available and/or makes Member Provider. Member Provider agrees to zaugements to have another Member Provider pmfomm such services with the same suadard of render care to Qualified Participant. Both parties care, Rill and diligence for all Qualified agree that Member Provider is a health care facility partite. Member Provider agrees that it is thou or other ancillary provider, and as such, the sols respomIffity to verify that the individual reclairemeats of 28 Texas Administrative Code § presenting for care is a Qualified Parti4ant. 10.4*X12) do not apply regarding Tzoatig Member Provider agrees to render healthcare Doctors. services to Qualified Participants at any and all facility or practice locations listed in Fzhibit "C". 18"Spree diet P1ysidan" means a Member Provider Member Pravidw shall male best efforts to couro who has met the credentialing its of that services provided are consistent with nationally ROCKPORT to be a Specialist Physician, and to rccogaizc�a treatment guidelines (i.e. OffioW whom Primary Treating Physicians/Clinics may DisabiliT Guidelines (ODG), American refer for necessary and authorized caro other than Occupational and Eiivixon lrftlal Medicine's primary treating services. Specialists will need to (ACOEM) and /or state rules and regulations. maintain their current board certifications for their Member Provider agrees to comply with and be particulw specialty to maintain t1rei k0CKP0KT bound by all State/Federal.Rules and Regulations. classification as such. 112 Tzeatmea Qaddm, Member Provider agrees 1.9 ")'sorer encu Medical or Mental Condition" is to follow the treatment guidelines, return-to work defined as the sudden onset of a medical condition gaideline.s and individual treatment protocols manifested by acute symptoms of sufficient severity; outlined in Exhibit A of this Agreement,pravided in including severe pain,that the absence of immediate ROCKPORT's Provider Handbook and/or Clients' medical attention could reasonably be expected to Utilization Review Programs. ROCKPORT agrees result ill: to furnish M=bor Provider or cause Payor to (a)placing the patient's health or bodily functions in furnish to Member Provider, and Member Provider serious jeopardy;or agrees to abide by, the list of,any treatments and services that require preauthozi.zation and by any ftge 2 pf 15 BIRJV,LU3.9-17 RCNEAC TX_062016 I +i I I Mar. 15. 2017 2:33PM No. 2025 P. 3 procedures to obtain,prtauthorizetion.Unless in an IL7 Professional RWk ments, emergency or after business hours. initial services provided for the work-related iajwyy/ilbaess require IL7.1 Licensure&Accreditation. Member Provider authorization by the carrier and/or Network either in shall comply with all applicable federal, state and writing or by telephone. Tho Client and/or Payor local laws, rules and regulations governing Mm may not deny treatment solely on the basis that a providers and their provision of savicts. Rvidenoe treatment for a compensable fi&y in question is not of such ounent licensing, certification and/or specificOy addressed by the treatment guidelines accreditation shall be submitted promptly to used by the Client andlar .Payor.However,Member ROUTORT capon request. Member Provider Provider must demonstrate medical necessity to represents and wammnts that it and each of its support services rendered to Qualified Participants employ= and contracted service providers has that are outside of treatment guidelines. obtained,and shall maintain througt w the term of this Agreement, all necessary registrations, 11.3 ijqn-Diccri[ w=i .Member Provider shall not oertif cations,howses,permits and approvals as are differentiate or discriminate in the treatment of its required for the lawful provision of Member patients as to iho quality of services delivered to Provider services to Qualified Participants.Member Qualified Participants because of race, sex, age, Provider shall immediately notify ROCVORT of religion, national oriM place of residence, source any revocation, =pension or restrictions, that of payment or health status. Member provider shall would affect any certifications, liceoees or observe,protect and promote the rights of Qualified aeoreditation's. Member Provider warrants that it is Participants. c=cndy accredited by the Agency that governs lilt providers and is =ffwd as a provider under Title 11.4 Medical Staff Partioipa6on. Member Provides XV711 (Medicare) and when appvimate,Title= shall cooperate to the Tallest extent possible in (Medioaid) of the Social Security Act and that it obtaining staff privileges for Participating Primary shall maintain such accreditation and cettifios6on Treatuog and Specialist PhysiciazWCHnios who during the term of this Agreement. Member meet Member Provider's oxedentialing standards and provider shall immediately notify ROCKPORT of Wee to comply with. the r'lrles and regulations, any revocation, suspension, restriction of such policies and pmoedarm'as may exist from time to acoreditation.or certiificatiov. time governing Member Provider and its medical staff Member Provider shall grant staff privileges IL7.2 Orpo z gion's ReelA=Ga. Member only to competent glllaAed physicians and Provider shall use best efforts to comply with healthcare profesaicnals and shall exercise ongoing ROCUORT's criteria for provider participation, peer review of the members of its medical staff inolu6ng cmdentialiag policies and processes. Upon request, Member Provider shall provide Member Provider slraA cooperate with ROCRPORT with a current copy of its medical staff ROC,KPORT's periodic evaluation of qualifications. roster. In addition,Member Provider shall use best efforts to cooperate with ROCKPPORT's and/or state rules U.S Referrals. Except in a medical emergency or and regulations for the expeditious resolution of any when authorized by ROCKPORT, Client, or its grievance or complaint. designated representative, Member 'Provider agrees to refer Qualified Participants only to other Member ILS Notification to ROCKPORT. Member Provider Providers,as defined in L6. represents and warrants that information provided herein and in the ROCKPORT application is true 11.6Rctz . For each encounter where Member and accurate in all respects and acknowledges that Provider provides services to a Qualified Participant, ROCKPORT is relying on the accuracy of such Member Provider shall report such encounter on an information in entering into and continuing the term appropriate form and shall include statistical, of this agreement. In addition Member Provider descriptive medical and patient data and identifying shall use best efforts to pravide written notice to information, if and to the extent That reports aro ROCKPORT of any(i)suspension,reduction or loss speca$ed by ROCKPORT, Client or its designated of license to provide healthcare services; (ii) denial, representative, and requested information is not suspda 0% xestriotion, reduction or unniwdon of prohibited by state and/or federal roles and accreditation/certification; (iii) changes in Federal regulations. Tare Idectiiication,Number(s),Civ)other information provided in its application or exhibit C for Pogo3 0 li BHLJV,LLP 3-9-17 RCWAC T&06ZQ16 i Mar. 15. 2017 2,33PM No. 2025 P. 4 i S participadon. (v) Member Provider's professional access to medical records and information of liability insurance if such insurance falls below the Qualified Participants for serviees prodded under requirements of state law and (vi) Member the terms of this Agreement as necessary to enable ' Provider's billing or facility address. A failure to such party to perfouml Utilization Review and give any notice required by this Section shall be a Quality Assurance activities in accordance with the material breach of Member Providers obligations applicable Utilization Review and Quality and responsibilities bcrenndM regardless of the .Assurance Program In addition, Membra Provider status,pendency or outcome of the ovent giving rise agrees that in the event an examination concerning to the obligation to give that notice, and may be the quality of healthcare services is conducted by ! grounds for termination of this Agreement appropriate officials, as required by federal, state, and/or local law, ROCKPORT shall submit, in a 11.9 Medical Records. Member Provider shall timely fashion, any required books and records and ! maintain Mete and timely medical records far shall facilitate such examination. ROCKPORT and Qualified Participants treated by Member Provider Member Provider agree to assist one another with and its medical staff Such records shall be prepared on-site inspection of facilities and records by in accordance with accepted principles of practice, tepresentatives of authorized federal,state and local shall document all services per�for Qualified regulatory agencies Participants and shall comply with all applicable state and federal laws. Member Provider shall 1L 11 ti2aft of Parties. Member Provider and maintain such records for the l&Wth of time required ROCKPORT understands and agrees that they are by applicable state or federal lave. Subject to all each an independent legal entity: Noticing in this applicable privacy and confidentiality requirements, agreement shall be construed or deemed to create a such medical records shall be made available to each relationship of employer and employee, principal Member Provider and other health professionals and agent, partnership or joint venture or any treating the Qualified Partioipant, aci4 upou request, relationship other than that of independent parties to the Payor, ROCKPORT or its designated contracting with each other solely to carry out the representative for re'v'iew at tbo gates approved by provisions of ibis Agmement for the purposes State law and as set forth in the current State recited in this Agreement. With regard to the Workers' Compensation Reimbursement Manual for provision of healthcare services, Member Provider Hospitals, if applicable. Member Provides shall acts as an independent entity and the Member obtain a valid consent fbr the release of the Qualified Provider-patient relationship shall in no way be Participant's medical records to other providers, affected. ROCKPORT, Payor, or its designated representative. R001KPORT agrees that medical IL12 Standards of Care Member Provider agrees records of Qualified Par'tidipanfs shall be treated as that all duties perFaamed hereunder shall be confidential so as to comply with all federal and consistent with the proper practice of their stats laws and regulations regarding the healthcare profinsion, and that such duties shall be confidentiality of patient records. The Member perfe med in woordaneo with the ca>stomary rules of Providees obliplioiss under this Section II9 shall ethics and conduct of the appropriate and applicable survive the termination of this Agreement. professional organizations and/or associatiams,as the case may be, and such other bodies, formal or 110 fimection of Raoords and Qpg p ions. informal, state, government or otherwise, or by ROCKPORT, Paym or a designated representative which they are subject to licensing/corttacation and shall bave the right to inspect and audit, at all control. .Additionally, Member Provider shall reasonable timers during normal business hours,Wm perform an medical and healthcare services in prior five. (5) business days, any of Member conformanoo'with the standards for their facilities as Provider`s medical records and operations established by the local/regional professional reasanably pertaining to ROCKPORT Qualified healtlroare community and applicable Participants, services provided to Qpalifled acerediting/licenaing agencies. Member provider Participants,and to Member Provider's perfaruiance agrees that,to the Ment feasible,it shall utilize such under flus Agreement. Member Provider frMher additional allied health and other qualified personnel agrees to allow ROCKPORT, Payor or a designated as are available and appropriate for effective and representative thereof, including the designated efficient dchvery of care. Member Provider sblall utilization review, quality management, case ensure that all suclu personnel are properly licensed management or peer review staff',to have reasonable Page 4 0£15 D13L YV;7.LP 3-9-17 Rc"Ac_&061016 i Mar. 15. 2017 2:33PM No. 2025 5 and/or possess the necessary credentials to render the services that they perform. Il I.2 Q�cdentialine. ROCKPORT will perform and/or delegate to qualified orgaubmtlons 11.13 Ri&.fm Use Member Provider's gr N ork's eredentialing of each Member Provider. Name. Member Provider agrees to allow Credentialing may include verification of all ROCKPORT to list Member Provider's name, information and documents provided in the spMalty, address, telopbo:wo number, and hours of application for participation and investigation, operation in a Member Provider directory,Provider including but not Br4ted to vatfioatwn with all state Search, ROCKPORT Site-Specific Provider and national licensing and certifying bodies that Panel(s), ROCKPORT website and/ or other apply to the services rendered by the Member materials to help promote and assist Clients with Provider,such as SCARO, AAAHC,NCQA, G'I,IA, Qualified Participants needing medical care for URAC, etc. Inquiries may also be made to current injurieahlInasses sustained ROCKPORT agrees to end previous profbmional liability can=,Medicare allow Member Provider to list ROCKPORT's name, and Medicaid.ROCKPORT's erededUing policies address, and telephone number on Member and paoeedares follow the American Accreditation Provider's Website or in other publications listing the Healthcare Commission (URAC) and/or NCAA health plans sooeptted by Member Provider. In standards for Worlmrs' Compensation provider addition,Member Provider agrees to post in waiting networks. room and make available to Qualified Participant notice of Member Provider's participation with III3 QW=mg hincUpa ROCKPORT shall ROCKPORT with name, addrwa and telephone utilize systems to respond to Member Providers number and process for Qualified Participants to requests for information and will Provide resolve complaints. The Member Provider is clarification of policies concerning the operation of required to post;in Member Provider's office,notice ROCKPORT*s programs. Member Provider agrees to employees on the process for resolving workers' to work in cooperation with ROCKPORT to market compensation health acre network complaints. The the services of the Member Provider to Clients an& notice must include the Teams Department of or Payors. Insurance's toll-free phone number for filing s complaint and must list allworkers' compemation ROCKPORT shall act as a liaison with the Member health care networks with which the Member Providers and Clients and/or Payors to devote Provider c aatracts. Necessary time and effort to perform ROCKPORT's responsibilities hereunder. M14 Nonco iance.Member Provider understands that failure to omply with any of the re p&ements )R4 Rataliatarx Action.. ROCKPORT agreea not to imposed pursuant to this Agreem=t may result in engage in any retaliatory action including termination of this Asro=trxt by ROCKPORT. WrminatiOn of contract or refusal to renew a ocntraot against Member Provider, because Member IL15 Antitrust Guidelines. Member Provider agrees Provider, on behalf of aux Qualified Pmt, to comply with all antitrust guidelines and reasonably filed a complaint against, or appealed a procedures promulgated by Federal and State decision of ROCKPORT or Payor, or requested entities. recorlsideiredon or independent review of an adverse deterrrlinetion. M. ROCLTORx"9 OBLIGATIONS 11I.5 Antitrust Guide=. ROCKPORT agrees to M.1 Marclreflllg to Climtsipavora. ROCKPORT comply with all, antacwt guidelines and procedure shall enter into agreements wxth Clients and/or promulgated.by Federal and Stabs entities. Payors as defined.in U and L4 for their access to ROCKPORT quality Member Providers through M6 Audit policy and Procedure QQwplixace. All specific real processes. ROCKPORT will bill audit requosts by Payor shall be done m market Member Providers for referral;inoluding but accordance with the State Law and/or Federal Rules not limited to the following: (i) Provider Search and Regulations. Provider Locator System (ii) Provider Directories (iii) Site-Specific Provider Panels (iv} Customized Local Networks and (v) Client Servieo Frovider JV, ].tUMMURSEMGNT,CLAIMS Referral Servioe. SMMMSION AND PAYMENT BIlk N.TU 3-¢17 RCNFAC,TX062016 i Mar, 15. 2017 2.33PM No, 2025 P. 6 IVA Reimbursement. ROCICORT shall arrange All billing and reimbursement will be, made in and provide the Member Provider,locations and/or accordance with Labor Code 408.027 and all other any additional Tax Identification Numbers as listed applicable state rules andregulations. in Exhibit C for Payors to pay Member Provider the reimbursement rates for Covered Services rendered IV'.3 Bill and/or Claim Forms. Claim fowls m to Qualified. Participants pursues to Exhibit B. required for all services. All claims must be Member Provider agrees and acknowledges that submitted complete and accurate on UB-92(or other ROCKPORT is acting solely in an administrative appropriate claim form or their successors)and must capacity in providing a network of quality health include Member Provider's usual and =tomaty services.ROCKPORT is not the claims paying agent bulled charges(not discounted rates)and appropriate and will not be liable for the payment of any amount codes, consistent with policies established or owed by a Mayor to Member Provider in the event approved by applicable state and/or federal that Member Provider is unable to collect such regulations.Member Provider must submit claims to amount of money up to and including the insolvency Payor not later than the 9r day after the date on of the Payor. Under no circumstance will a Member which services are provided to the Qualified Provider attempt to collect payment from a Qualified Participant, or as specified by state law. In Participant for Medical services rendered fora aceardanne with Labor Cade §408.027 and other compensable,work-related injurylilhiess, applicable statutes and rules,billing and payment to Member Provider willbe made within forty-five IV.2 RRbursement Rates.Meoober Provider is to (45) days of receipt of bills which ars accurate and be paid by the Payor in accordance with State Law complete, and otherwise in accordance with state and/or rales and regulations at the rates established rules and regulations. in Rxhibit B. Member Provider hereby agrees that rates in Ekbibit B,which may be amended from time 1V A U3*ed Recourse Atrainst Oufiec� to time Von mutual vonttea agreemen;represent the Participants. Except as otherwise provided in this total amount to be received and agrees to look solely Agreement(Section.7;.10), Member Provider agrees to the Payor for payment for such.Covered Services. to seeds 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 Muriel from claim. A. complete and accurate claim shall be Qualified Participants. In addition, Member defined as a clean claim by Medicare.ROCKPORT Provider agrees that neither ROCKPORT,the Payor does not guaranrtb, rgxtsent, warrant or covenant nor the Qualified Participant shall be billed or regarding the selection or use of Member Provider's ultimately held responsible for payment of services services by any Qualified Participant or Payor,or the deemed not to be covered by the Payor or its number of patients, if any, which may result from desigaw.When Qualified Participant is covered by a participation in ROCKPORPs provider network state or federally regulated Occupational Igjury and The obligation of a Payor to reimburse Member Illness program,Member Provider agrees to comply Provider in accordance with Exhibit B for the with state and federal regulations regarding holding provision of Covered Services to a Qualified Qualified Participants hanmless for amounts not paid Participant shall be conditioned upon a good faith by Payor for any resa xq including Payor or netwaik determination by the payor or its designated insolvency. This provision does not preclude billing representative that (i) such services are medically a Non-Qualified Puticipant for anon-compensable necessary, whether such determinations are made injury. before, on or after the provision of services to such Qualified Participant_ IV.4.1 Transfer of Risk This Agreement and any subcontraot 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(g) indicated in this .A,greeiu=4 any caro services from Payor to ROCKPORT as defined Amendments, Exhibit A, Exhibit B, Pathibit C, under Iuslaance Code §1305.004(a)(26). Member Applications or any updates regarding locations Provider agrees and acknowledges that ROCKPORT and/or a Member Provider as defined in section I.6 is acting solely in an administrative capacity in will be subject to the roimbursemw rates providing a DeWork of quality health providers, established in the Exhs-bit B of this Agreement. ROCKPORT is not the claims paying agent and will Pege 6 of M BIR Jv,LLP 3.9-17 KONFAC T}_0=16 i Mar. 15. 2017 2:34PM No. 2025 P. 7 not be liable for the payment of any amount owed by caused or alleged to have be caused by its employees a payor to Member Provider in the evwt that or representatives,in the parfonnance or omission of Member Provider is unable to collect such amount of any act or responsibility under this Agreement. In money up to and including the insolvency of Payor the event that a claim is made against ROCKPORT, or the Network it is the intent of ROCKPORT to cooperate in the defeoso of said claim However, ROCKPORT shall IV.S Payment of Forms. ROCKPORT shall have theright to take any and all actions they believe administratively arrange for the Payor or its necessary to protect dWr interest designated representative to pay undisputed claims which are accurate, complete and comply with the V.3 Indemnification of Member gp . Member Agreement within the time period mandated by state Provider will be responsible for its own acts or or federal law. omissions and any and all claims,liabR-djes,injuries, suits and dr-ands and agmnses of all kinds whim IV_6 Rrrrr�rutin EMML In the event that a payor may result or arise out of any alleged malbwanoe or and/or its designated representative pay's the neglect caused or alleged to have be caused by its Member Provider (i) more than once, or (ii) an employees or representatives, in the poz1banazice or incorrect amount,or(iii)an overpayment, the Payor omission of any act or responsibility under this or its designated representative may, at its sole Agreement. In the event that a claim is made against option and discretion, request the return of such Member Provider, it is the intent of Member amount from Member Provider The Member Provider to cooperate in the defense of said claim. Provider will not unreasonably withhold However, Member Provider shall have the right to reimbursement. If overpayment has been mads take any and all actions they believe nememy to Member Provider shall reimburse such overpayment protect filar inteseat. within pk4X90)days andlor follow State and Local Rules and Regulations. The Member Provider may VI. TUM AND TFRI% NATION not contest paymear of Claims after one hundred eighty (180) days from the date of payment, All VLl I&g& Thete tm ofthia Agreement shallbe for claims for overpayment or underpayment shall be one (1) year from the date hereof and shall be resolved in accordance with State Law and /or automatically renewed on an annual basis for l'edezal Rule&and 1toga atkm successive twelve(12)month periods,unless sooner to mimated in accordance with Section VL2. IV.7 AWe4 2f Meq 1✓lila.Member Provider may appeal a claim denial 180 days from the date the VL2 Vermination Both parties shall have the right denial letter is reoeive d not to oonflisr with or to terminate this Agreement without causer at any exceed state rules and regulations time following the initial term by providing ninety (90)day prior written notice to the other party by use V, WSURANCE AND INDEYIN MCATTON of a trackable delivery service such as CIPS or FedEx. This Agreement may be tern4nated sooner V.1 Insurance Rexluireameat Member Provider shall on the first to occur of the following: provide and maintain su&policies of professional liability insurance or a self-funded program. no VL2.1 Te amination by Member Provider. Member amounts and extent of sur4 insurance coverage or Provider may terminate this Agreement in the event self-funded program shall be in the amounts of a material default or breach of ROCKPORT's determined by comurrp iq standards for relevant obligations hereunder, upon ninety (90) days prior bmotsWacilities. Member Provider shall promptly written notice and the faRnre of ROCKPORT to cure demonstrate evidence, of inamabality or self fi nde d such breach or default within sixty(60) days of the program and that the required insurance is paid and notice. In addition, in tbt event of an"emergency in force upon request of ROCKPORT and/or meet situation", Member Provider may terminate tho the crodeatialing guidelines of ROCKPORT. Agreement zmmediately with acknowledgment by ROCKPORT that such an emergency condition does V.2 on of ROCKPORT. ROCKPMRT exist. T X v=uenoy Situation" shall mean an will be responsible for its own acts or omissions and unfo resp ble event, not resulting from Member any and all claims, liabilities, injuries, suits and Provider's act or omission,which materially affects demands and expenses of 411 hinds Which may result Member Provider's ability to continue the practise of or axis-,out of any alleged malfeasance or neglect medicine or to perform iris obligations hereunder. Pege7oflS BIEL N.LIP 3.0-17 k0WAC TX 062016 M f Mar. 15, 2817 2:34PM No. 2025 P. 8 The Network will provide notification to employees subject to any proceeding for the rehabilitation or of the terminating Member Provider immediately conservation of their fmamial affairs with writtm upon receipt of the Member Provider's termination notification. request or as soon as reasonably possible before the c feeiivo date of termination as required by 28 TAC VL2.4 Termination by Either Party. In case of 10.42(b)(6)(0). material breach of the teams of this Agreement, either party may terminate the Agreement with at VL2.2 Termination by ROCKPORT. A Member least ninety (90) days prior written notice to the Provider shall automatically be tezmiaated on the other party;however,the party in breach may cure date when:(i)Member Provider's license in the State the breach within sixty (60) days of the notice, in wIxte services are rendered is suspended or revolted, which case,the Agrees " and applicable rates and (ii)Member provider is excluded from participation terms shall continue in effect. Either patty may in the Medicaid.or Medicare programs,(iii)Member terminate this Agreement without cause upon ninety Provider losses their JCAHO, NCQA, AAAHC, (90)days prior written notice. URAC, CMA. or other applicable license, certitication and/or accreditation, (iv) Member V1.2.5 Unforeseen Events. In the event that tither Provider loses or experience a material reduction in part-/s ability to peirfonn their obligations under this liability insurance and such insurance falls below the Agreement is substantially interrupted by war, fire, requiren=s of State Law (v) Member Provider insurrection,riots, the elements, sarthqualro, acts of engages in any act omission, demeanor or conduct 04 or other similar circumstances beyond the that is reasonably Iikely to be detrimental to patient reasonable control of such party,the party shall be safety or to the delivery of quality patient care,or to relieved of those obligations for the duration of the lead to the provision of healthcare services below inteauptionupon notice to the other party. In the apglioable standards, or (vi) ninety (90) days event that the interruption is reasonably determined following written notice by ROCKPORT of a likely to persist far at least ninety(90) days, either material default or breach by Member Provider party may terminate this Agreement upon thurty(30) hereunder and the failure of Member Provider to days prior written notice. cure such default or breach within sbtty(60)days of the notice (vii) Member Provider fails to meet 'VI.3 Effiots of Termination. Ylpon termination of ROCKPORT's ar the State's credenfialing this Agreemen%neither party shall have any further requirements. ROCKPORT. however, may not obligation hereunder except for (t) obligations terminate this Agreement in direct response to accruing prior to the date of termination,including Physician filing a reasonable complaint,on behalf of without limitation, any obligation by Member a Qualified Participant against, or appealed a Provider to continue to provide healthcare services decision of, the network, or requested to Qualified Participants, and (ii) obligations, reconsideration or independent review of an adverse promises or covenants contained herein which we decision. expressly made to extend beyond the term of this Agreement. In the event ROCKPORT deems it necessary to terminate Member Provider's agreement based on VL4 Qualified Partied ant and Pater Notification.If the above requirements ROCF20RT will notify applicable,upon the termination of this Agreement, Member Provider at least ninety(90)days before the by tither party, Member Provider shall cooperate effective date of termination. with ROCKPORT to notify Qualified Participauts and Payors of such termination- Upon written notification from ROCKPORT, Member Provider may request a review by 'VII.CONTINUATION OF BXNXFM ROCKPORT's advisory review panel,not later than thirty (30) days after uo=ation. ROCKPORT VII.1 Continuation of Benefits. If Member Provider most then complete the review before the effective voluntarily tem bates its contract with date of tmuination. ROCKPORT, upon Member Provider's request, Payor must continue to reimburse Member Provider V1.2.3 Termination for Insolyen This Agreernwt for a period not to =reed 90 days at the Member shall terminate immediately in the event that either Provider's contracted rate set forth in Exhibit E of ROCKPORT or Member Provider volumitarily or this A reeraent with ROCKPORT, for care of an involunteriiy, liquidates, dissolves or becomes Qualified Participant with a life-Aweatering Page S of 15 EM N,UP 3-9-19 RCNFAC TX 062016 a Mar. 15. 2011 2:34PM No. 2025 P. 9 i condition or an acute condition, for which Agreement,and in particular the pricing information discontinuing or disruption of care would hast the herein. Qualified participant as per 28 TAC 10.42(b)(5)(A). Any disputes concerning continuity of care shall be IX- 11 MSC XLLA,NEOXJS resolved through the complaint process under Insurance Code §1305.401 - §1305.405 and 1X.1 DisM All disputes and difference between Subehaptw G of Iltle 28, Part 1 (relating to the Member Provider and.RfJCIi3'ORT upon whiiah Complaints). an amicable nndetstanding dannot be readied are to be derided by the following method: VIL2 Survival. The provisions of this Article VII shall survive the termination of this Agreement IX.1.1 Mediation through ROCKpORT. The regardless of the cause - giving rise to such Member Provider shall notify ROCKPORT in termination, as will sections M9, V.2, V.3, V13, writing of tht dispute or disagreement and shall VitlT. and lam. The provisions of this Article VII provide all necessary information to ROCKPORT. supersede any oral or written agreement to the ROCKPORT shall use hest efforts to mediate the contrary now existing or hereaft entered into dispute within the rules and regulations put forth by between Member Provider and any Qualified the State as referenco is ROCKPORT's Provider Participant or any person acting on it Qualified Handbook. Participant's behalf IX.12 Arbitration If the dispute cannot be Solved VM. CONFitDFMIALITY by the mediation process described above,either the Member Provider, ROCKPORT or Payor may elect All business, medical and other records relating to to subunit the disputa to binding arbitration under the the operation of ROCKPORT or Member Ptovidet, rules of the American Arbitration Association or any including but not hi3nited to, books of aocount, other method of arbitration,=Wally agreed upon by general administrative records, policies and the parties. Arbitration will be conducted m procedures, pricing idmination, teams of this Houston,Texas. P4ioh party will be responsible for Agreement and all information generated and/or their own legal fees. The cost of the arbitration contained in management information systems services will bb the solo imponsibility of the party owned by or pertaining to ROCKPORT or Member requesting the arbitration. Provider, and all aystnms, manuals, computer software and other materials,but each ung patient IX.1.3 Provider AMMIg.Except for termivadoxu due chats, sball be and remain the sole property of to contract expiration, Member Provider has the ROCKPORT or Member Provider respectively rigbt to appeal hm&w termination from the Natwodl, (collectively, the -0nifidential Information-). as follows: ROCKPORT and Member Provider acknowledges that the Confidential Information and all other. IX.1.3.1 ROCKPORT will provide notice to the information regarding ROCKPORT or Member Member Provider at least 90 days before tlic Provider that is competitively sensitive is the effective date of a tenrnination by ROCKPORT; property of R0C1G'ORT or Member Provider and ROCKPORT or Member Provider may be damaged M1.3.2 Upon receipt of the written nodfication of -if such information was revealed to a third parry. termination, a Member provider may request in Accordingly, ROCKPORT and Member Provider writing a review by the Network's advisory review agreecs to keep strictly confidential and to hold in pail no later than 30 days after receipt of the trust all Confidential.Infomnation.Upon termination notification; of this Agreement by either party fbr any reason whatsoever, ROCKPORT and Member Provider IX.l-3.3 The Network will provide as advisory shall promptly return to the other all rnate:ial review panel that consists of at least three Providers constituting Confidential lnformatim or oc staining of the sante licensure and the same or similar Confidc+atial Information,and neidier party will not specialty as the Member Provider, thereafter use, approprfatq or reproduce such information or disclose such information to any third 17(.1.3.4 The Network must complete the advisory party. ROCKPORT and Member Provider panel review before the effbative date of the specifically agrees that under no circumstances wih termination; either party discuss ruse terms and conditions of this hV9of15 Birt N;T 72 9.9-17 RCNFAG TA 062016 Mar 15, 20'7 2 35PM No, 2025 P. 10 IX,1.3.5 The Client,Payor,or ROCKPORT may not 11625, or any applicable rule or regulation notify patients of the ttrmination until the earlier of promulgated pursuant to any such law's or orders_ the effective date of the termination or the date the 11rovider Member repxcseaats and warrants that they advisory review panel makes a formal will use best efforts to inform any independent recommendation; contractor or oub-eontraotor to ensure that its employees abide by the terms and conditions in the 1X.1.3.6 I£MemberProvidar terminates the contract, Agreement. the Network or ROCIeORT's Client will provide notification of the tenarination to employees 1X.6 Qovernipg Law. This Agretmtat shall be receiving care fram the terminating provide. The governed by and o trued in accordance with Network shall give such notice immediately upon applicable state law. receipt of the Member Ptovider's %Tmination request or as soon as reasonably possible before the DC.7 Amendments. This Agreement may be effectivie date of termination. amended as agreed to by bolh parties in writing upon thirty {30} days written notice of such proposed IX.2 Non-Exclusivity Nothing in this Agreement amendment. shall be construed to restrict Member Provider or ROCKPORT from entering into other contracts or Ix.8 Severability. The invalidity or un- agreements to provide healthcare services to Pay= enforceability of any term or condition hereof shall or other healthcare delivery plans, patients, and in no way affect the validity or enforceability of any employer groups. other term or proviaica. 1X.3 Entine Agreement. This Agromnont contains IX-9 Assignment. Member Provider may not assign the entire understanding of the parties and or otherwise transfer ezry'right or delegate any duty supersedes any prior understandings and agree rients, of performance hereunder, in whole or in part written or oral, respecting the subjects discussed withow tho prior written consent of ROCKPORT. A ,herein, change in ownership will not negate the prior contractural agreeruent witbaut writtennotification to 1X.4 No'Waiver. no waiver by either party of a ROCKPORT. ROCIC ORT retains the right to breach or violation, of any provision of thia assign this Agreemout, in whole or in part, to any Agreement shall not operate as or be construed to be entity with which ROCKPORT or its parent a waiver of any subsequent breach:hereof. company or any of its subsidiaries is affiliated, or with which it merges or consolidates. 1X 5 Regulate+ Compliance. Member Provider, sub-contracting providers, and ROCKPORT agree IX.10 Third Party Beneficiaries. )accept for Payors that each shall comply with all applicable and the agents thereof there are no third party requirements of municipal,county,state and federal beneficiaries of this Agreement. autho itim, all municipal and county ordinances and regulations, and all applicable state and federal IX.11 QQtions. The captious and headings statuttc and regulations, now or hereafter in force contained in this Agreemcxmt are for reference and effect, governing ROC"ORT, Member purposes only and shall not affect in anyway the Provides,sub-contracting providers,the provision of meaning or interpretation of this Ag£eemeut. services by Member Provider or sub-contracting providers,and/or Payors,including but not limited to 1X.12 Execution of CThis Agreement applicable requirements under any state or *doral may be executed in any number of counterparts, fair employment practices, equal employment including facsimiles,each of which shall be deemed opportaal%or similar laws declaring discrimination to be an original as against any part whose signature in employment based upon race, color, creed, appears thereon, and all of which shall together religion,sex,or national origin as illegal,aud,Ticks oonstitute one and the same instrument- VI nstrumentVI and VII of the Civil Rights Act of 1964, Section 202 of Executive Order 11246 as amended by IX-13 Partial Invalidity. If any part, clause or Executivo Order 11375,Sections 503 and 504 or$me provision of this Agreement is held to be void by a Rehabilitation Act of 1973 and Title IV of the court of competent jurisdiction, idle remaining 'Vidnam Era Veterans Readjuatmeot Assistance Act provisions of this Agreement shall not be affected of 1974, and Sections l and 3 of Executive Order andshall be given construction. if possible, as to Page 10 oY15 131ELIV,UP3-9-17 AL"tEAC TY 062016 permit it to Campy with the minim7mt requitomenls IX.17 Offmial Notices Agy notice or Of 54Y applicable law, atd the intent of ptrtias c=mudoa+on•rupked,pewaNed or desued to be hereto. given hereunder'shah be dein ied eftctivdy given t when personally delivered or meed,return reoedpt i M14 PFgsncisl Ineentiyas,,Neitber u Client,Payor, vagassted, or ovemigltt express man addressed as � nor ROWORT may use f1moial incenfte or follows: i make a payment to a.health rare provider that acts dhwtly or indirwfy as an Inducement to Iimit Member Provider oxRep�a�tiv�lDesl�ae: medloolly necessary services. The adoption of (PlaW PrW) treatment and rMcn-to-work $uidelinve and Individual treatment mt000ls by ROCK?OR.T or lame; ]AM JV. LLP diVa Bmyor info fat Network is not in violation of this station as Itahhabilitatkno9Serviaos i pursasat to Insmmce, Code 1130. 304 and •, §10,83(a)of OV 10 ofTitle 28 Pad 1. Organization: j IX,15 ii'iir anoial bisolosare Ra arnants. E otT2 gym: 411 Worth Wsshiuctam A_vc.Ste,i 160 patties agree Member Provider is a facility or c tolsts of AolItiies and fbstefore M=ber providct CiVSlaWZIyt Was,TX75246 is not regnirad to file financial disoloamm in accardar= with Labor Code $140&0Z and Telephone:21"18-2540 H4I3,041, r7 t p Fax: DL16 Economia BroBlina: N'etw'odc=Wt provide wdttm wdoe to Member Provider before the Aletwmk conducts economic pmfilb*, 3ucluditig utllixetion managomerA studies or other profiling of pi on: the provider or group afproviders. WOICoxnp Nfanaged Care Servioes,Ino. One Uger Pond Ad.,Bldg,F,4s'Moor Parsippny,N'ew Jersey 07054 c Attn:Miohaol Kraig C,enwal Counsel,SVP or to such other address,and to the atWian of such. i YN'94nWUS WBEREOF,the uaftsimd,w!be other parson(s) of offim(a) es either party may deemed to have axecated this Agreement as of-&e designate by writinanotice. date the provider is fully aredardaled by ROCXPORT. For And an behalf of: For and an behalf oL hlemb&11rovid0r or Roprese-ntstivelY}esi$n Rockport Community Network,I=. Signature; Old I3ickozy$lvd.Ste.3Q0 Nanus: A fe'tL/ , ,i e Bre, WO \7b 3 7,W ) Oval) - - -- - P TIN.. [Dongla orkhama f. I Presldctr� ' -2 tat 7 ' Paea rl oC25 , B�N,z��-17 RQ�AC_'L7�a62Q1B • Y t t Mar. 15. 2017 2:35PM No. 2025 P. 12 EY'f A STANDARDS AND GULDALINICS 'UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS ROCKPORT and its Clients requiro Member Providers to follow naturally recognized treatment guidelines(i.e. Official Disability t:uldellnos(ODG) and/or Amcricsa Occupational and Favironmental Medicln&s (ACOEM) guidelines)in the treatment of work-rotated injuueshllnesseg for Qualified Participants. ROCKPORT's Clients provide utilization review and quality improvement programs for Qnellfisd Participates. ROCKPORT shall review each Clients Utilization Review and Quality Improvemant Program m accordance with ROCXPOR1% Credmrialing Standards and Guidelines as dcsonbcd 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 ofthe Utillzation Review Programs shall be to: 1) Ensure and cektify 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) Enure that healthcare services are provided at the appropriate level of care;and 3) Ensure that healthcare services follow,nationally recognized treatment guidelines that are cvideneod baled and outcome-focused. Treatments and Services that Require Preauthorization;unless othwwise specified by Etre netw(rk: 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 008.026; 4) All psychological testing and psychotherapy.repeat itervie ws, and biofacdbacic; except when any aervioe is part of a preauthorized or excrVt rehabilitation program: 5) All external and implantable bone growth stimulators: 6) All chemonucleolysis; 7) All myelograms,disenrarns,or surface electromyograms; S) Unless Aerwise specified„repeat individual diagnostic study,with a fee established in the current Medical Fee Guideline of greaw than 5350 or documentation ofprocedure(DOP); 9) Work hardening and work conditioning services provided in a facility that has not be®approved for exemption by the Division; 10) Rehabilitation programs to include (a) outpatient medical rehabilitation and(b) chronic pain management I imerdasciplinary pain rehabilitation; 11) All durable medical equipment(DME) in excess of 5500 per item(either purchm.or expected dumulative rental)and all transcutaneous electrical nerve stimulator(TENS)units; 12) Nursing home,convalescent,residential,and all home health care services and troatments; 13) Chemical dependency or weigh[loss programs; 14) Any iuvestisational or experimental service os'device for which there is early,developing scientific or clinical evidence demons Wng the potential eVicacy of the treatment sarvioe, or device but that is not yet broadly accepted as the prevailing standard of care;and 15) Physical and ooaupatimW therapy services;(a)physical and occupational therapy services are thoso listed in the Healthcare Common Procedure Coding System, (HCPCS) Level I code range for Physical Medicine and Rehabilitation, but limited to: (1) modalities, bol, supervised and constant attendance; (ii) therapeutic procedures,excluding work hardening and wo&conditioning;and(iii)other procedures,limited to the unlisted physical medicine and rehabilitation procedtae code. 16) Closed Formulary Drugs,as defatted by 28 TAC Chapter 134,Subchapter F. NOTE: Proauthorization 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(H)a surgical intervention previously approved by the payor_ Page 12 of 15 Bet YV,LLP 34,17 PJMVAC 10Q062016 r � I ' E1T B � Retmbursemelat Schedule L Rockport CommunityNetwork Fmvldar flea for the pxograms listed above shall be tehnbursed at the falluaving; All fees will be reimburse4 at,9S% (l+lhtety nve PtrCt o<t) of the state's MV00 '94"a*e1•s' Compeasatlott*es,rules and regulations or usual and customary eltovables. Caveragm Coverage for all procedures on the fee aohodule is subjeot to the ta=and conditions of t111S A.graamaut;st4o roles and.reguhdohs anNar the applicable Oaeupai coral l4my or Illness Benefit Plsn. ' I Ma narept the fees as outlined in th}s Exhibit B. Per and on behalf oh Iror and on behalf of; (Komtraddresa,etc.) t ROCRPOPT CO3EWUMr Y NETWOIK INC, BIR W.LLP We Baylor Ynsi inti for •` "abilitation--Outpatient Services - 761.Old HickoxyBlvd,Ste.300 411 North-'9VnhLagtonAve.Ste.3100 s x a o'od,TN 37027 ]Dallas,TX 73246 Signaticre _ Donglasa.kgr4m Muted$4m*7V &Lw�te�r IsWjftt Title r� Dme 1 7 L901Z TW 27-4$86141,20-9i1771f72 Rafe S" a31c7Y,LC�]9 i7 page�s oti5 ACMAC T)LO62016 e I I FooMfles ar:dler locatlouA vvhera w vide aro to be re Owed by Member Provider 'Cho Monber Provider ngreer that the fo&vring hanky]veatlons eadlar pre edea locatlom fisted an►ttmched LdAbit Cy sl►nll be indusive of the signed agreement and the signed ratan In kAlbit B.ly siguhxg bdaw Member Pro Mw olr its 3tagte�entstivelAeetgnae AJIQYPA Rodgtvrf Gaxnnrunity Network(Roekpoirt)�ftarerpk¢senta to uoaAiayaue] All otthe bolowinformailan os mgn4 to hs the elgnsd mmement. OR F (1) VuZhyll'sme(2 ftylloleil Name(if appllCable) Phrysiaion luno(if applioab s) PhysioalAftew Apiad Address M16 Stab 23p may,Stab Ztp Mailing Address(if diffe w* Meiling Address(if diffwe* Phone Number lFaxNumber PbansNambar/N�axllumber Tax ID Namber Tbx]D WuMW ' PadllkyNataa(3) Fodlk Wme,(4) ' Fa MdsutName(ifOplisable) PhysemNasae(if awliome) Physical Address Phyxloal.A tris Qty,Sim Zip City,Siete zip Muffing Address(if diibretlt) MallingAddrew(if dii3 v4 Phone Number/Fax Mmnber Phone Number/Feoc Niunbe"r TW IDKimber TAX ID Nualber For and on behalf of-, For and o>«belealf of: Ro deport Commaolty Network,Inc. f'7a old Hickory Blvd Ste 300 Member Providw or Repreeent9tiveMe stpee • oad,TN3'7QZ7j j�lou lcham] (pxl� nate: . / 2-O I Z-S� l i 'al<cN LL139-17 14 Otis gg�C "J�060016 Mar. 15. 2017 2:36PM No, 2025 P. 15 FIrT n Workers'Compensation Networks(WCN) Rockport may make this provider agreement available to other networks through delegation. As defined within the FaclIlty/Ancillary Provider agreement,Mcniber Providers agree to provide treatment for bijured employees who obtain workers'cobapeusetlon health csre service through the aetwotrks. The named networks are listed below: • [Rockport CommunftyNetwork] • [Wellcomp Managed Care Services,Inc.,Plan Name:CompRey plus] • [Broadspire HCN] I S P agal5of IS R-v06120/i6 RI NFA( V 06x016 { l i i Farm WM9 Request for Taxpayer Give t=ort to the May,Oecember2014) identification Number and Certification send to tthe R3.IRS, d�t o�rwswy s I 1 Name(as"%Yn on your Income lax raturn).Names Ss requ:f4d on 1•ils rna;du"t leavI this:(ne Wank. SIR A LLP 4 2 Business name/disregarded entity name,if dmerant from above Baylor Institute for Rehabilitation !i 3 Check appropriate box kw fadorral tax Wasolfloation;check only one of the folloWing seven boxes: !4 t°rer ,t'ana(,;Q:34 apply only to QladtWdtroitsobproprietor or 0Caporstiwt ❑8Corporation © Partnership ❑Truevestata 1ce:ElRFr.u!:e n.11ndhlduela;see i $Wlmrnembu LLC a rur.b:ne an pave 3): ]United liability company.Enter(he lox Maesatbn(0.0 corpordion,8.8 owpoiallm Papadwship)► p -.:r:,y;,.;;as cr o(!o hy) lfk b Mote.For a sin *~borLLO that Is dbmgarded,do not check 110;check the appropriate box in the one above bear —r " "° reporting the lex alaselfioagon of On skrgla-member omIar, *ode P AiM [�Other(seelaattuoflan�Y � ,aaaauraeeM�xaaenwwtee� I 6 Address(number,street,and apt or suite no,) Requcsler's rn;a ani a s3reas(optlo"l) PO Box 677486 df 8 My,slate,aid ZIP code Dallas,TX 76267-1466 7 tial account numbu(s)here(optlonaq Taxpaar ldent)floation Number IN EnIor your TIN In the appropriate box.The TIN provided must match the name given on line Ito avoid LScolol snowily number � up alien,sole For Individuals,f die ega Is generally see the security number(SSM.Flo•.�svar, � —W resident alien,sole proprietor,or disregarded entity,leo the Part I Instructions on page 3.far od;o• W • entities,it is your employer Identilloallon number(EIN).It you do not have a number,see No,v+0 flat TIN on page S. or Nota,If the account is In more then one name,sae Ute)astructlons for line 1 and the ehmi on page 4 for Employor idontilloallon number gukfollneb on whose ntantw to enter. 7 2 — A 6 8 6 { 411 I 11731 ,M1 Certification Under penalties of perjury,I certi(y that; 1.The number shown on this form 13 my correct taxpayer IdertIlWon number(or I am walling for a number to be Issued to me)(and 2. 1 am not subject to backup wIftelcMg beoause:(a)I am elampt from backup withholding,or(b)I have riot been notified by the Internal Revenue Servtoo pHs)that I am subject to backup withholding as a result of a future to report e(linterest ar dividends,of(a)the iRS has no1{Sad me that I am no longer sub(eot to backup withholding;and 3. 1 am a U.S.citizen or other U.S.person(dolled betowk and 4.The FATCA oode(s)entered on We form of any)ladteating that I am exempt from FATCA reporting is correot. Certification hhalruations.You must cross out item 2 above if you have been noWled by the iRS that you are currently subject to backup withholding i bac ause you have fated to report at Interest and dividends on your tax return.For real estate transactions,item 2 does not appy,For mortgage Inlaras i paid,acquisition or abandonment of secured property,cancellation of debt,contributions to at Individual reUrement arrangement SHA),and g eneralty,payme,it.other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the Instrucllons on page�. Sign &Igralure at ('{Br0 11,9.rwrao-n� filiGl l/ Date)- General ata►General Instructions ►Farm 1068(homemcrlp gsrfidereatj,1098-E(aludemloan htaresq,10-98-T a41111101a Section references are to Vw intsmal Revenve Oode unless otherwise noted. e Form 10880(canceled deb) Fulare devslapments.Information about developmentsaffeadn9 Form W-9 touch •Form 1099-A(acquisition oraben ionment of secured proper" as legbloWn enaotad aherwe rolsaee N Is at wwwJmI;ovA W. Use Form W-4 oatq Ityou are 6U.S,person(ittoiddhhg a reaidant chert,to Purpose of Form provide Yom oormotTIN. An individual or onlity(Form w-9 requester)who Is roqulred to filo an Information Nyoudomot retum form W-9 to fine mQuasfaravB,a TIN,you m*hf As subject I rclumwlth the iAS must obtain your correct taxpayer Identificogon number trlN) to baekrp n9lmmotdkrp.8w Marrs backup wllhhofdW 40 POW&2. wnichmayybeyour social security number(98M.IndWldualtaxpayer iden0ficallon Byskpftthe ftledoutform,you: number 911Pq,adoption taxpayer Idantilhxt{on number(MN),or employer i,Certify that the TIN you are 9lving Is correct(eryou are waWng for a number Identification number JEINJ,to toporl art an Inlormatidn return the amount pild to to betssuee you,or other amount reportable on an informallon return.Exam pies of Information returns Include,but are not limited to,the fdlowing: 2.Cattily thatyou are not subject to backup Withholding,or r form 10WINT pnterest earned of paid) S.Ctalm exempton ream backup withholding If you are a U.S.exempt payee-it •Form 109"IV(dMdends,Including those I rom alecks or mutu st fonds) any pp erms incoMo me Iroehm a U.S.trade or business Is note ubblj�o the are of •Form 1099-MISO(various types of blooms,prime,sward,,or gross,proceeds) wuhlhordiag tax an taelpn psrinm,atmns of effectively connected income,and I •Form 1099-B(tisk arms"fund seas and cardslc otter Irsnsac0ces by 4.ibr9fy that FATCA ccde(s)entered an this form(11 any)indicating that you vs, brokers) exempt Irom Iho FATCA repwllng,is cared.Sao N1rat is FATCArsporttngP on Form 10109-4S tprocaeds from real estate transactions) pepe2 brfurtur iniormetlon. r r Form t069-K(marahonb card and Rmld party network tronesetiont) Qat.No.10231X FonrmW9 lav 1¢-1014) :M&C-Review Page 1 of 3 Official site of the City of Fort Worth,Texas CITY COUNCIL AGENDA Foe+W� COUNCIL ACTION: Approved on 8/25/2015 DATE: 8/25/2015 REFERENCE NO.: C-27435 LOG NAME: 14YORK2015 CODE: C TYPE: NON-CONSENT PUBLIC NO HEARING: SUBJECT: Authorize Execution of an Agreement with York Risk Services Group, Inc.,for the Administration of the Workers'Compensation Program in an Amount of$1,414,420.00 for the First Year(ALL COUNCIL DISTRICTS) RECOMMENDATION: It is recommended that the City Council authorize the City Manager to execute an Agreement with York Risk Services Group, Inc., in the amount of$1,414,420.00 for the first year with a three-year initial term and two one-year renewal options for the administration of the City of Fort Worth's Workers' Compensation Program including claims administration, medical cost containment services and health care network. DISCUSSION: The City of Fort Worth currently contracts with CorVel Enterprise Comp, Inc., to provide workers' compensation claims adjusting, claims administration, medical cost containment, safety and loss control services. The third year of a three-year Professional Services Agreement with CorVel will expire December 31, 2015. CorVel has been notified that the City will exercise its option to terminate services early on October 31, 2015 with the commencement of the new vendor contract described below On June 3, 2015, a Request for Proposals (RFP)was issued requesting that interested vendors submit proposals by July 2, 2015. This RFP was advertised in the Fort Worth Star-Telegram each Wednesday from June 3, 2015 through July 1, 2015. The RFP was designed to solicit proposals on: (1)third party claims administration services for a self-funded workers' compensation program (including payment and adjusting, claim investigations, subrogation, establishing reserves, defense of denied claims), (2) medical cost containment services (including medical bill review, utilization review, preauthorization,telephonic and field case management, vocational case management), (3) 504 workers' compensation health care network program (including program administration, health care provider credentialing) (4)safety and loss control services, (5) serving as Austin representative for the City at the Texas Department of Insurance and the Texas Workforce Commission, (6) Medicare and Medicaid reporting for worker's compensation, (7) document scanning and indexing and (8) other miscellaneous claims-related services. The City received 10 competitive proposals in response to the RFP. Proposals were thoroughly evaluated by a committee comprised of representatives from the Human Resources, Water and Transportation &Public Works Departments and representatives from the Fort Worth Police Association and Fire Association Local 440. The Committee considered several factors in evaluating proposals, including price competitiveness, an organization's ability to administer the workers' compensation program, qualifications of each organization's staff, M/WBE participation and quality of service. The Committee agreed to recommend that York be awarded the contract based upon York's proposal representing the best combination of low/competitive pricing, experience and quality of services to provide the best services to the City. Overall, the expected total fixed administrative costs in the amount of$1,414,420.00 for York are within the requested proposed budget for Fiscal Year 2016. http://apps.cfwnet.org/council_packet/mc review.asp?ID=21392&councildate=8/25/2015 8/26/2015 'M&C Review Page 2 of 3 Staff recommends the contract be awarded to York Risk Services Group, Inc. (York), for an annual contract cost of$1,414,420.00 for the first year. Contract cost will not exceed $1,437,217.00 in Fiscal Year 2017 and$1,457,634.00 in Fiscal Year 2018. The City Manager's budget proposal for Fiscal Year 2015-2016 will include a recommendation to fund this contract through September 2016. Authority for the remaining fiscal years that are encompassed by the Agreement will be requested annually as part of the overall budget process and the contract will include a standard fiscal funding out clause that would comply with state law requirements by allowing the City to terminate the Agreement without penalty, if in the future, the City Council elects not to appropriate funds for services covered by this Mayor and Council Communication. While this is about a 23 percent increase in administration cost for the Workers' Compensation Program, services and quality are greatly enhanced with seven exclusively dedicated staff from York for the City of Fort Worth's Program (four on-site Indemnity Adjusters and one on-site Claims Associate, one Unit Manager and one Medical Only Adjuster located in York's Fort Worth office). The increase also includes the development and administration of a customized 504 health provider network. In 2005, the 79th Texas Legislature passed House Bill (HB)7,which authorized the use of workers' compensation health care networks certified by the Texas Department of Insurance (Department)for political subdivisions. HB 7 also added Section 504.053 which authorized political subdivisions to contract directly with health care providers for the provision of medical benefits, treatment and care for its injured employees. The York proposal includes establishment of such a direct contract"504 health care network"for City of Fort Worth employees. This 504 health care network will be customized to provide treating and referral doctors and other health care providers to meet the specific needs and requirements of the City. M/WBE OFFICE-A waiver of the goal for MBE/SBE subcontracting requirements was requested by the Purchasing Division and approved by the M/WBE Office, in accordance with the BDE Ordinance, because the purchase of goods or services is from sources where subcontracting or supplier opportunities are negligible. TERMS AND RENEWALS-On City Council approval, services under this contract will commence on November 1, 2015 for a three-year initial term. The Agreement may be renewed for two one-year terms at the City's option. This action does not require specific City Council approval, provided that the City Council has appropriated sufficient funds to satisfy obligations during the renewal term. l FISCAL INFORMATION/CERTIFICATION: The Financial Management Services Director certifies that funds will be included in the City Manager's proposed budget for Fiscal Years 2015-2016.for the Workers' Compensation Fund. Upon approval of the above recommendations and upon the adoption of the Fiscal Year 2015-2016 Budget by the City Council to include the above recommendations, funds will be available in the Fiscal Year 2016 operating budget, as appropriated. Prior to expenditure being made, the Workers' Compensation Fund has the responsibility to validate the availability of funds. Funding for the FY2017 and FY2018 will be contingent upon approval of funding in the FY2017 and FY2018 adopted budgets for the Workers' Compensation Fund. TO Fund/Account/Centers FROM Fund/Account/Centers 60111 5310101 0147310 $1.096.029.00 60111 5330201 0147310 $200.522.63 Submitted for City Manager's Office by: Susan Alanis (8180) Originating Department Head: Brian Dickerson (7783) Additional Information Contact: Margaret Wise(8058) http://apps.cfwnet.org/council_packet/mc review.asp?ID=21392&councildate=8/25/2015 8/26/2015