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HomeMy WebLinkAboutContract 49926 CITY SECRETARY CONTRACT NO. Letter of Intent This Letter of Intent (LOI) is entered into by and among LIT Southwestern Accountable Care Network d/b/a Southwestern Health Resources Accountable Care Network, a Texas non-profit corporation (herein after individually and collectively referred to as "Network"), and City of Fort Worth ("Employer"). The purpose of this LOI is to set forth an understanding between Network and Employer with respect to Employer's Health Benefit Plan Program. 1. This LOl may be terminated at any time by either party upon written notice to the other party. The provisions of paragraphs 2 through 3 shall remain in full force and effect. 2. This LOI is solely for the benefit of the parties hereto and will not be construed to give rise to or create any liability or obligation to, or to afford any claim or cause of action to, any other person or entity. This LOI will be superseded in its entirety by the provisions of a definitive written agreement upon execution of said agreement no later than 45 days from execution of the LOI. 3. This LOI and the information contained in this LOI shall be deemed confidential and proprietary and shall not be disclosed to third parties. 4. During the 45 day period referred to above, Employer shall work exclusively with Network and shall refrain from initiating or participating in any negotiations or discussions with any person or persons not a party to this LOI regarding the establishment, ownership or operation of a clinic health care program for Employer. Definitions Health Center Plan members means those members who choose the Health Center Plan option, which provides benefit differential enhancements versus other plan offerings. Health Center means one of the three dedicated work site clinics to be built with one opening on January 1 2018 and two opening no later than April 1, 2018 and operated by the Network. HSA Members means those members that selected the health saving account plan. Primary Care Services means those services described in Appendix D. Satellite Clinic means one of the five primary care medical homes configured to serve the City of Fort Worth employee population. ASO means any carrier chosen by Employer to administer health plan benefits. Purpose This LOI sets forth the key components that would be memorialized in a definitive agreement between the Parties. Network is designed to improve quality, reduce inefficiencies, and achieve savings on total cost of care through better overall results— and ultimately, redefine health care. Appendix A outlines the proposal in its entirety. Network and Employer will work in good faith to achieve the outcome and deliverables outlined below. • Clinics - Network shall provide Primary Care Services to Health Center Plan ?Su�NEo members at three dedicated Health Centers and SUnnlemented with access at 5 patient-centered medical home satellite clin aZM Zlr'3ccess for CCC`idFFpkl�Vv �a OFFICIAL RECORD CITY SECRETARY tea. 9 V �ti FT.WORTH,TX member/employees and dependents. The locations for all Health Centers and Satellite Clinics will be mutually agreed to by the parties. • Each Health Center will be in operation for a minimum of 40 hours a week (except for standard city holidays) staffed with at least 1 physician and 1 physician extender. • The Employer's total Health Center and Satellite Clinic fee (collectively herein termed as "Clinic Fee") for 3 Health Centers and 5 Satellite Clinics for Year 1 is $2.5 million. The Clinic Fee will increase by 3% each year in years 2 and 3 assuming configuration remains at 3 Health Centers and 5 Satellite Clinics with each Health Center staffed as described above. • The Clinic Fee is based on an assumption of 70% of Employer's membership selecting the Health Center Plan ("Health Center Plan Members"). • For Health Center Plan Members who access the Health Centers and/or Satellite Clinics for Primary Care Services there will be no out of pocket cost to the Health Center Plan Member and, other than the Clinic Fee, there will be no cost to the Employer for those services outlined in the definitive agreement. • HSA Members shall have access to the Health Centers and/or Satellite Clinics for physicals and medical visits. There will be no out of pocket fees for HSA Members who access the Health Centers and/or Satellite Clinics for annual physicals, including associated blood work as listed in Appendix D, and a $60 HSA Member responsibility for other medical visits. Other than the Clinic Fee, there will be no cost to the Employer for HSA Members' annual physicals, including associated blood work as listed in Appendix D at the Health Centers and/or Satellite Clinics. • Employer and Network will agree to reallocate staff or increase incremental Clinic Fees in the event that utilization exceeds a 70% utilization expectation in the 8 clinics. The 3 Health Centers are specifically designed and located to be convenient clinic destinations for Employer's members. The 5 Satellite Clinics are intended to operate as back-up for overflow. The Network and the Employer will develop utilization guidelines that ensure that intent. ■ Clinic utilization data will be reviewed in October of each year, and if utilization of the Satellite Clinics exceeds 20%, the Network reserves the right to re-allocate staff or increase incremental Clinic Fees. • The locations of the Health Centers and Satellite Clinics will be determined in collaboration with Employer based on geographical access and utilization needs. Downtown Fort Worth, SW Fort Worth/Burleson and Alliance have been identified as the highest priorities for the Health Centers. • Network will ensure additional sufficient staffing at the dedicated Health Centers to provide same-day or next-day appointments for episodic, acute care (treatment of illness or injury that is not preventive or emergency care). • Population health management services - Network is redefining health care shaped by cutting-edge population health services. Using data and direct support to improve clinical care, Network is helping Network providers with their clinical decisions with their patients. The impact is wide-ranging — from avoiding duplicative testing, guidance for appropriate level of care and diagnostic procedures to determine possible gaps in care. For patients, these services include support to navigate the care they need, as well as tools to help them stay healthier • Network guarantees a minimum 4.25% medical cost savings on attributed (per United Healthcare ACO methodology) Health Center Plan 2018 risk/benefit population adjusted cost trend for Year 1 as measured using the UHC ACO savings algorithm. The downside algorithm for the Network is illustrated in Appendix B and further defined in Appendix A. The algorithm 2 can result in guarantee payments from Network to Employer or shared savings payments from Employer to Network. • In order to generate utilization management savings, provide high quality care and offer an enhanced member experience, Network offers population health management and account management services including quarterly executive meetings to share reports and discuss strategies for improvement. • Population health services other than Primary Care Services will continue to be separately funded by Employer through the existing ASO or another ASO arrangement. (The City of Fort Worth will continue its participation in the United Healthcare ACO including payment of Care Coordination Fees.) Future trend guarantees-- for Health Center Plan Members in Years 2 through 5 will be agreed to between Employer and Network. The trend will index to the Standard and Poors (S & P) commercial ASO medical component for North Texas. • Facility network. Network offers Employer a savings plan with minimal disruption to the Employer's members. • During Year 1 all services provided by or billed through those facilities identified in Appendix C (including any associated freestanding emergency room facilities associated with the listed facilities regardless of the address of such freestanding emergency room facilities) will be subject to a 20% discount from Network's U n ited Healthcare (UHC) 2018 contractual rate arrangement between UHC and Network. The 20% discount shall be applied evenly on all Texas Health Resources inpatient and outpatient services. Outpatient services include all emergency room, lab and imaging at Network facility locations. • Should the Employer decide at any time to change ASOs (from UHC to other), Network agrees to work with the new ASO to develop a rate schedule that results in a comparable reimbursement to Network, subject to new ASO capabilities and Network's agreement. • Employer has set its plan design for plan year 2018. This LOI and the Year 1 amounts and guarantees do not include changes in plan design. In order to minimize disruption, no changes will be made year one. Parties will work in good faith to develop beneficial plan design changes in years 2 and 3 that better align members with Network. • Network and Employer agree that facility rate yield will increase by 3% from year 1 discounted rate for each of Years 2 and 3 and the two parties will come to agreement for Years 4 and 5. • Agreement term The contract term will be for an initial three year term with an option to extend for an additional 2 years with mutual consent. Parties may meet and confer in good faith for modifications in years 4 and 5. Except in the case of non-appropriation, termination within the initial term shall require one year's prior written notice. Because Employer is a government entity and cannot legally bind its governing body beyond the current fiscal year, in the event Employer's City Council does not appropriate funds for this Agreement in Year 2 or 3, Employer may terminate this Agreement and pay a termination fee of six months of Clinic Fees to the Network. There shall be no termination fee if the anticipated Agreement is terminated for cause by Employer. All the terms contained within this LOI shall comply with state and federal laws. 3 Appendix SWHR Proposal to of • Worth 10/4/2017 Health Centers For Health Center Plan:3 dedicated Health Centers(Fort Worth,Huguley and Lake Worth)and 5 patient- centered medical home Satellite Clinics • No cost to Health Center Members:$60 clinic fee for HSA members and cost to the City of Fort Worth:$2.5M • Estimated savings:$2M in PCP services Plan Design Facility coinsurance benefit differentials will be implemented for Health Center and HSA plans in years 2&3 if navigation is insufficient to achieve 75%utilization of SWHR facility providers Utilization management for SWHR includes nurse navigation for specialist visits on the Health Center Pian • For 2019 and 2020,new budgets will be determined on savings opportunity Contract Length • City of Fort Worth agrees to a minimum 3 year commitment with an option to extend for 2 additional years by mutual consent of SWHR and City of Fort Worth(see 1-01) Requirements 24 months prior claims data required • Collaboration between all parties and transparency How will we achieve lower • Savings will be achieved through a unit cost decrease and superior population health and risk management claims cost? SWHR will furnish a Letter of Credit to ensure availability of funds to support guaranteed savings Provider Payments and Risk Share for Year 1 Unit Cost Concession 20%discount on Texas Heafth/Envision Increase based on the hospital TOD based on Y2 branded facilities component of the CPI data Utilization Savings 4-25%guaranteed savings from medical Guarantee the S&P medical cost TOD based on Y2 cost trend for employees that choose trend;4.25%savings for the new data the Health Plan Clinic benefit design enrollees Sharing of Additional 4.25-8%In savings:100%goes to CoFW TOD based on Year 1 data TOD based on Y2 Savings 8-12%in savings:50%goes to the CoFW data and 50%to SWHR >12%in savings:100%goes to SWHR 'This calculation is based on current data provided by Hulnces Murphy and city of Fort worth as of 8/211/2017; lRu vertion will be required Collectively. transparency between UHC.the City,Holmes Murphyand SWHR is required to establish benchrrairksand to quarrt8y(potential)additional savings.Utittation savings will be calculated using UHC ACO model. Private and Confidential Appendix B Texas Health Resources/City of Fort Worth Clinic Plan Utilization Saving Guarantee Illustration Member Months-Performance Period 135,000 135,000 135,000 135,000 135,000 135,000 Average Membership-Performance Period 11,250 11,250 11,250 11,250 11,250 11,250 ACO Baseline Allowed Claims(1) $ 500.00 $ L50.00 $ 650.00 $67,500,000 $20,250,000 $87,750,000 Normalized Market Trend(2) 4.0% 10.0% 5.4% 4.0% 10.01A 5.4% Target Claims $ 520.00 $ 165.00 $ 685.00 $70,200,000 $22,275,000 $92,475,000 ACO Trend(Assumed Performance) 2.0% 9.0% 3.6% 2.0% 9.0% 3.6% ACO Final Allowed Claims(1) $ 510.00 $ 163.50 $ 673.50 $68,850,000 $22,072,500 $90,922,500 Calculated UM Savings $ 10.00 $ 1.50 $ 1L50 $ 1,350,000 $ 202,500 $ 1,552,500 Guaranteed Med Savings @4.25% $ 2210 $ - $ 22.10 $ 2,983,500 $ $ 2,983,500 Guarantee Payment from THR to CoFW S 12.10 $ 1,633,500 Total UM+Guarantee Savings $ 2,983,500 (1)Excluded from allowed claims are claimants with charges>$15Q000 as well as out of network claims (2)Normalized Market Trend is risk and benefit change adjusted to match the acuity and benefits of the membership 6 Appendix C Southwestern Health Resources/City of Fort Worth(to be effective 1/1/2018) Network Facility Listing A. Hospitals and Long Term Acute Care Hospital Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number 1 Texas Health 800 W Randol Mill PO Box 910818 75-0972805 Hospital Arlington Memorial Road Dallas,TX 75391- Hospital Arlington,TX 76012 0818 817-960-61_00 817-960-6130 2 Texas Health 1301 Pennsylvania 500 East Border St. 75-1648589 Long Term Specialty Hospital Ave.4I^Floor Main #124 Acute Care Fort Worth Ft.Worth,TX 76104 Arlington,TX Hospital 817-878-5500 76010-7498 (LTAC) 817-570-8500 3 Texas Health Harris 411 N. Belknap PO Box 916078 75-1752253 Hospital Methodist Hospital Stephenville,TX Ft.Worth,TX Stephenville 76401 76191-6078 254-965-1500 817-570-8500 4 Texas Health Harris 1301 Pennsylvania PO Box 916063 75-6001743 Hospital Methodist Hospital Ave., Ft Worth,TX 76191- Fort Worth Ft.Worth,TX 76104 6063 817-882-2000 817-570-8500 5 Texas Health Harris 6100 Harris Parkway PO Box 916047 75-2678857 Hospital Methodist Hospital Ft Worth,TX 76132 Ft Worth,TX 76191- Southwest Fort 817-433-5000 6047 Worth 817-570-8500 6 Texas Health Harris 1600 Hospital PO Box 916060 75 1438726 Hospital Methodist Hospital Parkway Ft.Worth,TX 76191- Hurst-Euless- Bedford,TX 76022 6060 Bedford 817-848-4000 817-570-8500 7 Texas Health Harris 108 Denver Trail PO Box 916066 75-1748586 Hospital Methodist Hospital Azle,TX 76020 Ft Worth,TX 76191- Azle 817-444-8600 6066 817-570-8500 8 Texas Health 1105 N. Central PO Box 910175 75-2890358 Hospital Presbyterian Expressway Dallas,TX 75391- Hospital Allen Allen,TX 75013 0175 972-747-1000 214-345-7260 9 Texas Health 8200 Walnut Hill Lane PO Box 910115 75-1047527 Hospital Presbyterian Dallas,TX 75231 Dallas,TX 75391- Hospital Dallas 214-345-6789 0115 214-345-7260 10 Texas Health 850 Ed Hall Drive PO Box 910206 75-2771437 Hospital Presbyterian Kaufman,TX 75142 Dallas,TX 75391- Hospital Kaufman 972-932-7200 0206 214-345-7260 11 Texas Health 6200 West Parker PO Box 910156 75-2770738 Hospital Presbyterian Road Dallas,TX 75391- Hospital Plano Plano,TX 75093 0156 972-981-8000 214-345-7260 12 Texas Health Harris 201 Walls Dr. PO Box 916051 75-1977850 Hospital Methodist Hospital Cleburne,TX 76033 Ft Worth,TX 76191- Cleburne 817-641-2551 6051 817-570-8500 7 Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number 13 Texas Health 3000 Interstate 35 PO BOX 731467 43-2008974 Hospital Presbyterian North Dallas,TX, 75373- Hospital Denton Denton,TX, 76201 1467 940-898-7000 940-898-7172 14 Southlake Specialty 1545 E. Southlake P.O. Box 676252 02-0555370 Hospital Hospital L.L.C., Blvd Dallas,TX, 75267- d/b/a Texas Health Southlake,TX, 76092 6252 Harris Methodist 817-748-8700 972-419-1535 Hospital Southlake 15 Texas Institute for 7115 Greenville P. O. Box 676249 77-0628004 Hospital Surgery, L.L.P., Avenue, Suite 100 Dallas,TX, 75267- d/b/a Texas Institute Dallas,TX, 75231 6249 for Surgery at 214-647-5300 972-419-1535 Texas Health Presbyterian Dallas 16 Physicians Medical 6020 W Parker Road P. O. Box 676266 48-1281376 Hospital Center, L.L.C.,d/b/a Plano,TX, 75093 Dallas,TX, 75267- Texas Health 972-403-2700 6266 Center for 972-419-1535 Diagnostics& _ Surgery Plano 17 Rockwall Regional 3150 Horizon Road P. O. Box 676868 20-2848116 Hospital Hospital, LLC d/b/a Rockwall,TX 75032 Dallas,TX 75267- Texas Health 469-698-1000 6868 Presbyterian 972.419.1535 Hospital Rockwall 18 USMD Hospital at 5900 Altarnesa Blvd PO Box 678491 20-3571243 Hospital Fort Worth, LP Fort Worth,TX 76132 Dallas,TX 75267- (817)433-9100 8491 817-576-0022 19 USMD Hospital at 801 Interstate 20 W PO Box 732156 73-1662763 Hospital Arlington, LP Arlington,TX 76017 Dallas,TX 73573- 817-472-3535 2156 817-576-0022 20 Flower Mound 4400 Long Prairie Rd PO Box 677305 26-0684968 Hospital Hospital Partners Flower Mound,TX Dallas,TX 75267- d/b/a Texas Health 75028 7305 Presbyterian 469-322-7000 972-419-1535 Hospital Flower Mound 21 AMH Cath Labs 811 Wright Street PO Box 975621 20-3003947 Hospital LLC d/b/a Texas Arlington,TX 76012 Dallas,TX 75397- Health Heart& 817-960-3500 5621 Vascular Hospital 817-960-6130 Arlin ton 22 Texas Health 11801 South Freeway P.O. Box 951571 45-2694620 Hospital Huguley, Inc.d/b/a Burleson,TX 76028 Dallas,Texas 75395 Texas Health 817-293-9110 817-551-2739 Huguley Hospital Fart Worth South 23 Texas Health Harriss 10864 Texas Health P.O. Box 731778 45-1502252 Hospital Methodist Hospital Trail Dallas,TX 75373- Alliance Fort Worth,TX 76244 1778 682-212-2000 800-890-6034 24 First Texas Hospital 1401 East Trinity Mills PO Box 847460 47-3440744 Hospital Carrollton, LLC Road Dallas TX 75284- d/b/a Carrollton TX 75006 7460 972-810-0700 855-694-6452 8 Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address& Phone Number Type Number Texas Health Hospital B. Ancillary Facilities Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number 1 SWDIC Imaging 8230 Walnut Hill Lane, PO Box 678146, 75-2008026 Imaging/ Center Partnership, Building 3,Suite 100, Dallas,TX 75267- Radiology LLP,d/b/a Dallas TX 75231 8146 Center Southwest 214-345-6905 214-345-2098 Diagnostic Imaging Center 2 The Center for 8196 Walnut Hill Lane, PO Box 678182, 11-3699951 Imaging/ Molecular Imaging Suite LL30, Dallas,TX Dallas,TX 75267- Radiology Limited Partnership 75227 8182 Center d/b/a Southwest 214-345-8300 214-345-2098 (PET/CT Diagnostic Center Scans) for Molecular Imaging 3�i Denton Surgery 207 N. Bonnie Brae, PO Box 844214 47-0926556 Ambulatory Center, LLC d/b/a Denton,TX 76201 Dallas,TX 75284- Surgery Texas Health 940-383-7100 4214 Center Surgery Center 940-383-7102 Denton 4 Women's Specialty 8230 Walnut Hill Lane, PO Box 650814 26-2310072 Ambulatory Surgery Center of Suite 101 Dallas,TX 75265 Surgery Dallas LLC d/b/a Dallas,TX 75231 214-345-6747 Center Texas Health 214-345-6747 Women's Specialty Surgery Center Dallas 5 Health Imaging 710 Hunters Row Ct PO Box 975542 27-1385885 Imaging/ Partners LLC d/b/a Mansfield,TX 76063- Dallas,TX 75397- Radiology Envision Imaging at 4001 5542 Center Hunters Row 817-453-7444 866-965-1093 6 Health Imaging 12201 Merit DR Suite PO Box 975542 27-1385885 Imaging/ Partners LLC d/b/a 100 Dallas,TX 75397- Radiology Envision Imaging of Dallas,TX 75251-2122 5542 Center Dallas 214-276-0050 866-965-1093 7 Health Imaging 1111 Raintree Cir, PO Bax 975542 27-1385885 Imaging/ Partners LLC d/b/a Ste. 100 Dallas, TX 75397- Radiology Envision Imaging of Allen,TX 75013-4903 5542 Center Allen 972-747-8300 866-965-1093 8 Health Imaging 3211 Internet Blvd, PO Box 975542 27-1385885 Imaging/ Partners LLC d/b/a Suite 120 Dallas,TX 75397- Radiology Envision Imaging of Frisco,TX 75034-1948 5542 Center Frisco 972-334-0908 866-965-1093 9 Health Imaging 10840 Texas Health PO Box 975542 27-1385885 Imaging/ Partners LLC d/b/a Trail Suite 140 Dallas,TX 75397- Radiology Envision Imaging Fort Worth,TX 76244 5542 Center North Fort Worth 817-741-0008 866-965-1093 10 Health Imaging 6957 W. Plano Pkwy PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a Plano,TX 75093 Dallas,TX 75397- Radiology 972-395-7533 5542 Center 9 Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number Envision Imaging of 866-965-1093 Plano 11 Health Imaging 2911 Oak Park Circle PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a Fort Worth,TX 76109 Dallas,TX 75397- Radiology Envision Imaging of 817-923-6858 5542 Center Hulen 866-965-1093 12 THR/STT Rockwall 3142 Horizon Road, 1340 Main Street, 26-2429878 Ambulatory ASC, LLC Suite 100, Rockwall, Suite 100, Surgery d/b/a Texas Health TX 75032 Grapevine,TX Center Spine Surgery 972-772-9600 76051 Center Rockwall 682-651-1908 13 THR/STT 290 Miron Road, 1340 Main Street. 20-1728912 Ambulatory Southlake ASC, Southlake,TX 76092 Suite 100, Surgery LLC 817-442-9300 Grapevine,TX Center d/b/a Texas Health 76051 Spine Surgery 682-651-1908 Center Southlake 14 Health Imaging 3920 W.Wheatland PO Box 975542 27-1385885 Imaging/ Partners, Road, Ste 120 Dallas,TX 75397- Radiology LLC d/b/a Envision Dallas,TX 75237 5542 Center Imaging of Desoto 972-820-8050 866-965-1093 15 Health Imaging 925 W. Royal Lane, PO Box 975542 27-1385885 Imaging/ Partners, Suite 100 Dallas,TX 75397- Radiology LLC d/b/a Envision Irving,TX 75039 5542 Center Imaging of Las 214-483-6200 866-965-1093 Colinas 16 Texas Health 10840 Texas Health PO Box 731893 80-0800294 Ambulatory Surgery Center Trail, Suite 100 Dallas TX 75373- Surgery Alliance, LLC Fort Worth,TX 76244 1893 Center d/b/a 877-410-6290 800-890-6034 Texas Health Surgery Center Alliance 17 Surgical Caregivers 2001 West Rosedale 2001 West Rosedale 75-1925497 Ambulatory of Fort Worth, L.P. Street Street Surgery d/b/a Texas Health Fort Worth TX 76104 Fort Worth,TX Center Surgery Center 817-877-4777 76104 Fort Worth Midtown 817-877-4777 18 Greenville Surgery 7150 Greenville 7150 Greenville 74-2411643 Ambulatory Center, Ltd., d/b/a Avenue, Avenue, Surgery Texas Health Ste 200 Ste 200 Center Surgery Center Dallas TX 75231 Dallas TX 75231 Dallas 214-891-0466 214-891-0466 19 Texas Health Craig 8080 State Highway 8080 State Highway 38-3897811 Ambulatory Ranch Surgery 121,Suite 100 121, Suite 100 Surgery Center LLC d/b/a McKinney, TX 75070 McKinney, TX Center Texas Health 972-521-5600 75070 Surgery Center 214-547-2700 Craig Ranch 20 Texas Health 5000 Long Prairie 5000 Long Prairie 80-0866449 Ambulatory Flower Mound Road, Suite 202 Road Surgery Orthopedic Surgery Flower Mound,TX Suite 202 Center Center LLC. 75028 Flower Mound,TX d/b/a Texas Health 469-240-8540 75028 Orthopedic Surgery 469-240-8540 Center—Flower Mound 10 Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number 21 Cleburne Surgical 2010 W Katherine P 2010 W Katherine P 20-3742012 Ambulatory Center, LLC d/b/a Raines Blvd Raines Blvd Surgery Texas Health Suite 100 Suite 100 Center Surgery Center Cleburne,TX 76033 Cleburne,TX 76033 Cleburne 817-645-0811 817-645-0811 22 Health Imaging 3400 Carp Bowie PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a Blvd., Ste 100 Dallas,TX 75397- Radiology Envision Imaging at Fort Worth,TX 76107 5542 Center Camp Bowie 817-885-7739 866-965-1093 23 Health Imaging 815 Pennsylvania PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a Avenue Dallas,TX 75397- Radiology Envision Imaging at Fort Worth,TX 76104 5542 Center Pennsylvania 817-321-0300 866-965-1093 24 Health Imaging 1600 Central Drive, PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a Ste 195 Dallas,TX 75397- Radiology Envision Imaging of Bedford,TX 76022 5542 Center Bedford 817-803-0100 866-965-1093 25 Health Imaging 203 Walls Drive, Suite PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a 101 Dallas,TX 75397- Radiology Envision Imaging of Cleburne,TX 76033 5542 Center Cleburne 817-517-2600 866-965-1093 26 Health Imaging 801 Road to Six Flags PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a West, Ste 106 Dallas,TX 75397- Radiology Envision Imaging of Arlington,TX 76012 5542 Center North Arlington 817-265-1099 866-965-1093 27 Health Imaging 525 East Southlake PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a Blvd. Dallas,TX 75397- Radiology Envision Imaging at Southlake,TX 76092 5542 Center Southlake 817-424-5872 866-965-1093 28 Health Imaging 4601 Matlock Road PO Box 975542 27-1385885 Imaging/ Partners, LLC d/b/a Arlington,TX 76018 Dallas,TX 75397- Radiology Envision Imaging of 817-375-3170 5542 Center South Arlington 866-965-1093 29 Health Imaging 1800 N. Lake Forest PO Box 975542 27-1385885 Imaging/ Partners, Dr., Suite 100 Dallas,TX 75937- Radiology LLC d/b/a Envision McKinney,TX 75071 5542 Center Imaging of 469-420-9077 866-965-1093 McKinney 30 Fort Worth 900 W. Magnolia, 900 W. Magnolia, 77-0368346 Ambulatory Endoscopy Suite 101 Suite 101 Surgery Centers, LLC Fort Worth,TX 76104 Fort Worth,TX Center d/b/a Fort Worth 817-332-6500 76104 Endoscopy Center 817-332-6500 31 Fort Worth 6445 Hams Parkway, 6445 Harris 77-0368346 Ambulatory Endoscopy Suite 150 Parkway, Suite 150 Surgery Centers, LLC Fort Worth,TX 76132 Fort Worth,TX Center d/b/a Southwest 817-423-2888 76132 Fort Worth 817-423-2888 Endoscopy Center 32 ! North Dallas 17980 Dallas Parkway, 17980 Dallas 27-2248103 Ambulatory Surgical Center, Suite 100, Dallas, Parkway, Suite 100, Surgery LLC Texas 75287 Dallas,Texas 75287 Center d/b/a Texas Health 972-913-7715 972-913-7715 Surgery Center Addison 33 Wilson Creek 8855 Synergy Drive 8855 Synergy Drive 27-4815683 Ambulatory Surgical Center McKinney,TX 75070 McKinney,TX 75070 Surgery LLC d/b/a 972-632-3811 372-6.32-3811 Center 11 Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type _ Number Stonebridge Surgery Center 34 Texas Health 17950 Preston Road, PO Box 840046 20-3991622 Ambulatory Surgery tenter Suite 75 Dallas,TX 75284 Surgery Preston Plaza, LLC Dallas,TX 75252 972-267-5400 Center d/b/a Texas Health 972-267-5400 Surgery Center Preston Plaza 35 Ophthalmology 10740 North Central 10740 North Central 26-1914835 Ambulatory Surgery Center of Expressway, Suite 400 Expressway, Suite Surgery Dallas, LLC d/b/a Dallas,TX 75231 400 Center Ophthalmology 214-750-9288 Dallas,TX 75231 Surgery Center of 214-750-9288 Dallas 36 Arlington Surgery 918 N. Davis Drive 918 N. Davis Drive 75-2055800 Ambulatory Center, LLC d/b/a Arlington,TX 76012 Arlington,TX 76012 Surgery Texas Health 817-860-9933 972.421.4813 Center Surgery Center Arlington 37 Park Hill Surgery 3455 Locke Avenue 3455 Locke Avenue 45-1484375 Ambulatory Center, LLC d/b/a Suite 100 Suite 100 Surgery Texas Health Fort Worth TX 76107- Fort Center Surgery Center 5747 817-585-1900 Worth TX 76107- Park Hill 5747 817-585-1900 38 Texas Health 1605 Airport Freeway 1605 Airport 82-1307876 Ambulatory Surgery Center Suite 100 Freeway Surgery Bedford, LLC d/b/a Bedford Texas 76021 Suite 100 Center Texas Health 817-585-1900 Bedford Texas Surgery Center 76021 Bedford 817-585-1900 C. Behavioral Health Facilities Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number 1 Texas Health Harris 2717 Tibbets Drive PO Box 916080 75-1438726 Behavioral Methodist Hospital Bedford,TX 76022 Fort Worth TX Health Hurst-Euless- 817-355-7771 76191-6060 Bedford 817-570-8500 d/b/a Texas Health Springwood Behavioral Health Hospital 2 Texas Health Harris 2421 Westport PO Box 916080 75-1438726 Behavioral Methodist Hospital Parkway, Suite 500 Fort Worth TX Health Hurst-Euless- Fort Worth,TX 76177 76191-6060 Bedford 817-693-2527 817-570-8500 d/b/a Texas Health Behavioral Health Center Alliance 12 Network Facility Service Address & Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number 3 Texas Health Harris 3100 West Southlake PO Box 916060 75-1438726 Behavioral Methodist Hospital Blvd, Suite 120 Fort Worth TX Health Hurst-Euless- Southlake,TX 76092 76191-6060 Bedford 817-310-5856 817-570-8500 d/b/a Texas Health Behavioral Health Center Southlake 4 Texas Health Harris 7213 Red Hawk Court PO Box 916080 75-1438726 Behavioral Methodist Hospital Fort Worth,TX 76132 Fort Worth TX Health Hurst-Euless- 682-236-3662 76191-6060 Bedford 817-570-8500 d/b/a Texas Health Behavioral Health Center Southwest Fort Worth 5 Texas Health 2929 Carlisle Street, PO Box 910115 75-1047527 Behavioral Presbyterian Suite 300 Dallas TX 75391- Health Hospital Dallas Dallas,TX 75204 0115 d/b/a 214-345-2916 214-345-7260 Texas Health Behavioral Health Center Uptown Dallas 6 Texas Health Harris 101 Crown Pointe PO Box 916080 75-1438726 Behavioral Methodist Hospital Blvd, Suite 320 Fort Worth TX Health Hurst-Euless- Willow Park,TX 76191-6060 Bedford 76087 817-570-8500 d/b/a Texas Health 817-757-1694 Behavioral Health Center Willow Park 7 Texas Health 11801 South Freeway PO Box 9515711 45-2694620 Behavioral Huguley, Inc dba Burleson,TX 76028 Dallas,TX 75395 Health Texas Health 817-568-3336 817-551-2721 Huguley Hospital Fort Worth South _ 8 Texas Health 8200 Walnut Hill Lane PO BOX 910115 75-1047527 Behavioral Presbyterian Dallas,TX 75231 Dallas,TX 75391- Health Hospital Dallas 214-345-7355 0115 d/b/a Texas Health 214-345-7260 Behavioral Health Hospital Dallas 9 Texas Health 890 Rockwall PO BOX 910115 75-1047527 Behavioral Presbyterian Parkway, Suite 115 Dallas,TX 75391- Health Hospital Dallas Rockwall TX, 75032 0115 d/b/a 214-345-8799 214-345-7260 Texas Health Behavioral Health Center Rockwall 10 Texas Health 6110 W. Parker Rd. PO BOX 910156 75-2770738 Behavioral Presbyterian Plano,TX 75093 Dallas TX 75391- Health Hospital Plano d/b/a 972-981-8301 0156214-345-7260 Texas Health Seay Behavioral Health Hospital 11 Texas Health 5858 Main St. #200 PO BOX 910156 75-2770738 Behavioral Presbyterian Frisco,TX 75034 Dallas TX 75391- Health Hospital Plano d/b/a 972-981-4214 0156 Texas Health 214-345-7260 13 Network Facility Service Address& Claims Payment Tax ID Facility Phone Number Address&Phone Number Type Number Behavioral Health Center Frisco 12 Texas Health 3661 North Plano PCS B5X 010156 75-2770738 i Behavioral Presbyterian Road, Suite#2100 Dallas TX 75391- Health Hospital Plano d/b/a Richardson TX 75082 0156 Texas Health 972-981-4300 214-345-7260 Behavioral Health Center Richardson 13 Texas Health 1970 West University PO BOX 910156 75-2.770738 Behaviaral Presbyterian Drive Dallas TX 75391- Health Hospital Plano d/b/a Suite 201 0156 Texas Health Prosper TX 75078 Behavioral Health Center Prosper 14 Texas Health 800 West Randol Mill PO Box 910818 75-0972805 Behavioral Arlington Memorial Rd Dallas,TX 75391- Health Hospital Arlington,TX 76012 0818 d/b/a Texas Health 817-960-6659 817-960-6130 Behavioral Health Facility Arlington 15 Texas Health 1001 N.Waldrop PO Box 910818 75-0972805 Behavioral Arlington Memorial Drive, Suite 510 Dallas,TX 75391- Health Hospital d/b/a Arlington,TX 76012 0818 Texas Health 817-960-6540 817-960-6130 Behavioral Health Center Arlington— 16 Texas Health 915 W. Exchange PO Box 910175 752890358 Behavioral Presbyterian Parkway, Suite 150 Allen, TX 75391- Health Hospital Allen d/b/a Allen TX 75013 0175 Texas Health 972-908-2304 817-570-8500 Behavioral Health Center Allen 17 Texas Health 1105 Central PO Box 910175 752890358 Behavioral Presbyterian Expressway, North Allen, TX 75391- Hospital Allen d/b/a Allen TX 75013 0175 Texas Health 972-747-4280 817-570-8500 Behavioral Health Hospital Allen 18 Texas Health 240 North Miller Road PO BOX 733551 81'-2813227 Behavioral Recovery and Mansfield TX 76063 Dallas TX 75373- Health Wellness Center 682-812-6150 3551 817-570-8500 • Facility list is subject to change as new locations are added to Network. 14 Appendix D Primary Care Services Primary care and lab services as listed in Table 1 shall be provided at the Health Centers and Satellite Clinics. Typical services include, but are not limited to: • Abdominal Pain • Abrasion • Bronchitis • Cold • Constipation • Contusion • Couth • Dermatitis • Diarrhea • Dizziness • Elev Blood Pressure • Headache • Heartburn • Hives • Influenza • Joint Pain • Minor Laceration • Minor Injuries • Muscle Strain • Nausea • Neck Pain • Nose Bleed • Painful Urination/UTI • Palpitations • Wellness Exams • Chronic Disease Management • Radiology services are excluded from Primary Care Services and can be referred to our conveniently located radiology partners. • Any additional services (other than Table 1 and 2 below)will be billed directly to the Employer or the ASO. 15 Table 1-Primary Care Services CPT CPT Description 10061 Skin-incision/drainage-abcess/Wound Complex with Packing 10160 Under Incision and Drainage Procedures on the Skin,Subcutaneous and Accessory Structures 11101 Skin-Biopsy separate/add lesion(list primary code first) 11200 Skin Destroy Skin Tags up to and including 15 lesions 11201 Skin Destroy Skin Tags-charge each additional 10 lesions 11300 Skin-Shave Lesion<O.Scm-single-trunk,arms,legs-no suture 11301 Skin Shave Lesion 0.6-1.Ocm-arms,trunk,legs,no suture 11305 Shave Skin Lesion 11306 Skin Shave Lesion 0.6-1.Ocm scalp,neck,hands,feet,genitals 11400 Skin Excise Lesion Benign w/margines/closure<0.5cm,trunk,arm,le 11401 Skin Excise Lesion Benign w/margines/closure 0.6-1 cm,trunk,arm,le 11402 Skin Excise Lesion Benign w/margines/closure 1-2cm,trunk,arm,ie 11420 Skin excise lesion Benign scalp,neck,hands,feet genitals<0.5 11730 Skin excise nail plate-one(partial or complete) 11750 skin excise lesion nail bed/matrix partial/complete(permanent) 11765 Skin excise nail fold,toe wedge excision 15851 Removal of Sutures 36415 Venipuncture Routine 69210 Heent Cerumen Removal-1 ear,if doing both use modifier 50 80053 Metabolic Panel-comprehenvisve 80061 lipid Panel w/reflect to direct LDL 81001 Urinalysis w/scope 81003 Urine Dip 82043 Urine Microalbumin-Quant 82306 Vitamin D,25 Hydroxy 82570 Urine Creatinine 83036 HA1C-Glycosylated Hemogobin 84153 PSA-Prostate Specific Antigen 84403 Testosterone Total 84439 Free T-4 84443 TSH-Thyroid Stimulating Hormone 84702 Quantitative on the immunoassay analyzer 84703 Pregnancy Test-HGC Urine 85025 CBC W/Diff 87086 Culture UA w/COL CT 87088 Culture UA w/COL CT 87186 Culture Step Throat 87481 Candida,DNA,AMP Probe 87491 Culture-Chlamydia 87591 Culture-Gonorrhea 87661 Trich Vag By NAA 87510 Detect agent NOS,DNA,AMP Gardnerella 86308 Mono 16 87804 Influenza A&B Nasal Swab 88175 Thin Prep Pap 85610 PT/INR 90471 Admin-immunization/Vaccine/Toxoid First or Single Injection 90472 Admin-immunication/vaccine/Toxoid Each Additional Injection 93000 Cardiac EKG w/interpretation 94060 Spirometer Post Bronchodilator 94640 RESP Nebulizer updraft Tx Chg once pertx(also chgJcode) 96372 Postop follow up visit during global period-no charge 99024 Office/Outpatient visit,new 99201 Office/Outpatient visit,new 99202 Office/Outpatient visit,new 99203 Office/Outpatient visit,new 99204 Office/Outpatient visit,new 99205 Office/Outpatient visit,new 99211 Office/Outpatient Visit,Est 99212 Office/Outpatient Visit,Est 99213 Office/Outpatient Visit,Est 99214 Office/Outpatient Visit,Est 99215 Office/Outpatient Visit,Est 99383 Wellness/Preventative Visit,new,age 5-11 99384 Wellness/Preventative Visit,new,age 12-17 99385 Wellness/Preventative Visit,new,age 18-39 99386 Wellness/Preventative Visit,new,age 40-64 99387 Wellness/Preventative Visit,new,age 65+yrs 99393 Wellness/Preventative Visit,est.age 5-11 99394 Wellness/Preventative Visit,est.age 12-17 99395 Wellness/Preventative Visit,est.age 18-39 99396 Wellness/Preventative Visit,est.age 40-64 99397 Wellness/Preventative Visit,est.age 65+yrs 99401 Preventative counseling,indiv-15 min 99402 preventtivecounseling,indiv-30 min 99406 Tobacco cessation counseling,intermiate 3-10 min 99407 Tobacco Counsling>10 Minutes A7003 Nebulizer administration,set chg one/tx with 94640&Jcode 59470 Counseling-Nutritional Table 2—Injections List CPT Code Common Injections Recommendation J1200 Benadryl 50mg/mL In office J1040 Depo-Medrol In office J1100 Dexamethasone_ In office J0171 Epinephrine Ampule In office J3301 Kenalog In office J3490 Lidocaine 1% In office J3490 Lidocaine w/ Epi 1% In office J3490 Lidocaine 2% In office J3490 Lidocaine w/ Epi 2% In office 17 J2550 Promethazine (Phenergan) In office J0696 Rocephin Ceftriaxone In office 90714 Td In office J1885 Toradol (Ketorolac) In office J3420 B-12 C anocobalamin) In office Depo-Testosterone J1080 Cypionate In office; no pellats 18 Agreed and Accepted by UT Southwestern Accountable Care Network d/b/a Southwestern Health Resources Accountable Care Network ("'Network) City ofAFortrthp 4er) Signature: �k /Lly� - --- J SignatuName: Marinan Williams Name: Title: Senior Executive Officer, Market Relations Title: Director of Human Resources and Civil Service City of FW Date:_ '� Date: 11 L SignaturL Si nature• �az��_ Name: Jeffrey Canose, MD Name: Sus Alanis Title: Senior EVPhief O eratin Officer Title: Ass' tai t CitV"V ana er Cit of FW Date: % / . Date: ii Pc -o'v I'7 Signature: Name: Dr. Dan Vara APen"n'��"'n AS m FnRM AND LEGALITY. Title: Senior Execu iv is r WHR ACN �' Date: is QTY ATTORNEY 3dti"� 8• s�'°�`� GIT Y p A y' rP Max3/J. Kayser, City S s .*.Ny-,a. 4