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HomeMy WebLinkAboutContract 47186-P2 WECRETARYoLmvittACT NO. c� ADDENDUM To BlackStone 504 Program Provider Agreement This Addendtun is entered into by and among Wright Singleton,MD ("Member Pro 'der' , Rockport Healthc -e,Group ("Rockport"), and the City of Port Worth ("City") on this La day of 20� VIMREAS,Rockport and Member Provider entered into a Provider Agreement,effective May 21,2004 ("Provider Agreement"), and desire that this Addendum apply to covered services that are governed by the Texas lnswwce 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 S action 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 instued workers' compensationprogram 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). I I 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 i 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 conditlons 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 ceitifi.ed networks as well as the Texas Insurance Code, Chapter 1305 and Sections 403,023, 408.027, and•413,041 of the Texas Labor Coda 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 BlackStoue) shall instead apply to matters of notice, billing, dispute resolution, complaints, preauthorization,and related matters. 2. The parties agree that the City will bear the financial responsibility for payment to Member Provider under the terms of the Provider Agreement subject to the applicable Provider Manual and the provisions of the Texas Labor Code and applicable rules under the Texas Administrative Code. Rockport will continua to provide applicable network administrative services. 3. When used in this Addendum,-unless the content otherwise clearly requires,the following words and terms sliall have the meaning set forth below. All other defined terms shall have the meaning ascribed to them in the Provider Agreement. OFFICIAL RECORD CITY SECRETARY FT-WORTH,,,`i'% a, Wright Singleton,MD 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,Rcckport 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 ofthe Texas Labor Code. 4. Member Provider agrees to participate in the BIackStone provider panel for the benefit of fhe City and Qualified Participants. 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 WI NBBS WETBROF,the parties bereto have executed this Addendum effective on the day and year first written above. For and on behalf of: City of Fort Worth EIackStone Signatures Name: Sus anis Title: Assistant City Manager Date: T—" ® F APPROVED AS TO Poithi AND LEGALITY: . S e int ity Attomey� 0000 19 AZ Wo- a els''City Secre y Wxlght$ingleton,W Provider Agreoment )&OCIOOztTIW,Ax,'xJEl CA=' GROW ' )dame:j�mPaolacol l'itle:Sr.Vice resident 3Jafe: 5 L4 i �Q MEMBER PROVICDBR or Repx•esentatf�•eJDc�ignee _ Nam$:WiigbtSin;letom AD Title: i TIiYt 7S 2593+198 RECEIVED APR 2 8 2004 ::<.;.::;. . ski:: �,[ ►G✓ �� �����t/ � :�:t•• •::• ,- EI�,��:`t'•�:#fi'>�t:'t<:�;t2�t�i?: . :....-.. ago" ... . . PHYSICIAN AGREEMENT ROCKPORT HEALTHCARE GROUP,INC. This Physician Agreement("Agreement"),is entered into by and between Rockport Healthcare Group, I, DEFINITIONS Inc., a Delaware Corporation ("RHG"), dba Rockport United Network, Inc. (a preferred provider When used in this Agreement and unless the content organization for 'Occupational Injuries and Illnesses) otherwise clearly requires, the following words and and Rockport Community Network, LLC (a terms shall mean: preferred provider organization for group and individual health) and I.1 "Physician'means a licensed Medical Doctor or _("Physician"), and Doctor of Osteopathic Medicine, or group of same will become effective as of the date the Agreement who desire to become a Member Provider with is executed by RHO. RHO. WHEREAS, RHO is engaged in the business of I.2 "Qualified Participant" means: (a) a person who developing and acting in an administrative capacity presents with authorization from the Employer prior in providing Occupational Injury and Illness and to the initiation of treatment that the worker is individual and group accident and health provider currently employed and that the presenting problem networks that offer direction of care while providing was work related, either in writing or by telephone savings to RHO Payors. These networks will offer (b) an employee, member and/of dependent of an greater coverage of services and savings;and RHO payor/client who is eligible to receive certain healthcare benefits under an individual or group WHEREAS, RHO has networks of contracted accident and health benefit plan or any other physici9rls, physician groups, hospitals and insurance program providers of ancillary healthcare services (collectively, the "Member Providers") to provide a I.3 "Payor" means an insurance company,employer, full-range of healthcare services. These services are self-insured employer, bill .review/medical cost available for use by "Qualified Participants" as containment company,software bill review company defined in L2 of this Agreement; and - or third party administrator. These Payors have entered into a Payor Agreement with RHO for the WHEREAS, Physician desires to provide medical provision of healthcare services to Qualified care services to "Qualified Participants" who are Participants and have agreed to pay for such covered by Payor Agreements at the rates in Exhibit 'Covered Services, pursuant to such Payor A and in locations listed in Exhibit B;and Agreement. WHEREAS, RHO has entered into Agreements with I.4 "Pavor Agreement" means the agreement one or more Payors who provide,but are not limited between RHO and a Payor, which is made before, on to, payment of claims for employers, case or after the effective date of this Agreement and management,bill review/cost containment and other which expresses the agreed upon contractual rights medical utilization services. and obligations of the parties. NOW, THEREFORE, in consideration of the I.5 "Member Provider" means, any physician; premises,the mutual promises contained herein, and physician group; hospital; surgery center; diagnostic other good and valuable consideration, the receipt imaging center; laboratory; clinic; chiropractor; and sufficiency of which are hereby acknowledged, dentist; podiatrist; psychologist; social worker; it is mutually agreed as follows: physical, occupational and speech therapist; etc. Page 1 of 11 021802 W.Singleton Revised 121603 04/19/04 .licensed or certified to practice a healthcare . in the community in which such services, are profession or licensed as a facility to offer healthcare rendered. Physician agrees that it is his/her sole services,in the state where services are rendered and responsibility to verify that the individual presenting who has executed a contract with RHO. for care is a Qualified Participant. Physician agrees to render healthcare services to Qualified I.6 'Primary Care Physician" means a Member Participants at any and all facility or practice Provider, Family Practice, General Practice, locations. Physician shall ensure that services Occupational Medicine whose practices are largely provided are consistent with RHG's programs. dedicated to caring for work related injuries and Physician agrees to comply with-and be bound by all illnesses and is designated by RHO as a Primary Benefit Plan Designs, State/Federal Rules and Care Physician. Regulations, Utilization Review and Quality Assurance Programs. 1.7 "Specialist Physician" means a Member Provider whom Primary Care Physicians may refer for I1.2 Non-Discrimination. Physician shall not necessary and authorized care other than primary differentiate or discriminate in the treatment of care services. i his/her services delivered to Qualified Participants because of race, sex, age, religion, national origin, 1.8 "Enver enc means a medical conditions place of residence, source of payment or health manifesting itself by acute symptoms of sufficient status. Physician shall observe,protect and promote severity such that a prudent layperson who the rights of Qualified Participants. possesses average knowledge of health and medicine could reasonably expect the absence of immediate 11.3 Covering Physician. Physician agrees to devote medical attention to result in; (i) placing the such time as is necessary to the performance of individual in serious jeopardy (and in the case of a his/her obligations under this Agreement, including pregnant woman, her health- or that of her unborn maintaining reasonable office hours. Physician child); or(ii)serious impairment to bodily functions; agrees to maintain accessibility either personally or or (iii) serious dysfunction of any bodily organ or by covering arrangements with another Member part. Provider of like specialty or other qualified physician approved by RHO, on a twenty-four (24) I.9 "Covered Services" are those healthcare and hour-per-day,seven(7)day-per-week basis. health-related services as defined by individual state and/or federal rules and regulations and/or Payor II.4 Referrals. Except in a medical emergency or benefit plan, when authorized by RHO or its designated representative, Physician agrees to refer Qualified 1.10 `Bill and/or ClaimForiiV means a HCFA 1500 Participants only to other Member Providers, as and/or UB 92 used for billing for all services with defined in 1.5, regard to Occupational Injury and„Illness and Accident and Health Plans. II.5 Reports. For each encounter where Physician provides services to a Qualified Participant, II, PHYSICIAN OBLIGATIONS Physician shall report such encounter on an appropriate form and shall include statistical, II.1 Services. Physician agrees to provide or arrange descriptive medical and patient data and identifying for all medically necessary health care for Qualified information, if and to the extent that reports are Participants who seek care from Physician, specified by RHO or its designated representative, Physician agrees to perform such services with the and requested information is not prohibited by state same standard of care, skill and diligence which is and/or federal rules and regulations. customarily used by Physicians I1.6 Professional Requirements. II.6.1 Licenses. Physician shall be duly licensed to practice medicine in the state where care is rendered and hold such other .licenses, certifications, registrations, permits and approvals as are required for the lawful conduct of Physician's practice. Page 2 of 11 021802 W.Singleton Revised 121603 04/19/04 .Evidence of . such current licensing and/or sanction under the Medicare program or Medicaid certifications shall be submitted promptly to RHO program. In addition, Physician shall provide prior when data changes or renewal occurs and upon written notice to RHO of any changes in (i) Federal request. Physician will have, where appropriate, a Tax Identification Number, (ii) other information current narcotics number issued by the appropriate provided in his/her application for participation, (iii) authority, currently the United States Drug Physician's professional liability insurance, (iv) Enforcement Administration("DEA")and/or various Physician's billing or office address, and(v)services State Controlled Substance Registration Authorities. provided by Physician. A failure to give any notice required by this Section shall be a material breach of 11.6.2 Medical Staff Privileges. Certain medical Physician's obligations and ' responsibilities specialties may not require hospital privileges such hereunder, regardless of the status, pendency or as Occupational Medicine, Pathology, Dermatology, outcome of the event giving rise to the obligation to Allergy, and those Primary Care Physicians whose give that notice,and may be grounds for termination practice is dedicated to treating work-related injuries of this Agreement. and illnesses. Where appropriate, Physicians.must maintain active, unrestricted staff privileges with at 11.8 Medical Records. Physician shall maintain least one RHG Member Provider hospital or Surgery complete and timely medical records for Qualified Center. Physician hereby consents to disclosure by Participants treated by Physician. Such records shall such facility to RHO of all data collected with be prepared in accordance with accepted principles respect to Physician in connection with Physician's of practice, shall document all services performed medical staff membership, including without for Qualified Participants and shall comply with all limitation all applications for staff privileges and any applicable state and federal laws. Physician shall renewals thereof. maintain such records for the length of time required by applicable state or federal law. Subject to all II.6.3 Or2anization's Requirements. Physician shall applicable privacy and confidentiality requirements, comply with and be bound by RHO's criteria for such medical records shall be made available to each .provider participation including credentialing physician and other health professionals treating the policies and procedures,. Physician shall cooperate Qualified Participant,and upon request,to the Payor, with RHO's periodic evaluation of professional RHO or its designated representative for.review at qualifications, which shall include, but not be the rates approved by State law. Physician shall limited to,Physician giving consent to the release of obtain a valid consent for the release of the Qualified information from any facility at which Physician has Participant's medical records to other providers, medical staff privileges. In addition,Physician shall RHO, Payor, or its designated representative. RHG cooperate with RHO's and each Payor's programs agrees that medical records of Qualified Participants and procedures, as approved by RHO, for the shall be treated as confidential so as to comply with expeditious resolution of any grievance or all federal and state laws and regulations regarding complaint, the confidentiality of patient records. The Physician's obligations under this Section 11.8 shall II.7 Notification to RHO. Physician represents and survive the termination of this Agreement. warrants that information provided herein and in the RHG provider application is true and accurate in all .11.9 Inspection of Records and Operations. RHO, respects and acknowledges that RHO is relying on Payor or a designated representative, shall have the the accuracy of such information in entering into and right to inspect and audit, at all reasonable times continuing the term of this agreement. Physician during normal business hours, upon prior written shall notify RHO immediately of any investigation, notification, any of Physician's medical records and disciplinary action, sanction, or peer review action operations reasonably pertaining to RHO Qualified against Physician that could result in (i) suspension, Participants, services provided and to Physician's reduction or loss of license to practice Physician's ability to perform under this Agreement. Physician profession or to provide healthcare services; (ii) further agrees to allow RHO, Payor or a designated denial, suspension, restriction, reduction or representative thereof, including the designated termination of privileges or staff membership at any utilization review, quality management, case health facility or by any peer review body; (iii) management or peer review staff,to have-reasonable impairment of Physician's ability to provide access to treatment records and information of healthcare services safely; or (iv) imposition of any Qualified Participants for services provided tinder Page 3 of 11 021802 W.Singleton Revised 121603 04/19/04 .the terms of this Agreement as necessary to enable 11.12 Right to Use Physician's Name. Physician such party to perform Utilization Review and agrees to allow RHO to list Physician's name, Quality Assurance activities in accordance with the specialty, address and telephone number and other applicable Utilization Review and Quality relevant information in a Member Pirovider Assurance Program. In addition, Physician agrees directory, Provider Search, RHO. Site-Specific that in the event an examination concerning the Provider Panel, RHO website and/or other materials quality of healthcare services is conducted by to help promote and solicit contracts with Payors appropriate officials, as required by federal, state, and promote utilization of Physician's services to and/or local law, RHO shall submit, in a timely Payors. Physician agrees not to use RHO's fashion, any required books and records and shall trademarks or trade names without RHG's prior facilitate such examination. RHO and Physician written consent, agree to assist one another with on-site inspection of facilities and records by representatives of 11.13 Noncompliance. Physician understands that authorized federal, state and local regulatory his/her failure to comply with any of the agencies, requirements imposed on him/her pursuant to this r Agreement may result in termination of this 11.10 Relationship of Parties. Physician understands Agreement by RHO. and agrees that he/she is an independent legal entity. Nothing in this agreement shall be construed or I1.14 Antitrust Guidelines. Physician agrees to deemed to create a relationship of employer and comply with all antitrust guidelines and procedures employee, principal and agent, partnership or joint promulgated by Federal and State entities, venture or any relationship other than that of independent parties contracting with each other III, RIIG's OBLIGATIONS solely to carry out the provisions of this Agreement - for the purposes recited in this Agreement. With III.1 Marketing to Payors. RHO shall enter into regard to the provision of medical and healthcare agreements with Payors for their access to RHO services,Physician acts as an independent entity and quality Member Providers through specific referral the Physician-patient relationship shall in no way be processes. RHO will market Member Providers for affected, referral, including but not limited to the following: (i) Provider Search Provider Locator System (i1) Il.11 Standards of Care. Physician agrees that all Provider Directories (iii) Site — Specific Provider duties performed hereunder shall be consistent with Panels (iv) Payor Marketing Force (v) Customized the appropriate practice of medicine, and that such Local Networks(vi) Client Service Referrals. duties shall be performed in accordance with the customary rules of ethics and conduct of the III.2 Credentialina. RHO will perform and/or American Medical Association or American delegate to qualified organizations credentialing of Osteopathic Association, as the case may be, and each Physician. Credentialing may include such other bodies, formal or informal, state, verification of all information and documents government or otherwise, or by which they are provided in the application for participation and subject to licensing/certification and control. investigation of Physicians education, training and Additionally, Physician shall perform all medical practice history, including but not limited to queries and healthcare services in conformance with the to the National Practitioners Data Bank and current standards for his/her specialty as established by the and previous professional liability carriers, Medicare applicable specialty board and the local/regional and Medicaid. medical community. Physician agrees that, to the extent. feasible, he/she shall utilize such additional 111.3 Operational Functions. RHO shall utilize allied health and other qualified personnel as are systems to respond to Member Providers requests available and appropriate for the effective and for information and will provide clarification of efficient'delivery of care. Physician shall ensure that policies concerning the operation of RHO's all such personnel are properly licensed/certified Programs. Physician agrees to work in cooperation and/or possess the necessary credentials to render with RHO to market the services,of the Physician's the services that they perform. to Payors. Page 4 of 11 021802 W.Singleton Revised 121603 04/19/04 RHG shall act as a liaison with the Physicians and the reimbursement rates established in the Exhibit A Payors to devote necessary time and effort to of this Agreement, perform RHO's responsibilities hereunder. IV.3 Bill and/or Claim Forms. Claim forms are IV. REIMBURSEMENT,CLAIMS required for all services, All claims must be SUBMISSION AND PAYMENT submitted complete and accurate on HCFA 1500 and must include Member Providers usual and IV.1 Reimbursement. RHG shall arrange and customary billed charges (not discounted rates) and provide the Physicians, locations and/or any appropriate codes, consistent with policies additional Tax Identification Numbers as listed in established or approved by applicable state and/or Exhibit B for Payors to pay Physician the federal regulations. All claims must be submitted reimbursement rates for Covered Services rendered within thirty (30) days, or within such time period to Qualified Participants pursuant to Exhibit A. from the date of service, or as specified by the state Physician agrees and acknowledges that RHO is rules and regulations. acting solely in an administrative capacity in providing a network of quality health services. RHO IV A Limited Recourse Against Qualified is not the claims paying agent and will not be liable Participants. Except as otherwise provided in this for the payment of any amount owed by a Payor to Agreement (Section I,9), Physician agrees to seek Physician in the event that Physician is unable to payment from each Payor for Covered Services collect such amount of money. provided to its Qualified Participants,and agrees that he/she will not seek additional payments or IV.2 Reimbursement Rates. Physician is to be paid reimbursement from Qualified Participants. In by the Payor according to the rates established in addition, Physician agrees that neither RHO, the Exhibit A. Physician hereby agrees that rates in Payor nor the Qualified Participant shall be billed or Exhibit A,which may be amended from time to time ultimately held responsible for payment for services upon mutual agreement, represent the total amount deemed not to be a covered service by Payor or its to be received and agrees to look solely to the Payor designee. for payment for such Covered Services. Payment will be made for Covered Services actually rendered. When Qualified Participant is covered by a state or All claims will be paid, when appropriate, only after federally regulated occupational injury and illness submission of a complete and accurate claim, RHO program, Physician agrees to comply with state and does not guarantee, represent, warrant or covenant federal regulations regarding holding Qualified regarding the selection or use of Physician's services Participants harmless for amounts not paid by Payor by any Qualified Participant or Payor, or the number for any reason,linclud ng Payors insolvency, of patients, if any, which may result from participation in RHG's provider network, The In the event that services are considered to be a obligation of a Payor to reimburse Physician in Covered Service and the Payor does not make accordance with Exhibit A for the provision of payment, Physician reserves the right to seek Covered Services to a Qualified Participant shall be payment from the Qualified Participant unless the conditioned upon a good faith determination by the Qualified Participant is covered by a state,federal or Payor or its designated representative that (i) such .Payor Occupational Injury and Illness program. services are medically necessary, whether such determinations are made before, on or after the IV.5 Payment of Claims. RHO shall provision of services to such Qualified Participant. administratively arrange for the Payor or its (ii) Physician is in compliance with the Payor's designated representative to pay undisputed claims, utilization management program and /or state rules which are accurate, complete and comply with the and regulations. Agreement within the time period mandated by state or federal law. All services billed under the Tax Identification Number(s) indicated in this Agreement, any IV.6 Erroneous Payment, In the event that a Payor, Amendments, Exhibit A, Exhibit B, Applications or and/or its designated representative pays the any updates regarding locations and/or a Member Physician (i) more than once, or (ii) an incorrect Provider as defined in section I.5 will be subject to amount, or (iii) an overpayment, the Payor or its designated representative may, at its sole option and Paje 5 of 11 021802 W.singleton Revised 121603 04/19/04 discretion, request the return of such amount from any act or responsibility under this Agreement. In Physician. The Physician will not unreasonably the event that a claim is made against RHO, it is the withhold reimbursement. Physician may not intent of RHO to cooperate.in the defense of said contest payment of Claims after one hundred eighty claim. However, RHO shall have the right to take (180)days from the date of service. any and all actions it believes necessary to protect its interest. V. HOSPITAL/FACILITY ADMISSIONS VI.3 Indemnification of Physician. Physician will be responsible for its own acts or omissions and any If a Qualified Participant requires a non-emergency and all claims, liabilities, injuries, suits and demands hospital/facility admission by Physician, Physician and expenses of all kinds which may result or arise shall verify the patient's status as a Qualified out of any alleged malfeasance or neglect caused or Participant, arrange for admission with a Member alleged to have be caused by its employees or Provider and, if required by RHO or the.Payor, representatives, in the performance or omission of secure authorization for such admission prior to the any act or responsibility under this Agreement. In admission in accordance with the applicable the event that a claim is made against Physician,it is Utilization Review and Quality Assurance Program, the intent of Physician to cooperate in the defense of For all other Qualified Participants a Physician who said claim and to cause their insurers to do likewise. does not secure the required prior authorization or However, Physician shall have the right to take any comply with continuing stay review processes under and all actions.they believe necessary to protect their the applicable Utilization Review and Quality interest. Assurance Program, may be denied payment for professional services associated with the Qualified VII. TERM AND TERMINATION Participant's admission, Finally,Physician agrees to cooperate and participate in a coordinated discharge- VII.1 Term. The term of this Agreement shall be planning program as may be established by RHO or for one (1) year from the date hereof and shall be applicable Payor. automatically renewed on an annual basis . for successive twelve(12)month periods, unless sooner VI. INSURANCE AND INDEMNIMCATION terminated in accordance with Section VII,2, VI.1 Insurance Requirement. Physician shall provide VII.2 Termination. This Agreement may be and maintain such policies of professional liability terminated sooner on the first to occur of the insurance or a self-funded program and/or meet the following: credentialing guidelines of RHO. The amounts and extent of such insurance coverage or self-funded VII.2.1 Termination by Physician Physician may program shall be in the amounts determined by terminate this Agreement in the event of a material community standards for relevant specialties,If such default or breach of RHO's obligations hereunder, coverage is under a"claims-made" policy,Rhysieiim upon thirty (30) days prior written notice and the Woes failure of RHO to cure such breach or default within WyerAge. �� , �110atimmim— such thirty(30)day period. In addition, in the event f of an "emergency situation", Physician may Physician shall promptly demonstrate evidence of terminate the Agreement upon thirty (30) days prior insurability or self-funded program and that the written notice and the acknowledgment by RHO that required insurance is paid and in force upon request such an emergency condition does exist. of RHO and/or meet the credentialing guidelines of "Emergency Situation" shall mean an unforeseeable RHO. event,not resulting from Physician's act or omission, which materially affects Physician's ability to VI.2 Indemnification of RHO. RHO will be continue the practice of medicine or to perform his responsible for its own acts or omissions and any obligations hereunder. and all claims, liabilities, injuries, suits and demands and expenses of all kinds which may result or arise VII.2.2 Termination by RHG. A Physician may out of any alleged malfeasance or neglect caused or automatically be terminated on the date when: (i) alleged to have be caused by its employees or Physician's license to practice medicine or other representatives, in the performance or omission of licensed healthcare profession in the state where Page 6 of 11 021802 W.Singleton Revised 121603 04/19/04 .services are rendered, is suspended or revoked, (ii) continue to provide healthcare services to Qualified Physician's medical staff privileges at a participating Participants, and (ii) obligations, promises or facility are revoked or suspended, unless such covenants contained herein which are expressly Physician's privileges are reinstated within twenty made to extend beyond the term of this Agreement. (20) days of such suspension, (iii) Physician's DEA or applicable State Controlled Substance VIIA Qualified Participant and Payor Notification. Registration number required by Section I1.6 above Upon the termination of this Agreement, by either is suspended or revoked, unless such Physician can party, Physician shall cooperate with RHO to notify arrange for other Member Providers to prescribe Payors and Qualified Participants of such regulated drugs for Qualified Participants under the termination, care of Physician within ten(10)days of such loss of such Registration number(s) and gives RHO notice VIII. CONTINUATION OF BENEFITS of the same, (iv) Physician is excluded -from participation in the Medicaid or Medicare programs, V1I1.1 Continuation of Benefits. Upon termination (v) Physician engages in any act, omission, of this Agreement, Physician shall continue to demeanor or conduct that is likely to be detrimental provide services in accordance with this Agreement to patient safety or to the delivery of quality patient to any Qualified Participant currently undergoing care, or(vi) Physician is convicted of a Felony, (vii) treatment by Physician until a medically appropriate Physician is found in violation of professional transfer of care-has been accomplished provided, conduct, or (viii) thirty (30) days following written however, that Physician shall exercise best efforts to notice by RHG of a material default or breach by accomplish such transfer within thirty(30) days after Physician hereunder and the failure of Physician to the date this Agreement terminates. cure such default or breach during such thirty (30) Physician shall be reimbursed for any such Covered day period. Services in accordance with the terms of this Agreement. V11.2.3 Termination for Insolvency. This Agreement shall terminate immediately in the event.that either VI11.2 Survival The provisions of this Article VIII RHO or Physician voluntarily or involuntarily, shall survive the termination of this Agreement liquidates, dissolves or becomes subject to any regardless of the cause-giving rise to such proceeding for the rehabilitation or conservation of termination, as will sections II.8, VI.2, V1.3, VII.3, their financial affairs with written notification IX, and X. The provisions of this Article VIII supersede any oral or written agreement to the VII.2.4 Termination by Either Party. Either party contrary now existing or hereafter entered into may terminate this Agreement without cause upon between Physician and any Qualified Participant or one hundred twenty(120)days prior written notice. any person acting on a Qualified Participant's behalf, V11.2.5 Unforeseen Events. In the ev@pt that either IX. CONFIDENTIALITY party's ability to perform their obligations under this Agreement is substantially interrupted by war, fire, All business, medical and other records relating to insurrection, riots, the elements, earthquake, acts of the operation of RHO, including, but not limited to, God, or other similar circumstances beyond the books of account, general administrative records, reasonable control of such party, the party shall be policies and procedures, pricing information, terms relieved of those obligations for the duration of the of this Agreement and all information generated interruption upon notice to the other party. In the and/or contained in management information event that the interruption is reasonably determined systems owned by or pertaining to RHO, and all likely to persist for at least ninety (90) days, either systems, manuals, computer software and other party may terminate this Agreement upon thirty (30) materials, but excluding patient charts, shall be and days prior written notice. remain the sole property of RHO (collectively, the "Confidential Information"). Physician VII.3 Effects of Termination. Upon termination of acknowledges that the Confidential Information and this Agreement, neither party shall have any further all other information regarding RHO, that is obligation hereunder except for (i) obligations competitively sensitive, is the property of RHO and accruing prior to the date of termination, including RHG may be damaged if such information was without limitation, any obligation by Physician to revealed to a third party. Accordingly, Physician Page 7 of 11 021802 W.Singleton Revised 121603 04/19/04 agrees to keep,strictly confidential and to hold in X.3 Entire Agreement. This Agreement contains trust all Confidential information. Upon termination the entire understanding of the parties and of this Agreement by either party for any reason supersedes any prior understandings and agreements, whatsoever, Physician shall promptly return to RHG written or oral, respecting the subjects discussed all material constituting Confidential Information or herein. containing Confidential Information, and Physician will not thereafter use, appropriate, or reproduce X.4 No Waiver. The waiver by either party of a such information or disclose such information to any breach or violation of any provision of this third party. Physician specifically agrees that under Agreement shall not operate as or be construed to be no circumstances will Physician discuss the terms a waiver of any subsequent breach hereof. and conditions of this Agreement and in particular the pricing information herein, with any Member X.5 Regulatory Compliance. Physician and RHG Provider, healthcare provider or purchaser of agree that each shall comply with all applicable healthcare services. requirements of municipal, county, state and federal authorities, all municipal and county ordinances and X. AUSCELLANE,OUS regulations, and all applicable state and federal statutes and regulations, now or hereafter in force X.1 Di'sputes. All disputes and differences between and effect, governing RHG, Physician the provision the Physician and RHG upon which an amicable of services of-by a Physician, and/or Payors, understanding cannot be reached are to be decided including but not limited to applicable requirements by the following method. under any state or federal fair employment practices, equal employment opportunity, or similar laws X.l.l Mediation through RHG. The Physician shall declaring discrimination in employment based upon notify RHG in writing of the dispute or race, color, creed, religion, sex, or national origin as disagreement, he/she shall supply RHO with all illegal,and,Titles VI and VII of the Civil Rights Act pertinent information and state his/her position on of 1964, Section 202 of Executive Order 11246 as the dispute. Upon receipt of this information, RHG amended by Executive Order 11375, Sections 503 will immediately contact Payor and require the same and 504 or the Rehabilitation Act of 1973 and Title information. RHG will then attempt to mediate the IV of the Vietnam Era Veterans Readjustment dispute to the mutual satisfaction of all parties. If Assistance Act of 1974, and Sections 1 and 3 of mediation is not possible within a reasonable time, Executive Order 11625, or any applicable rule or not to exceed thirty (30) days from the time of first regulation promulgated pursuant to any such laws or notice,the following procedure will apply. orders. X..1.2 Arbitration. If the dispute cannot be solved X.6 Governing Law. This Agreement shall be by the mediation process described above, either the governed by and construed in accordance with Physician, RHG or Payor may elect t9 submit the applicable state law. dispute to binding arbitration under the rules of the American Arbitration Association or any other X.7 Amendments. This Agreement may be method of arbitration mutually agreed upon by the amended as agreed to by both parties in writing upon parties. Arbitration will be conducted in Houston, thirty (30) days written notice of such proposed Texas. Each party will be responsible for their own amendment. legal fees. The cost of the arbitration services will be the sole responsibility of the party requesting the X.8 Severability. The invalidity or un-enforceability arbitration. of any term or condition hereof shall in no way affect the validity or enforceability of any other term X..2 Non-Exclusivity. Nothing in this Agreement or provision. shall be construed to restrict the Physician or RHO from entering into other contracts or agreements to X.9 Assignment. Physician may not assign or provide healthcare services to Payors or other otherwise transfer any right or delegate any duty of healthcare delivery plans, patients, and employer performance hereunder, in whole or in part without groups, the prior written consent of RHG. A change in ownership will not negate the prior contractual agreement without written notification to RHG. Page 8 of 11 021802 W.Snigleton Revised 121603 04/19/04 -RHG retains the right to assign this Agreement, in X.14 Official Notices. Any notice or-communication whole or in part,to any entity with which RHG or its required,permitted or desired to be given hereunder parent company or any of its subsidiaries is shall be deemed effectively given when personally affiliated, or with which it merges or consolidates. delivered or mailed, return receipt requested, or overnight express mail addressed as follows: X.10 Third Party Beneficiaries. Except for Payors and the agents thereof, there are no third party Physician or Representative/Designee:(Please Print) beneficiaries of this Agreement. Name: 1/II ria kf G1�� S/ncrCP t, til.b. X.11 Captions. The captions and headings J contained in this Agreement are for reference Organization: me, d �' �r ��.�•'� � purposes only and shall not affect in anyway the meaning or interpretation of this Agreement. Address: 1 z- 11/L LW ?&2 f lDD X.12 Execution of Counterparts. This Agreement City/State/Zip: / may be executed in any number of counterparts, including facsimiles, each of which shall be deemed Telephone: to be an original as against any part whose signature appears thereon, and all of which shall together Fax: 00 ) 50- 172,9— constitute one and the same instrument, Dl?l�'es alta 6� Gras, Hyl e Organization: X.13 Partial Invalidity, If any part, clause or ,Ydr V provision of this Agreement is held to be void by a Rockport Healthcare Group,Inc. court of competent jurisdiction, the remaining Attn: Director of Network Development provisions of this Agreement shall not be affected 50 Briar Hollow Lane,Suite 515W and shall be given construction, if possible, as to Houston,TX 77027 permit it to comply with the minimum requirements Telephone: (713) 621-9424 of any applicable law, and the intent of parties Fax: (713)621-9511 hereto, or to such other address,and to the attention of such other person(s)or officer(s)as either party may designate by written notice. IN WITNESS WHEREOF, the undersigned will be deemed to have executed this Agreement as of the date this Agreement is signed by RHO. For and on behalf of: For and on behalf of; Rockport Healthcare Group,Inc. Physician or Representative/Designee 50 Briar Hollow Lane,Suite 515W Houston,.T 27 Signature:4 �� X Name: Mark C. er (Print Sr. Vice P esident,Bu cess eve opment TIN: 75 "2 5rl 5��� Date; / 7 4 Date: Page 9 of 11 021802 W.Singleton Revised 121603 04/19/04 EXHIBIT A Reimbursement Schedule I, Rockport United Network- Occupational Injury and Illness Provider fees for the programs listed above shall be reimbursed at the following: The following fees will be reimbursed at the following rates: 99499 100%of TWCC fee schedule 99080-73 100%of TWCC fee schedule 99456 100%of TWCC fee schedule 99075 100%of TWCC fee schedule All other fees will be reimbursed at90%(ninety percent)of the state's mandated fees,rules and regulations or usual and customary allowables. Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of the applicable Occupational Injury or Illness Benefit Plan or applicable state rules and regulations. II. Rockport Community Network, Inc, -Accident& Health Provider fees for the programs listed above shall be reimbursed at the following: All fees will be reimbursed at 90% (ninety percent)of billed charges. Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of the applicable Benefit Plans. I/We accept the fees as outlined in this Exhibit A. For and on behalf of: For and on behalf of: (Name,address,etc.) ROCKPORT HEALTHCARE GROUP,INC. 50 Briar Hollow Lane,Suite 515W IzIllyk Z6A-;7 Lo # Houston,TexM772 �r 6053 Signature Mark C.Neer Prhrted Naame �P16fti% /�2C�2T�7� /7 Sr.Vice President,Bus'less DeIQP meat Title Date TIN 7S'2.Sq 3�9g Date Page 10 of 11 021802 W.Singleton Revised 121603 04/19/04 EXHIBIT B Physicians and/or locations where services are to be rendered by Member Provider The Member Provider agrees that the following facility locations and/or physician practice locations listed on attached Exhibit B,which shall be inclusive of the signed agreement and the signed rates in Exhibit A. By signing below Member Provider or its Representative/Designee allows Rockport Healthcare Group,Inc.(RHG)and its representatives to use any and all of the below information as agreed to in section II.12 of the signed agreement. Pra ti e Name 1) Practice Name (2) l Mysi ian Name(if ap le)� Lbs 6larl ?y/et" . Physichm Name(if applicable) !�l Physical� Address Physical Address Ni= low✓ 820 10/4y �ursf/�7Gdr3 Billing Address0Billing Address Mail' Address (if different) Mailing Address(if-different) 'T171) s - 2s -i7 5175:/7a 7. Phone Number/ ax umber Phone Number/Fax Number TIN Number TIN Number Practice Name (3) Practice Name (4) Physician Name(if applicable) Physician Name(if applicable), ,Physical Address Physical Address Billing Address Billing Address Mailing Address(if different) Mailing Address(if different) Phone Number/Fax Number Phone Number/Fax Number TIN Number TIN Number For and on behalf of: For and on behalf of: Rockport Healthcare Group,Inc. Member Provider or Representative/Designee 50 Briar Hollow Lane,Suite 515W Houston,TX 7702 Signature: ,( Name: d W) Marls C.Nee (grin) Sr.Vice Pre ldent B sines v opment Date: Date: 0 V Page 11 of 11 021802 W.Singleton Revised 121603 04/19/04 , .� ., Nae RT T-63AV1'Ef-C-AI7tIV ADDENDUM TO AGREEMENT (Rockport Healthcare Group,Inc.) The parties hereby agree that this Addendum for a compensative injury in question is not be incorporated into the existing Agreement, specifically addressed by the treatment effective 512-1.12z04 entered into,by guidelines used by the Client and/or Payor. and between W r 1 ct"'4' W S+nA Un r However,Member Provider must demonstrate medical necessity to support (Memb6r Provider)and Rockport services-rendered to Qualified Participants Healthcare Group,Inc.,a Delaware that are outside of treatment guidelines. -Corporation("RHG"), dba Rockport United Network(a preferred provider network for (4)Retaliatory-Action: RHG agrees not to Occupational Injuries and Illnesses); engage in any retaliatory action including Rockport SelectHealth Network(an termination of contract or refusal to renew a exclusive provider network). contract against Member Provider,because Member Provider,on behalf of an Qualified Pursuant to §10.42 of Texas Insurance Code Participant,reasonably filed a complaint 1305 regarding Network Contracts with against,or appealed a decision of RE-IG or Providers seeking to participate in Texas Payor,or requested reconsideration or Certified Workers' Compensation Networks, independent review of an adverse determination. (1)When a Qualified Participant is covered by a state or federally regulated (5) Continuity of Treatment: Occupational Injury and Illness program, Member Provider and Provider Network (5A)If Member Provider leaves the . agree to comply with state and federal network,upon the Provider's request,the regulations regarding holding Qualified Client and/or Payor is obligated to continue Participants harmless for health care to reimburse the provider'fox a period not to services for compensible injuries not paid by exceed 90 days at the contracted rate for Payor under any circumstances,including care of a Qualified Participant with a life- Payor's or network's insolvency. This threatening condition or an acute condition provision does not preclude billing a non- for which disruption of care would harm the Qualified Participant for a non-compensible Qualified Participant. injury. (5B)Member Provider shall use best efforts (2)Treatment Guidelines: Member Provider to comply with RHG's criteria for provider agrees to follow the treatment guidelines, participation,including credentialing . return-to-work guidelines and individual policies and procedures, complaint treatment protocols outlined in Exhibit A of processes as identified in the RHG Provider this Addendum provided in RHG's Provider Handbook,Member Provider shall Handbook and/or Clients'Utilization cooperate with RHG's periodic evaluation of Review Programs, qudlifications and Clients'Utilization Review programs', In addition,Member (3)The Client and/or Payor may not deny Provider shall use best efforts to cooperate treatment solely on the basis that a treatment and comply with RHG's and/or state rules Page 1 of 5 and regulations for the expeditious can arrange for other Member Providers to, resolution of any grievance or complaint.A prescribe regulated drugs for Qualified dispute concerning continuity of care shall Participants under the care of Physician be resolved through the complaint resolution within ten(10) days of such loss of such process. Registration number(s) and gives RHG notice of the same, (iv) Physician is (6)Termination of network provider status excluded-from participation in the Medicaid (except for termination due to contract or Medicare programs, (v)Physician expiration)and applicable written engages in any act, omission, demeanor or notification to employees receiving care conduct that is likely to be detrimental to regarding such termination: patient safety or to the delivery of quality patient care,or(vi)Physician is.convicted of. (6A)RHG will provide notice to the a Felony, (vii) Physician is found in Member provider at least 90 days before the violation of professional conduct, or(viii) effective date of a termination by RHG; thirty(30)days following written notice by RHG of a material default or breach by (6B)Upon receipt of the written notification Physician hereunder and the failure of of termination,a Member Provider may Physician to cure such default or breach request in writing a review by the network's during such thirty(30) day period. advisory review panel no later than 30 days after receipt of the notification; (60)If Member Provider terminates the contract,RHG's Client will provide (6C)Utilization Review Agent for network notification of the termination to employees will provide an advisory review panel that receiving care from the terminating consists of at least three Providers of the provider.The network shall give such notice same licensure and the same or similar immediately upon receipt of the Member specialty as the Member Provider; Provider's termination request or as soon as reasonably possible before the effective date (6D)Utilization Review Agent for network of termination; must complete.the advisory panel review before the effective date of the termination; (7)The Member Provider is required to post, in the office of the Member.Provider, a (6E)The Client,Payor,or RHG may not notice to employees on the.process for notify patients of the termination until the resolving workers' compensation health care earlier of the effective date of'the network complaints. The notice must termination or the date the advisory review include the Texas Department of Insurance's panel makes a formal recommendation; toll-free telephone number for filing a complaint and must list all workers' (0)A Physician may automatically be compensation health care networks with terminated on the date when: (i)Physician's which the Member Provider contracts; license to practice medicine or other licensed healthcare profession in the state (8)Member Provider agrees to abide by,the where services are rendered,is suspended or list of any treatments and services that .revolted, (ii) Physician's medical staff require the networks'preauthorization and privileges at a participating facility are any procedures to obtain preauthorization revolted or suspended,unless such according to those listed on Exhibit A of Physician's privileges are reinstated within. Addendum. twenty(20) days of such suspension, (iii) Physician's DBA or applicable State Controlled Substance Registration number required by Section 11.7.1 above is suspended or revoked,unless such Physician Wage 2 of 5 (9)Member Provider agrees and provider will be made in accordance with acknowledges that RHG is acting solely in Labor Code§408.027 and other applicable an administrative capacity in providing a statutes and rules, network of quality health providers. RHG is (13)Member Provider agrees to provide` not the claims paying agent and will not be treatment for Qualified Participants who liable for the payment of any amount owed obtain workers' compensation healthcare by a Payor to Member Provider in the event services through the network that is that Member Provider is unable to collect specifically identified in the contract as a 'such amount of money up to and including contracting party, "Qualified Participant" the insolvency of the Payor. 'means a person who sustained a work- related injury/illness that is determined (10)Regulatory Compliance;Member eompensible by an employer that Provider and RHG agree that each shall participates in the Rockport United Network comply with all applicable requirements of or Rockport SelectHealth Network through state and federal statutes,rules and Rockport's Client. Unless in an emergency regulations,now or hereafter in force and or after business hours,initial services effect, provided for the work-related injury/illness require authorization by the Employer (11)Primary Treating Physician/Clinic and/or network either in writing or by means a Member Provider who is a Medical telephone. Doctor(MD) or a Doctor of Osteopathic Medicine(DO)that specializes,in Family (14)Neither a Client,a Payor,nor RHG may Practice,General Practice,Occupational use any financial incentive or make a Medicine or Internal Medicine and whose payment to a health care provider that acts practice is.largely dedicated to caring for directly or indirectly as an inducement to work related injuries and illnesses and is limit medically necessary services.The designated by RHO as a Primary Treating adoption of treatment guidelines,return-to- . physician/Clinic(PTP). PTP agrees to work guidelines, and individual treatment render medical care to Qualified Participants protocols by a network is not a violation of ,without a scheduled appointment and this section. operate during normal business hours, Monday-through Friday of any given week (15)Client and/or Payor or RHG must excluding recognized holidays. provide written notice to a Member Provider or group of Member Providers before the (12)Bill and/or Claim Forms:- Claim forms Client/Payor or RHG conducts economic are required for all services. All claims profiling,including utilization management must be submitted complete and accurate on studies comparing the provider to other HCFA 1500 or UB-92 form(or their providers,or other profiling of the provider successors)and must include Member or group of providers. Provider's usual and customary billed 16 A11 terms and conditions to Agreement charges(not discounted rates)and ( ) appropriate codes, consistent with policies including the Reimbursement Fee Schedule established or approved by applicable state remain in effect.if there should be any and/or federal regulations. All claims must question,dispute,or conflict of the terms be submitted within thirty(30) days, or and conditions between the Agreement and within such time period from the date of the Addendum,the Addendum supercedes service,or as specified by the state rules and any and all other terms or conditions. regulations,Billing by and payment to the Page 3 o£5 05('1'1/2006 'l b:2b H1 t-b9b-17'2 t W 51NULL 1 UN t(AUL UJI uj --• .-vvv +r.6 .6 (tJUL17:.f11 NUUKPLJRT PAGE FIF.� Rew 24d IN Wi';'N ESS WH"'E'PF,t r N rkies hepta through their authorized repMcntatim have agreed to ft Addend=ef'foadve the date of executiop by go d, For and On behalf of. For mud on behalf of 10 Briar 74t„?jvw T.ane,$15 W Hauatoti,,Texas 7702 ,Mark C.14cor Sr.Vico Preside pt sf D clopment Title �atG lax u� . Page 4 of 5 EXHIBIT A STANDARDS AND GUIDELINES UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS RHG and its Clients require Member Providers to follow nationally recognized treatment guidelines (i.e, Official Disability Guidelines(ODG) and/or American Occupational and Environmental Medicine's (ACOEM) guidelines) in the treatment ofwork-related injuries/illnesses for Qualified Participants, RHG's Clients provide utilization review and quality improvement programs for Qualified Participants, RHG shall review each Clients Utilization Review and Quality Improvement Program in accordance with RHO's Credentialing Standards and Guidelines as described in this Exhibit. Physician and/or Member Provider agrees to comply and be bound by such programs and any state or federal rules and regulations, Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written notice to Physician and/or Member Provider. The primary goals of the Utilization Review Programs shall be to: 1) Ensure and certify for the payment of benefits that healthcare services meet the,definition of medical necessity as defined by the network,Payor or the Payors designee; 2) Ensure that healthcare services are provided at the appropriate level of care;and 3) Ensure that healthcare services follow nationally recognized treatment guidelines that are evidenced-based and outcome-focused. Treatments and Services that may Require Preauthorization: 1) In-patient hospital admissions including the principal scheduled procedures(s)and the,length of stay; 2) Outpatient surgical or ambulatory surgical services; 3) Spinal surgery,as provided by Texas Labor Code§408.026; 4) All psychological testing and psychotherapy, repeat interviews, and biofeedback;•except when any service is part of a preauthorized or exempt rehabilitation program; 5) All external and implantable bone growth stimulators; ,6) All chemonucleolysis; 7) All myelograms,discograms,or surface electromyograms; 8) Unless otherwise specified,repeat individual diagnostic study,with a fee established in the current Medical Fee Guideline of greater than$350 or documentation of procedure(DOP); 9) Work hardening and work conditioning services provided in a facility that has not,been approved for exemption by the Division; 10) Rehabilitation programs to include (a) outpatient medical rehabilitation and (b) chronic pain management/ interdisciplinary pain rehabilitation; 11) All durable medical equipment (DME) in excess of$500 per item (either purchase or expected cumulative rental)and all transcutaneous electrical nerve stimulator(TENS)units; 12) Nursing home,convalescent,residential,and all home health care services and treatments; 13) Chemical dependency or weight loss programs; 14) Any investigational or experimental service or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care;and 15) Physical and occupational therapy services;(a)physical and occupational therapy services are those listed in the Healthcare Common Procedure Coding System -(HCPCS) bevel I codd-farige"for Physical Medicine and Rehabilitation, but limited to: (i) modalities, both supervised and constant attendance; '(ii) therapeutic procedures,excluding work hardening and work conditioning;and(iii) other procedures,limited to the unlisted physical medicine and rehabilitation procedure code. NOTE:Preauthorization is not required for the first two visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediately following: (i) the date of injury,or(ii)a surgical intervention previously approved by the payor, Page 5 of 5