Loading...
HomeMy WebLinkAboutContract 47186-P1 A CITY SECRETARY � CONTRACT X10,� LP� ADDENDUM To BIa9kStone 504 Program 1?rovldor Agreement This Addendum is entered into by and among DEW Qenter for SyJnal Dtsordeis ("Me er Provider"), Rockport althcare G�9up("Rookport"), and the City of Fort Worth ("City") on this day of 20�, WHEREAS,Rockport and Member Provider entered into a Provider Agreement, effective February 15, 2013, ("Provider Agreement"), and desire that this Addendum apply to covered services that are governed by ilia Texas Insane Code,Taxes Labor Code,and Texas Administrative Code, WHEREAS,Rockport has contracted with Member Provider on behalf of the City in the process of setting up a direct contracted 504 provider panel pursuant to Texas Labor Code Section 504.053. WHEREAS, the City has determined that a workers'compensation health care network eertlfied tinder Texas Insurance Code Cliapter 1305 is not available or practical for its self-insured workers' compensation program needs and,as such,have elected to provide medical benefits to injured workers by directly contracting with health care providers, WHEREAS, Rockport,Member Provider, and the City desire to execute this Addendum in order to establish a direct contract between Member Provider and the City under Texas Labor Code Subsection 504.053(bx2), WMREAS,Rockport,Member Provider,and the City desire for the terns and conditions of the Provider Agreement to be the same terms and conditions that apply to the direct contract between Member Provider and the City that make available covered services for Qualified Participants'needs to the injured workers ofthe City, NOW,71-73RUORE,for good and valuable consideration,the sufficienoy and receipt of which Is hereby acknowledged,the parties agree.as follows; 1, All terms and conditions of the Provider Agreement are hereby adopted by both Member Provider and the City, with full consent and agreement of Rockport, to apply as a direct contractual agleement behveen Member Provider and the City.All references to certified networks as well as the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413.041 of the Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under section 504.053 of the Texas Labor Code, The City's Provider Manual (under the name of BlackStone) sball instead apply to matters of notico, billing, dispute resolution, complaints, preauthorization,and related matters, ' 2. The parties agree that ilia City will bear the financial responsibility for payment to Member Provider under the terins of the Provider Agreement subject to the applicable Provider Manual and the provisions of the Texas Labor Cade and applicable rules under the Texas Administrative Code, Rockport will continue to provide applicable network administrative services. 3. Witea used in this Addendtim,unless the content otherwise clearly requires,the following words and terms shall have the meaning set forth below, All other defined terms shall have the meaning ascribed to thein in the Provider Agreement. OFFICIAL RECORD CITY SECRETARY FT.WORTH)TX i i i f DF W Center for Spinal Disorders provider Agreement i "Payors" will be the City as they are responsible for payment of medioal benefits for compensable injrnies and or illnesses sustained by Its injured workers according to the ! Texas Workers Compensation Act. I ,Blackstone"is the 504 Provider Panel established by the City of Port Worth through this and other direct contracts using Rockport as its contracting agent "Provider Manual"means the Blackstone Provider Manual as amended from time to time and available upon request to the Member Provider. "Provider Panels"ate those d mot contracted panels foamed by political subdivisions or public pool entities authorized by Section 504.053 of tfae ToRas Labor Code, 4. Member Provider agrees to participate in the Blackstone provider panel for the benefit of the City and Qualified Participants. S. Nothing in this Addandnm or the Provider Agreement waives sovereign immunity or creates a new cause of action, 6. All other terms of the Provider Agiveanent shall remain in force and unchanged. Any conflicts between this Addendum and the Provider Agreement shall be superseded by the terms provided herein. IN VnTNPSS V/Mt REO}{,the parties hereto kava executed this Addendum emotive on the day and year { first written above. i For and on behalf of: City of Fort Worth I I IilaeltSfoaae I signature, Name: �usan, (anis Title: Assistant City Manager Date: -NPPROVED AS TO FORM AND LEGALITY: / ��fj0000p0 yCA �/ I I IJI)l1' ®O° p �O 1 S�CITY ATTORNEY RECORD Xtks�ad by: , °°$�� Fv. W010"t'iX Maty . yser, ity Seamy 5 DFW Center for Spinal Disorders Provider Agreement ROCIQ'ORT HEALT11CARE GROUP Signature: Name: LAX, Title; A • (� 1 I .. Date,• 3d i i MEMBER PROVIDER or Representa tive/Designee Signature: I Name; �1iCv,•. ��Ley MeD Title: 5�'��1���lf Date: �� TIN:26-3968733 I I I ' i 3 Fax Server b RuIr" C l 1 P 0 R T ` .PHYSICIAN AGREE VWM ROCKPORT UNITED NEM01M ROCKPORT SELECTHEALMI NEMOM This Physician Agreement("Agreement'),is entered L DEFIMTIONS into by and between Rockport Community Network, Jnr,., •a Nevada Corporation, dba Rockport When used in this Agreement and unless the content Healthcare Group ("RHG"), dba Rockport United otherwise clearly requires,the following words and Network (a preferred provider network for terms shall mean: Occupational. Injuries and Illnesses), dba Rockport SelectHealth Network (an exclusive provider 11 TPhysician"means a licensed Medical Doctor or network) and Jmoit Tinley, MD {"Member Doctor of Osteopathic Medicine, or group of same Provider"),and will became effective as of the date who desire to become a Member Provider with the provider is.fully credentialed by RHG, RHG. WHEREAS, RHG is engaged in the business of Pursuant to §10.42 of Texas Insurance Code 1305 developing and acting in an-administrative capacity regarding Network Contracts with Providers seeking in providing Occupational Injury and health provider to participate in Texas Certified Workers' networks that offer direction of care while providing Compensation Networks, savings to RHG clients and/or Payors. These networks will offer greater coverage of services and L2 "99alified Participant" means ail "employee" as savings;and defined and used in the Texas Labor Code, the Network Act Section 1305 and the implementing WHEREAS, RHG has networks of contracted rules who sustained a work-related injurylillness that physicians, physician groups, hospitals and is determined compensible by an employer.and that providers of ancillary ,healthcare services participates in the Rockport United Network or (collectively,the "Member Providers")to provide a Rockport SelectHealth Network through Rockport's full-range of healthcare services. These services are Client. Unless in an emergency or after business available for use by "Qualified Participants" as hours, initial services•provided for the work-related defined in 1.2 of this Agreement;and injury/illness require authorization by the Employer WHEREAS, Member Provider desires to provide and/or network either in writing or by telephone. medical care services to "Qualified Participants" 1.3 "Client" means an insurance company, certified who are covered by Payor Agreements at the rates in self-insured or governmental entity as those terms ExlAit B and in locations listed in Exhibit C:and are defined and used in the Texas Labor Code,the Network Act Section 1305 and the implementing WHEREAS,RHG has entered into Agreements with rules. These Clients have entered into a Client one or more Payors who provide payment of claims Agreement with RHG for the provision of healthcare for medical care rendered to Qualified Participants. services to Qualified Participants. NOW, THEREFORE, in consideration of the 1.4 "Pa or" means an insurance carrier or network premises,the mutual promises contained herein,and certified by an insurance carrier for its own benefit, other good and valuable consideration, the receipt certified self-insured or governmental entity as those and sufficiency of which are hereby acknowledged, terms are defined and used in the Texas Labor Code, it is mutually agreed as follows: the Network Act Section 1305 and the implementing rales who is responsible for payment of medical benefits for on the job injuries-and or illnesses according to State and/or Federal Rules and Regulations. Page 1 of 14 0039B7C0.002XOC RUNPRY TX 01-2012 E x-t t!cu.LL G:44:UZ PM PAGE 6/425 Fax Server I.5 "Client Agreement" means the agreement specialty to maintain their RHG classification as between RHG and a Client, winch agreement is such and be willing and able to treat.Qualified made before, on or after the effective date of this Participants as needed or required., Agreement and which expresses the agreed upon contractual rights and obligations of the parties. 1.9 "Emercy Medical or Mental Condition" is Such Client Agreements will require Payors to pay defined as the sudden onset of a medical condition Member Provider for Covered Services rendered to manifested by acute symptoms of sufficient severity, Qualified Participants pursuant to this Agreement, including severe pain,that the absence of immediate Furthermore, such Client Agreements shall authorize medical attention could reasonably be, expected to RHG to enter this Agreement and contractually bind result in: Payors to the terms hereof unless there is a conflict (a)placing the patient's health or bodily functions in with,State and/or Federal rules and regulations. serious jeopardy;or I.b "Member 'Provider" means any phy (b)serious dysfunction of any body organ or part as sician; defined in TIC 1305.004(13);and physician group;hospital;surgery center,diagnostic (c)in the case of a mental health condition,one that imaging center, laboratory; clinic; chiropractor; could reasonably present danger to the person dentist; podiatrist psychologist; social worker; experiencing the mental health condition or another physical, occupational and speech therapist; etc. person as defined in nC 1305.004(15). licensed or certified to practice a healthcare profession or licensed as a facility to offer healthcare 1.10 "Coyered Services" are those healthcare and services,in the state where services are rendered and health.-related services provided to Qualified who has executed a contract with RHG, Participants for treatment of a compensible, work related injury/illness as defined by either nationally I.7 "Pr' 'Treatin ysieian/Clinie" According recognized treatment guidelines and/or individual to'Texas law for certified workers' compensation treatment protocols that do not conflict with any networks, the Network decides who will be a state and/or federal rules and regulations. 'Keating Doctor.Therefore,a Member Provider who is a Medical Doctor (MD) or a Doctor of 1.11 "Bill and/or Claim Form" CMS 1500(or other Osteopathic Medicine (DO) that specializes in appropriate claim form or their successors) Family Practice, General Practice, Occupational completed in accordance with the guidelines Medicine or Internal Medicine as well as a physician established by the National Uniform Billing that provides initial and/or follow-up care in Occ- Committee or CMS 1500 billing guidelines, and/or Med or Urgent Care Clinics whose practice is state rules and regulations. largely dedicated to caring for work related injuries and illnesses is designated by RHG'as a Primary II. IYIEMER PRODDER OBLIGATIONS Treating Physician/Chnic (PTP). PTP agrees to render medical care to Qualified Participants without 11.1 Services. Member Provider agrees to provide or a scheduled appbintment and must be available and arrange for all medically necessary medical care for accesible to employees twenty-four (24)hours per- Qualified Participants who present themselves to day, seven (7) days-per-week as per 28 TAC Member Provider. Member Provider agrees to 10.80(b)(1). Should a Qualified Participant need perform such services with the same standard of medical attention outside of Member Provider's care, skill and diligence for all Qualified normal business hours, Member Provider will be Participants. Member Provider agrees that it is their available and/or make arrangements to have another sole responsibility to verify that the individual Member Provider render care to Qualified presenting for care is a Qualified Participant, Participant twenty-four(24)hours-per-day,seven(7) Member Provider agrees -to render healthcare days-per-week. services to Qualified Participants at any and all facility or practice locations listed in Exhibit "C". L8* 1st Physician" means a Member Provider Member Provider shall make best efforts to ensure who has met the credentialing requirements of RHG that services provided are consistent with nationally to be a Specialist Physician, and to whom Primary recognized treatment guidelines (i.e. Official Treating Physicians/Ciinies may refer for necessary Disability Guidelines (ODG), American and authorized care other than primary treating Occupational and Environmental Medicine's services. Specialists will need to .:maintain their (ACOEM) and /or state rules and regulations. i current board certifications for their particular Page;2 of 14 0039BIC0.002DOC RUNP.HY TX 01-2012 -- —�. •, w� 4:of:v4 rm rAUE 7/025 Fax Server Member Provider agrees to comply with and be L6 Reports. For each encounter where Member bound by all State/Federal Rules-and Regulations. Provider provides services to a Qualified Participant, 11.2 Treatment Guidelines. Member Provider agrees Member Provider shall report such encounter on an to follow the treatment guidelines, return-to-work appropriate form and shall include statistical, guidelines and individual treatment protocols descriptive medical and patient data and identifying outlined in Exhibit A of this Agreement,provided in information, if and to the extent that reports are RHG's Provider Handbook and/or Clients' specified by RHG, Client or its designated Utilization Review Programs.REG agrees to furnish representative, and requested information is not Member Provider or cause Payor to furnish to prohibited by state and/or federal rules and Member Provider, and Member Provider agrees to regulations. abide by,the list of any treatments and services that require preauthorization and by any procedures to 117 Professional Requirements. obtain preauthorization. Unless in an emergency or after business hours,initial services provided for the 117.1 Licensure&Accreditation. Member Provider work-related -injury/illness require authorization by shall comply with all applicable federal, state and the Employer and/or Network either in writing or by local laws, rules and regulations governing like telephone. The Client and/or Payor may not deny providers and their provision of services. Evidence treatment solely on the basis that a treatment for a of such current licensing, certification and/or compensible injury in question is not specifically accreditation shall be submitted promptly to RHG addressed by the treatment guidelines used by the upon request. Member Provider represents and Client and/or Payor. However, Member Provider warrants that it and each of its employees and must. demonstrate medical necessity to support contracted service providers has obtained,and shall services rendered to Qualified Participants that are maintain throughout the term of this Agreement, all outside of treatment guidelines. necessary registrations, certifications, licenses, permits and approvals as are required for the lawful II.3 Non-Discriurination.Member Provider shall not provision of Member Provider services to Qualified differentiate or discriminate in the treatment of its Participants. Member Provider shall immediately patients as to the quality of services delivered to notify RHG of any revocation, suspension: or Qualified Participants because of race, ser, age, restrictions, that would affect any certifications, religion, national origin, place of residence, source licenses or accreditation's. Member Provider of payment or health status. Member Provider shall warrants that it is currently accredited by the Agency observe,protect and promote the rights of Qualified that governs like providers and is certified as a Participants, provider under,Title XVIII (Medicare) and when ' appropriate, Title XIX (Medicaid) of the Social IIA Medical Staff Partie�on. Certain medical Security Act and that it shall maintain such specialties may not require hospital privileges such accreditation and certification during the term of this as Occupational Medicine,Pathology,Dermatology, Agreement. Member Provider shall immediately Allergy, and those Primary - Treating notify RHG of any action, investigation or Physicians/Clinics whose practice is dedicated to proceeding to revoke, suspend,restrict,or otherwise treating work-related injuries and illnesses. Where affect such accreditation or certifications. appropriate. Physicians must maintain active, unrestricted staff privileges with at least one RUG 11.7.2, C3tganization's Requirements, Member Member- Provider hospital ' or Surgery Center. Provider shall use best efforts to comply with RHG's Physician hereby consents to disclosure by such criteria. for provider participation, including facility to REG of all data collected with respect to credentialing policies and procedures. Member Physician in connection with Physician's medical Provider shall cooperate, with RHG's periodic staff membership, including without limitation"all evaluation of qualifications. In addition, Member applications for staff privileges and any renewals Provider shall use best efforts to cooperate with thereof RHG's and/or state rules and regulations for the expeditious resolution of any grievance or 11.5 Referrals. Except in a medical emergency or complaint. when authorized by RUG, Client, or its designated representative, Member Provider agrees to refer "11.8 . Notification to RUG. Member Provider Qualified .Participants only to other Member represents and warrants that information provided Providers,as defined in 16. herein and in the RHG application is true and Page,3 of 14 0039117C0.002.DOC KNPFIY ; 01-2012 4;�'%;VZ YM PACrE 8/025 Fax Server i i accurate in all respects and acknowledges that RHG business days, any Of Member Provider's medical is relying on the accuracy of such information in records and operations reasonably pertaining to entering into and continuing the term of this RHG Qualified Participants, services provided to agreement. In addition Member Provider shall use Qualified Participants, and to Member Providers best efforts to provide written notice to RHG of any performance under• this Agreement. Member (i)suspension,reduction or loss of license to provide Provider further agrees to allow RHG, payor or a healthcare services; (ii) denial, suspension, designated representative thereof, including the restriction, reduction or termination of designated utilization review, quality management, accreditation/certification; (iii) changes in Federal case management or peer review staff, to have Tac Identification Number(s),(iv)other information reasonable ,access to medical records and provided in its application or Exhibit C forinformation of Qualified Participants for services participation, (v) Member Provider's professional provided under the terms of this Agreement as liability insurance if such insurance falls below the necessary to enable such party to perform Utilization requirements of state law and (vi) Member Review and- Quality Assurance activities in Provider's billing or facility address. . A failure to accordance with the applicable Utilization Review give any notice required by this Section shall be-a and Quality Assurance Program, In addition, material breach of Member Providers obligations Physician agrees that in the event an examination and responsibilities hereunder, regardless of the concerning the quality of healthcare services is status,pendency or outcome of the event giving rise conducted by appropriate officials, as required by to the obligation to give that notice, and may be federal,state,and/or local law,REG shall submit,in grounds for termination of this Agreement. a timely fashion,any required books and records and shall facilitate such examination, RHG and IG9 Medical Reeords. Member Provider shall Member Provider agree to assist one another with maintain complete and timely medical records for' on-site inspection of facilities and records by Qualified Participants treated by Member Provider representatives of authorized federal, state and local and its medical staff. Such records shall be prepared regulatory agencies in accordance with accepted principles of practice, shall document all services performed for Qualified II.11 Relationship of Parties. Member-Provider and Participants and shall comply with all applicable RHG understands and agrees that they are each an state and federal laws. Member Provider shall independent legal entity. Nothing in this agreement maintain such records for the length of time required shall be construed or deemed to create a relationship by applicable state or federal law, Subject to all of employer and employee, principal and agent, applicable privacy and confidentiality requirements, partnership or joint venture or any relationship other such medical records shall be trade available to each than that of independent parties contracting with Member Provider and other health professionals each other solely to carry out the provisions of this treating the Qualified Participant, and upon request, Agreement .for the purposes recited in this to the Payer, RHG or its designated representative Agreement. With regard to the provision of for review at the rates approved by State law and as healthcare services, Member Provider acts as an set forth in the current State Workers'Compensation independent entity and the Member Provider-patient Reimbursement Manual for Hospitals,if applicable, relationship shall in no way be affected. Member Provider shall obtain a valid consent for the release of the Qualified Participant's medical records H.12 Standards of Care. Member Provider agrees to other providers, RbIG, Payor, or its designated that all duties performed hereunder shall be representative. RHG agrees that medical records of consistent with the proper practice of their Qualified Participants shall be treated as confidential healthcare profession, and that such duties shall be so-as to comply with all federal and state laws and performed in accordance with the customary rules of regulations regarding the confidentiality of patient ethics and conduct of the appropriate and applicable records. The Member Provider's obligations under professional organizations and/or associations,as the this Section II,9 shall survive the termination of this case may be,'and such other bodies, formal or Agreement, informal, state, government or otherwise; or by which they are subject to licensing/certification and 1110 Inspection of Records and Operations. RHG, control. Additionally, Member 'Provider shall Payor or a designated representative shall have the perform all medical and healthcare services in right to inspect and audit, at all reasonable times conformance with the standards for their facilities as I during normal business hours, upon prior five (5) established by the local/regional professional Paged of td 003987C0.002J)OC RUNPHr TX 01-2012 I PALiE 9/025 Fax Server healthcare community and applicable (i) Provider Search Provider Locator System (ii) ace.rediting/licensing agencies. Member Provider Provider Directories (iii) Site-Specific Provider agrees that:to the extent feasible,it shall utilize such Panels (w) Customized Local Networks and (v) additional allied health and other qualified personnel Client Service Provider Referral Service. as are available and appropriate for effective and efficient delivery of care. Member Provider shall 111.2 Credentiatmg. RHG will perform and/or ensure that all such personnel are properly.licensed delegate to qualified organizations credentialing of and/or possess the necessary credentials to render each Member Provider. Credentiaiing may include the services that they perform. verification of all -information and documents provided in the application for participation and IL13 Right to Use Member Provider's or Network's investigation, including but not' limited to Name. Member Provider agrees to allow JZHG to verification with all state and national licensing and list Member Provider's name, specialty, address, certifying bodies that apply to the services rendered telephone number, and hours of operation in a by the Member Provider, such as J'CAHO,AAAHC, Member Provider directory, Provider Search, RHG NCQA, CLIA, URAL, etc. Inquiries may also be Site-Specific Provider Panel(s), RHG website and/ made to current and previous professional liability or other materials to help promote and assist Clients carriers, Medicare and Medicaid. RHG's with Qualified Participants needing medical care for credentialing policies and procedures follow the injuries/illnesses sustained. RHG agrees to allow American 'Accreditation Healthcare Commission Member Provider to list RHG's name, address, and (URAL) and/or NCAA standards for Workers' telephone number on Member Provider's website or Compensation provider networks. in other publications listing the health plans accepted by Member Provider.In addition,Member Provider M3 Operational Functions. RHO shall utilize agrees to post in waiting room and make available to systems to respond to Member Providers requests Qualified Participant notice of Member'Provider's for information and will provide clarification of participation with RHG with name, address and policies concerning the operation of RHG's telephone number and process for Qualified programs. Member Provider agrees to work in Participants to resolve complaints. The Member Cooperation with RHG to market the services of the Provider is required to post, in Member Provider's Member Provider to Clients and/or Payors. office, notice to employees on the process for resolving workers' compensation ' health care RHG shall act as a liaison with the Member network Complaints. The notice must include the Providers and Clients and/or Payors to devote Texas Department of Insurance's toll-free phone necessary time and effort to perform RHO's number for filing a complaint and must list all responsibilities hereunder. workers' compensation health one networks with which the Member Provider contracts. 111.4 Retaliatory Action.RHO agrees not to engage in any retaliatory action.including termination of IL14Noncompliance.Member Provider understands contract or refusal to renew a contract against that failure to comply with any of the requirements Member Provider, because Member Provider; on imposed pursuant to this Agreement may result in behalf of an Qualified Participant,reasonably filed a termination of this Agreement by REG, complaint against,or appealed a decision.of RHG or Payor, or requested reconsideration or independent 11.15 Antitrust Guidelines. Member Provider agrees review of an adverse determination, to comply with all antitrust- guidelines and procedures promulgated by Federal and State 111.5 Antitrust Guidelines. RHG agrees to comply entities. with all antitrust guidelines and procedure promulgated by Federal and State entities. III. RHG's OBLIGATCONS 111.6 Audit Policy and Procedure Compliance. All II1.I Marketing_to ClientgTg ors. RHG shall enter bill audit requests by Payor shall be done in.. jinto agreements with Clients and/or Payors as accordance with the State Law andfor Federal Rules defined in U and I.4 for their access to RHG quality and Regulations. Member Providers through specific referral processes. RHG will market Member Providers for 4 referral; including but not limited to the following: Page 5 of 14 0039B7C0.002XCC RUNPRY TX 01-2012 i c G;4%:VL P"! PAGE 10/025 Fax Server IV. REIMBURSENEM,CLAIMS will be subject to the reimbursement rates SMMLSSION AND PAYMENT established in the Exhibit B of this Agreement IV-1 ReimnburSemetit. RHG shall arrange and. All billing and reimbursement will be made in provide the Member Provider, locations and/or any accordance with Labor Code 405.027 and all other additional Tax Identification Numbers as listed in applicable state rules and regulations. Exhibit C for Payors to pay Member Provider the reimbursement rates for Covered Services rendered IV.3 Bill and/or Claim Forms. Claim forms are to Qualified Participants pursuant'to Exhibit B. " required for all services. All claims must be Member Provider agrees and acknowledges that submitted complete and accurate on CMS 1500 (or RHG is acting solely in an administrative capacity in other appropriate claim form or their successors)and providing a network of quality health services.RHG must include Member . Provider's usual and is not the claims paying agent and will not be liable customary billed charges (not discounted rates)and for the payment of any amount owed by a Payor to appropriate codes, consistent with policies Member Provider in the event that Member Provider established or approved by applicable state and/or is unable to collect such amount of money up to and federal regulations. Member Provider must submit including the insolvency of the Payor. Under no claims to Payor not later than the 956'day after the circumstance will a Member Provider attempt to date on which services are provided to the Qualified collect payment from a Qualified Participant for Participant, or as specified by state Iaw. In medical services rendered for a compensable, work accordance with Labor Code §405.027 and other related injuryPallness. applicable statutes and rules,billing and payment to Member Provider will be made within forty-five N.2 Reimbursement Rates,Member Provider is to (45)days of receipt of bulls which are accurate and be paid by the Payor in accordance with State Law complete, and otherwise in accordance with.state and/or rules and regulations at the rates established rules and regulations. in Exhibit B. Member Provider hereby agrees that rates in Exhibit B,which may be amended from time IVA L-sited Recourse Against qualified to time upon mutual written agreement,represent the Participants. Except as otherwise provided in this total amount to be received and agrees to look solely Agreement (Section 110),Member Provider agrees to the Payor for payment for such Covered Services. to seek payment from each Payor for Covered . Payment will be made for Covered Services actually Services provided to its Qualified Participants, and rendered.All claims will be paid,when appropriate, agrees that it will not seek additional payments or only after submission of a complete and accurate reimbursement for compensable -injuries from claim. A complete and "accurate claim shall be Qualified Participants. In addition, Member defined as a clean claim by Medicare.REG does not Provider agrees that neither RHG,the Payor nor the guarantee, represent, warrant or covenant regarding Qualified Participant shall. be billed or ultimately the selection or use of Member Provider`s services held responsible for payment of services deemed not by any Qualified Participant or Payor,or the number to be covered by the Payor or its designee. When of patients, if any, which may result from Qualified Participant is covered by a state or participation, in RHG's provider network. The federally regulated Occupational Injury and Illness obligation of a Payor to reimburse Member Provider program, MemberProvider"agrees to comply with in accordance with Exhibit B for the provision of state and federal regulations regarding holding Covered Services to a Qualified Participant shall be Qualified Participants harmless for amounts not paid conditioned upon a good faith determination by the by Payor for any reason, including Payors Payor or its designated representative that (i) such insolvency. This provision does not preclude billing services are medically necessary, whether such a Non-Qualified Participant for a non-compensible determinations are made before, on or after the injury. provision of services to such Qualified Participant. IV.4.1 Transfer of Risk This Agreement and any All services billed under the Tax Identification subcontract within shall not be interpreted to involve Number(s) indicated in this Agreement, any a transfer of financial risk for the provision of Health Amendments, Exhibit A, Exhibit B, Exhibit.C,, care services from Payor to RHG as defined under l Applications or any updates regarding locations Insurance Code§1305.004(a)(26).Member Provider and/or a Member Provider as defined in section I.6 agrees and acknowledges that RHG-is acting solely in an administrative capacity in providing a network 0039B7CO.002.DOC Page G of 14 RUNPHY TX 01-2012 1 llfurtk Fax Server of duality health providers. RkG is not the claims intent of RHG to cooperate in the defense of said paying agent and will not be liable for the payment claim. However, RHG shall have the right to take of any amount owed by a Payor to Member Provider any and all actions they believe necessary to protect in the event that Member Provider is unable to their interest. collect such amount of money up to and including the insolvency of Payor. V.3 Indemnification of Member provider. Member Provider will be responsible for its own acts or SVS Payment o€ Claim Forms. RHO shall omissions and any and all claims,liabilities,injuries, administratively arrange for the Payor or its suits and demands and expenses of all kinds which designated representative to pay undisputed claims may result or arise out of any alleged malfeasance or which are accurate, complete and comply with the neglect caused or alleged to have be caused by its Agreement within the time period mandated by state employees or representatives, in the performance or or federal law. omission of any act or responsibility under this Agreement. In the event that a claim is made against IV.6 Erroneous Payment. In the event that a Payor Member Provider, it is the intent of Member and/or its designated representative pays the Provider to-cooperate in the defense of said claim. Member Provider (i) more than once, or (ii) an However, Member Provider shall have the right to incorrect amount, or(ilii)an overpayment,the Payor take any and all actions they believe necessary to or its designated representative may, at its sole protect their interest. option and discretion, request the return of such amount from Member Provider The Member VI. TERM AND TERMINATION Provider will not unreasonably withhold reimbursement. If overpayment has been made VI.I Terns. The term of this Agreement shall be for Member Provider shall reimburse such overpayment one (1) year'from the date hereof and shall be within forty-five (4.5) days and/or follow State and automatically renewed on an annual basis for Local Rules and Regulations. The Member Provider successive twelve(I2)month periods,unless sooner may not contest payment of CIaims after one terminated in accordance with Section VL2. hundred eighty 080)days from the date of payment. All claims for overpayment or underpayment shall VI.2 Termination, This Agreement may be be resolved in accordance with State Law and /or terminated sooner on the first to occur of the Federal Rules and Regulations. following! V. WSU ANCE AND INDEMNIFICATION VI.2.1 Termination by Member Provider. Member Provider may terminate this Agreement in the event V.I Insurance Retluirement. Member Provider shall of a material default or breach of RHG`s obligations provide and maintain such policies of professional hereunder,upon ninety(90)days prior written notice liability insurance or a self-funded program. The and the failure of RHG to cure such breach or amounts and extent of such insurance coverage or default within sixty (60) days of the notice. In self-funded program shall be in the amounts addition, in the event of an "emergency situation", determined by community standards for relevant Member Provider may terminate the Agreement hospital/faciliries. Member Provider shall promptly immediately with the acknowledgment by RHO that demonstrate evidenee'of insurability or self-funded such an emergency condition does exist. program and that the required insurance is paid and 'Emergency Situation" shall mean an unforeseeable in force upon request of RHG and/or meet the event, not resulting from Member Provider's act or credentialing guidelines of RHG. omission, which materially `affects Member Provider's ability to continue the practice of 'V'2 Indemnification of RHG_ RHG will be medicine or to perform his obligations hereunder. responsible for its own acts or omissions and any The network will provide notification to employees and all claims,liabilities,injuries, suits and demands of the terminating Member Provider'immediately and expenses of all kinds which may result or arise upon receipt of the Member Provider's termination _ f out of any alleged malfeasance or neglect caused or request or as soon as reasonably possible before the alleged to have be caused ,by its employees or effective date of termination as required by 28 TAC representatives, in the performance or omission of 10_42(b)(6)(G). any act or responsibility under this Agreement, In the event that a claim is made against RHG,it is the 003987C0.002X0C Page 7 of id f - RUNP1iY TX 01-2012 1G/025 Fax Server VI.2.2 Termination by,RHG. A Member Provider the breach within sixty (60) days of the notice, in shall automatically be terminated on the date when: which case,the Agreement and applicable rates and (i) Member Provider's license in the State where terms shall continue in effect. Either party may services are rendered is suspended or revoked, (ii) terminate this Agreement without cause upon ninety Member Provider is excluded from participation in (90)days prior written notice. the Medicaid or Medicare programs, (iii) Member Provider losses their JCAHO, NCQA,, AAAHC, VI.2.5 Unforeseen Events. In the event that either URAL, CLIA or other applicable license, party's ability to perform their obligations under this certification and/or accreditation, (iv) Member Agreement is substantially interrupted by war, tue, Provider loses or experience a material reduction in insurrection,riots,the elements, earthquake,acts of liability insurance and such insurance falls below the God, or other similar circumstances beyond the requirements of State Law (v) Member Provider reasonable control of such party, the party shall be engages in any act, omission, demeanor or conduct relieved of those obligations for the duration of the that is reasonably likely to be detrimental to patient interruption upon notice to the other party. in the safety or to the delivery of quality patient care,or to event that the interruption is reasonably determined lead to the provision of healthcare services below likely to persist for at least ninety (90) days, either applicable standards, or (vi) ninety (90) days " party may terminate this.Agreement upon thirty(30) following written notice by RHG of a material days prior written notice. default or breach by Member Provider hereunder and the failure of Member Provider to cure such VI.3 Effects of Termination. Upon termination of default or breach within sixty(60)days of the notice this Agreement, neither party shall have any further (vii) Member Provider fails to meet RHws or the obligation hereunder except for (i) obligations State's credentialing requirements. RHG, however, accruing prior to the date of termination, including may not terminate this Agreement in direct response without limitation, any obligation by Member to Physician filling a reasonable complaint,on behalf Provider to continue to provide healthcare services of a Qualified Participant against or appealed a to Qualified Participants,- and (ii) obligations, decision of the network, or requested promises or.covenants contained herein which ate -reconsideration or independent review of an adverse expressly made to extend beyond the term of this decision. Agreement. In the event RHG deems it necessary to terminate VL4 Qualified Participant and Payor Notification,If Member Provider's agreement based on the above applicable,upon the termination of this Agreement, requirements RHG will notify Member Provider at by either party, Member Provider shall cooperate least ninety (90) days before the effective date of with RHG 'to notify Qualified Participants and termination. Payors of such termination. Upon written notification from RHO Member VH.CONTINUATION OF BENEFITS Provider may request a review by RHG's advisory review panel, not later than thirty (30) days after VILI Continuation of Benefits.If Member Provider notification. RHG must then complete the review voluntarily terminates its contract with RHG, upon before the.effeotive date of termination. Member Provider's request, Payor must continue to reimburse Member Provider for a period not to VI.2.3 Termination for Insolvency. This Agreement exceed 90 days at the Member Provider's contracted shalt terminate immediately in the event that either rate set forth in Exhibit B of this Agreement with. RHG or Member Provider voluntarily or RHG,for care of an Quali€ied Participant with a life- involuntarily, liquidates, dissolves or becomes threatening condition or an acute condition for subject to any proceeding for the rehabilitation or which discontinuing or disruption of care would conservation of their financial affairs-with written harm the Qualified Participant as per 28 TAC notification. 10.42(6) (A).Any disputes concerning continuity of care shall be resolved through the complaint process Termination by Either Partv. In case of under Insurance Code §1305.401 and material breach of the terms of this Agreement, Subchapter G of Title 28, Part 1 (relating to either party may terminate the'Agreement with at Complaints). least ninety (90) days prior written-notice to the other party; however,the party in breach may cure I pRse s of ra i 0039B7C0.002MOC 1 RUNPRY TX 01-2012 LZ$IUZ* Fax server VI1.2t�lvai. The provisions of this Article VII IX.1.1 Mediation through RHG. The Member shall survive the termination of this Agreement Provider shall notify RHG in writing of the dispute regardless of the cause - giving rise to such or disagreement and shall provide all necessary termination, as will sections 11.9, V.2, V.3, V1.3, information to RHG. RHG shall use best efforts to VIII, and IX. The provisions of this Article VII mediate the dispute within the rules and regulations supersede any oral or written agreement to the put forth by the State as reference in RHG's contrary now existing or'hereafter entered into Provider Handbook. between Member Provider and any Qualified Participant or any person acting on a Qualified 1X.1.2 Arbitration. If the dispute cannot be solved Participant's behalf. by the mediation process described above,either the Member Provider, REG or Payor may elect to VIII. CONFIDENTIALITY, submit the dispute to binding arbitration under the rules of the American Arbitration.Association or any All business, medical and other records relating to other method of arbitration mutually agreed upon by the operation of- RHG or Member Provider, the•parties. Arbitration .will be conducted in including but not limited to, books of account, Houston,Texas. Each party will be responsible for general admiaistratitre records, policies and their own legal fees. The cost of the arbitration Procedures, pricing information, terms of this services will be the sole responsibility of the party Agreement-and all information generated and/or requesting the arbitration. contained in management information systems owned by or pertaining to RHG orMember IX.1.3 Provider Anneals Except for termination due Provider, and all systems, manuals, computer to contract expiration, Member Provider has the software and other materials, but excluding patient right to appeal his/her termination from the Network, charts,shall be and remain the sole property of REG as follows: or Member Provider respectively (collectively, the . "Confidential Information"}. RHG and Member IX.1.3.1 RING will provide notice to the Member .Provider .acknowledges that the Confidential Provider at least.90 days before the effective date of Information and all' other information regarding a termination by RHG; RHO or Member Provider that is competitively sensitive is the property •of RHG or Member 1X.1.3.2 Upon receipt of the written notification of Provider and RHG or Member Provider may be termination, a Member Provider may request in damaged if such information was revealed to a third writing a review by the Network's advisory review Party. 'Accordingly, RHG and Member Provider panel no later than 30 days after receipt of the agrees to keep.strictly confidential and to hold in notification; trust all Confidential Information.Upon termination Of this Agreement by either party for any reason IX.1.3.3.The Network will provide an advisory whatsoever, RHG and Member Provider- shall review panel that consists of, at least three Providers Promptly return to the other all material constituting of the same licensure and the same or similar Confidential Information or containing Confidential specialty as the Member Provider; Information, 'and neither party will not thereafter use, appropriate, or reproduce such information or IX-1-3.4 The Network must complete the advisory disclose such information to any third party. RHG panel review before the effective date of the and Member Provider specifically agrees that under termination; no circumstances will either party discuss the terms and conditions of this Agreement, and in particular IX.1.3.5 The Client,Payor, or RHG may not notify the pricing information herein. patients of the termination until the earlier of the effective date of the termination or the date the IX. MISCELLANEOUS advisory review-- panel makes a formal recommendation; 1X.1 Disputes. All disputes and difference between the Member Provider and RHG-upon which an 1X.1.3.6 HMember Provider terminates the contract, amicable understanding cannot be reached are to be the Network or RHG's Client •will provide decided by the'following method: notification of the termination to employees receiving care from-the terminating provider. The Network shall.give such notice immediately upon Page 9 of 14 • 0039B7C'.0.002JaOC � ItUNFH'i"'TX 01-2012 141025 Fax Server receipt of the Member Provider's termination request or as soon as reasonably possible before the IX-8 Severability. The invalidity or un- effective date of termination. enforceability of any term or condition hereof shall in no way affect the validity or enforceability of any IX.2 Non-Exclusivity. Nothing in this Agreement other term or provision: shall be construed to restrict Member Provider or RHG from entering into other contracts or IX-9 Assignment Member Provider may not assign agreements to provide healthcare services to Payors or otherwise transfer any right or delegate any duty or other healthcare delivery plans, patients, and of performance hereunder, in whole or in part employer groups. without the prior written consent of RHG. A change in ownership will not negate the prior contractual DU Entire Agreement. This Agreement contains agreement without written notification to RHG. the entire understanding of the parties and RHG retains the right to assign this Agreement, in supersedes any prior understanding&and agreements, whole or in part,to any entity with which RHG or its written or oral, respecting the subjects discussed parent company or any of its subsidiaries is herein. affiliated,or with which it merges or consolidates. IX.4 No Waiver. The waiver by either party of a IX-10 Third BM Beneficiaries. Except for Payors breach or violation of any provision of this and.the agents thereof, there are no third party Agreement shall not operate as or be construed to be beneficiaries of this Agreement a waiver of any subsequent breach hereof. 1X.11 C tions. The captions and headings IX.5 Regulatory Compliance. Member Provider, contained in this Agreement are for reference sub-contracting providers,and RHG agree that each purposes only and shall not affect.in anyway the shall comply. with all applicable requirements of meaning or interpretation of this,Agreement, municipal, county, state and federal authorities, all municipal and county ordinances and regulations, IX.12 Execution of Counterparts. This Agreement and all applicable state and federal statutes and may be executed in any number of counterparts, regulations, now or hereafter in'force and effect,. including facsimiles, each of which shall be deemed governing RHO, Member Provider, sub-contracting to be an original as against any part whose signature Providers, the provision of services by Member appears thereon, and all of which shall together Provider or- sub-contracting providers, and/or constitute one and the same instrument. Pay=, including but not limited to applicable requirements under any state or federal fair IX.13 Partial Invalidity. If any part, clause or employment practices, equal employment provision of this Agreement is held to be void by a opportunity,or similar laws declaring discrimination court of competent jurisdiction, the remaining in employment based upon race, color, creed, provisions.of this Agreement shall not be affected religion, sex,or national origin as illegal,and,Titles and shall be given construction, if possible, as to VI and VII of the Civil Rights Act of 1964, Section permit it to comply with the minimum requirements 202 of Executive Order 112,46• as amended by of any applicable law, and the intent of parties Executive Order 11375,Sections 503 and 504 or the hereto. Rehabilitation Act of 1973 and Title IV of the Vietnam Era Veterans Readjustment Assistance Act of 1974, and Sections 1 and 3 of Executive Order 11625, or .any applicable rule or regulation promulgated pursuant to any such laws or orders. IX.6 Governing -law. This Agreement shall be i governed by and construed is .accordance with applicable state law. IX-7 Amendments. This Agreement may be amended as agreed to by both parties in writing upon thirty (30) days written notice of such proposed amendment. ` Page 10 of 14 0039B7C0.002 K)C RUNPHY'TX_01-2012 I ---- --==,V4 rtt 'Llftu. LDlOZb Fax Server IX.14 Financial Incentives.Neither a Client, Payor, iX,17 Official. Notices. Any notice or .nor RHG may use financial incentive or make a communication required,permitted or desired to be payment to a health care provider that acts directly given hereunder shall be deemed effectively given or indirectly as an inducement to limit medically when personally delivered or mailed,return receipt necessary services. The adoption of treatment and requested, or overnight express mail addressed as return.-to-work guidelines and individual treatment follows: protocols by RHG or Network is not in violation of this section as pursuant to Insurance Code §1305. 304 and §10.83(a)of Chp 10 of Title 28 Part 1. IXJ5 Financial Disclosure Requirements. Member Provider is required to file financial disclosures in Member Provider or RepresentativelDesignee: accordance with Labor Code §§408.023 and §§413.041. (Please Print) Name:Jason Tinley,MD IX.16 Economic Profilin. Network must provide written notice to Member Provider before the practice:Jason Tines, 4L PA Network conducts economic profiling, including utilization management studies or other profiling of Address: 4441 Bret j3jU Rd N the provider or group of providers. City/Stat&Zip:Fort North.TX 76.107 Telephone:(817)916-4685 Fax: f817)769-3718 Organization: Rockport Community Network,Inc. dba Rockport Healthcare Group Attn: Network Development 50 Briar Hollow Lane,Suite 515W Houston,TX 77027 Telephone:(713)621-9424 Fax:(713)621-9511 IN WHNESS WbI11ItEOF, the undersigned will be deemed to Have executed this Agreement as of the or to such other address,and to the attention of such slate the provider is fully credentialed by RHG other person(s) or officer(s) as either party may designate by written notice For and on behalf of: Rockport Community Network,Inc. For and on behalf of: dba Rockport Healthcare Group Member Provgormtative/Designee 50 Briar Hollow Lane,Sni a 515W Houston,TX 7'702 Signature. 1 Nam72 -3 ,3 Mark C.Neer Sr.Vice ens,N /lo/rk D velopmenk Tom• Date: ` `7 3 Dake: l r • Pete 11 of l4 0039B7C0.002MOC R NPRY TX O1-2012 I . 1U/925 Fax Server EXMIT A STANDARDS AND GUIDELINES UI'ILIZATI©NREVIEW AND QUALITYIMPROV,I MENTPRpQtAMS RHG and its Clients require Member Providers to follow nationally recognized treatment guidelines(i,e. Official ! Disability Guidellnes(ODG) and/or American Occupational and Environmental Medicine's(ACO in the treatment of work-related injuries/illnesses for Qualified.Participants ) guidelines) . j RHG's Clients provide utilization review and quality improvement programs for Qualified Participants. RHG shall i review each Clients Utilization Review and Quality Improvement Program in,accordance with RHG s Credentialing Standards and Guidelines as described in this Exhibit. Physician and/arMember 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/orMemberProvider. Theprimary*goals of ft UtaizationReviewPrograms 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 ara evidenced-based and outcome-focused. Treatments and Services that may Require Preauthorization: 1) In-patient hospital admissions including the principal scheduled pmeedures(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 acrd 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) chrorric 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 code range for Physical Medicine and Rehabilitation, but limited to:•(i) modalities, both supervised and constant .attendance; (ii) therapeutic procedures,excluding work hardening and work conditioning;and('vii)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 weep immediately following:(i)the date of injury, or(R)a surgical intervention previously approved by the payor. i 0039B700.0021>0C Page 12 of 14 RUNMY TX 01-2012 I ,c'!/ULD Fax Server EXMIT B Reimbursement Schedule L Rockport United Network/Rockport Seleefflealth Network-Occupational Injury and Tllmss Provider fees for the programs listed above shalt be reimbursed at the following: All fees will be reimbursed at 97% (ninety-seven percent) of the state's current Workers'. Compensation fees,rules and regulations or usual and customary allowables. Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of this Agreement,state rales and regulations anchor the applicable Occupational Injury or Illness Benefit Plan. I(We accept the fees as outlined-in this Exhibit B. For and on behalf of: For and on behalf of.- (Name, f:(Name,address,etc.) ROCKPORT COlVI1YIiWTV NETWORS,INC. Lson Tinleq.AVID dba Rockport Healthcare Group 4441 Bryant Irvin Rd N 50 Briar hollow Lane,Suite 515W Fort Worth,TX 761.07 Houston,Tetras 770 .�� Signa /Mark C.Neer Print arae^ on Twe Sr.Vice President,Nieffivork elopment Title "r Date / 7 f TIN 26-3968733 Date i Page 13 of 14 0039B7C0.002 DOC RtMPRY.TX 01-2013 -ttt:vz rrl VAUt 18/025 Fax Server EXflWIT C Physicians and/or locations where services are to be rendered.by Member Provider The Member Provider agrees that the following physicians and/or practice locations listed on attached Exhibit C, shall be inclusive of the signed agreen wnt and the signed rates in Exhibit B. By signing below Member Provider or its Representative/Designee allows Rockport Healthcare Group MIG)and its representatives to we any and all of the below information as agreed to in this signed agreement. Jason Tinley_ND PA Jason Tinleys MD PA Practice Name(1) Practice Name(1) Jason Tinley,MD Jason Tim,MD Physician Name(if applicable) Physician Name(if applicable) 4441 Bryant Twin Rd N 649 NE AlsbW Rd Physical Address Physical Address Fort Worth,TX 761€17 _Burleson,TX 76024 City,State Zip City,State Zip Mailing Address(if different) Mailing Address(if different) (817)916-4685/(817)769-3718- (81D 216-46851(817)769 3718 Phone Number I Fax Number Phone Number!Fax Number 26-3968733 26-3968733 Tax ID Number Tax ID Number Practice Name(3) Practice Name(4) Physician Name(if applicable) Physician Name(if applicable) Physical Address Physical Address City,State Zip • . Mailing Address(if different) City,State lip .Mailing Address(if different) Phone Number I Fax Number Phone Number l Fax Number Tax ID Number Tax 1D Number For and on behalf of: For and on behalf of Rockport Community Network,Inc. Member Provider or Representativellesignee dba Rockport.healthcare Group 50 Briar hollow Lane,Suite 515W f Houston,TX 77027 Signatu Name:,Iaso lniev.MD Mark C.Neer Sr.Vice Presid t,Network D eloprrtent j ]Date: Date: t -0039B7CA.002MCC TaSo 14 of 14 RUNPFIY TX 01-2012 i 1 1463- -- _.. ir� C.__,v4 ri'l L aut G;I/025 Fax Server X20(30212 ROCKPORTlid ADDENDUM TO AGRELEMM T Rockport Community Network,Ine. This Addendum is entered into by and among ,Tason Tinley,MD ("Member Provider"), Rockport Community Network, The. d/b/a Rockport Healthcare Group ("Rockport"), and Tarrant County ('Tarrant')on this 12—_day of-A"'2012. W MIZEAS, Rockport and Member Provider entered into a Provider or Physician.Agreement,effective ("Provider Agreement"),and desire that this Addendum apply to Covered Services that are govemed by the Texas Insurance Code,Texas Labor Code,and Texas Administrative code.. WHEREAS,Rockport has contracted with Tarrant pursuant to a proposal set forth in RFP NO.2012-105 to assist in the process of setting up a direct contracted 504 provider panel pursuant to Texas Labor Code Section 500..053. WHEREAS, Tarrant has determined that a workers'compensation health care network certified under Texas htsurAnce Code Chapter 1305 is not.available or practical for its self-insured workers' compensation program needs and,as such,it has elected to provide medical benefits to its injured workers by dimctly contracting with health care providers. WHMMAS, Rockport, Member Provider, and Tarrant desire to execute this Addendum in order to establish a direct contract between Member Provider and Tarrant under Texas Labor Code Subsection 504.053(b)(2). WI3ERHAS,Rockport,Member Provider,and Tarrant 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 Tarrant that make available Coveted Services for Qualified Participants'needs to the injured workers ofTar ant. NOW,T EREEORF,for good and valuable consideration,the sufficiency and receipt of which is hereby acknowledged,the parties agree as follows; 1. All terms and conditions of the Provider Agreement are hereby adopted by both Member Provider and Tarrant, with fall consent and agreement of Rockport, to apply to a direct contractual agreement between Member Provider and Tarrant.The parties agree that Tarrant will bear the financial responsibility for payment to Member Provider under the terms of the Provider Agreement subject to the applicable provider manual and the provisions of the Texas Labor Code and applicable rules under the Texas Administrative Code. Rockport will continue to provide applicable network administrative services as outlined in the Provider Agreement and agreed to by Tarrant and Rockport. i i 2. When used in this Addendum;unless the content otherwise clearly requires, the following words and terms shall have the meaning set forth below. All other defined terms shall have the mcamng ascribed to them in the Provider Agreement. "Pavors will be Tarrant as it is responsible for payment of medical benefits for compensable injuries and or illnesses sustained by its injured workers according to the Texas Workers Compensation Act. 504 Provider Panels are those direct contracted panels formed by political subdivisions or public pool entities authorized by Section 504.053 of the Texas Labor Code. "River Vim,Provider Group" is the 504 Provider Panel established by Tarrant through this and other direct contracts using Rockport as it%contracting agent. 3. Member Provider agrees to participate in the River View Provider Group. 4. Nothing in this Addendum or the Provide Agreement waives sovereign immunity or creates a new cause of action. 5. All other tenns 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. 6 Claims are not to exceed the County's workers'compensation medical claims budget. IN WITNESS WHEREOF, the parties hereto have executed this Addendum effective on the day and year first written above. For and on behalf of: *APPROVED 0 FORM By. TARRANT COUNTY Tarrant o ty District Attorney's Office River View Provider Group *By law, the District Attorney's Office may only advise or approve contracts or legal Fort Worth,Texas documents:on behalf of its clients. It may not advise or approve a contract of legal document on behalf of other parties. Our review of this document was conducted solely Signature from the legal perspective of our client. Our approval of this document was offered r solely for the benefit of our client. Other Printed Name parites should not rely on this approval, and should seek review and approval";by their own respect a B y: o Date Tarrant County Auditor's Office 2 f j. :For and on.ii.ehalf.or, Far ani on behalf ofe;: `I20CgPORT'CO1VIMi)1VITYHETWORK IIYC:: asori�nlev,MDSPA dba ROCKPORT HEALTHCARE GROUP 4441 Bryant Irvin Rd N 50 Briar Hollow Lane;5L5'W Fort worth.TX 76107 $oustO,`Texas 7702Z S' ure' a Mark C.Neer, anon Time lUII) PrintedName inted'Narne,. Sr:Vice Presided':Network Develo"meat; Title • �y i TI 2d-3968733: i I i 3