HomeMy WebLinkAboutContract 47186-P5 CITY SECRETARY/ J
CONTRACT NO.
Thomas Diliberti,MD B1ackStone 504 Provider Agreement
ADDENDUM
To
BlackStone 504 Program
Provider Agreement
This Addendum is entered into by and among Thomas Dilibert' 1 (` ember Pro ider" ,ick rt
He care("Rockport"),and the City of Fort Worth("City")on this day o
20 1�.4
WHEREAS, Rockport and Member Provider entered into a Provider Agreement,
effective ,(Provider Agreement"), and desire that this Addendum apply to covered
services that are governed by the Texas Insurance Code, Texas Labor Code, and Texas Administrative
Code.
WHEREAS, Rockport has contracted with Member Provider on behalf of the City in the process of
setting up a direct contracted 504 provider panelptrsuant to Texas Labor Code Section 504.053.
WHEREAS,the City has determined that a workers' compensation health care network certified tinder
Texas Insurance Code Chapter 1305 is not available or practical for its self-insured workers'
compensation program needs and,as such,have elected to provide medical benefits to injured workers by
directly contracting with health care providers.
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504.053(b)(2).
WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
Agreement to be the same terms and conditions that apply to the direct contract between Member
Provider and the City that make available covered services for Qualified Participants'needs to the injured
workers of the City.
NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
I
L All terms and conditions of the Provider Agreement are hereby adopt--d by both Member Provider
and the City, with Rill consent and agreement of Rockport, to apply as a direct contractual
agreement between Member Provider and the City.All references to certified networks as well as
the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413.041 of the
Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up tinder
section 504.053 of the Texas Labor Code. The City's Provider Manual (tmder the name of
BlackStone) shall instead apply to matters of notice, billing, dispute resolution, complaints,
preauthorization,and related matters. .
2. The parties agree that the City will bear the financial responsibility for payment to Member Provider
under the terms of the Provider Agreement subject -b 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.
3. When used in this Addendum,unless the content otherwise clearly requires,the following words and
terms shall have the meaning set forth below. All other defined terms shall have the meaning
ascribed to them in the Provider Agreement.
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�A•.Oyu u�G��a V3'1
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•,.; Thornes Diliberti,MD Blackstone 504 Provider Agreement
' "Payors" will be fhe City as they are responsible for payment of medical benefits for
1 4 compensable injuries and or illnesses sustained by its injured workers according to the
1 Texas Workers Compensation Act.
"Blackstone" is the 504 Provider Panel established by the City tf Fort Worth through
this and other direct contracts using Rockport as its contracting agent
"Provider l%Aanu0 means the BlaGkStone Provider Manual as amenddd from time to time
and available upon request to the Member Provider.
"Provider Panels"are those direct contracted panels formed by political subdivisions or
public pool entities authorized by Section 504,053 of the Texas Labor Code.
4. Member Provider agrees to participate in the BlackStone provider panel for the benefit of the City
and Qualified Participants.
5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a
new cause of action.
All other terms of the Provider Agreement shall remain in force and unchanged.Any conflicts
between this Addendum and the Provider Agreement shall be superseded by the terms provided
herein.
IN WITNESS)AFHEREOF,Off+,the parties hereto have executed this Addendum effective on the day and year
first written above.
For and on behalf of
City of Fort Worth
Ii $lacl�Sfone �� '
I
Signatur
Name: Su- lanis
Title: Assistant City Manager
Date:
APPROVED AS TOO POl M AND LEGALITY: r
Astalat City Attognev ` 0
00
OFFICIAL(DECOR® 1b,
2 °40000pOXA
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CITY SECRETARY ���reo
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FT.WORTH,TX �'t. I .:
Thomas Diliberti,MD BlackStone 504 Provider.Agreement
ROCKPORT BEA'C,THCAtt}✓
Signature:
Mime: Soar. Pc�O,c�c c i
itle: `�2 n i o It' V P
W,M-URMOVIDER or
Represen to tine/Designee
Signature: ~'V
Name,Tlcomas Dilftrti,MD
Title.
JOate., -
TM,752810194
ji
3
i
1
Provfder/Ilacility Entry Stteet
Contractor lnitiirls, ND'I'ra0k IDN: NotiiTypo; rj,�.,�r ,JZ sf�"e�r ./+�5
Contracted Provider/Practice;Nnitm —5 LL /T_ y
;)at�Now Coutract U Anieudnieirt p Addendmil
A Add-On to_6.Asting Gt'ojrp/Parent RUG, Group/Practico Co►itractNi►uie:.
D A.dd-Olt anti address,pl},#ttiY`'Pte s RHG .. .
Q COK(ract LfIMO vo Datc:. (16
Q l'ee$ohedirle ty*Pe:WC: ' 13C/ R GH: -BC/BRA.
(TX HCN onl))WCC:- BC IDR
'ContrAet:R+:�ttircutafits:
Goal(,*(Signed ,�E\ll,'ult C cotppletcd and sighed
Gabibit D Sfgired q ClteeklfCredeittialfugDelegnted
Tract' roger Name: a:�-
Q/"Application Completed LP"All.licobses and iitsuratice;rttached
0 ProE►Icm TIN:Y off)If Y,dclails:
Tnx ID Nuniber(s): "7 5 7ZOZIci�
WIN: NPI: Lid: 7
Rrful Specially; CJr �rc�S Zucispec: Languages:
Pradtitioner Name:.
• Apptiption completed U' Alt liccpses'and instrrAke,attacitcd
O Prb4lem TUN: Y O N. If Y,details:
-Tax ID NmOor(s), . .
UPIN:.
O n Specialty; 2ad Spec: Languages:
location Info,tind 1-lours of Operation(desigrf►tte P,4t}:��,(
Sun *kWon 'Coos 1Ved Tiu►rs Fri $at
� x � `75,2-S it Pli1cad Paxi:weer _153i?35
Sun Mon Tttcs Wed 'Chtirs Fri Sot
2.
I'lt2 P'ax2:.
Coutracf notes:.
NOT.091 Dnte. j Dala 1-I8111: 'VAla l.fgtiit.Da
Submitted: lnilitrls; RIfOID: . Completed:
Aevisedt s19/2613 ND
IX.14 Financhat Incentives. Neither it Client, Payor, 1X.17 Oftichil` Notices. Any notice or
nor RHO may use financial incentive or make a communication required, permitted or dostred to be
payment to a,health care provider thot acts directly given here ndej-stall be deemed effectively givon
.or indirectly to tin indlteement. to limit medbally %Alen personally dcllvered or moited, Otum receipt
iiecassaly. services; Tl>e A.doptiou of treiih nt acid requested, or overnight ex*ss mail utidl'essecE as
return.t6AOrk guidelines and ittdivi(lnal treatment follows:
Pte,( eON by Fj-10 or Net1Vork 3s not itl v€elation of
lhis $cction as.pill�uollt-to Insuranco Cede 1305.
304 anal§l{),$3(a)pf Cfip 10 of Title 28 batt 1.
IX.15 Financial Disclosure Renulrements.Member
Provider is regttimd to file f;jttincial cijselosures in
ace.413oidattaa with. _L;abor Code §§40$.023 and hgenttierPravider-gi'ItepresentzttYe/llestgnoe:
§§ .1141, y
{1'leasd Print)
1X.16 Hoorionilo Profilin Network must provide Name.Tlignias bi€ibetti,MD
written notice to ,Member Provider- bsfore the
-Network conducts economle profiling, including Practice:Xexas Hand Center
utilization management studies or other profiling of
the provider or grbut)ofprovidets, Address: 9301:N Central > xpresswaY,Ste 310
City/Stat0Ztp:D4116s,TX 75231
Telephone: 214 528-6210
Fax: (214)528-3885
Organization:
Rockport Community NetWokk, Ino.
dba Rockport Healthcam'Qr6uji
Atm: Netkvork.DevelopmOv
50 Briar Hell my UW,-Suite 50W
Houston,TX 0621
Telephone:(713)62-1-9424
•
IN NV.1TNPSS WHEREOF, the.undersigned.will be Fax:(713)621-9511
deemed to have executed this Agreement:as of tiro or to such other address,aid to the attention of such
date the provider is fully credentialed by RUG. other persons) ..or officer(s) as Cither_ party mtsy
designate by written notice.
p'or'and oit belralt ofs
Por mit-on bomif qt)
Rockport Co11 mimity Ne ivolih,Inc, `/
dba Roctcpol't-He;titltcitre Orotlp Member Provider'or Represe (nd,!D _g ce
/50 B11ar.Hollow Dane,8111te 515VV
Xion'tottfT� 77 27' Slgnattit'G, ,
Mine:Thomas Dl1lbee(1,MI)
D.alCgtn, .� �t'Irltsttli ...
1'rskit t \
MLN.-15-28101-0
Date:. DIA0.
No$e t t or is
'CltomA�Ailibertf,;4fi 0324 t¢ R.lrN�HY 77{'0501)S
E XMBIT B
L.12qcicpoi1Vmte(l Network/koelcooet SelectUealih Notivork-Ocoupationol Injury find Illness
Trovider fees.for the progrpnis listed above shall be relwbuo'edaffha foll4whio.,
All -fees will be Yeltubumed at 85% (eiglity-Ave pucomt) of the suite's current Workers'
Coverage: Coverage Por g1l,procedures on the tee schedule Is subject to the terms Anel conditions of
this Agreement,state miles andjsjlllflilons and/or the applicable 0*ccu p,atlotull Injuty or Illness 13enefkt
Plan.
IlWo Adecp(the fe0s*outlined In th's Exhibit B,
For and on'b0calf of; Vor rind on b6alf of;
(411me,address,ON)
ROCTOORT COMMUNITY NEVOIUC,INC. Thomas Dillborti,
9301 N COitry I 1,;xjjrcsmyftL Ste 340
1)Hak1jo11owLfiucj$yite 5.45AW Dnitns,TX 75231
`Hot) ton,,. pa
T6 as 77027 l
Signature �.
President Title
Date /a;A"O TIN 75-28-10194 Date gS.'
pap 13 or 15
'Momm DffiWfflj_MO 032416 RUNPRY TX-050115
:t
Physicinns and/ar ioeations Svltere services aro to be rendered by Momber Provider
Tito Aleauber Frovi4or ngrees thot lite listed on attnelted tolbit C,
s1101 are taeittsive of tau.signed:agreement and tiro signets rates to Exhibit B. Dy Slgldug below Member Provide!•oi•its
)(2eprasolifiitivMDesignee Allows Rocitjaort Hcattitearo Group(R11G)and Its k6preseniptives to use 6"y And all of the
l?eltt}v iufar wtion as ngreed to iti,this signed krealiient.
Texas bland�erater _
Practice Name(1): Practice.Name(2)
Thomas b1'i e11iL MD
Physieiaii Name(if appi108b.le) 1?hysioiari Name(if applianble)
9301 N Central ExpresswuX,Ste 340
Physical Address Physieal Address
:Danlos,TX 75231
City,State Gip laity,State Zip
' Mauling Addt�ss.(if.different) Maiilhig Andress(if different)
(214)528-6210 . % L214)528-3885
Phone Number%NX Ndmbet- Phone ittuiibai•1 Fax Number
75.28.10194
Tax`1D Number Tax 1D 7+fttntber
Practice Namo(3) Practice Name.(4)-
Pltysiciali.Nauie(If applicable) Pttysicinri 'TFaiito 00 11
-r
Physical Address Physical Address
City,State Zip City,State Zip
ivlailing Address(if<liiferettt) � :Mailing Address(ifdifferont)
Phone NuinberY Fax Nuinber PhoueNiisnirer I Fax Ntimbar
Tax ID Number Tax'[D Ni Umber �^T
Mor and oil WWI`of Fov aiid on b6half'of:
Roci(port Connttunity Netrvovl(,Inc reniUor:Provider of)teprese iv e atiee
itba Roclwort 11t.olthcairc Croup `"
p)hilts'M119w ilnci Sulte:31z)W
`r Holl to'nrT 77027 Slg»atrii'es. _
ime:Th6mits Dillberti,MD
f.
llotrgia .1 rlthani
-Presidei
pst te: 3 �� Date:,..
'gagatai of iS
'rlioniasDilibuti,11D032416 RUMPHY TX 0501 IS