HomeMy WebLinkAboutContract 47186-P7 CITE`SECRETARY
GGATRACT NO
ADDENDUM
To
BlackStone 504 Program
Provider Agreement
,This Addendum is entered into by and among Concentra Health Services. Inc. C`Me er rovider"),
R port Healthcare Grou ("Rockport"), and the City of FortWorth ("City") on this-day of
20
WHEREAS,Rockport and Member Provider entered into a Provider Agreement,-effective November 11.
1999. ("Provider Agreement"); and desire that this Addendum apply to covered services that are
governed by the Texas Insurance Code,Texas Labor Code,and Texas Administrative Code,
WHEREAS, Rockport has contracted with Member Provider on behalf of the-City in the process of
setting up a direct contracted 504 provider panel pursuant to Texas Labor Code'Section 504.053..
WHEREAS, the City has determined that a workers' compensation health care network.certified under
Texas Insurance Code Chapter 1305:is not available or practical for its self-insured workers'
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 yin 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 Provi&r
Agreement to.be the same terms and conditions that apply to:the direct contract between Member
Provider and the City that makeavailable covered services for'Qualified Participants'needs to the injured
workers'ofthe City.
NOW,THEREFORE,for good and valuable consideration,the sufficiency:and receipt of which is hereby
acknowledged,the parties agree as follows:
L All terms and conditions of the Provider-Agreement are hereby adopted by_both2YIember Provider
and the City, with.full. consent.and agreement of Rockport, to apply as a direct contractual
agreement-between Member Provider and the City.All references to certified networks as well as
the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413.041 of the
Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under
Section 504.053 of the. Texas Labor Code. The City's Provider Manual (under the name of
BlackStone) shall 'instead apply to matters of notice, billing, dispute resolution,. complaints,
preauthorization;and related matters.
2. The parties agree that the City will bear the financial responsibility for payment to Member-Provider
under the terms of the Provider_Agreement subject to the applicable Provider Manual and the
provisions of the Texas Labor Code and applicable rules under the Texas 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.
4 71L
LFW0R70
Concentra Health Services;Inc. 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:
"BlackSt6ne"is the 504 Provider Panel established by the City of Fort Worth through
this and other direct contracts using Rockport as its contracting agent
"Provider Manual"means the Blackstone Provider.Manual as amended from time to time
and available upon request to the Member Provider..
"Provider Panels" are those direct contracted panels formed by political subdivisions or
public pool entities authorized by Section 504.053 of the Texas Tabor Code.
4. Member Provider agrees to participate in the B1ackStone 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.
6. : All other terms of the Provider Agreement shall remain in force and unchanged. Any conflicts
between-this Addendum and the-Provider Agreement shall be superseded by the terms provided
herein.
IN WITNESS WHEREOF,the parties.hereto have executed this Addendum effective on the day and year
first written above.
For and ori behalf of:
City of Fort Worth
Blackstone
Signatu e.
Name:S)' inlanis
Title: Assistant
City Manager
Date:
APPROVED AS TO FOR61 AND LECALI'I`Y:
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CKPORT"
t•It=AcTrIc.ARr GROUP
.PROVIDER AGREEMENT
ROCKPORT HEALTHCARE GROUP,INC.
This facility/Ancillary Agreement("Agreement"),is I. DEFINITIONS
entered into by and between Rockport Healthcare
Group, Inc., a Delaware Corporation ("RHG"), dba When used in this Agreement and unless the content
Rockport United Network,Inc. (a preferred provider otherwise clearly requires, the following words and
organization for Occupational Injuries and Illnesses) terms shall mean:
and Rockport SelectHealth Network (an exclusive
provider network) and Occupational Health 1.1 "Physician"means a licensed Medical Doctor or
Centers of the Southwest, PA ("Member Doctor of Osteopathic Medicine, or group'of same
Provider"), and will become effective as of the date who desire to become a Member Provider with
the Agreement is executed by RHG. RHG.
WHEREAS, RHG 'is engaged in the business of 1.2 ",Qualified Participant" means a person who
developing and acting in an administrative capacity sustained a work-related injury/illness that is
in providing Occupational Injury and health provider determined ebmpensible by an employer that
networks that offer direction of care while providing pazticipates in the Rockport United Network or
savings to RHG clients and/or Payors. These Rockport SelectHealth Network through Rockport's
networks will offer greater coverage of services and Client. Unless in an emergency or .after business
savings;and hours, initial services provided for the work-related
injury/illness require authorization by the Employer
WHEREAS, RI4G has networks of contracted and/or network either in writing or by telephone.
physicians, physician groups, hospitals and
providers of ancillary healthcare services 1.3 "Client" means an insurance company,
(collectively, the "Member Providers") to provide a employer, managed care company, or third party
full-range of healthcare services, These services are administrator. These Clients have entered into a
available for use by "Qualified Participants" as Client Agreement with RHG for the provision of
defined in 1.2 of this Agreement; and healthcare services to Qualified Participants.
WHEREAS, Member Provider desires to provide IA "Payor" means the entity responsible for
medical care services to "Qualified Participants" payment of medical benefits for on the job injuries
who are covered by Payor Agreements at the rates in and or illnesses according to State and/or Federal
Exhibit B and in locations listed in Exhibit C: and Rules and Regulations.
WHEREAS, RHG has entered into Agreements I.5 "Client Agreement" means the agreement
and/or services with one or more Payors who between RHG and a Client, which agreement is
provide payment of claims for medical care rendered made before, on or after the effective date of this
to Qualified Participants. Agreement and which expresses the agreed upon
contractual rights and obligations of the parties.
NOW, THEREFORE, in consideration of the Such Client Agreements will require Payors to pay
premises, the mutual promises contained herein, and Member Provider for Covered Services rendered to
other good and valuable consideration, the receipt Qualified Participants pursuant to this Agreement.
and sufficiency of which are hereby acknowledged, Furthermore,such Client Agreements shall authorize
it is mutually agreed as follows: RHG to enter this Agreement and contractually bind
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Payors to the terms hereof unless there is a conflict treatment protocols that do not conflict with any
with State and/or Federal rules and regulations. state and/or federal rules and regulations.
1,6 "Member Provider" means any physician; 1.11 'Bill and/or Claim Form"HCFA 1500(or other
physician group;hospital; surgery center; diagnostic appropriate claim form or their successors)
imaging center; laboratory; clinic; chiropractor; completed in accordance with the guidelines
dentist; podiatrist; psychologist; social worker; established by the National Uniform Billing
physical, occupational and speech therapist; etc. Committee or HCFA 1500 billing guidelines,and/or
licensed or certified to practice a healthcare state rules and regulations,
profession or licensed as a facility to offer healthcare
services,in the state where services are rendered and II. MEMBER PROVIDER OBLIGATIONS
who has executed a contract with RHG.
11.1 Services. Member Provider agrees to provide or
I.7 "Primary Treating-Physician/Clinic"means arrange for all medically necessary medical care for
a Member Provider who is a Medical Doctor(MD) Qualified Participants who present themselves to
or a Doctor of Osteopathic Medicine(DO)that Member Provider. Member Provider agrees to
specializes in Family Practice,General Practice, perform such services with the same standard of
Occupational Medicine or Internal Medicine and care, skill and diligence for all Qualified
whose practice is largely dedicated to caring for Participants. Member Provider agrees that it is their
work related injuries and illnesses and is designated sole responsibility to verify that the individual
by RHG as a Primary Treating Physician/Clinic presenting for care is a Qualified Participant.
(PTP). PTP agrees to render medical care to Member Provider agrees to render healthcare
Qualified Participants without a scheduled services to Qualified Participants at any and all
appointment and operate during normal business facility or practice locations listed in Exhibit "C".
hours, Monday through Friday of any given week Member Provider shall make best efforts to ensure
excluding recognized holidays, that services provided are consistent with nationally
recognized treatment guidelines (i.e. Official
1.8 "Specialist Physician" means a Member Provider Disability Guidelines (ODG), American
who has met the credentialing requirements of RHG Occupational and Environmental Medicine's
to be a Specialist Physician, and to whom Primary (ACOEM) and /or state rules and regulations.
Treating Physicians/Clinics may refer for necessary Member Provider agrees to comply with and be
and authorized care other than primary treating bound by all State/Federal Rules and Regulations.
services. Specialists will need to maintain their
current board certifications for their particular 11.2 Treatment Guidelines, Member Provider agrees
specialty to maintain their RHG classification as to follow the treatment guidelines, return-to-work
such. guidelines and individual treatment protocols
outlined in Exhibit A of this Agreement,provided in
I.9 "Emergency" .means, a medical condition RHG's Provider Handbook . and/or Clients'
manifesting itself by acute symptoms of sufficient Utilization Review Programs.
severity such that a prudent layperson who
possesses average knowledge of health and medicine 11.3 Non-Discrimination. Member Provider shall not
could reasonably expect the absence of immediate differentiate or discriminate in the treatment of its
medical attention to result in: (i) placing the patients as to the quality of services delivered to
individual in serious jeopardy (and in the case of a Qualified Participants because of race, sex, age,
pregnant woman, her health or that of her unborn religion, national origin, place of residence, source
child);or(ii)serious impairment to bodily functions; of payment or health status. Member Provider shall
or (iii) serious dysfunction of any bodily organ or observe,protect and promote the rights of Qualified
part. Participants.
1.10 "Covered Services" are those healthcare and IIA Referrals. Except in a medical emergency or
health-related services provided to Qualified when authorized by RHG, Client, or its designated
Participants for treatment of a compensible, work- representative, Member Provider agrees to refer
related injury/illness as defined by either nationally Qualified Participants only to other Member
recognized treatment guidelines and/or individual Providers,as defined in 1.6.
i
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accreditation/certification; (iii) changes in Federal.
!
11.5 Reports. For each encounter where Member Tax Identification Number(s), (iv) other information
Provider provides services to a Qualified Participant, provided in its application or Exhibit C for
Member Provider shall report such encounter on an participation, (v) Member Provider's professional
appropriate form and shall include statistical, liability insurance if such insurance falls below the
descriptive medical and patient data and identifying requirements of state law and (vi) Member
information, if and to the extent that reports are Provider's billing or facility address. A failure to
specified by RHG, Client or its designated give any notice required by this Section shall be a
representative, and requested information is not material breach of Member Providers obligations
prohibited by state and/or federal rules and and responsibilities hereunder, regardless of the
regulations. status,pendency or outcome of the event giving rise
to the obligation to give that notice, and may be
H.6 Professional Requirements. grounds for termination of this Agreement.
II.6.1 Licensure&Accreditation. Member Provider 11,8 Medical Records, Member Provider shall
shall comply with all applicable federal, state and maintain complete and timely medical records for
local laws, rales and regulations governing ,like Qualified Participants treated by Member Provider
providers and their provision of services. Evidence and its medical staff. Such records shall be prepared
of such current licensing, certification and/or in accordance with accepted principles of practice,
accreditation shall be submitted promptly to RHG shall document all services performed for Qualified
upon request. Member Provider represents and Participants and shall comply with all applicable
warrants that it and each of its employees and state and federal laws. Member Provider shall
contracted service providers has obtained, and shall maintain such records for the length of time required
maintain throughout the term of this Agreement, all by applicable state or federal law. Subject to all
necessary registrations, certifications, licenses, applicable privacy and confidentiality requirements,
permits and approvals as are required for the lawful such medical records shall be made available to.each
provision of Member Provider services to Qualified Member Provider and other health professionals
Participants. Member Provider shall immediately treating the Qualified Participant, and upon request,
notify RHG of any revocation, suspension or to the Payor, RHG or its designated representative
restrictions, that would affect any certifications, for review at the rates approved by State law and as
licenses or accreditations. set forth in the current State Workers' Compensation
Reimbursement Manual for Hospitals, if applicable.
11.6.2 Organization's Requirements. ' Member Member Provider shall obtain a valid consent for the
Provider shall use commercially reasonable efforts release of the Qualified Participant's medical records
to comply with RHG's criteria for provider to other providers, RHG, Payor, or its designated
participation, including credentialing policies and representative. RHG agrees that medical records of
procedures. Member Provider shall cooperate with Qualified Participants shall be treated as confidential
RHG's periodic evaluation of qualifications. In so as to comply with all federal and state laws and
addition, Member Provider shall use best efforts to regulations regarding the confidentiality of patient
cooperate with RHG's and/or state rules and records. The Member Provider's obligations under
regulations for the expeditious resolution of any this Section 11.8 shall survive the termination of this
grievance or complaint. Agreement.
II.7 Notification to RHG. Member Provider 11.9 Inspection of Records and Operations.RHG,
represents and warrants that information provided Payor or a designated representative,shall to the
herein and in the RHG application is true and extent permissible under applicable laws,have the
accurate in all respects and acknowledges that RHG right to inspect and audit, at all reasonable times
is relying on the accuracy of such information in during normal business hours,upon prior five(5)
entering into and continuing the term of this business day written notification,any of Member
agreement. In addition Member Provider shall use Provider's medical records and operations
best efforts to provide written notice to RHG of any reasonably pertaining to RHG Qualified Participants,
(i)suspension,reduction or loss of license to provide services provided and to Member Provider's
healthcare services; (ii) denial, suspension, performance under this Agreement. Member
restriction, reduction or termination of Provider further agrees,to the.extent permissible
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under applicable laws, to allow RHG,Payor or a additional allied health and other qualified personnel
designated representative thereof,including the as are available and appropriate for effective and
designated utilization review,quality management, efficient delivery of care. Member Provider shall
case management or peer review staff,to have ensure that all such personnel are properly licensed
reasonable access to medical records and and/or possess the necessary credentials to render
information of Qualified Participants for services the services that they perform.
provided under the terms of this Agreement as
necessary to enable such party to perform Utilization 1.12 Right to Use Member Provider's or Network's
Review and Quality Assurance activities in Name. Member Provider agrees to allow RHG to
accordance with the applicable Utilization Review list Member Provider's name, specialty, address,
and Quality Assurance Program.In addition, telephone number, and hours of operation in a
Member Provider agrees that in the event an Member Provider directory, Provider Search, RHG
examination concerning the quality of healthcare Site-Specific Provider Panel(s), RHG website and/
services is conducted by appropriate officials,as or other materials to help promote and assist Clients
required by federal,state,and/or local law,RHG with Qualified Participants needing medical care for
shall,to the extent permissible under applicable injuries/illnesses sustained. RHG agrees to allow
Iaws,submit in'a timely fashion,any required books Member Provider to list RHG's name, address, and
and records and shall facilitate such examination. telephone number on Member Provider's website or
RHG and Member Provider agree to assist one in other publications listing the health plans accepted
another with on-site inspection of facilities and by Member Provider. In addition, Member Provider
records by representatives of authorized federal, agrees to post in waiting room and make available to
state and local regulatory agencies. Qualified Participant notice of Member Provider's
participation with RHG with name, address and
II.10 Relationship of Parties. Member Provider and telephone number and process for Qualified
RHG understands and agrees that they are each an Participants to resolve complaints.
independent legal entity. Nothing in this agreement
shall be construed or deemed to create a relationship H.13 Noncomnliance.Member Provider understands
of employer and employee, principal and agent, that failure to comply with any of the requirements
partnership or joint venture or any relationship other imposed pursuant to this Agreement may result in
j than that of independent parties, contracting with termination of this Agreement by RHG.
I each other solely to carry out the provisions of this
Agreement for the purposes recited in this 11.14 Antitrust Guidelines. Member Provider agrees
Agreement. With regard to the provision of to comply with all antitrust guidelines and
healthcare services, Member Provider acts as an procedures promulgated by Federal and State
independent entity and the Member Provider-patient entities.
relationship shall in no way be affected.
III. RHG's OBLIGATIONS
11.11 Standards of Care. Member Provider agrees
that all duties performed hereunder shall be III.1 Marketing to Clients/Payors. RHG shall enter
consistent with the proper practice of their into agreements with Clients and/or Payors as
healthcare profession, and that such duties shall be defined in I.3 and 1.4 for their access to RHG quality
performed in accordance with the customary rules of Member Providers through specific referral
ethics and conduct of the appropriate and applicable processes. RHG will market Member Providers for
professional organizations and/or associations, as the referral; including but not limited to the following:
case may be, and such other bodies, formal or (i) Provider Search Provider Locator System (ii)
informal, state, government or otherwise, or by Provider Directories (iii) Site-Specific Provider
which they are subject to licensing/certification and Panels (iv) Customized Local Networks and (v)
control. Additionally, Member Provider shall Client Service Provider Referral Service.
perforin all medical and healthcare services in
conformance with the standards for similar services
as established by the locaUregional professional III.2 CredentialinQ. RHG will perform and/or
healthcare community and applicable delegate to qualified organizations credentialing of
aecrediting/lice,nsing agencies. Member Provider each Member Provider. Credentialing may include
agrees that,to the extent feasible,it shall utilize such verification of all information and documents
l
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t
provided in the application for participation and Member Provider agrees and acknowledges that
investigation, including but not limited to REG is acting solely in an administrative capacity in
verification with all state and national licensing and providing a network of quality health services. RHG
certifying bodies that apply to the services rendered is not the claims paying agent and will not be liable
by the Member Provider,such as 7CAHO, AAAHC, for the payment of any amount owed by a Payor to
NCQA, CLIA, URAC, etc. Inquiries may also be Member Provider in the event that Member Provider
made to current and previous professional liability is unable to collect such amount of money up to and
carriers, Medicare and Medicaid. RHG's including the insolvency of the Payor. Under no
credentialing policies and procedures follow the circumstance will a Member Provider attempt to
American Accreditation Healthcare Commission collect payment from a Qualified Participant for
(URAC) standards for Workers' Compensation medical services rendered for a compensible, work-
provider networks. related'injury/illness.
M.3 Operational Functions. RHG shall utilize If Member Provider voluntarily terminates its
systems to respond to Member Providers requests contract with RHG, upon Member Provider's
for information and will provide clarification of request, Payor must continue to reimburse Member
policies concerning the operation of RHG's Provider for a period not to exceed 90 days at the
programs. Member Provider agrees to work in Member Provider's contracted rate with RHG, for
cooperation with RHG to market the services of the care of an Qualified Participant with a life-
Member Provider to Clients and/or Payors. threatening condition or an acute condition for
which discontinuing care would harm the Qualified
RHG shall act as a liaison with the Member Participant.
Providers and Clients and/or Payors to devote
necessary time and effort to -perform RHG's FV.2 Reimbursement Rates. Member Provider is to
responsibilities hereunder, be paid by the Payor in accordance with State Law
and/or rules and regulations at the rates established
IIIA Retaliatory Action. RHG agrees not to engage in Exhibit B. Member Provider hereby agrees that
in any retaliatory action including termination of rates in Exhibit B,which may be amended from time
contract or refusal to renew a contract against to time upon mutual written agreement,represent the
Member Provider, because Member Provider, on total amount to be received and agrees to look solely
behalf of an Qualified Participant,reasonably filed a to the Payor for payment for such Covered Services.
complaint against, or appealed a decision of RHG or Payment will be made for Covered Services actually
Payor, or requested reconsideration or independent rendered. All claims will be paid, when appropriate,
review of an adverse determination, only after submission of a complete and accurate
claim. A complete and accurate claim shall be
1115 Antitrust Guidelines. RHG agrees to comply defined as a clean claim by the Texas Department of
with all antitrust guidelines• -and procedure Insurance, RHG does not guarantee, represents
promulgated by Federal and State entities. warrant or covenant regarding the selection or use of
Member Provider's services by any Qualified
III.6 Audit Polic and Procedure Co liance. All Participant or Payor, or'the number of patients, if
bill audit requests by Payor shall be done in any, which may result from participation in RHG's
accordance with the State Law and/or Federal Rules provider network. The obligation of a Payor to
and Regulations. reimburse Member Provider in accordance with
Exhibit B for the provision of Covered Services to a
Qualified Participant shall be conditioned upon a
IV. REIMBURSEMENT, CLAIMS good faith determination by the Payor or its
SUBMISSION.AND PAYMENT designated representative that (i) such services are
medically necessary, whether such determinations
IV.l Reimbursement. RHG shall arrange and are made before,on or after the provision of services
provide the Member Provider, locations and/or any to such Qualified Participant.
additional Tax Identification Numbers as listed in
Exhibit C for Payors to pay Member Provider the All services billed under the Tax Identscation
reimbursement rates for Covered Services rendered Number(s) indicated in this Agreement, any
I to Qualified Participants pursuant to Exhibit B. Amendments, Exhibit A, Exhibit B, Exhibit C,
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Applications or any updates regarding locations incorrect amount, or(iii) an overpayment, the Payor
and/or a Member Provider as defined in section I.6 or its designated representative may, at its sole
will be subject to the reimbursement rates option and discretion, request the return of such
established in the Exhibit B of this Agreement. amount from Member Provider The Member
Provider will not unreasonably withhold
All'-billing and reimbursement will be made in reimbursement. If overpayment has been made
accordance with Labor Code 408.027 and all other Member Provider shall reimburse such overpayment
applicable state rules and regulations. within forty-five (45) days and/or follow State and
Local Rules and Regulations. The Member Provider
N.3 Bill and/or Claim Forms. Claim forms are may not contest payment of Claims after one
required for all services. All claims must be hundred eighty(180)days from the date of payment.
submitted complete and accurate on HCFA 1500 (or All claims for overpayment or underpayment shall
other appropriate claim form or their successors)and be resolved in accordance with State Law and /or
must include Member Provider's usual and Federal Rules and Regulations.
customary billed charges (not discounted rates) and
appropriate codes, consistent with policies V. INSURANCE AND INDEMNIFICATION
established or approved by applicable state and/or
federal regulations. All claims must be submitted V.1 Insurance Requirement. Member Provider shall
within thirty (30) days, or within such time period provide and maintain such policies of professional
from the date of service, or as specified by the state liability insurance or a self-funded program. The
rules and regulations. amounts and extent of such insurance coverage or
self funded program shall be in the amounts
IVA Limited Recourse Against Qualified determined by community standards for relevant
ParticiRants. Except as otherwise provided in this hospital/facilities. If such coverage is under a
Agreement (Section I.10), Member Provider agrees "claims-made" policy, Mbmber Provider agrees to
to seek payment from each Payor for Covered provide and maintain such insurance coverage or a
Services provided to its Qualified Participants, and "tail" policy in the same amounts following the
agrees that it will not seek additional payments or termination of this Agreement. Member Provider
reimbursement for compensible injuries from shall promptly demonstrate evidence of insurability
Qualified Participants. In addition, Member or self-funded program and that the required
i Provider agrees that neither RHG,the Payor nor the insurance is paid and in force upon request of RHG
Qualified Participant shall be billed or ultimately and/or meet the credentialing guidelines of RHG.
i held responsible for payment of services deemed not
to be covered by the Payor or its designee. When V.2 Indemnification of RHG. RHG will be
Qualified Participant is covered by a state or responsible for its own acts or omissions and any
federally regulated Occupational Injury and Illness and all claims,liabilities,injuries,suits and demands
program, Member Provider agrees to comply with and expenses of all kinds which may result or arise
state and federal regulations regarding holding out of any alleged malfeasance or neglect caused or
Qualified Participants harmless for amounts not paid alleged to have be caused by its employees or
by Payor for any reason, including Payors representatives, in the performance or ornission of
insolvency. This provision does not preclude billing any act or responsibility under this Agreement. In
a Non-Qualified Participant for a non-compensible the event that a claim is made against RHG,it is the
injury. intent of RHG to cooperate in the defense of said
claim. However, RHG shall have the right to take
IV.5 Pa ent of Claim Forms. RHG shall any and all actions they believe necessary to protect
administratively arrange for the Payor or its their interest.
designated representative to pay undisputed claims
which are accurate, complete and comply with the V.3 Indemnification of Member Provider. Member
Agreement within the time period mandated by state Provider will be responsible for its own acts or
or federal law. omissions and any and all claims,liabilities,injuries,
suits and demands and expenses of all kinds which
N.6 Erroneous Pa ment. In the event that a Payor may result or arise out of any alleged malfeasance or
and/or its designated representative pays the neglect caused or alleged to have be caused by its
Member Provider (i) more than once, or (ii) an employees or representatives, in the performance or
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i
omission of any act or responsibility under this following written notice by RHG of a material
Agreement. In the event that a claim is made against default or breach by Member Provider hereunder
Member Provider, it is the intent of Member and the failure of Member Provider to cure such
Provider to cooperate in the defense of said claim. default or breach during such thirty (30) day period
However, Member Provider shall have the right to (vii) Member Provider fails to meet RHG's or the
take any and all actions they believe necessary to State's credentialing requirements. RHG, however,
protect their interest, may not terminate this Agreement in direct response
to Physician-filing a reasonable complaint, on behalf
VI. TERM AND TERMINATION of a Qualified Participant against, or appealed a
decision of, the network, or requested
VI.1 Term. The term of this Agreement shall be for reconsideration or independent review of an adverse
one (1) year from the date hereof and shall' be decision.
automatically renewed on an annual basis for
successive twelve(12) month periods,unless sooner In the event RHG deems it necessary to terminate
terminated in accordance with Section VI.2. Member Provider's agreement based on the above
requirements RHG will notify Member Provider at
VI.2 Termination. This Agreement may be least ninety (90) days before the effective date of
terminated sooner on the first to occur of the termination.
following:
Upon written notification from RHG, Member
VI.2.1 Termination by Member Provider. Member Provider may request a review by RHG's advisory
Provider may terminate this Agreement in the event review panel, not later than thirty (30) days after
of a material default or breach of RHG's obligations notification. RHG must then complete the review
hereunder,upon thirty(30) days prior written notice before the effective date of termination.
and the failure of RHG to cure such breach or
default within such thirty (30) day period. In VI.2.3 Termination for Insolvency. This Agreement
addition, in the event of an "emergency situation", shall terminate immediately in the event that either
j Member Provider may terminate the Agreement RHG or Member Provider voluntarily or
upon thirty (30) days prior written notice and the involuntarily, liquidates, dissolves or becomes
acknowledgment by RHO that such an emergency subject to any proceeding for the rehabilitation or
condition does exist. "Emergency Situation" shall conservation of their financial affairs with written
mean an unforeseeable event, not resulting from notification.
Member Provider's act or omission,which materially
affects Member Provider's ability to continue the VI.2-4 .Termination bv Either Par . Either party
practice of medicine or to perform his obligations may terminate this Agreement without cause upon
hereunder. one hundred and twenty (120) days prior written
notice.
VI.2.2 -Termination by RHG. A Member Provider
shall automatically be terminated on the date when: VI.2.5 Unforeseen Events. In the event that either
(i) Member Provider's license in the State where party's ability to perforin their obligations under this
services are rendered is suspended or revoked, (ii) Agreement is substantially interrupted by war, fire,
Member Provider is excluded from participation in insurrection, riots, the elements, earthquake, acts of
the Medicaid or Medicare programs, (iii) Member God, or other similar circumstances beyond the
Provider losses their 7CAHO, NCQA, AAAHC, reasonable control of such party, the party shall be
URAC, CLIA. or other applicable license, relieved of those obligations for the duration of the
certification and/or accreditation, (iv) Member interruption upon notice to the other party. In the
Provider loses or experience a material reduction in event that the interruption is reasonably determined
liability insurance and such insurance falls below the likely to persist for at least ninety (90) days, either
requirements of State Law (v) Member Provider party may terminate this Agreement upon thirty(30)
engages in any act, ornission, demeanor or conduct days prior written notice.
that is reasonably likely to be detrimental to patient
safety or to the delivery of quality patient care, or to VU Effects of Termination. Upon temunation of
lead to the provision of healthcare services below this Agreement, neither party shall have any further
applicable standards, or (vi) thirty (30) days obligation hereunder except for (i) obligations
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accruing prior to the date of termination, including or Member Provider respectively (collectively, the
without limitation, any obligation by Member "Confidential Information"). RHO and Member
Provider to continue to provide healthcare services Provider acknowledges that the Confidential
to Qualified Participants, and (ii) obligations, Information and all other information regarding
promises or covenants contained herein which are RHO or Member Provider that is competitively
expressly made to extend beyond the term of this sensitive is the property of RHO or Member
Agreement. Provider and RHO or Member Provider may be
damaged if such information was revealed to a third
VIA Qualified Participant and Payor Notification.If party. Accordingly, R.HG and Member Provider
applicable, upon the termination of this Agreement, agrees to keep strictly confidential and to hold in
by either party, Member Provider shall cooperate trust all Confidential Information. Upon termination
with RHO to notify Qualified Participants and of this Agreement by either party for any reason
.Payors of such termination. whatsoever, RHO and Member Provider shall
promptly return to'the other all material constituting
VII. CONTINUATION OF BENEFITS Confidential Information or containing Confidential
Information, and neither party will not thereafter
VII.1 Continuation of Benefits.Upon termination of use, appropriate, or reproduce such information or
this Agreement, Member Provider shall continue to disclose such information to any third party. RHO
provide services in accordance with this Agreement and Member Provider specifically agrees that under
to any Qualified Participant currently undergoing no circumstances will either party discuss the terms
treatment by Member Provider, until a medically and conditions of this Agreement, and in particular
appropriate transfer of care has been accomplished the pricing information herein.
provided, however, that Member Provider shall
exercise best efforts to accomplish such transfer IX. MISCELLANEOUS
t within at least thirty (30) days of written notification
of desire to terminate. Member Provider will be IX.l Disputes. All disputes and difference between
reimbursed for any such services in accordance with the Member Provider and RHO upon which an
the rates as set forth in Exhibit B and the terms of amicable understanding cannot be reached are to be
this Agreement. decided by the following method:
VII.2 Survival. The provisions of this Article VII Etl.l Mediation through RHO. The Member
shall survive the termination of this Agreement Provider shall notify RHO in writing of the dispute
regardless of the cause - giving rise to such or disagreement and shall provide all necessary
termination, as will sections R.9, V.2, V.3, VI.3, information to RHO. 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 IX.1.2 Arbitration. If the, dispute cannot be solved
Participant's behalf. by the mediation process described above, either the
Member Provider, R.HG 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 RHO 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 administrative 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 RHO or Member 1X.2 Non-Exclusives. Nothing in this Agreement
Provider, and all systems, manuals, computer shall be construed to restrict Member Provider or
software and other materials, but excluding patient RHO from entering into other contracts or
charts,shall be and remain the sole property of RHO agreements to provide healthcare services to Payors
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or other healthcare delivery plans, patients, and without the prior written consent of RHG. A change
employer groups, in ownership will not negate the prior contractual
agreement without written notification to RHG.
IX.3 Entire Agreement, This Agreement contains RHG retains the right to assign this Agreement, in
the entire understanding of_ the parties and whole or in part,to any entity with which RHG or its
supersedes any prior understandings and agreements, parent company or any of its subsidiaries is
written or oral, respecting the subjects discussed affiliated,or with which it merges or consolidates.
herein:
IX.10 Third Party Beneficiaries. Except for Payors
IX.4 No Waiver. The waiver by either party of a and the agents thereof, there are no third party
breach or violation of any provision of this beneficiaries of this Agreement.
Agreement shall not operate as or be construed to be
a waiver of any subsequent breach hereof. IX.l 1 Captions. The captions and headings
contained in this Agreement are for reference
IX.5 ReeulatoU Compliance. Member Provider purposes only and shall not affect in anyway the
and RHG agree that each shall comply with all meaning or interpretation of this Agreement.
applicable requirements of municipal, county, state
and federal authorities, all municipal and county IX.12 Execution of Counterparts. This Agreement
ordinances and regulations, and all applicable state may be executed in any number of counterparts,
and federal statutes and regulations,now or hereafter including facsimiles, each of which shall be deemed
in force and effect, governing RHG, Member to be an original as against any part whose signature
Provider, the provision of services by Member appears thereon, and all of which shall together
Provider, and/or Payors, including but not'Iimited to constitute one and the sarne instrument.
applicable requirements wider any state or federal
fair employment practices, equal employment IX.13 Partial Invalidity. If any part, clause or
opportunity, or similar Iaws declaring discrimination provision of this Agreement is held to be void by a
in employment based upon race, color, creed, court of competent jurisdiction, the remaining
religion, sex, or national origin as illegal, and,Titles provisions of this Agreement shall not be affected
VI and VII of the Civil.Rights Act of 1964, Section and shall be given construction, if possible, as to
202, of Executive Order 11246 as amended by permit it to comply with the minimum requirements
Executive Order 11375, Sections 503 and 504 or the of any applicable law, and the intent of parties
Rehabilitation Act of 1973 and Title IV of the hereto.
Vietnam Era Veterans Readjustment Assistance Act
of 1974, and. Sections I and 3 of Executive Order
11625, or any applicable mile or regulation .
promulgated pursuant to any such laws or orders.
IX.6 Governing Law. This Agreement shall be
governed by and construed in accordance with the
laws of the State of Texas.
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.
IX.8 Severability. The invalidity or un-
enforceability of any tern or condition hereof shall
in no way affect the validity or enforceability of any
other term or provision.
IX.9 Assignment. Member Provider may not assign
or"otherwise transfer any right or delegate any duty
of performance hereunder, in whole or in part
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IX.14 Official Notices. Any notice or
communication required, permitted or desired to be
given hereunder shall be deemed effectively given
when personally delivered or mailed, return receipt
requested, or overnight express mail addressed as
follows:
Member Provider or Representative/Designee:
�(
(Please Print)
Name: kt 4(P (?C gte n e ra (A r16L
Organization: ut=Cu�tL�'►L1f1e.1�P�.l�-H �..t,,�fr5 6�`F'ti2
` 6 rl , e!2E f�
� � aAddress: r A Lj
City/State/Zip: kA/f t SbA 4
Telephone: t.L1(. E
Fax:
Organization:
Rockport Healthcare Group,Inc.
Attn: Director of Network Development
50 Briar Hollow Lane,Suite 515W
Houston,TX 77027
Telephone:(713)621-9424
Fax:(713)621-9511
IN WITNESS WHEREOF, the undersigned will be or to such other address, and to the attention of such
deemed to have executed this Agreement as of the other person(s) or officer(s) as either party may
date this Agreement is signed by RHG. designate by written notice.
For and on behalf of: For and on behalf of:
Rockport Healthcare Group,Inc. Member Provider or Representative/Designee
50 Briar Hollow bane,Suite 515W =(Prino
Houston,TX 770 Signature:Name-
Rark .Nee
Sr.Vice Pre ident,Busi ss De lopment TIN: q5`ac)
Date: ! Q w Date: r rf�h 4�da�o
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I
EXHIBIT A
STANDARDS AND GUIDELINES
UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS
RHO 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 of
work-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 RHG'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)Level 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(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 I 1 of 13
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EXHIBIT B
Reimbursement Schedule
I.Rockport SelectHeaith Network--Workers' Compensation Medical Care—TX Certified Network plans
Provider fees for the programs listed above shall be reimbursed at the following:
All fees will be reimbursed at 140% (one hundred and forty percent) of Medicare,rules and regulations or
usual and customary allowables,'These rates apply exclusively to Texas certified network clients for Workers'
Compensation claims in Texas.
Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of this
Agreement and state rules and regulations.
i
I[We accept the fees as outlined in this Exhibit B.
For and on behalf of: For and on behalf of:
/(Naive,address,etc.)
ROCKPORT HEALTHCARE GROUP,INC. tJCC I I ,ge,, Ig 1,C1 Pr, r5 I~t p S6r�ft is `FP.A
50 Briar Hollow Lane,Suite 515W
Houston,Texas 777027 A-A d t 4?) ,, Tk?S
GSignature
Mark C.Ne� Printed Name
Sr.Vice President,B sines eves pment Title
rt--
Date TIN iE-a.O( Ab Date t f 1A 1^L��h Q, da
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EXHIBIT C
Signature page
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 C Spreadsheet and/or an equivalent spreadsheet provided by Member Provider,shall be inclusive
of the signed agreement and the signed rates in Exhibit B. 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 attached information as agreed to in this signed agreement.
For and on behalf of: For and on behalf of:
Rockport Healthcare Group,Inc. Member Provider or Representative/Designee
50 Briar Hollow Lane,Suite 5I5W
Houston,TX 77027 Signature:
Mark .Neer (print)
Sr.Vice Presi en#,Bu ness evelop-m
' (}
Date: Date: I i�CL tr c.k 9 , a0D
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