HomeMy WebLinkAboutContract 47186-P8 CITY SECRETARY
CC{�TOCT No.
ADDENDUM
To
BIa9kStone 504 Program
Provider Agreement
This Addendum is entered into by and among DEW Center for Spinal D}sordeis ("Me f rrrrovider"),
R ort ealt}care G;up("Rockport'), and the City of Fort Worth ("City") on t[usrr �, day of
0
WBEREAS,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 the Texas Insurance Code,Texas Labor Code,and Texas Administrative Code.
WHEREAS,Rockport has contracted with Member Provider on bebalf 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 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(bx2).
WMIZEAS,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 contraot between Member
Provider and the City thatmake available covered services for Quailfied.Participants'needs to the injured
workers ofthe City,
NOW,T BUFORE,for good and valuable consideration,the sufficlenoy 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
agmement 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
seotion 504.053 of the Texas Labor Code, The City's Provider Manual (under the name of
B1ackStone) sball 'Instead apply to matters of notice, bluing, 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 terns 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. Witon used in this Addendum,unless the content otherwise clearly requhw,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.
[ OFFICAL RECORD
CIT' ' SECRETARY
P4,T.V40RTH9 TX
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DFW Center for Spinal Disorders provider Agreement
i "Payors" will be the City as they are xesponsible for payment of medical-benefits for
compensable injuries and or illnesses sustained by Its injured workers according to the
i Texas Workers Comp ensationAct,
"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 B1ackStone Provider Manual as amended from time to time
and available gpon request to the Member Provider.
"Provider Panels"are those duwt contracted panels foamed by political subdivisions or
public pool entities authorized by Section 504.053 of the Tekas Labor Code.
4. Member Provider agrees to participate in the B1ackStone provider panel for the benefit of the City
and Qualified Participauts.
5. Nothing in this A.ddejtdun 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 WITNFSS VVBN L07i,the parties hereto have executed this Addendum effective on the day and year
I fust written above.
1 For and on behalf of:
City of Fort Worth
IilackSfone
Signatur p
a
Name: San lanis
Title: Assi tantC' Manacer
Date:
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APPROVED AS TO FORM AND LEGALI'T'Y:
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fa�slatant City Attarre u� e 1(,.e l/ ���°°°°°°°
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OfTIC1AL RECORD
CITY SECRETARY
FT.WORTH,TX ZY >iCle � 4 - r
DFW Center For Spinal Disorders Provider Agreement
RocxroRT HEALTHCARE GROUP
Signature: so
Name: e /�A-h a2 ►�.� r � ,r
ITitle; Co 1 ��
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MEMBER PROVIDER or
Represents tive/Designee
Signature.,
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Name; ecu,•. �/-1�Lrt( 1�r�i�
Title: fC�'L`�, Car�lf
Date:
TIN:26-3968733
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ROCKPORT `
PHYSICIAN AGRE99vffNT
ROCKPORT UNITED NETWORK
ROCKPoipT SELECTHE,A.]LTH NETWORK
This Physician Agreement("Agreement'),is entered L DEFINITIONS
into by and between Rockport Community Network,
.Inc., •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 1.1 "Physician"means a licensed Medical Doctor or
network) and Jasoit Tinlev. MD ("Member Doctor of Osteopathic Medicine, or group of sante
Provider"),and will become 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 proAding 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 1.2 "Qualified PartkipW means air "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 t4 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
Exhibit 8 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 "Paor" 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
rules 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.
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1.5 "Client Mement" means the .agreement specialty to maintain their RHG classification as
between- RHG and a Client, which agreement is such and be willing and able to treat.Qualified
made before, on or alter the effective date of this Participants as neoded or required..
Agreement and which expresses the agreed upon
contractual lights and obligations of the parties. 1.9 "Emergency 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 ofsufficient 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
(b)serious dysfunction of any body organ or part as
I.6 "Member Provider" means any physician; 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 TIC 1305.004(15).
licensed or certified to practice a healthcare
profession or licensed as a facility to offer healthcare 1.10 "Covered 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
orkrelated injury/illness as defined by either nationally
1.7 "Primary Treating Physician/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.
Treating Doctor.Therefore,a Member Provider who
is a Medical .Doctor (MD) or a Doetor of 1.11 "Bill and/or Claim Form" CIMS 1500(or oilier
Osteopathic Medicine (DO) that specializes in appropriate claim form or their successors)
Fancily 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
ithat 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. MEMBER PROVIDER OBLIGATIONS
Treating Physician/Clinic (PTP). PTP agrees to
render medical care to Qualified Participants without MI Services. Member Provider agrees to provide or
a scheduled appointment and must be available and arrange for all medically necessary medical care for
accesible to employees twenty-four (2¢)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(6)(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* 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/Clinics 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.
current board certifications for their particular
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Member Provider agrees to comply with and be 16 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.RHC"r agrees to fiuxnish representative, and requested information is not
Member Provider or cause Payor to famish 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 II.71'rofessional Requirements.
obtain preauthorization. Unless in an emergency or
after business hours,initial services provided for the 11.7.1 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 life
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
R.3 Non-Discrimination,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, sex, 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
r
HA Medical Staff Partieipation. 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. Qhganization'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 RHG of all data collected with respect to credentialing policies and procedures. Member
Physician in connection with Physician's medical Provider shall cooperate: with RFIG'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 RHG, Client, or its designated
representative, Member Provider agrees to refer •11.8 - Notification to RHG 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
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accurate in all.respects and acknowledges that RkIG 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 Provider`s
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 m Federal case management or peer review staff, to have
Tax Identification Number(s),(iv)other information reasonable access to medical records and
provided in its application or Exhibit C for information 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,RHG shall submit,in
grounds for termination of this Agreement. a timely fashion,any required books and records and
shall facilitate such examination. RHG and
119 Medical Records. 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 111 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 constmed 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 made 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 Payor, 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 ll.b Standards of Care. Member Provider agrees
to other providers, RHG, 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 11.9 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
II-10 InsWation of Records and Operations. RHG, control. Additionally, Member 'Provider shall
Payor or a designated representative shall have the perform all medical and healthcare services mi
right to inspect and audit, at all reasonable times conformance with the standards for their facilities as
l during normal business hours, upon prior five (S) established by the locallregional professional
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healthcare community and applicable (i) Provider Search Provider Locator System (ii)
accrediting/licensing agencies. Member Provider Provider Directories (iii) Site-Specific Provider
agrees that,to the extent feasible,it shall utilize such Panels (iv) 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 Ill.2 QWMfigLffi& RHG will perforin 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. Credentialing may include
the services that they perform.- verification of all 'information and documents
provided in the application for participation. and
U-13 Ri ht to Use Member Provider's or Network's investigation, including but trot' limited to
Name. Member Provider agrees to allow RHG 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, REG NCQA, CLIA:, URAL, etc. laquiries may also be
Site-Specific Provider Panel(s), RHO 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 (URAC) and/or NCQA 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 111.3 9perational Functions. RING 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-feee phone necessary time and effort to perform RHG's
number for filing a complaint and must list all responsibilities Hereunder.
workers' compensation health care networks with
which the Member Provider contracts. M.4 Retaliatory Action.REG agrees not to engage
in any,retaliatory action.including termination of
11.14-Non_ compliance.Member Provider understands contract or refusal to renew a contract against
that failure to conVly 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
H.1.5 Antitrust Guidelines. Member Provider agrees review of an adverse determination,
to comply with all - antitrust. guidelines and
procedures promulgated by Federal and State M.5 .Antitrust Guidelines. RHG agrees to comply
entities. with all antitrust guidelines and procedure
promulgated by Federal and State entities.
III. RHG's OBLIGA'T'IONS
111.6 Audit Policy and Procedure Compliance. All
f IlI.1 Marketing to Clients/Payors. RHG shall enter bill audit requests by Payor shall be done in
I into agreements with Clients and/or Payors as accordance with the State Law and/or Federal.Rules
defined in-13 and I.4 for their access to RHG quality and Regulations.
Member Providers through specific referral
processes. RUG will market Member Providers for
referral; including but not limited to the following;
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PV. REIMBURSEMENT,CLAS will be subject to the reimbursement rates
SUBMISSION AND PAYI1W-M established in the Exhibit B of ibis Agreement.
IV.1 Reimbursement. RHG shall arrange and. All billing and reimbuirsecnent will be made in
provide the Member Provider, locations and/or any accordance with Labor Code 408.027 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 pursuanf 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 95's 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 §408.027 and other
related injury/illness. applicable statutes and rules,billing and payment to
Member Provider will be made within forty-five
-TV-2 Reimbursement Rates.Member Provider is to (45)days of receipt of bills 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 IVVA Limited Recours. a 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 1:10),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 compensible -injuries from
claim. A complete and -accurate claim shall be Qualified Participants. In addition, Member
defined as a clean claim by Medicare.RUG 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 RHUs provider network. The federally regulated Occupational Injury and Illness
obligation of a Payor to reimburse Member Provider program, Member Provider 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 Dion-Qualified Participant for a non-compensible
determinations are made before, on or after the injury.
provision of set-vices 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 -
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
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Of quality health providers. RHG 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, REG 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
IV.5 Payment of Claim Forms. RHG 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
Ior 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
I and/or its designated representative pays the Provider too-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("Iii)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.1 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 (45) days and/or follow State and automatically renewed on an annual basis for
Local Rules and Regulations. The Member Provider successive twelve(12)month periods,unless sooner
may not contest payment of Claims after one terminated in accordance with Section VL1
hundred eighty(180)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. INSURANCE AND MIQVINIIa(CATION VI.Z.I Me—m-nation by Member Provider, Member
Provider may terminate this Agreement in the event
V.I Insurance Regi ikLment. Member Provider shallof 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/facili[ies. Member Provider shall promptly immediately with the acknowledgment by RHG that
demonstrate evidence*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 ofRHG. omission, which materially -,affects Member
Provider's ability to continue the practice of
V.2 Indemnification of REG. 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
I 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
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VI.2.2 Termination by RHG. A Member Provider the breach within. sixty (50) 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
URAC, 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, fine,
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 shalt 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 RHG's 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 filing 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 V14 c)rralified PartrCii�ant 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 shalt 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 RHG, Member V11.CONTINUATION OF BENEFITS
Provider may request a review by RHG's advisory
review panel, not later than thirty (30) days after VIII Continuation of Benefits.If Member Provider
notification. RHG must then complete the review voluntarily terminates its contract with.RHG, upon
before the•effective 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
shall 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 Qualified 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(b) (A).Any disputes concerning continuity of
care shall be resolved through the complaint process
VI.2.4 Termination by Either Party. In case of under Insurance Code §1305:401 - §13Q5.4tlS and ----
material breach of the terms of this Agreement, Subchapter G of Title 28, Part. 1 (relating to
I either party may terminate the'Agreement with at Complaints).
least ninety (90) days prior written-notice to the
i
other party; however,the party in breach may cure
Page 3 of ra
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VI1.2 Survival. 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, VL3, information to RHG. RHG shall use best efforts to
VIII, and 1X. 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, RHG or Payor may elect to
VIII. COlY1kID+Pl�'I'IAI, TY 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 awe 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 or Member 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 RHG as follows:
or Member Provider respectively (collectively, the
"Confidential Information"). RHG and Member IX.1.3.1 RHG 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;
RHG or .Member .Provider that is competitively
sensitive is the property •of RHG or Member IX.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 JX.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 1X.1.3.4 The Network must complete the advisory
disclose such information to any third party. RHG panel review before the effective da#e 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;
IX.1 Disputes. All disputes and difference between
i the Member Provider -and RHG,upon which an IX.1.3.6 If Member 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
i
receiving care from the terminating provider, The
Network shall_give such notice immediately upon
0039MC0.002MOC Page 9 of 14
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receipt of the Member Provider's termination
request ar 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 performancee 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
7X.3 Entire Agrreement. 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 understandings 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 Party 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.
IX-11 C tions. The captions and headings
IX.5 Re tg_IIatgU-Comer Bance. 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,
mmnieipal, 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 RHG, 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.
Payors, 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 11246• as amended by of any applicable law, and the intent of parties
Executive Order 11375,Sections 503 and SO4 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 shalt be
governed by and construed in .accordance with
applicable state law.
JX-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
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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 personalty 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 RHO 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.
IX-i5 Financial Disclosure Requirements. Member
Provider is required to file financial disclosures in Member Provider or Representative/Designee-
accordance with Labor Code §§408.023 and (Please Print)
§§413.041.
IX.16 Economic Profilins. Network must provide Name:Jason Tinley�MD
written notice to Member Provider before the Practice:Jason Tinley MD PA
Network conducts economic profiling, including
utilization management studies or other profiling of Address: 4441 Brypat hvm Rd N
the provider or group of providers.
City/State/Zip:Fart Worth.TX 76107
Telephone: 817 916-4685
Fax: _(817)769-3718
Organization:
Rockport Community Network,Tho.
dba Rockport Healthcare Group
Attn: Network Development
50 Briar Hollow Lane,Suite 515W
Houston,TX 77027
Telephone:(713)621-9424
IN WUNESS WHEREOF, the undersigned will be Fax:(713)621-9511
deemed to have executed this Agreement as of the or to such other address,and to the attention of such
date 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 Cormnunity Network,l!nc.
For and on behalf of..
dila Rockport Healthcare Group Member Progor ,ntatrive/Designee
50 Briar Hollow Lane,Sui a 515W
Houston,TY 7702 Signature•
I � Name-
Mark C.Neer/
Sr.Vice Pr dent,Network D vetopment
TIN-.26-39 .3
{
Date: /`7
3 Date: l
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EXMff A
STANDARDS AND GUIIDELDWS
UPILIZAn0NREVIEW AND QUALITY BIPROVEMIENT7PROGR MS
RHG and its Clients require Member Providers to follow nationally recognized treatment guidelines(i.e. Official
Disability Guidelines(ODG) and/or.American Occupational and Envimnruental Medicine's ACC)
in the treatment of work-related in'uries/ilhtesses for f �M? guidelines)
J Qualified.Participants.
1
RHC,'s Clients provide utili2ation review and quality improvement Programs for Qualified Participants. RHG shall
review each Clients Utilization Review and Qualitylmprovement Program In accordance with.RHGs Credentialing
Standards and Guidelines as described in this Exhibit. Physician andlor Member Provider agrees to comply and be
j� bound by such programs and any state or federal rales and regulations.
i. Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written
notice to physician and/orMemberPwvider.
Theprimary goals of the UtilizationReviewPrograms 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) Ensurethat healthcare services areprovided at the appropriate level of care;and
J) Finsure.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) AJI 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) chrome 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 healthcare services and treatments;
13) Chemical dependency mweight 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; (11) therapeutic
procedures,excluding work hardening and work conditioning;and(iii)other procedures,limited to the unlisted
physical medicine and rehabilitationprocedure 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.
i .
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El XMIT B
Reimbursement Schedule
L RockportUnited Network/Rockport Selectliealth Network..Occupational Injury and Illness
Provider fees for the programs listed above shall be reimbursed at the following:
All fees will be reimbursed at 97% (nlnety-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 rules and regulations and/or the applicable Occupational Injury or Illness Benefit
Plan.
i
I/We accept the fees as outlined-in this Exhibit B.
For and on behalf of: For and on behalf of:
(Name,address,etc.)
ROCKPORT COMMUNITY NETWORK,INC. Jason Tinley.AM
dba Rockport Healthcare Group 440 Bryant Irvin Rd N
50 Briar Hollow Lane,Suite 515W Fort North,TX 761.07
Houston,Teras 770
Signa
Mark C.Neer Prdinted ame an Tinley,
Sr.Vice President,Ne ork elopment Title T
Date f TIN 26-3968733 pate
i
t
R1So 13 of I4
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EX�BIT 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 Iocations listed on attached Exhibit C,
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(RHG)and its representatives to we any and all of the
below information as agreed to in this signed agreement.
Jason Tinley,MD,PA Jason Tinley,MD,PA
Practice Name(1) Practice Name(1)
Jason'1mla,MD Jason Tinley,MM
Physician Name(if applicable) Physician.Name(1f applicable)
4441.BMant Irvin Rd N 649 NE Alsb�+Rd
Physical Address Physical Address
Fort Worth.TX 76107 Burleson,TX 76028_
City,State Zip City,State Zip r
Mailing Address(if different) Mailing Address(if different)
(817)916-4685j(817)769-3718- M2104685/017)769-3718
Phone Number/Fax Number Phone Number I Fax Number
263968733 26-3968733
Tax ID Number Tax ID Number
Practice Name(3)
'
Physician Name(if applicable) Practice Name(4)
Physician Name(if applicable)
Physical Address
Physical Address
City,State Zip
City,State Zip
Mailing Address(if different)
Mailing Address(if different:)
Phone Number 1 Fax Number
Phone Number/Fax Number
Tax ID Number
Tax III Number
For and on behalf of; For and on behalf of:
Rockport Community Network,Inc. Member Provider or RepresentativeMesignee
dba Rockport healthcare Group
50 Briar Follow Lane,Suite 515W
Houston,TX 77027 Signatu
Name: aso inlev MI
DMD
C.Neer
Sr.Vice Pres
id t,Network D elopment
'
Date: Date: � 1
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