HomeMy WebLinkAboutContract 47186-P16 CITYSECRETARY
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ADDENDUM
To
Blackstone 504 Program
Provider Agreement
i
This Addendum is entered into by and among Midtown Medical Imaging("Member Pro 'der",Rockport
=thce Gr up (" ockport"), and the City of Fort 'Worth ("City") on this day of
+ � 20�.
WHEREAS, Rockport and Member Provider entered into a Provider Agreement, effective August 9,
2015, ("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'
compensation program needs and,as such,have elected to provide medical benefits to injured workers by
directly contracting with health care providers.
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504.053(b)(2).
WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
j Agreement to be the same terms and conditions that apply to the direct contract between Member
Provider and the City that make available covered services for Qualified Participants'needs to the injured
workers of the City.
NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
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
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
B1ackStone) 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 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. When used in this Addendum,unless the content otherwise clearly requires, the following words and
terms shall have the meaning set forth below. All other defined terms shall have the meaning
ascribed to them in the Provider Agreement.
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FACILITY/ANCILLARY AGPME11Y NI T
ROCITORT UiYITET3 NE11WORK
ROCKPORT SE LECTM,ALTA NETWORK
This Facility/AncillaryAgreement("Agreement'),is L DEFLNMONS
entered 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 "Phvsician'means a licensed Medical Doctor or
network.) and.Midtown\medical Imagine:("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 provider is fully credentialed by RHG. RHO.
WHEREAS, RHO is engaged in the business of Pursuant to Title 23, Texas Administrative Code
developing and acting in an administrative capacity §1.0.42 regarding Network Contracts with Providers
in providing Occupational Injury and health provider seeking to participate in Texas Certified Workers'
networks that offer direction of care while providing Compensation Networks,
savings to RUG clients and/or Payors. These
networks will offer greater coverage of services and 1.2 "Qualified Participant" means an"employee' as
savings;and defined and used in the Texas Labor Code, the
i Network Act Section 1305 and the implementing
WI)EREAS, RHG has networks of contracted rules who sustained a work-related injury/illness that
physicians, physician groups, hospitals and is detennined compensable by a Client and that
providers of ancillary healthcare services participates in the Rockport United Network or
(collectively, the "Member Providers'D to provide a RockTort SelecEealth Network through Rockport's
fall-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 I.2 of this Agreement;and injuryhllness require authorization by the network
either in writing or by telephone.
WHEREAS, Member Provider desires to provide
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 B and in locations listed in Exhibit C: and are defined and used in the Texas Labor Code, the
inclusive of the networks included in Exhibit D;and Netwoxk Act Section. 1.305 and the implementing
rules. These Clients have entered into a Client
NV11BREAS, REG has entered into Agreements Agreement with RHG for the provision of healthcare
and/or services with one or more Payors who services to Qualified Participants.
provide payment of claims for medical care rendered
to Qualified Participants. 1.4 !Payor" means an insurance carrier or network
certified by an insurance carrier for its own benefit,
NOW, THEREFORE, in consideration of the certified self-insured or governmental entity as those
premises,the mutual promises contained herein, and terms are defined and used in the Texas Labor Code,
other good and valuable consideration, the receipt the Network Act Section 1305 and the implementing
and sufficiency of which are hereby acknowledged, rules who is responsible for payment of.medical
itis mutually agreed as follows: benefits for on the job injuries and or illnesses
according to State and/or Federal Rules and
Regulations.
Page 1 of 15
i Mdtm mMe&calIa ngiag 7-5-2015 RUNFAC Tx 050115
1.5 "Client Agoxeement" means the agreement specialty to maintain their RHO classification as
between RHG and a Client; which agreement is such.
made before, on or ager the effective date of this
Agreement and which expresses the agreed upon I.9 "Emergency Medical or Mental Condition" is
contractual rights and obligations of the parties. defined as the sudden onset of a medical condition
Such. Client Agreements will require Payors to pay manifested by acute symptoms of sufficient severity,
Member Provider for Covered Services rendered to including severe pain,that the absence of immediate
Qualified Participants pursuant to this Agreement. , medical attention could reasonably be expected to
Furthermore,such Client Agreements shall authorize result in:
REG to cuter this Agreement and contractually bind (a)placing the patient's health or bodily functions an
Payors to the terms hereof unless there is a conflict serious jeopardy,or
with State and/or Federal rales and regulations. (b)serious dysfunction of any body organ or part as
defined in TIC 1305.004(B);and
1.6 "Member Provider" means any physician; (c)in the case of a mental health condition, one that
physician group;hospital;surgery center; diagnostic could reasonably present danger to the person
imaging center; laboratory; clinic; chiropractor; experiencing the mental health condition or another
dentist; podiatrist; psychologist; social worker; person as defined in TIC 13 05,004(15),
physical, occupational and speech therapist; etc.
licensed or certified to practice a healthcare I,10 "Covered Services" are those healthcare and
profession or licensed as a facility to offer healthcare health-related services provided to Qualified
services,in the state where services are rendered and Participants for treatment of a compensable, woxk-
vvho has executed a contract with RHO. related injury/illness as defined by either nationally
recognized treatment guidelines and/or individual
1.7"Bju axv Treating,Physieian/Clinic"means treatment protocols that do not conflict with any
a Member Provider who is a Medical Doctor W) state and/or federal rules and regulations.
or a Doctor of Osteopathic Medicine(DO)that
specializes in Family Practice,General Practice, I.11 "Bill and/or Claim. Form" UB-92 (or other
Occupational Medicine or Internal Medicine as well appropriate claim form or their successors)
j as a physician that provides initial and/or follow-up completed in accordance with the guidelines
care in Occ-Med or Urgent Care Clinics whose established by the National Uniform Billing
practice is largely dedicated to caring for work Committee or UB-92 billing guidelines, and/or state
related injuries and illnesses is designated by RHO rules and regulations,
as a Primary Treating Physician/Clinic (PTP). PTP
agrees to render medical care to Qualified II, TW EIWER PROVIDER OBLIGATIONS
Participants without a scheduled appointment and
must be available and accesible to employees 111 Services. Member Provider agrees to provide or
twenty-four(24)hours-per-day, seven (7) days firer- arrange for all medically-necessary medical care for
week as per 28 TAC 10.80(b)(1).Should a Qualified Qualified.Participants who present themselves to
Participant need medical, attention outside of Member Provider. Member Provider agrees to
Member Provider's normal business hours, Member perform such services with the same standard of
Provider will be available and/or make arrangements care, skill and diligence for all Qualified
to have another Member Provider render care to Participants. Member Provider agrees that it is their
Qualified Participant Both parties agree that sole responsibility to verify that the individual
Member Provider is a health care facility or other presenting. for care is a Qualified Participant
ancillary provider, and as such, the requirements of Member Provider agrees to render healthcare
28 Texas Administrative Code§ 10.42(b)(12)do not services to Qualified Participants at any and all
apply regarding Treating Doctors. facility or practice locations listed in Exhibit "C".
Member Provider shall make best efforts to ensure
I.8 "Specialist Physician" means a Member Provider that services provided are consistent with nationally
who has met the credentialing requirements of RHO recognized treatment guidelines (i.e. Official
to be a Specialist Physician, and to whom Primary Disability Guidelines (ODG), American
Treating Physicians/Clinics may refer for necessary Occupational and Environmental Medicine's
and authorized care other than primary treating (ACOEM) and /or state rules and regulations.
services. Specialists will need to maintain their Member Provider agrees to comply with and be
current board certifications for their particular bound by all State/Federal Rules and Regulations.
I Page 2 of 15
Mdt0PnMediC4Imaging 7-6-2013 RUNFAC T3-050115
ZE.6 Reports. For each encounter where Member
11.2 Treatment Guidelines. Member Provider agrees Provider provides services to a Qualified Participant,
to follow the treatment guidelines, return-to work Member Provider shall report such encounter on an
guidelines and individual treatment protocols appropriate form and shall include statistical,
outlined in Exhibit A of this Agreement,provided in descriptive medical and.patient data and identifying
RHG's Provider Handbook and/or Clients' information, if and to the extent that reports are
Uti]izatiori Review Programs.REG agrees to f n-nisn specified by RHG, Client or its designated
Member Provider or cause Payor to furnish to representative, and requested information is not
Member Provider, and Member Provider agrees to prohibited by state and/or federal rules and
abide by, the list of any treatments and services that regulations.
require preauthorization and by any procedures to
obtain preauthorization.Unless in an emergency or 11JProfessionalRequirements.
after business hours,initial services provided for the
work-related iajury/iilness require authorization by R.7.1 Licensure&Accreditation Member Provider
the carrier and/or Network either in writing or by shall comply with all applicable federal, state and
telephone. The Client and/or Payor may not deny local laws, rules and regulations governing like
treatment solely on the basis that a treatment for a providers and their provision of services. Evidence
compensable injury in question is not speoifreally of such, current licensing, certification and/or
addressed by the treatment guidelines used by the accreditation shall be submitted promptly to RHG
Client and/or Payor. However, Member Provider upon request. Member Provider represents and
must demonstrate medical necessity to support warrants that it and each of its employees and
services rendered to Qualified Participants that are contracted service providers has obtained, and shall
outside of treatment guidelines. maintain throughout the term of this Agreement, all
necessary registrations, certifications, licenses,
71.3 Non-Discrimination.Member.Provider shall,not permits and approvals as are required for the lawful
differentiate or discriminate in the treatment of its provision of Member Provider services to Qualified
patients as to the quality of services delivered to Participants. Member Provider shall immediately
Qualified Participants because of race, sex, age, notify RHO of any revocation, suspension or
religion, national origin, place of residence, source restrictions, that would affect any certifications,
of payment or health status. Member Provider shall licenses or accreditation's. Member Provider
j observe,protect and promote the tights of Qualified warrants that it is currently accredited by the Agency
Participants. that governs like providers and is ceded as a
Provider under Title .XVIII (Medicare) and when
11.4 _Medical Staff Pard&ation. Member Provider appropriate, Title XIX (Medicaid) of the Social
shall cooperate to the fullest extent possible in Security Act and that it shall maintain such
obtaining staff privileges :for Participating Primary accreditation and certification,during the term of this
Treating and Specialist Physicians/Clinics who Agreement. Member Provider shall immediately
meet Member Provider's credentialing standards and notify RHG of any action, investigation or
agree to comply with the rules and regulations, proceeding to revoke, suspend,restrict, or otherwise
i policies and procedures as may exist from time to affect such accreditation,or ceriifr.cations,
time governing Member Provider and its medical
staff. Member Provider shall grant staff privileges 11.7,2 Qrganization's Requirements. Member
only to competent qualified physicians and Provider shall use best efforts to comply with RHG's
healthcare professionals and shall exercise ongoing criteria for provider participation, including
peer review of the members of its medical staff. credentialing policies ajid procedures. Member
Upon request,Member Provider shall provide RHG Provider shall cooperate with RHas periodic
with a current copy of its medical staffroster, evaluation of qualifications, In addition, Member
Provider shall use best efforts to cooperate with
11.5 Referrals. Except in a medical emergency or RHO's and/or state rules and regulations for the
when authorized by RHO, Client, or its designated expeditious resolution of any grievance or
representative, Member Provider agrees to refer complaint.
Qualified Participants only to other Member
Providers,as defined in 1.6. ILS Notification to RHO. Member Provider
represents and warrants that information provided
i
herein and in the RHG application is true and
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M3dtawaMed 4Ibtaging7-6-2015 RMTFAC TX 050115
I
accurate in all respects and acknowledges that RHG business days, any of Member Provider's -medical.
' is relying on the accuracy of such information in records and operations reasonably pertaining to
entering into and continuing the term of this RHG Qualified Participants, services provided to
agreement. In addition Member Provider shall use Qualified Participants, and to Member Provider's
best efforts to provide written notice to RUG of any performance under this Agreement. Member
(i)suspension,reduction.or loss of license to provide Provider further agrees to allow RUG, Payor or a
healthcare services; (Ji) denial, suspension, designated representative thereof including the
restriction, reduction or termination of designated utilization review, quality management,
acoreditation/certifioation; (iii) changes in 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 fox 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
II.9 -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 11,11 Relationship of Parties. Member Provider and
Participants and shall comply with all applicable RHO understands and agrees that they are each an
state and federal laws. Member Provider shall independent legal entity. Nothing in this agreement
maintain such records for the length of time required shall be construed or deemed to create a relationship
by applicable state or federal law. Subject to all of employer and employee, principal and agent,
applicable privacy and confidentiality requirements, partnership or joint venture or any relationship other
such medical records shalt 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 Participants medical records U.12 Standards of Care. Member Provider agrees
to other providers, RHCI, Payor, or its designated that all duties performed hereunder shall be
representative. R1IG 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 axe subject to licensing/certification and
II10 Inspection of Records and Operations; RHG, control. Additionally, Member Provider shall
Payor or a designated representative shall have the perform all medical and healthcare services in
right to inspect and audit: at all reasonable times conformance with the standards for their facilities as
during normal business hours, -upon prior five (S) established by the locallregional professional
lyli t mMedical Iiuna Page 4 of 15
�v7-6 20li 1ZUIQPAC 1X_05011:5
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i 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 shalt utilize such Panels (iv) Customized Local Networks and (v)
additional allied health and other qualified personnel Client Service Provider Referral Service.
as axe available and appropriate for effective and
efficient delivery of care. Member Provider shall 111.2 Credeatialina. REG will perform, and/or j
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
11.13 Right to Use Member Provider's or Network's investigation, including but not limited to
Name. Member Provider agrees to allow RHO 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 JCARO,AAAHC,
Member Provider directory, Provider Search, RHO NCQA, CLLR, URAL, etc. Inquiries may also be j
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, 1NIedicare and Medicaid. RH(Ts
with Qualified Participants needing medical care for credentialing policies and procedures follow the
injuries/Ohesses sustained. RHO agrees to allow American Accreditation Healthcare Commission
Member Provider to list RHG's name, address, and (JRAC) 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 D13 OQgerational Functions. RHO shall utilize
agrees to post in waiting room and make available to systems to respond to Member Providers requests
Qualified Participant notice of Member .Provider's for information and will provide clarification of
participation with RHO 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 RHO 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
resohring workers' compensation health. care RHG shall act as a liaison with the Member I
network complaints. The notice must include the Providers and Clients and/or Payors to devote j
Teras Department of Insurance's toll-free phone necessary time and effort to perform RHUS
number for filing a complaint and must list all responsibilities hereunder.
workers' compensation health care -networks with
which the Member Provider contracts, 111.4 Retaliatory Action, RHO agrees not to engage
in any retaliatory action including termination of
11.14 Noncompliance.Member Provider understands contract or refusal to renew a contract against
that failure to comply with any of the requirements Member Provider, because Member Provider, on
j imposed pursuant to this Agreement may result in behalf of an.Qualified Participant,reasonably filed a
termination of this Agreement by RHO. complaint against, or appealed a decision of RHO or
Payor, or requested reconsideration or independent
11.15 Antitrust Guidelines. Member Provider agrees review of an adverse determination. j
to comply Frith all antitrust guidelines and j
procedures promulgated by Federal and State IU-5 Antitrust Guidelines. RHG agrees to comply
entities. with all antitrust guidelines and procedure
promulgated by Federal and,State entities. j
)M. RHG's OBLIGATIONS
111.6 Audit Policy and Procedure ompliance, All
Rf.1 Marketing to Chents/Pa ors. RHG shall enter bill audit requests by Payor shall be done in
into agreements with Clients and/or Payors as accordance with the State Law and/or Federal Rules
defined in 1.3 and 1.4 for their access to RHG quality and Regulations. �
Member Providers through specific referral
processes. RHG will market Member Providers for
referral; including but not limited to the following:
Pap 5 of 15
MdfomMe&4Ima&g7-6-Z(TI5 RUNFAC TX o5o})5
I
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and/or a Member Provider as defined in section 1.6
will be subject to the reimbursement rates
)!V. REIll BURSEIV.IENT,CLAMS established in the Exhibit B of this Agreement.
SUBAVIIMSION AAT PAXWIENT
All billing and reimbursement will be made in
nlT I Reimbursement. RHO shall arrange and accordance with. Labor Code 408.027 and all other
provide the Member Provider, locations and/or any applicable state rules and regulations.
additional Tax Identification Numbers as listed in
Exhibit C fox Payors to pay Member Provider the SV.3 Bill and/or Claim Forms. Claim forms are
reimbursement rates for Covered Services rendered required for all services. All claims must be
to Qualified Participants pursuant to Exhibit B. submitted complete and accurate on UB-92(or other
Member Provider agrees and aclmowledges that appropriate claim form or their successors)and niast
RHG is acting solely in an administrative capacity in include Member Provider's usual and customary
providing a network of duality health services.RHO billed charges (not discounted rates) and appropriate
is not the claims paying agent and will not be liable codes, consistent with policies established or
for the payment of any amount owed by a Payor to approved by applicable state and/or federal
Member Provider in the event that Member Provider regulations,Member Provider must submit claims to
is unable to collect such amount of money up to and Payor not later than the 95x' day after the date on
including the insolvency of the Payor. Under no which services are provided to the Qualified
circumstance will a Member Provider attempt to Participant, or as specified by state law. In
collect payment from a Qualified Participant for accordance with Labor Code §408.027 and other
medical services rendered for a compensable,work- applicable statutes and rules,billing and payment to
related injury/illness. Member Provider will be made within forty-five
(45) days of receipt of bills which are accurate and
1V.2 Reimbursement Rates.Member Provider is to complete, and otherwise in accordance with state
be paid by the Payor in accordance with State Law rules and regulations.
and/or rules and regulations at the rates established
in Exhibit B. Member Provider hereby agrees that IVA Limited Recourse Against Qualified
rates in Exhibit B,which may be amended from time Participants; Except as otherwise provided in this
to time upon mutual written agreement represent the Agreement(Section 1.10), Member Provider agrees
total amount to be received and agrees to look solely to seek payment from each Payor for Covered
to the.Payor for payment for such Covered Services. Services provided to its Qualified Participants, and
Payment will be made for Covered Services actually agrees that it will not seek additional payments or
rendered.All claims will be paid,when appropriate, reimbursement for compensable injuries from
only after submission of a complete and accurate Qualified Participants. In addition, Member
claim A complete and accurate claim shall be Provider agrees that neither RHO,the Payor nor the
defined as a clean claim by Medicare.RHO does not Qualified Participant shall be billed or ultimately
guarantee,represent, warrant or covenant regarding held responsible for payment of services deemed not
the selection or use of Member Provider's services to be covered by the Payor or its designee. When
by any Qualified Participant or Payor,or the number Qualified Participant is covered by a state or
of patients, if any, which may result from federally regulated Occupational Injury and Illness
participation in RHUs provider network. The program, Member Provider agrees to comply with
obligation of a Payor to reimburse Member Provider state and federal regulations regarding holding
in accordance with Exhibit B for the provision of Qualified Participants harmless for amounts not paid
Covered Services to a Qualified Participant shall be by Payor for any reason,including Payor or network
conditioned upon a good faith determination by the insolvency. This provision does not preclude billing
Payor or its designated representative that (i) such a Non-Qualified Participant for a non-compensable
services are medically necessary, whether such injury.
determinations are made before, on or after the
provision of services to such Qualified Participant, IVAJ Transfer of Risk. This Agreement and any
subcontract within shall not be interpreted to involve
All services billed under the Tax Identification a trausfex of fmancial risk for the provision of health
Number(s) indicated in this Agreement, any care services from Payor to RHG as defined under
Amendments, Exhibit A, Exhibit B, Exhibit C, Insurance Code§1305.004(a)(26).Member Provider
Applications or any updates regarding locations agrees and acknowledges that RHO is acting solely
i
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Midtown Medical Imaging 7-6-2015 RDN.FAC_ 3 050115
in an administrative capacity in providing a network the event that a claim is made against RHG,it is the
of quality health providers. RHO is not the claims intent of RHG to cooperate in the defense of said
paying agent and will not be liable for the payment claim. However, RHG shall have the right to take
of any amount owed by a Payor to Member Provider any and all actions they believe necessary to protect
in the event that Member Provider is unable to theiriaterest.
collect such amount of money up to and including
the insolvency of Payor or the Network. V.S Indemnification of Member Provider. Member
Provider will. be responsible for its own acts or
IV.5 Payment of Claim Foxms. .RHO shall omissions and any and all claims,liabilities,injuries,
administratively arrange for the Payor or its suits and demands and expenses of all kinds which
designated representative to pay undisputed claims may result or arise out of any alleged malfeasance or
Which, are accurate, complete and comply with the neglect caused or alleged to have be caused by its
Agreement within the time period-mandated by state employees or representatives,in the performance or
or federal law. omission of any act or responsibility under -this
Agreement. In the event that a claim is remade against
IV.6 Erroneous Pgym In the event that a Payor Member Provider, it is the intent of Member
and/or its designated representative pays the Provider to cooperate in the defense of said claim.
Member Provider (i) more than once, or (ii) an However, Member Provider shall have the right to
incorrect amount: or(iii)an overpayment,the Payor tape 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 VZ. TE101ANT'I.ERIV.iNATION
Provider rNo It not unreasonably withhold
reimbursement. If overpayment has been made VL 1 Term. 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 Mules 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 VI.2.
hundred eighty(180)days from,the date of payment.
All claims for overpayment or underpayment shall V1.2 Ten ' ation. 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. ]NSURAINCE A.NA ME*TVJMICAnON VI 2.1 Termination by Member Provider. lvlember
Provider may terminate this Agreement in the event
V.1 Insurance Requirement. Member Provider shall of a material default or breach of RHG's obligations
provide and maintain such policies of professional hereunder,upon ninety(90)days priorwHtten notice
liability insurance or a self--funded program. The and the failure of RHO 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
hospitallfacilities. Member Provider shall promptly immediately with 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 meann an unforeseeable
in force upon request of RHO and/or meet the event, not resulting from.Member Provider's act or
eredentialing guidelines of RHO. omission, which materially affects Member
Provider's ability to continue the practice of
I V.2 Indemnification of RHG. RHG will be medicine or to perform his obligations hereunder.
responsible for its own acts or omissions and any 11e 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
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
Page 7 of 15
MidIaNin viedied Imaging 7-6-2015 AURFAC 73f 050)15
VI.2.2 Termination by RHG. A Member Provider the breach within sixty (60) days of the notice, in
shall automatically be terminated on the date when: which case, the Agreement and applicable rates and
(i) Member Provider's license in the State where terms shall continue in effect. Either party may
services are rendered is suspended or revolted, (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 JUJI0, NCAA, AAAHC, VI.2.5 Unforeseen Events. In the event that eifher
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, fire,
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 sball be
engages in any act, omission, demeanor or conduot relieved of those obligations for the duration of the
that is reasonably likely to be detrimental to patient interruption upoa notice to the other party_ In the
safety or to the delivery of quality patient care,or to event that the intenuptiou 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 RHO 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 Terminations. 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 credentialiug 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 conoplaint, 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 are
reconsideration or independent review of an adverse expressly made to extend beyond the term of this
decision. Agreement.
Ia the event REG deems it necessary to terminate VIA Qualified Participant and PUor Noifiicatioz-.If
Member Provider's agreement based on the above applicable,upon the termination of:this Agreement,
requirements RHG will notify Member Provider at by either party, Member Provider shall cooperate
least ninety (90) days before the effective date of with RHO to notify Qualified Participants and
termination. Payors of such termination.
Upon written notification from RHG, Member V.Q.COINTLNUAT10N OF 3BRiNEF1TS
Provider may request a review by RHO's advisory
review panel, not later than. thirty (30) days atter VIIA Continuation of Benefits. IfivlemberProvider
notification. RHO 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 M=ber Provider's contracted
shall terminate immediately in the event that either rate set forth in Exhibit B of this Agreement-with.
RHO or Member Provider voluntarily or RHO,for care of an Qualified Participautwith 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)(5) (A).Any disputes concerning continuity
Of care shall be resolved through the complaint
VI.2.4 Termination by Either Party. In case of process under Insurance Code §1305.401 -
material breach of the terms of this Agreement §1305.405 and Subchapter O of Title 28, Part 1
either party may terminate the Agreement with at (relating to Complaints).
least ninety (90) days prior written notice to the
other party; however, the party in breach may cure
Page8 of is
MidfoNmMedical 7maging7.6.2015 RMT-AC 1X 050115
VII.2 Sin tn. 'vat. The provisions of this Article VII LY.I.I Mediation through. RHO. 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 U.9, V.2, V.3, VU, information to RHO. RHO shall use best efforts to
VIII, and a. The provisions of this Article VII mediate the dispute witbin the rules and regulations
supersede any oral or written agreement to the put forth by the State as reference in UIG s
contrary now existing or hereafter entered into PxoviderRandbook
between Member Provider and any Qualified
Participant or any person acting on a Qualified 1.X.1.2 Arbitration. If the dispute cannot be solved
Participant`s behalf. by the mediation process described above, either the
Member Provider, RHO or Payor may elect to
V111. CONFIDENTIALITY submit the dispute to binding arbitration under the
rales of the American Arbitration Association or any
All business, medical and other records ielatiug 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 RHG or Member ,X.1.3 Provider Appeals.Rxcept;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 xemain the sole property of RHO as follows:
or Member Provider respectively (collectively, the
"Confidential Information"). RHO and Member IX.1.3.1 RHO will provide notice to the Member
i Provider acknowledges that the Confidential Provider at least 90 days before the effective date of
Information and all other information regarding a termination.by RHO;
RRGr or Member Provider that is competitively
sensitive is the property of RHO or Member IX.1.3.2 Upon receipt of the written notification of
Provider and RHO 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, RHO and Member Provider panel no later than 30 days after receipt of the
agrees to keep strictly confidential and to hold in notification;
i trust all Confidential Information.Upon termination
of this Agreement by either party for any reason 1X.7..3.3 The Network will provide an advisory
whatsoever, RTO 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
i Confidential Information or containing Confidential specialty as the Member Provider;
Information, and neither party will not thereafter
use, appropriate, or reproduce such information or IX.1.3.4 The Network must complete the advisory
disclose such information to any third party. RHO panel review before the effective date of the
and Member Provider specifically agrees that under termination;
no circumstances will either party discuss the terms
and conditions of this Agreement; and in particular 1X.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
1X. MGSCELLANEOUS advisory review panel makes a formal
recommendafiio
IX.1 Disputes. All disputes and difference between
the Member Provider and RHO upon which an 7X.1').6 If Member Provider terminates the contract;
amicable understanding cannot be reached are to be the Network or RHO's Client will provide
decided by the following method: notification of the termination to employees
receiving care from the terminating provider. The
Network shall give such notice immediately upon.
Pegc 9 0f15 '
Midtown Medical Tma&g 7-6-2015 RUNT-AC TX 0501 15
I
receipt of the Member Provider's termination
request or as soon as reasonably possible before the 1X.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,
DU Non-Exclusivity. Frothing in this Agreement other term or provision.
shall be construed to restrict Member Provider or
.RHO from entering into other contracts or 1X.9 Assiimment. Member Provider xray not assign
agreements to provide healthcare services to Payors or otherwise transfer any right or delegate any duty
or other healthcare delivery plans, patients, and of performance hereunder, in whole or in part
employer groups. without the prior written consent of RHO. A change
in ownership will not negate the prior contractual
1X.3 Entire AP-Teement. This Agreement contains agreement without written notification to RHO.
the entire understanding of the parties and RHO retains the right to assign this Agreement; in
supersedes any prior-understandings and agreements, whole or in part to any entity with which RHO or its
written or oral, xespeoting the subjects discussed parent company or any of its subsidiaries is
herein. affiliated,or with which it merges or consolidates.
LX'.4 -No 'Waiver. The waiver by either party of a 1X.10 Third Party Beneficiaries. Except for Payors
breach or violation of any provision of this and the agents thereo.A 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 Captions. The captions and headings
1X.5 Regulatory Compliance, MemberProvider, contained in this Agreement are for reference
sub-contracting providers, and RHO agree that each purposes only and shall not affect in anyway the
shall comply with all applicable requirements of meaning or interpretation of this Agreement
municipal, county, state and federal authorities, all
municipal and county ordinances and regulations, IX.12 Execution of Colmterparts. 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 RHQ, 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
jrequirements 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 50.3 and 504 or the hereto.
Rehabilitation Act of 1973^ and Title IV of the
Vietnam Era Veterans Readjustment Assistance Act IX-14 Financial Incentives. Neither a Client; Payor,
of 1974, and Sections 1 and 3 of Executive Order nor RHO may use financial incentive or make a
11625, or any applicable rule or xegulation payment to a health care provider that acts directly
promulgated pursuant to any such laws or orders. or indirectly as an inducement to limit medically
necessary services. The adoption of treatment and
IX.6 Governing Law. This Agreement shall be return-to-work guidelines and individual treatment
governed by and construed in accordance with protocols by RHO or Network is not in violation of
applicable state law. this section as pursuant to Insurance Code §1305.
304 and§10.83(a)of Chp 10 of Title 28 Part 1,
IX.? Amendments. This Agreement may be
amended as agreed to by both parties in writing upon 1X.15 Financial Disclosure Requirements. Both
thirty (30) days written notice of such proposed parties agree Member Provider is a facility or
amendment. consists of facilities and therefore Member Provider
is not required to file financial disclosures in
Page 10 of 15
NlidtomMedicalImaging 7-6-201.5 RUNFAC TQC 050115
accordance with Labor Code §§408.023 and M17 Oficial Notices. Any notice or
§§413.041, communication required, permitted or desired to be
given hereunder shall be deemed effectively given
IX.16 Economic Profilin. Network must provide 'Ffta persomlly delivered or mailed, return receipt
-wntten notice to Member Provider before the requested, or overnight express mail addressed as
Network conducts economic profiling, including follows.
utilization.management studies or other pzoflling of
the provider or group of providers.
Member Provider or R.epresentativefDesignee:
(Please Print)
r
Name' G�C�
Organization:Midtown IYSedical hna2kg
Address: 900 Ierome St.Ste 104
CitylStatelzip:Fort oxtlo,TX76104
Telephone: 817468-537.7
IN WITNESS WBERFO1i,the undersigned will.be Fax: 917-920-9992
deemed to have excecuted this Agreement as of the
date the provider is fully oredendaled by REG. Organization:
Rockport Community hTetwork,Inc.
dba Rockport Healthcare group
For-and•on beh-alf-of, A—tta:.Network Development
50 Briar Hollow Lane,Suite 5ISW
Rockport Community Network,Xne. Houston,TX 77027
dba RockportHealtheare Group Telephone:(713).621-949-4
PBriar
Hollow Zane,Suite 515 Fax:(713)621-9511�ston,TX 77gfT)
M1 t✓ or to such other address, and to the attention.of such
other person(s) or officer(s) as either party may
[Doug, sU.1�,Ur'kham) designate byvai#tennotice.
1'resid'e�nt
Date: ZO l
For and on behalf of:
ilfembe l3rovider or epresentafavelDesignee
Signature: �
TName: �Dd (A
`� (.QrIA
M.46-343756.4
Date: & off. 1
E
PaaelT nf15
IvfidtoNNnMedk91Imaging 7-6-2015 73 _0301 I
EXHIBIT A
STA.r'�IDARDS AND GUIDELINES
UTMITA'T`ION REVIEW AND QUALITY IMPRO'VEAIBNT PROGRAMS
I RHG and its Clients require Member Providers to follow nationally recognized treatment guidelines (i.e. Official
Disability Guidelines(ODG) and/or American Occupational and Environmental Medicine's (ACOEIVI) guidelines)
I in the treatment of work-related injuries/illnesses for Qualified Participants.
I
i 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:
j 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 Require Preauthorization;unless otherwise specified by the network:
1) Zn-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§908.026;
4) All psychological testing and psychotherapy,repeat interviews, and biofeedback; except when any service is
j part of apreauthorized or exempt rehabilitation program;
5) All extemal 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 greaterthan$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(D1VIE) in excess of$500 per item(either purchase or expected cumulative
rental)and all transcutaneous electrical nerve stimulator(TENS)units;
i 12) Nursing home,convalescent,xesidential,and all home health care services and treatments;
13) Cheraical 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(Ili)other procedures,limited to the unlisted
physical medicine and rehabilitation procedure code.
16) ClosedFormWary Drugs,as defined by 28 TAC Chapter 134,Subchapter F,
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 follotitdng: (i)the date of injury,
or(ii)a surgical intervention previously approved by the payor.
Page 12 of 15
I Wtown Medical Imaging 7-6-2015 RTINFAC TX_OSOl I5
I
f
Reimbursement Schedule
L Ro ckport United N'etsrork[Rockport SelecMealth Network-Occupational Injury and Illness
Provider"fees for the programs listed above shalt be reimbursed atthe following:
All fees wM be. rehnbuxsed at 95% (Ninety five percent) of the state's c.uxrent Workers'
Compensation fees,rules and regulations or usual and customary allowables.
Coverage: Covezage for all.procedures on the fee schedule is subject to the temis and conditions of
this Agreement,state n-des and zegalations and/or the applicable Occupational Injury or Illness Benefit
Flan.
I/Veaccept-thefe3es••as outlined-inthis-Bxh-IMM
For and on behalf of: Ybr and on behalf of-
(
(N'ame;address,etc.)
ROCTO ORT COTVRYIMTY NETWORE,MC. Midtawn Medical xmagin�
dba ROCIO OR.TH+ALTHCARE GROUP 900 Jerome St,Ste 104
[-5D Briar Rollow Lane,Suite.5MV Fort North,TX 16104
�I stc 9 T 7700227,1f)
Signature
[Dou s Briar
Printed Name
J
-Presldent 1 Title • 1Ulf}7`i ��' 1�
Date ` 2 CJ TIN463427564 Date `?
• Page 13 aP75
1Y0dtoivaMediea1Iza&S 7-6-2015 xRUNFAC T;f 050115
Facilities and/or locations where services are to be rendered by Member Provider
The,jXembez'Provider agrees that theMow"ing AcilityIocations and/or practice locations listed on attached rxhibit
C,shall be inclusive of the signed agreement and the signed rates in Exhibit B. By signing below I'vlember Provider or
its Representative/Designee allows Rockport Healthcare Group(RHG)and its represeirtatives to use any and all of the
below information as agreed to in the signed agreement
1vlidtown,Vi edical Xznaeiutr
Facility,-Name.(j) Facility Name(2)
N/A.
Physician Name(if applicable) Physician Frame(if applicable)
900 rerome St Ste 104
Physical Address Pbysical Address
Fort Worth TX 76194
City,State Zip City;State Zip
'U/
Mailing Address(if different) Mailing Address(i£different)
&17L-768-:53 17/317-920-9992
.'Phone Number/Fax Number Phone-Number/Fax Number
46-39427664
Tax ID Number Tax IDN-amber
Facility Name.(3) Facility Name(4)
Physician Name(if applicable) Physician Name(if applicable)
Physical Address Physical Address
City,State Zip City,State Zip
Maiiin�Address(if different) IYtailiug Address(if different)
Phone Number/Fax Number Phone Number/Fax Number
Tax ID Number Tax ID Number
For and on behalf of. For and.on behalf of•
Rockport Community Network,Inc.
dbaRockport Healthcare Group iYlemberPro-vi der orRe resentative/Designee
(50 Briar Hollow Lane,Suite 5:L5W
Houston, 77027] Signature:
S
Name; c&,-,,
jDouglas x_Markhaml (priA9
'resident
Date. g -Z _57 Date: 0
Page 14 of 25
M&OIV.Medical7maging7_&2o7S7?7J`'FAC TX QSOIIS
i
:Z�1]BZT D
Workers'Compensation Networks('QVC\)
Rockport may make this provider agreement available to other networks through delegation, As defined within the
Facility/AncMary Provider agreement,Member Providers agree to provide treatment for injured employees who
obtain workers'compensation health care service through the networks. The named networks are listed helew:
• [RockportSelecfRealthNetwork)
[Wellcomp Managed Care Services,Inc.,Plan Name: Compl(eyPlus)
• (BroadspireHUN)
I
I
i
t
Page 15 of 15
Rev050115 RUNFAC TX 050115
j