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HomeMy WebLinkAboutContract 47186-P19 MY SMETARY CZ NTR ACT NC. �y Aci ADDENDUM To BlackStone 504 Program Provider Agreement This Addendum is entered into by and among Balch Interventional Pain and Wellness Center ("Member Rock ort Healthcare Group, ("Rockport"), and the City of Fort Worth ("City") on this ay o 2 WHEREAS,Rockport and Member Provider entered into a Provider Agreement, effective June 29,2012,, ('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 Lmder Texas Labor Code Subsection 504.053(b)(2). WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider Agreement to be the same terms and conditions that apply to the direct contract between Member Provider and the City that make available covered services for Qualified Participants'needs to the injured workers of the City. NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby acknowledged,the parties agree as follows: 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 Blackstone) shall instead apply to matters of notice, billing, dispute resolution, complaints, preauthorization,and related matters. 2. The parties agree that the City will bear the financial responsibility for payment to Member Provider i under the terms of the Provider Agreement subject to the applicable Provider Manual and the provisions of the Texas Labor Code and applicable rules under the Texas Administrative Code. Rockport will continue to provide applicable network administrative services. 3. When used in this Addendum,unless the content otherwise clearly requires, the following words and terms shall have the meaning set forth below. All other defined terms shall have the meaning ascribed to them in the P Agreement. FOFFIIGd : Sr- FT. " :: i Balch lntervcntional Pain and Wellness Center Provider Agreement "Payors" will be the City as they are responsible for payment of mcdiea.l benefits for compensable injuries and or illnesses sustained by its injured workers according to the f Texas Workers Compensation Act, "BlackStone" is the 504 Provider Panel established by the City of Fort Worth through this and other direct contracts using Rockport as its contracting agent "Provider Manual"means the BlackStone Provider Manual as amended from time to time and available upon request to the Member Provider. "Provider Panels" are those direct contracted panels formed by political subdivisions or Public pool entities authorized by Section 504.053 of the Texas labor Code, 4. Member Provider agrees to participate in the BlackStone provider panel for the benefit of the City and Qualified Participants. 5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a new cause of action. 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 WITNrSS WITFRFOF,the parties hereto have executed this Addendum effective on the day and year I first written above. For and on behalf of: City of Fort Worth BlackStone Signatuee• Name: 5ananis Title: Assistant City Manager Date: APPROVED AS TO FORM AND LEGALITY. O i" r. 0000 d •?. jj tlsslstant(C 5� tY Att©s4?�� 0 r OFFICIAL RECORD 2 A Fk , CITY SECRETARY FT. WORTH, TX �3alcli Iu�e3'Yoiztzot�at.l'aizi�aiid VS'ellness•Geizt�r Pcc��id�r.A�ieeut�u� • ,. sa ;9;�xtriftire; . NgIltet Johnaolacci ` RIO:St VIoe Pebsident r• xbZ17[ JG.`1'i7Q�iUTb or �tepz'eSfl�ltntiY.0/.1�nS3gile',e,.,. .S�giiafiii•ei jlgijjw Robert 13a.loli 11.1.DO Date: } Ift 46-1935.782 i • 3 t IPAJPHO/MSO AGREEMENT ROCKPORT COMMUNITY NETWORK,INC. This Agreement ("Agreement") is entered into by I. DEFINITIONS and between Rockport Community Network, Inc., ("RCN'), a Nevada Corporation and T.I.O.P.A. Inc. When used in this Agreement and unless the content ("Provider"), on behalf of its member physicians otherwise clearly requires, the following words and ("Physician"), a corporation composed of physicians terms shall mean: licensed to practice medicine in the state where services are rendered, and will become effective as I.1 "Physician" means a licensed Medical Doctor or of the date the Agreement is executed by RCN. Doctor of Osteopathic Medicine, or group of same who desire to become a Member Provider with WHEREAS, RCN is engaged in the business of RCN. developing and acting in an administrative capacity in providing individual and group accident and I.2 "Qualified Participant" means: (a) an employee, health; industrial and occupational; personal injury member and/or dependent of an RCN payor/client protection; and Medical Access Savings Card who is eligible to receive certain healthcare benefits provider networks that offer a new integrated under anindividual individual or group accident and health continuum of healthcare services. These networks benefit plan, personal injury protection plan, or any r will offer greater efficiency, economy, quality and other insurance program; (b) a person who presents availability of healthcare services; and with authorization from the Employer prior to the initiation of treatment that the worker is currently WHEREAS, RCN has networks of contracted employed and that the presenting problem was job physicians, physician groups, hospitals and related, either in writing or by telephone; and (c) providers of ancillary healthcare services individuals and/or families eligible to receive (collectively, the "Member Providers") to provide a contracted rates as described in Exhibit B by virtue full-range of healthcare services. These services are of their verified participation in the Medical Access available for use by "Qualified Participants" as Savings Card Program, which is neither an insurance defined later in this document; and or benefit plan. WHEREAS, Physician desires to provide I.3 "Payor" means an individual, organization, firm appropriate and cost-effective healthcare services to or governmental entity, including but not limited to "Qualified Participants" who are covered by Payor an employer, self-insured employer, employer Agreements at the rates in Exhibit B; and coalition, health insurance purchasing cooperative, insurer, third party administrator, or a Qualified WHEREAS, RCN has entered into Agreements with Participant in a Medical Access Savings Card one or more insurance carriers, self insured groups, Program. These Payors have entered into a Payor and third party administrators to provide for Agreement with RCN for the provision of healthcare review, medical service, and other healthcare services to Qualified Participants and medical utilization services for employers which have agreed to pay for such services, pursuant to maintain self-insured funds, third party such Payor Agreement. administrators, insurance carriers and individuals who have contracted with RCN, 1.4 "Payor Agreement" means the . agreement between RCN and a Payor, which is made before, NOW, THEREFORE, in consideration of the on or after the effective date of this Agreement and premises, the mutual promises contained herein, and which expresses the agreed upon contractual rights . other good and valuable consideration, the receipt and obligations of the parties. and sufficiency of which are hereby acknowledged, it is mutually agreed as follows: I.5 "Member Provider" means any physician; physician group; hospital; surgery center; diagnostic imaging center; laboratory; -clinic; chiropractor; Page 1 of l l TIOPA.doe rR,,,:KP0IIT CMENIUNrrY NETWORK.INC.' 01/03/00 dentist; podiatrist; psychologist; social worker; resources is sought and utilization and practice physical, occupational and speech therapist; etc. patterns are monitored in order to identify and, as licensed or certified to practice a healthcare appropriate, to correct deviations from established profession or licensed as a facility to offer healthcare norms. Medical necessity and medically necessary services, in the state where services are rendered, determinations are established and administered by who has met the credentialing requirements of RCN, the Payor or the Payor's designee, in accordance and who has been accepted by RCN as a Member with Exhibit A, with the exception of Qualified Provider and who has executed a contract with RCN. Participants in the Medical Access Savings Card Program. 1.6 "Primary Care Physician" means a Member Provider who has met the credentialing requirements I.11 "Claim and/or Claim Form" means a HCFA of RCN to be a Primary Care Physician.and is 1500 and/or UB 92 used for.billing for all services designated by RCN as a Primary Care Physician. with regard to Accident and Health, Personal Injury Protection, and Workers' Compensation Plans, For 1.7 "Specialist Physician" means a Member Provider services rendered to Qualified Participants of the i who has met the credentialing requirements of RCN Medical Access Savings Card Program, Member to be a Specialist Physician, and to whom Primary Provider can and should make payment Care Physicians may refer for necessary and arrangements prior to the delivery of care with the authorized care other than primary care services, patient or.responsible party. Services provided in connection with the use of the Medical Access 1.8 "Emergency" means the sudden and unexpected Savings Card must be documented by a receipt that onset of a medical condition or accidental injury the Qualified Participant may use for tax purposes or manifesting itself by acute symptoms of sufficient in conjunction with other coverage. Member severity (including severe pain) such that the Provider can pursue collection efforts directly with absence of immediate medical attention could these Qualified Participants if necessary. All others reasonably be expected to result in any of the will be paid, when appropriate, only after following: (i) placing the Qualified Participant's submission of a complete and accurate claim. health in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any H. PHYSICIAN OBLIGATIONS bodily, organ or part; and which the Qualified Participant secures immediately after the onset II.1 Services. Physician agrees to provide or arrange thereof, or as soon thereafter as practicable,but in no for all medically necessary medical care for event later than twenty-four (24) hours after onset. Qualified Participants who seek care from Physician. To the maximum extent permitted by law, the Physician agrees to perform such services with the determination of whether an Emergency existed at same standard of care, skill and diligence which is the time covered services were provided shall be customarily used by Physicians in the community in made exclusively by Payor. which such services are rendered. Physician agrees that it is his/her sole responsibility to verify that the 1.9 "Covered Services" are those healthcare and individual presenting for care is a Qualified health-related services as defined by each individual Participant. Physician agrees to render healthcare Payor. RCN will' communicate Payor specific services to Qualified Participants in the same Covered Services to each Member Provider, manner, in accordance with the same standards, and Services covered under the Medical Access Savings with the same time availability as offered to Card Program are not subject to this definition. Physician's other patients. Physician shall ensure that services provided are consistent ;with RCN's 1.10 "Utilization Review and Quality Assurance programs,policies and procedures and the applicable Program" means the program or programs, Accident and Health, Personal Injury Protection, applicable to the Payor, with the exception of Workers' Compensation, Medical Access Savings Utilization Programs for Qualified Participants in Card programs and plans. Physician agrees to the Medical Access Savings Card Program, as comply with and be bound by all Utilization Review amended from time to time, through which and Quality Assurance Programs, including appropriate, cost-effective utilization of health discharge planning programs, adopted by RCN and Page 2 of 11 TIOPA.doc �RociuomT Commc.Nrry NETWORK.ivr.:,' 01/03/00 the Payor, when approved by RCN, from time to and hold such other licenses, certifications, time, registrations, permits and approvals as are required. for the lawful conduct of Physician's practice. I1.2 Non-Discrimination. Physician shall not Evidence of such current licensing and/or differentiate or discriminate in the treatment of certifications shall be submitted promptly to RCN his/her patients as to the quality of services delivered when data changes or renewal occurs and upon to Qualified Participants because of race, sex, age, request. Physician will have, where appropriate, a religion, national origin, place of residence, source current narcotics number issued by the appropriate of payment or health status. Physician shall observe, authority, currently the United States Drug protect and promote the rights of Qualified Enforcement Administration ("DEA") and/or various Participants as patients. State Controlled Substance Registration Authorities. 11.3 Continuity of Care,Covering_Physician. 11.6.2 Medical Staff Privileges. Certain medical Physician agrees to devote such time as is necessary specialties may not require hospital privileges such to the performafice of his/her obligations under this as Industrial and Occupational Medicine, Pathology, Agreement, including maintaining reasonable office Dermatology, Allergy, etc. Where appropriate, hours. Physician agrees to maintain accessibility Physicians must maintain active, unrestricted staff either personally or by covering arrangements with privileges with at least one RCN Member Provider another Member Provider of like specialty or other hospital or Surgery Center. Physician hereby r qualified physician approved by RCN, on a twenty- consents to disclosure by such facility to RCN of all four (24) hour-per-day, seven (7) day-per-week data collected with respect to Physician in basis. Physician shall ensure that such Member connection with Physician's medical staff Provider or other physician shall comply with RCN's membership, including without limitation all and each Payors Utilization Review and Quality applications for staff privileges and any renewals Assurance Programs and will comply with Article thereof. IV of this Agreement. II.6.3 Organization's Requirements. Physician shall IIA Referrals. Except in a medical emergency or comply with and be bound by RCN's criteria for when authorized by RCN or its designated provider participation, including RCN's representative, Physician agrees to refer Qualified credentialing and administrative policies and Participants only to other Member Providers, as procedures, as adopted and amended from time to defined in 1.5, when medically necessary and time by RCN. Physician shall cooperate with RCN's appropriate. All referrals must be in accordance with periodic evaluation of professional qualifications the applicable Utilization Review and Quality which shall include, but not be limited to, Physician Assurance Program unless specifically directed by giving consent, to the release of information from RCN: In addition,Physician agrees to use RCN's or any facility at which Physician has medical staff the applicable Payors pharmaceutical formularies, if privileges. In addition, Physician shall cooperate any, when prescribing medications for Qualified with RCN's and each Payor's programs and Participants. procedures,as approved by RCN,for the expeditious resolution of any grievance or complaint. 11.5 Reports. For each encounter where Physician provides services to a Qualified Participant, H.7 Notification to RCN. Provider represents and Physician shall report such encounter on an warrants that information provided herein and in the appropriate form and shall include statistical, RCN provider application is true and accurate in all descriptive medical and patient data and identifying respects and acknowledges that RCN is.relying on information, if and to the extent that reports are the accuracy of such.information in entering into and specified by RCN or its designated representative. continuing the term of this agreement.Provider shall notify RCN within two or three business days upon 11.6 Professional Requirements, becoming aware of the initiation of any investigation, disciplinary action, sanction, or peer H.6.I Licenses. Physician shall be duly licensed to review action against Physician that could result in practice medicine in the state where care is rendered (i) suspension, reduction or loss of license to, NZ:Kpom- Page 3 of I1 TIOPA.doc COAI:<7CNaY NETWORK.INC." 01/03/00 _practice Physician's profession or to provide inspect and audit, at all reasonable times during healthcare services;. (ii) denial, suspension, normal business hours, upon prior notice, any of restriction, reduction or termination of privileges or Physician's accounting, administrative, medical staff membership at any health facility or by any records and operations reasonably pertaining to peer review body; (iii) impairment of Physician's RCN, to services provided to Qualified Participants, ability to provide healthcare services safely; or (iv) and to Physician's performance under this imposition of any sanction under the Medicare Agreement. Physician further agrees to-allow RCN, program or Medicaid program. In addition, Provider Payor (with the exception of Qualified Participants shall provide prior written notice to RCN of any in the Medical Access Savings Card Program), or a changes in (i) Federal Tax Identification Number, designated representative thereof, including the (ii) other information provided in his/her application designated utilization review, quality management, for participation, (iii) Physician's professional case management or peer review staff, to have liability insurance, (iv) Physician's billing or office reasonable access to treatment records and address, and (v) services provided by Physician. A information of Qualified Participants for services failure to give any notice required by this Section provided under the terms of this Agreement as shall be a material breach of Provider's obligations necessary to enable such party to perform Utilization and responsibilities hereunder, regardless of the Review 'and Quality Assurance activities in status, pendency or outcome of the event giving rise accordance with the applicable Utilization Review to the obligation to give that notice, and may be and Quality Assurance Program. In addition, grounds for delay in payment, claim denial and/or Physician agrees that in the event an examination immediate termination of this Agreement. concerning the quality of healthcare services is conducted by appropriate officials, as required by I1.8 Medical Records. Physician shall maintain federal, state, and/or local law,RCN shall submit, in complete and timely medical records for Qualified a timely fashion, any required books and records and Participants treated by Physician. Such records shall shall facilitate such examination. RCN and be prepared in accordance with accepted principles Physician agree to assist one another with on-site of practice, shall document all services performed inspection of facilities and records by representatives for Qualified Participants and shall comply with all of authorized federal, state and local regulatory applicable state and federal laws. Physician shall agencies. maintaip such records for the length of time required by applicable state or federal law. Subject to all 11.10 Relationship of Parties. Provider understands applicable privacy and confidentiality requirements, and agrees that he/she is an independent legal entity. such medical records shall be made available to each Nothing in this agreement shall be construed or physician and other health professionals treating the deemed to create a relationship of employer and Qualified Participant,and upon request,to the Payor, employee, principal and agent, partnership or joint RCN or its designated representative for review at venture or any relationship other than that of the guidelines as established by the TMA. Physician independent parties contracting with each other shall obtain a valid consent for the release of the solely to carry out the provisions of this Agreement Qualified Participant's medical records to other for the purposes recited in this Agreement. With providers, RCN, Payor, or its designated regard to the provision of medical and healthcare representative. RCN agrees that medical records of services,Physician acts as an independent entity and Qualified Participants shall be treated as confidential the Physician-patient relationship shall in no way be so as to comply with.all federal and state laws and affected. regulations regarding the confidentiality of patient records. The Physician's obligations under this II.11 Standards of Care. Physician agrees that all Section H.8 shall survive the termination of this duties performed hereunder shall be consistent with Agreement. the proper practice of medicine, and that such duties. . shall be performed in accordance with the customary 11.9 Inspection of Records and Operations. RCN, rules of ethics and conduct of the American Medical Payor, with the exception of Qualified Participants Association or American Osteopathic Association, in the Medical Access Savings Card Program or a as the case may be, and such other bodies,formal or designated representative, shall have the right to informal, government or otherwise, from which Page 4 of I I TIOPA.doc IROCKPORT COMMUNCCY NETWORK.INC.' 01/03/00 .physicians seek advise and guidance or by which III.2 Utilization Review and Quality .Assurance they are subject to licensing/certification and Programs. Payor with the exception of Qualified control. Additionally, Physician shall perform all Participants in the Medical Access Savings Card medical and healthcare services in conformance with Program or RCN may establish Utilization Review the standards for his/her specialty as established by and Quality Assurance Programs. Such programs the applicable specialty board and the local/regional shall be in accordance with -the Standards and medical community. Physician agrees that he/she Guidelines established by RCN as outlined in shall not engage in any acts of moral turpitude, as Exhibit A, which may be amended from time to time determined by RCN in good faith. Physician agrees upon written notice to Physician. that, to the extent feasible, he/she shall utilize such additional allied health and other qualified personnel III.3 Credentialing. RCN or Provider will perform as are available and appropriate for the effective and credentialing of each Physician to be included under efficient delivery of care. Physician shall ensure that this Agreement. Credentialing may include all such personnel are properly licensed and/or verification of all information and documents possess the necessary credentials to render the provided in the application for participation and services that they perform. investigation of Physicians education, training and practice history, including but not limited to queries 11.12 Right to Use Physician's Name. Provider to the National Practitioners Data Bank and current agrees to allow RCN to list Physician's name, and previous professional liability carriers,Medicare specialty, address and, telephone number and other and Medicaid. relevant information in a Member Provider.directory or other materials to help promote and solicit IIIA Operational Functions. RCN shall assign a contracts with Payors. Provider agrees not to use designated representative to be a liaison with the RCN's trademarks or trade names without RCN's Providers and Payors, with the exception: of prior written consent. Qualified Participants in the Medical Access Savings Card Program, to devote reasonable time and effort H.13 Noncompliance. Physician understands that to perform RCN's responsibilities hereunder. RCN his/her failure to comply with any of the shall arrange for claims processing except for requirements imposed on him/her pursuant to this Qualified Participants in the Medical Access Savings Agreement may result in corrective action, Card Program. adjustments to Physician's reimbursement, or termination of this Agreement by RCN. IV. REIMBURSEMENT, CLAIMS SUBMISSION AND PAYMENT 11.14 Antitrust Guidelines. Physician agrees to comply with all antitrust guidelines and procedures IV.1 Reimbursement. RCN shall arrange for Payors promulgated by Federal and State entities and RCN to pay Physician the reimbursement rates for from time to time. services rendered to Qualified Participants pursuant to Exhibit B. Physician agrees and acknowledges III. RCN's OBLIGATIONS that RCN is acting solely in an administrative capacity in providing a network of quality health III.1 Marketing_to Pgy rs. RCN shall enter into services. RCN is not the claims paying agent and agreements with Payors; implement systems to will not be liable for the payment of any amount respond to Payors, Customers and Member owed by a Payor to Physician in the event that Providers requests for information; provide Physician is unable to collect such amount of clarification of policies concerning the operation of money. Plans or Programs, as defined by Payor Agreements; and assist Member Providers to obtain information IV.2 Reimbursement Rates. Physician is to be paid or clarification regarding the Plans or Programs. by the Payor according to the rates established in Physician agrees to work in cooperation with RCN Exhibit B. Physician hereby agrees that rates in to market the services of the Member Providers to Exhibit B, which may be amended from time to time Payors, upon mutual agreement, represent the total amount to be received and agrees to look solely to the Payor -�— Page 5 of I I TIOPA.doc ROCKPORT COMMUNPCY NEMORK.INC." 01/03/00 for payment for such services. Payment will be IVA Limited Recourse Against Qualified made for healthcare services actually rendered. For Participants. Except as otherwise provided in this services rendered to Qualified Participants of the Agreement (Section I.9),. Physician agrees to seek Medical Access Savings Card Program, Physician payment from each Payor for services provided to its can and should make payment arrangements prior to Qualified Participants, and agrees that he/she will the delivery of care directly with the patient or not seek additional payments or reimbursement from responsible party. Services provided under the Qualified Participants. In addition,Physician agrees provisions of the Medical Access Savings Card that neither RCN, the Payor nor the Qualified Program must be documented by a receipt that the Participant shall be billed or ultimately held- Qualified Participant may use for tax purposes or in responsible for payment for services deemed not to conjunction with other coverage. Physician can be a covered service by RCN or its designee unless, pursue collection efforts directly with Qualified prior to providing such services, the Qualified Participants of the Medical Access Savings Card Participant has been informed that (i) the services(s) Program, if necessary. All others will be paid, when to be .provided are not covered, and (ii) that the appropriate, onl ji after submission of a complete and Payor with the exception of Qualified Participants in accurate claim. RCN does not guarantee and makes the Medical Access Savings Card Program, will not no guarantees, representations, warranties or pay for such services, and (iii) that the Qualified covenants •regarding the selection or use of Participant will be financially liable for such Physician's services by any Qualified Participant or services, and (iv) the Qualified Participant Payor, or the number of patients, if any, which may voluntarily agrees, in writing, to pay for such result from participation in RCN's provider network. services. When Qualified Participant is covered by a The obligation of a Payor to reimburse Physician in state or federally regulated workers' compensation accordance with Exhibit- B for the provision of program, Physician agrees to comply with state and services to a Qualified Participant shall be federal regulations regarding holding Qualified . conditioned upon a good faith determination by the Participants harmless for amounts not paid by Payor Payor or its designated representative that (i) for any reason, including Payors insolvency. Physician is in compliance with the Payor's utilization management program, and (ii) such IV.5 Payment of Claims. RCN shall services are medically necessary, whether such administratively arrange for the Payor or its determinations are made before, on or after the designated representative to pay undisputed claims provision of services to such Qualified Participant. which are accurate, complete and comply with the Agreement within the shorter of (i) the time period IV.3 Claim Forms. Claim forms are required for all mandated by state law as it relates to workers' services with the exception of services provided compensation, or (ii) the time period established by under the provisions of the Medical Access Savings the applicable Payor Agreement,thirty(30)days. Card Program. All claims must be submitted complete and accurate on HCFA 1500 and in the IV.6 Erroneous Payment. In the event that a Payor, manner designated by RCN and must include billed and/or its designated representative pays the charges(not discounted rates)and appropriate codes, Physician (i) more than once, or (ii) an incorrect consistent with policies established or approved by amount, or (iii) an overpayment, the Payor or its RCN or the applicable state regulations. All claims designated representative may, at its sole option and must be submitted within ninety 90 days, or within discretion, request the return of such amount from such time period from the date of service, or as Physician or off set the amount of such overpayment specified by RCN or its designee. In the event that against. any amounts owed to Physician by the Physician is unable to submit a claim in accordance Payor. with this Section IV.3, as a result of factors not within Physician's reasonable control, Physician IV.7 Claims Appeal. The claims appeal process shall notify RCN in writing of the cause of shall be for a period of no less than one hundred_ Physician's inability to submit the claim and RCN eighty(180)days from the date of claim processing. may, but shall not be required to, waive the provisions of this Section IV.3. -+�— Page 6 of 11 TIOPA.doo ROC:KPORT Co11munry NETWORK.INC.' 01/03/00 V. HOSPITAL/FACILITY ADMISSIONS (ii) medical malpractice liability arising during periods in which Physician has failed to maintain the If a Qualified Participant requires a non-emergency malpractice coverage required by Section VI.1. hospital/facility..admission by Physician, Physician shall verify the patient's status as a Qualified VI.3 Indemnification of Physician. RCN hereby Participant, arrange for admission with a Member indemnifies and holds harmless Physician from.and Provider and, if required by RCN or the Payor, against any claim, loss, damage, cost, expense or secure authorization for such admission prior to the liability arising out of or related to the performance admission in accordance with the applicable or nonperformance by RCN,- or RCN's officers, Utilization Review and Quality Assurance Program. directors, employees, or independent contractors, of Medical Access Savings Card Program Participants any service to be performed or provided by RCN do not require pre-certification, authorization or under this Agreement. utilization management for hospital/facility admission. For all other Qualified Participants a VIL.TERM AND TERMINATION Physician who does not secure the required prior authorization or comply with continuing stay review VII.1 Term. The term of this Agreement shall be processes under the applicable Utilization Review for one (1)year from the date hereof and shall be and Quality Assurance Program, may be denied automatically renewed on an annual basis for payment for professional services associated with successive twelve (12) month periods, unless sooner the Qualified Participant's admission. Finally, terminated in accordance with Section VII.2. Physician agrees to cooperate and participate in a coordinated discharge planning program as may be VII.2 Termination. This Agreement may be established by RCN or applicable Payor. terminated sooner on the first to occur of the following: VI. INSURANCE AND INDEMNIFICATION VII.2.1 Termination by Physician. Physician may VI.1 Insurance Requirement.Physician shall provide terminate this Agreement in.the event of a material and maintain such policies of professional liability default or breach of RCN's obligations hereunder, insurance, in a form and with insurance carriers upon thirty (30) days prior written notice and the acceptable to RCN. The amounts and extent of such failure of RCN to cure such breach or default within insurance coverage shall be in the amounts such thirty (30) day period. In addition, in the event determined by state requirements or community of an "emergency situation", Physician may standards for relevant specialties and shall be subject terminate the Agreement upon thirty (30) days prior to the approval from time to time of RCN. If such written notice and the acknowledgment by RCN that coverage is under a "claims-made policy,Physician such an emergency condition does exist. agrees to provide and maintain such insurance "Emergency Situation" shall mean an unforeseeable coverage or a "tail" policy in the same amounts event,not resulting from Physician's act or omission, following the termination of this Agreement, which materially .affects Physician's ability to Physician shall promptly demonstrate evidence of continue the practice of medicine or to perform his insurability and that the required insurance is paid obligations hereunder. and in force upon request of RCN. VH.2.2 Termination by RCN. This Agreement shall VI.2 Indemnification of RCN. Physician hereby automatically terminate on the date when: (i) indemnifies and holds harmless RCN from and Physician's license to practice medicine, or other against any claim, loss, damage, cost, expense or licensed healthcare profession in the state where liability arising out of or related to the performance services are rendered, is suspended or revoked, (ii) or nonperformance by Physician, or Physician's Physician's medical staff privileges at a participating partners, employees or independent contractors, of facility are revoked or suspended, unless such any services to be performed or provided by Physician's privileges are reinstated within twenty Physician under this Agreement,.including but not (20) days of such suspension, (iii) Physician's DEA limited to (i) liabilities unrelated to the practice of or applicable State Controlled Substance the profession of medicine by Physician, or Registration number required by Section 11.6 above r Page 7 of l l TIOPA.doc xrocc� Co��aurrvrry N]:Twc)nx,stir,." 01/03/00 Js suspended Qr revoked, unless such Physician can covenants contained herein which are, expressly arrange for other Member Providers to prescribe made to extend beyond the term of this Agreement. . regulated drugs for Qualified Participants under the care of Physician within ten(10) days of such loss of VIIA Qualified Participant and Payor•Notification. . such Registration number(s) and gives RCN notice Upon the termination of this Agreement, by either of the same, (iv) Physician is excluded from party, Physician shall cooperate with RCN to notify participation in the Medicaid or Medicare programs, Payors and Qualified Participants of such (v) Physician loses or experiences a material termination. reduction in malpractice insurance, (vi) Physician engages in any act, omission, demeanor or conduct VIII. CONTINUATION OF BENEFITS that is reasonably likely to be detrimental to patient safety or to the delivery of quality patient care, or to VIII.1 Continuation of Benefits. Except for Medical lead to the provision of professional services below Access Savings Card Program Participants, upon applicable professional standards, or (vii) Physician termination of this Agreement, Physician shall is convicted.of a Felony, (viii) Physician is found in continue to provide services in accordance with this violation of professional conduct, or(ix) thirty (30) Agreement to any Qualified Participant currently days following written notice by RCN of a material undergoing treatment by Physician until a medically : default or breach by Physician hereunder and the appropriate transfer of care has been accomplished failure of Physician to cure such default or breach provided, however, that Physician shall exercise best during such thirty (30) day period. efforts to accomplish such transfer within thirty (30) days after the date this Agreement terminates. VII.2.3 Termination for Insolvency. This Agreement Physician shall be reimbursed for any such services shall terminate immediately in the event that.either in accordance with the terms of this Agreement. RCN or Physician voluntarily or involuntarily, liquidates, dissolves or becomes subject to any VIII.2 Survival. The provisions of this Article VIII proceeding for the rehabilitation or conservation of shall survive the termination of this Agreement their financial affairs, regardless of the cause giving rise to such termination, as will sections II.8, VI.2, VI.3, VII.3, VII.2.4 Termination by Either Party. Either party IX, and X. . The provisions of this Article VIII may terminate this Agreement without cause upon supersede any oral or written agreement to the ninety(90)days prior written notice. contrary now existing or hereafter entered into between Physician and any Qualified Participant or VII15 Unforeseen Events.. In the event that either any person acting on a Qualified Participant's behalf. party's ability to perform their obligations under this Agreement is substantially interrupted by war, fire, IX. CONFIDENTIALITY insurrection, riots, the elements, earthquake, acts of God, or other similar circumstances beyond the All business, medical and other records relating to reasonable control of such party, the party shall be the operation of RCN, including, but not limited to, relieved of those obligations for the duration of the books of account, general administrative records, interruption upon notice to the other party. In the, policies and procedures, pricing information, terms event that the interruption is reasonably determined of this Agreement and all information generated likely to persist for at least one hundred twenty(120) and/or contained in management information days, either party may terminate this Agreement systems owned by or pertaining to RCN,. and all upon thirty (30)days prior written notice. systems, manuals, computer software and other materials, but excluding patient charts, shall be and VII.3 Effects of Termination. Upon termination of remain the sole property of RCN (collectively, the this Agreement, neither party shall have any further "Confidential Information"). . Physician obligation hereunder except for (i) obligations acknowledges that the Confidential Information and. accruing prior to the date of termination, including all other information regarding RCN, that is without limitation, any obligation by Physician to competitively sensitive, is.the property of RCN and continue to provide healthcare services to Qualified RCN may be damaged if such information was Participants, and (ii) obligations, promises or revealed to a third party. Accordingly, Physician A. - Page 8 of 1 I TIOPA.doc -ROCKPORT Com muww NLTWORK.IKC.' 01/03/00 ,agrees- to keep strictly confidential and to hold in (1) neutral arbitrator to be selected in accordance trust all Confidential Information. Upon termination with the Commercial Rules of AAA. Neither party . of this Agreement by either party for any reason nor the arbitrator may disclose the existence, whatsoever, Physician shall promptly return to RCN content, or results of any arbitration- hereunder all material constituting Confidential Information or without the prior written consent of both parties containing Confidential Information, and Physician Each party will be responsible for theirown legal . will not thereafter use, appropriate, or reproduce fees. The cost of the arbitration services will be the such information or disclose such information to any sole responsibility of the party requesting the third party. Physician specifically agrees that under arbitration. no circumstances will Physician discuss the terms and conditions of this Agreement, and in particular X.2 'Non-Exclusivity, Nothing in this Agreement the pricing information herein, with any Member shall be construed to restrict Physician or RCN from Provider, healthcare provider or purchaser of entering into other contracts or agreements to healthcare services. The Agreement prohibits RCN provide healthcare services to Payors or other from disclosing any information provided by or healthcare delivery plans, patients, employer groups, about the provider in connection with any provided Physician uses his/her best efforts to bring credentialing or peer review deliberations, unless opportunities for contracting and other new ventures such disclosure is otherwise required bylaw. to RCN for consideration and to have the right of first refusal. The Physician agrees to provide RCN X. MISCELLANEOUS with ninety (90)-days to consider and have the right of first refusal before he/she enters into negotiations X.1 Disputes. All disputes and differences between with such-entity on his/her sole behalf. the Physician and RCN upon which an amicable understanding cannot be reached are to be decided X.3 Entire Agreement. This Agreement contains by mutual agreement in Houston, Texas by the the. entire understanding of the parties and following method: supersedes any prior understandings and agreements, written or oral., respecting- the subjects discussed X.1.1 Mediation through RCN. The Physician,shall herein. notify RCN in writing of the dispute or disagreement, he/she shall supply RCN with all X.4 No Waiver. The waiver by either party of a pertinent information and state his/her position on breach or violation of any provision of this the dispute. Upon receipt of this information, RCN Agreement shall not operate as or be construed to be will immediately contact Payor and require the same a waiver of any subsequent breach hereof. information. RCN will then attempt to mediate the dispute to the mutual satisfaction of all parties. If X.5 Regulatory Compliance. Physician and RCN mediation is not possible within a reasonable time, agree that each shall comply with all applicable not to exceed thirty (30) days from the time of first requirements of municipal, county, state and federal notice,the following procedure will apply: authorities, all municipal and county ordinances and regulations, and all applicable state and federal X.1.2 Arbitration. Any controversy, claim or statutes and regulations, now or hereafter in force dispute arising out of or relating to this Agreement, and effect, governing RCN, Physician the provision or the breach thereof, shall be settled by binding of services of by a Physician, and/or Payors, arbitration in accordance with the Commercial including but not limited to applicable requirements Arbitration Rules of the American Arbitration under any state or federal fair employment practices, Association (AAA) and judgment upon any award equal employment opportunity, or similar laws rendered by the arbitrator may be entered in any declaring.discrimination in employment based upon court having_jurisdiction thereof. Any provisional race, color, creed,religion, sex, or national origin as remedy which would be available from a court of illegal, and,Titles VI and VII of the Civil Rights Act law, shall be available from the arbitrator, to the of 1964, Section 202 of Executive Order 11246 as parties to this Agreement pending arbitration. The amended by Executive Order 11375, Sections 503 arbitration.shall be conducted in Fort Worth Tarrant and 504 or the Rehabilitation Act of 1973 and Title County, Texas.. The arbitration shall be before one IV of the Vietnam Era Veterans Readjustment Page 9 of I 1 TIOPA.doc RocxrosT CommunrY NETWORK.INC:.' 01/03/00 Assistance Act of 1974, and Sections 1 and 3 of X.13 Partial Invalidity, If any part, clause or Executive Order 11625, or any applicable rule or provision of this Agreement is held to be void by a regulation promulgated pursuant to any such laws or court of competent jurisdiction, the remaining orders. provisions of this Agreement shall not.be affected and shall be given construction, if possible, as to X.6 Governing Law, This Agreement shall be permit it to comply with the minimum requirements governed by and construed in accordance with of any applicable law, and the intent of parties applicable Texas State law. hereto. Not withstanding_ any other provision in this X.14 Assistance in Litigation. Physician and Agreement, the parties hereto shall comply with the Physician's personnel, shall be available to RCN and minimum requirements of the preferred provider Payors, at no cost to RCN or Payors, to testify as organization regulations of the Texas Department of expert witness, or otherwise, in the event of Insurance as those regulations currently exist and as litigation being brought against RCN and/or Payors, they may adopted and amended from time to time. or their respective directors, officers, employees, agents or other representatives, based upon a claim X.7 Amendments. This Agreement may be of negligence, malpractice or any other cause of amended by RCN upon thirty (30) days written action arising out of, or related to, Physician's notice of such proposed amendment. Failure of performance of services,except where Physician is a Physician to provide written objection to such named adverse party. RCN and Payors shall provide amendment within the sixty (60 day period shall similar assistance to Physician, except where RCN constitute Physician's objection of such amendment. and/or Payors are named as adverse parties. X.8 Severability. The invalidity or un-enforceability X.15 Official Notices. Any notice or of any term or condition hereof shall in no way communication required, permitted or desired to be affect the validity or enforceability of any other term given hereunder shall be deemed effectively given or provision. when personally delivered or mailed, return receipt requested, or overnight express mail addressed as X.9 Assignment. Physician may not assign or follows: otherwise transfer any right or delegate any duty of performance hereunder, in whole or in part without Physician or Representative/Designee: (Please Print) the prior written consent of RCN. RCN retains the right to assign this Agreement,in whole or in part, to Name: any entity with which RCN or its parent company or any of its subsidiaries is affiliated, or with which it Organization: merges or consolidates. Address: X.10 Third Party Beneficiaries. Except for Payors and the. agents thereof, there are no third party City/State/ZIP: beneficiaries of this Agreement. Telephone: X.11 motions. The captions and headings contained in this Agreement are for reference FAX: purposes only and shall not affect in anyway the meaning or interpretation of this Agreement. Organization: Rockport Community Network, Inc. X.12 Execution of Counterparts. This Agreement Attn: Director of Provider Relations may be executed in any number of counterparts, 50 Briar Hollow Lane,Suite 515W including facsimiles, each of which shall be deemed Houston,TX 77027 to be an original as against any part whose signature Telephone: (713) 621-9424 appears thereon, and all of which shall together FAX(713) 621-9511 constitute one and the same instrument. - Page 10 of 11 TIOPA.doc rRo,KP0JU' COMMUNPPY NF-nvORK,tic." 01/03/00 or to such other address, and to the attention of such other person(s) or officer(s) as either party may designate by written notice. X.16 Silent PPO. RCN agrees not to offer discounted services to any Poor who sells or leases RCN's list of contract providers, either directly or indirectly to other Payor type entity or to a broker. who then sell the list to other Payor type entities. This does not apply to access network agreements. IN WITNESS WHEREOF, the undersigned will be deemed to have executed this Agreement as of the date this Agreement is signed by RCN. For and on behalf of: For and on behalf of.- Rockport f:Rockport Com?2w ' etwork,,Inc. Physician or Representative/Designee 50 Briar Holloa it 15W Houston,TX 7 Signature Name_-M Jro u4n, William W.Vrtrg (Print) President TIN `Z S ' L, S 5F,0 q- Date: _1- 7- Date Page 11 of 11 TIOPA.doc rR,—)cKP0RT COMMUNl'rY N1:T%VORK.INI:. .01/03/00 EXHIBIT A STANDARDS AND GUIDELINES FOR PAYORS' UTILIZATION REVIEW AND QUALITY ASSURANCE PROGRAMS ROCKPORT COMMUNITY NETWORK,INC.(RCN) Each Accident and Health, Workers'Compensation, Personal Injury Protection Payor or RCN may have or may establish a Utilization Review and Quality Assurance Program for its Qualified Participants. Medical Access Savings Card Program Participants do not fall under any Utilization Guidelines. All other Payors or RCN may designate a utilization review organization to conduct the utilization review and case management of healthcare. services under such Utilization Review and Quality Assurance Program. RCN shall review each Payor's, with the exception of Qualified Participants in the Medical Access Savings Card Program,Utilization Review and Quality Assurance Program in accordance with RCN's Standards and Guidelines for Payors' Utilization Review and Quality Assurance Programs as described in this Exhibit. Physician and/or Member Provider agrees to comply and be bound by such program in accordance with Article II of this Agreement. Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written notice to Physician and/or Member Provider. The primary goals of the Utilization Review Programs shall be to: 1) Ensure and certify for the payment of benefits that healthcare services meet the definition of medical necessity as defined by the Payor or the Payors designee; 2) Ensure that healthcare services are provided at the appropriate level of care; and 3) Ensure that healthcare services meet local community standards for quality of care. Utilization Review Programs may include one or more of the following components: 1) Pre-Admission/Prospective Review of elective admissions for all inpatient and ambulatory surgical services. 2) Post-Admission Review of emergency and urgent inpatient admissions. 3) Admission and/or Concurrent Review of all inpatient stays. Concurrent reviews may include periodic reviews and certification of treatment plans. 4) Continued Stay Review of all inpatient cases-when the proposed length-of-stay exceeds that which was initially certified by reviewers of the applicable Utilization Review Program. 5) Retrospective Review of inpatient and ambulatory surgical cases. 6) Outpatient Certification of certain outpatient services prior to rendering such services, as determined by the applicable Plan. (continued on next page) I I Roc:i:l0ter Comm oi,y Nivrwoim INC." Page 1 of 2 RCNEXA0798.doe EXHIBIT A (continued) PREADMISSION/PROSPECTIVE REVIEW The Physician and/or Member Provider shall notify the designated utilization review organization for all elective hospital inpatient, day surgery (hospital, free standing facility, office-based), and short stay admissions. The Physician and/or Member Provider is responsible.for providing the designated utilization review organization with the necessary pre-admission information. Whenever possible Physician and/or Member Provider will do, or cause to 'have done, pre-admission testing when Qualified Participant is to be hospitalized. Unless otherwise approved in writing by RCN or,Payor any Qualified Participant requiring any elective surgical procedure shall have such surgery performed on day of admission to the facility(hospital or surgery center). The following information is required: (a) Patient's name, age,sex, and date of birth; (b) Qualified Participant's name,address,social security number; (c) Name of Payor; (d) Diagnosis(ICD-9 code) and Procedure(CPT code)if applicable; (e) Name, address, and telephone number of the Admitting Physician and/or Member Provider; (f) Name,address, telephone number of the Hospital or Facility; (g) Date of service(admission and/or procedure date); and (h) Admit type: Emergency, Scheduled,Urgent,Psychiatric. r After obtaining the information and determining that the admission is medically necessary, the designated utilization review organization shall provide the admitting Physician and/or Member Provider with a certification/authorization and/or case number: If the Physician and/or Member Provider has not received notice of a pre-admission determination at the time of a. scheduled admission, including ambulatory surgery, the Physician and/or Member Provider shall contact the designated utilization review organization'to request the determination. Claims/Cases which are subject to retrospective review and potential denial of payment include but are not limited to the following: 0 Any admission that was not pre-certified prior to admission or within the Payor specified time frame for emergency admissions; 0 Any service that required pre-certification prior to the provision of such service which was not pre- certified;and 0 Services which are determined not to be medically necessary. SECOND OPINION When a second opinion is required,the Physician and/or Member Provider shall provide the second opinion Physician and/or Member Provider with the necessary information to evaluate the patient and to minimize duplication of services. CONCURRENT REVIEW Throughout the hospital stay, the attending Physician and/or Member Provider shall provide the necessary information to substantiate the need for treatment and continued stay. The Member Provider, Physician or Qualified Participant may appeal a utilization review determination by notifying the utilization review organization that did the initial review. Such requests shall be made in accordance with the Payor's Utilization Review Program's appeal process and shall contain. documentation justifying a reconsideration. Final decisions on payment determination shall reside with the Payor. rR,),KIIORT COMMUNITY Nr,TwonK,INC." Page 2 of 2 RCNEXA0798.doc EXHIBIT B Amended Reimbursement Schedule (FS ) a.!: � The parties hereby agree that this Amendment be incorporated into the existing agreement entered into by and between Texas Independent Osteopathic Physicians Association (TIO-PA) and Rockport Healthcare Group,Inc. (RHG). I. Accident& Health, Personal Injury Protection (PIP), & Medical Access Savings Card Provider fees for the programs listed above shall be based on the following percentage of RBRVS: Surgery(10040-69979) 145% Medicine(98925-99499) 145% Medicine(90700-96999) 145% Radiology(70010-79999) 145% Pathology(80002-89399) 145% Physical Medicine(97001-97799) 145% Anesthesia* (00100-01999) 43.00 *Based on the American Society of Anesthesiologists 15-minute increments. Reimbursement for Anesthesiologists billing with codes listed in the Relative Value Guide as published by ASA, will be determined by adding a Basic Value, which is related to the complexity of the service,plus Modifying Units(if any)plus Time Units,if applicable. The sum of which will be multiplied by the anesthesia unit value listed above. Time increments,as defined by ASA Guide,is 1 unit per 15 minutes up to 4 hours,after 4 hours, 1 unit per 10 minutes. "BR" (By Report), -'RNE-.' (Relativity Not Established), HCPCS (Health Care Financing Administrations Common Procedure Coding System), Immunizations and any Unlisted Procedure Code will be paid at 90% (ninety percent)of reasonable and customary charges.. Coverage: Coverage for all procedures on the fee schedule are subject to the terms and conditions of the applicable Benefit Plans and/or the provisions of the Medical Access Savings Card Program. Schedule: Schedule shall apply to St. Anthony's Complete RBRVS, Relative Value Studies, Inc., published by St. Anthony Publishing Company, copyright 2001 and will update accordingly in conjunction with the Tarrant,County St. Anthony's Complete RBRVS. II. Workers' Compensation Provider fees for the program listed above shall be based on the following: States with mandated fee schedules -All fees will be reimbursed at 85% (eighty five percent) of. each state's mandated fees,.the fee schedule provided in I.., or covered charges,whichever is less. JUN 0 0 2001 A�3 = Page 1 of 2 PS71 Romofa Cowimp.T NETWORK, IN(%" 05/11/01 EXHIBIT B Reimbursement Schedule (FS ) (Continued) C2c 540 "BRIT (By Report), I'RNEII (Relativity Not Established), IIHCPCS" (Health Care Financing Administrations Common Procedure Coding System) and IIDOPII (Documentation of Procedure) and any unlisted procedure code will be paid at 90% (ninety percent) of reasonable and customary charges. Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of the applicable Workers' Compensation Benefit Plan. Schedule:%Schedule II shall apply to the state mandated fee schedule in the state where services were rendered and will update accordingly in conjunction with the same. I/We accept the fees as outlined in this Amended Exhibit B. For and on behalf of: For and on behalf of: PHYSICIAN/DESIGNEE (Practice name,address,etc.) ROCKPORT HEALTHCARE GROUP,INC. T.I.O.P.A,Inc. 50 Briar Hollow Lane, Suite 515W 3632 Tulsa Way Houst ,T ;77027 Fort Worth,Texas 76107 ! , Signature Harry 4eer Printed Name M o Y)Av 1�jz-oLu fi-y�r) �U President Title e•1�a i r T• P-D:Q• A. , Date TIN Date 2 U — Page 2 of 2 PS71 ROCIO'ow Commumn, NKTWORIL, INC.' 05/11/01 EXHIBIT B Reimbursement Schedule (171) I. Accident & Health, Personal Injury Protection (PIP), & Medical Access Savings.Card Provider fees for the programs listed above shall be based on the following percentage of R 3RVS: Surgery (10040-69979) 135% Medicine (98925-99499) 135% Medicine (90700-96999) 135% Radiology(70010-79999) 135% Pathology(80002-89399) 135% Physical Medicine(97001-97799) 135% Anesthesia* (00100-01999) 42.00 *Based on the American Society of Anesthesiologists 15-minute increments. Reimbursement for Anesthesiologists billing. with codes listed in the Relative Value Guide as published by ASA, will be determined by adding a Basic Value, which is related to the complexity of the service,plus Modifying Units (if any)plus Time Units, if applicable. The sum of which will be multiplied by the anesthesia unit value listed above. Time increments, as defined by ASA Guide, is 1 unit per 15 minutes up to 4 hours, after 4 hours, 1 unit per 10 minutes. ' Standard Professional Discount: If fee schedule reimbursement rate meets or exceeds billed charges, a 10% (ten percent)standard professional discount will be applied to billed charges. "BR" (By Report), "RNE" (Relativity Not Established), HCPCS (Health Care Financing Administrations Common Procedure Coding System)and any unlisted procedure code will be paid at 80% (eighty percent) of reasonable and customary charges. Coverage: Coverage for all procedures on the fee schedule are subject to the terms and conditions of the applicable Benefit Plans and/or the provisions of the Medical Access Savings Card Program. Schedule: Schedule shall apply to St. Anthony's Complete RBRVS, Relative Value Studies, Inc., published by St., Anthony. Publishing Company, copyright 1998 and will update accordingly in conjunction with the St. Anthony's Complete RBRVS. II. Workers' Compensation Provider fees for the program listed above shall be based on the following: States with mandated fee schedules -All fees will be reimbursed at 85% (eighty five percent) of each state's mandated fees, the fee schedule provided in I., or billed charges, whichever is less. If fee schedule reimbursement rate meets or exceeds billed charges, a 10% (ten percent) standard professional discount will be applied to billed charges. "BR" (By Report), "RNE" (Relativity Not Established), "HCPCS" (Health Care Financing Administrations .Common Procedure Coding System) and "DOP" (Documentation of Procedure) and any unlisted procedure code will be paid at 80%(eighty percent) of reasonable and customary charges. rRocKPORT COMMUNITY NtiTWORK,INC,` Page I oft 171.doc EXHIBIT B Reimbursement Schedule (171) (Continued) Coverage: Coverage for all procedures on the fee schedule is subject to the terms and'conditions of the applicable Workers'Compensation Benefit Plan. Schedule: Schedule II shall apply to Texas Workers Compensation Commission Medical Fee Guidelines, copyright 1996 and will update accordingly in conjunction with the same. nVe accept the fees as outlined in this Exhibit B. For and on behalf of: For and on behalf of: PHYSICIAN/DESIGNEE (Practice name,address,etc.) ROCKPORT COM UN NETWORK,INC. `I r r L .A�_�-7,_n . 50 Briar Hollow 'k S ite 515W Houston,Texas Signature � C. � ` William W. le erg Printed Name_ P1To President Title CkcL i r )�1 Date �,?.��- TIN '7 5 ---D.5'q Ll- Date rRoexPORT Coaiatt-Nn-Y Nvuwon,r.c." Page 2 of 2 17 Ldoc : Z000 0( 07 4KPORT 1106 fi AXT1°tC:tkt7►s Cr�tC7C.ET> ADDENDUM TO AGREEMENT (Rockport Healthcare Group,Inc.) The parties hereby agree that this Addendum for a compensative injury in question is not be incorporated"into the existing Agreement, specifically addressed by the treatment effective 02/01/2000 entered into,by and guidelines used by the Client and/or Payor. between TIOPA Member Provider)and However, Member Provider must Rockport Healthcare Group,Inc.,a demonstrate medical necessity to support Delaware Corporation("RI-10%dba services rendered'to Qualified Participants Rockport United Network(a preferred that are outside of treatment guidelines, provider network for Occupational Injuries and Illnesses);Rockport SeleetHealth (4)Retaliatory Action: REG agrees not to Network(an exclusive provider network). engage in any retaliatory action including termination of contract or refusal to renew a Pursuant to§10.42 of Texas Insurance Code contract against Member Provider,because 1305 regarding Network Contracts with Member Provider,on behalf of an Qualified Providers seeking to participate in Texas Participant,reasonably filed a complaint Certified Workers' Compensation Networks, against,or appealed a decision of RHG or Payor,or requested reconsideration or independent review of an adverse (1)When a Qualified Participant is covered determination. by a state or federally regulated Occupational Injury and Illness program, (5)Continuity of Treatment: Member Provider and Provider Network agree to comply with state and federal (5A)If Member Provider leaves the regulations regarding holding Qualified network,upon the Provider's request,the Participants harmless for health care Client and/or Payor is obligated to continue services for compensible injuries not paid by to reimburse the provider for a period not to Payor under any circumstances,including exceed 90 days at the contracted rate for Payor's or network's insolvency. This care of a Qualified Participant with a life- provision does not preclude billing a non- threatening condition or an acute condition Qualified Participant for a non-compensible for which disruption of care would harm the injury. Qualified Participant. (2)Treatment Guidelines: Member Provider (513)Member Provider shall use best efforts agrees to follow the treatment guidelines, to comply with RHG's criteria for provider return-to-work guidelines and individual participation, including credentialing treatment protocols outlined in Exhibit A of policies and procedures, complaint this Addendum provided in RHG's Provider processes as identified in the RHG Provider Handbook and/or Clients' Utilization Handbook.Member Provider shall Review Programs. cooperate with RHG's periodic evaluation of qualifications and Clients' Utilization (3)The Client and/or Payor may not deny Review programs. In addition,Member treatment solely on the basis that a treatment Provider shall use best efforts to cooperate Page 1 of 5 Addendum Agreement-TIOPA and comply with RHG's and/or state rules required by Section II.7.1 above is and regulations for the expeditious suspended or revoked, unless such Physician resolution of any grievance or complaint.A can arrange for other Member Providers to dispute concerning continuity of care shall prescribe regulated drugs for Qualified be resolved through the complaint resolution Participants under the care of Physician process, within ten(10)days of such loss of such Registration number(s) and gives RHG (6)Termination of network provider status notice of the same, (iv)Physician is (except for termination due to contract excluded from participation in the Medicaid expiration)and applicable written or Medicare programs, (v)Physician notification to employees receiving care engages in any act, omission,-demeanor or regarding such termination: conduct that is likely to be detrimental to patient safety or to the delivery of quality (6A)RHO will provide notice to the patient care,or(vi)Physician is convicted of Member Provider at least 90 days before the a Felony, (vii) Physician is found in effective date of a termination by RIIG; violation of professional conduct,or(viii) thirty(30)days following written notice by (613)Upon receipt of the written notification RHO of a material default or breach by of termination,a Member Provider may Physician hereunder and the failure of request in writing a review by the network's Physician to cure such default or breach advisory review panel no later than 30 days during such thirty(30)day period. - after receipt of the notification; (6G)If Member Provider terminates the (6C)Utilization Review Agent for network contract,RHG's Client will provide will provide an advisory review panel that notification of the termination to employees consists of at least three Providers of the receiving care from the terminating same licensure and the same or similar provider.The network shall.give such notice specialty as the Member Provider; immediately upon receipt of the Member Provider's termination request or as soon as (6D)Utilization Review Agent for network reasonably possible before the effective date must complete the advisory panel review of termination; before the effective date of the termination; (7)The Member Provider is required to post, (6E)The Client,Payor,or RHG may not in the office of the Member Provider, a notify patients of the termination until the notice to employees on the process for earlier of the effective date of the resolving workers' compensation health care termination or the date the advisory review network complaints. The notice must panel makes a formal recommendation; include the Texas Department of Insurance's toll-free telephone number for filing a (617) A Physician may automatically be complaint and must list all workers' terminated on the date when:(i)Physician's compensation health care networks with license to practice medicine or other which the Member Provider contracts; licensed healthcare profession in the state where services are rendered,is suspended or (8)Member Provider agrees to abide by,the revoked,(ii) Physician's medical staff list of any treatments and services that privileges at a participating facility are require the networks' preauthorization and revoked or suspended,unless such any procedures to obtain preauthorization Physician's privileges are reinstated within according to those listed on Exhibit A of twenty(20)days of such suspension, (iii) Addendum. Physician's DEA or applicable State. Controlled Substance Registration number Page 2 of 5 Addendum Agreement-TIOPA (9)Member Provider agrees and (13)Member Provider agrees to provide acknowledges that RHO is acting solely in treatment for Qualified Participants who an administrative capacity in providing a ' obtain workers' compensation health care network of quality health providers. RHO is services through the network that is not the claims paying agent and will not be specifically identified in the contract as a liable for the payment of any amount owed contracting party. "Qualified'Participant" by a Payor to Member Provider in the event means a person who sustained a work- that Member Provider is unable to collect related injury/illness that is determined such amount of money up to and including compensible by an employer that the insolvency of the Payor. participates in the Rockport United Network or Rockport SelectHealth Network through (10)Regulatory Compliance:Member Rockport's Client. Unless in an emergency Provider and RHO agree that each shall or after business hours, initial services comply with all applicable requirements of provided for the work-related injury/illness state and federal statutes,rules and require authorization by the Employer regulations,now or hereafter in force and and/or network either in writing or by effect. telephone. (l 1)Primary Treating Physician/Clinic (14)Neither a Client, a Payor,nor RHO may means a Member Provider who is a Medical use any financial incentive or make a Doctor(MD)or a Doctor of Osteopathic payment to a health care provider that acts - Medicine(DO)that specializes in Family directly or indirectly as an inducement to Practice,General Practice,Occupational limit medically necessary services.The Medicine or Internal Medicine and whose adoption of treatment guidelines,return-to- practice is largely dedicated to caring for work guidelines,and individual treatment work related injuries and illnesses and is protocols by a network is not violation of designated by RHO as a Primary Treating this section. Physician/Clinic(PTP). PTP agrees to render medical care to Qualified Participants (15)Client and/or Payor or RHO must without a scheduled appointment and provide written notice to a Member Provider operate during normal business hours,. or group of Member Providers before the Monday through Friday of any given week Client/Payor or RHO conducts economic excluding recognized holidays, profiling,including utilization management studies comparing the provider to other (12)Bill and/or Claim Forms: Claim forms providers,or other profiling of the provider are required for all services. All claims or group of providers. must be submitted complete and accurate on HCFA 1500 or UB-92 form(or their (16)All terms and conditions to Agreement successors)and must include Member including the Reimbursement Fee Schedule Provider's usual and customary billed remain in effect.If there should be any charges(not discounted rates)and question,dispute, or conflict of the terms appropriate codes,consistent with policies and conditions between the Agreement and established or approved by applicable state the Addendum,the Addendum supercedes and/or federal regulations. All claims must any and all other terms or conditions. be submitted within thirty(30)days,or within such time period from the date of. service, or as specified by the state rules and regulations. Billing by and payment to the provider will be made in accordance with Labor Code§408.027 and other applicable statutes and rules. Page 3 of 5 Addendum Agreement-TIOPA IN WITNESS WHEREOF,the parties hereto through their authorized representatives have agreed to the.Addendum effective the date of execution by Rockport. For and on behalf of: For and on behalf of: ROCKPORT HEALTHCARE GROUP, INC TIOPA 50 Briar Hollow Lane,515 W4t ��%.1j G 76/0 y Houston,Texas 77027 CpLjd21 pG-L_bo Signature Signature Mark C.Neer C,Hi I e Sr. Vice President, usin s D velopment Title Date Date 5 �.sg ocl3a Tax ID Page 4 of 5 Addendum Agreement-TIOPA EXHIBIT A STANDARDS AND GUIDELINES' UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS RHG and its Clients require Member Providers to follow nationally recognized treatment guidelines (i.e. Official Disability GLlidelineS(ODG) and/or American Occupational and Environmental Medicine's (ACOEM) guidelines) in the treatment of work-related injuries/illnesses for Qualified Participants. RHG's Clients provide utilization review and quality improvement programs for Qualified Participants. RHG shall review each Clients Utilization Review and Quality Improvement Program in accordance with RHG's Credentialing Standards and Guidelines as described in this Exhibit. Physician and/or Member Provider agrees to.comply and be bound by such programs and any state or federal rules and regulations. Such Standards and Guidelines for Utilization Review Programs-may be amended from time to time upon written notice to Physician and/or Member Provider. The primary goals of the Utilization Review Programs shall be to: 1) Ensure and certify for the payment of benefits that healthcare services meet the definition of-medical necessity as defined by the network,Payor or the Payors designee; 2) Ensure that healthcare services are provided at the appropriate level of care;and 3) Ensure that healthcare services follow nationally recognized treatment guidelines that are evidenced-based and outcome-focused. Treatments and Services that may Require Preauthorization: 1) In-patient hospital admissions including the principal scheduled procedures(s)and-the length of stay; 2) Outpatient surgical or ambulatory surgical services; 3) Spinal surgery,as provided by Texas Labor Code§408:026; 4) All psychological testing and psychotherapy, repeat interviews,.and biofeedback;except when any service is part of a preauthorized or exempt rehabilitation program; 5) All external and implantable bone growth stimulators; 6) All chemonucleolysis; 7) All myelograms,discograms,or surface electromyograms; 8) Unless otherwise specified,repeat individual diagnostic study,with a fee established in the current Medical Fee Guideline of greater than$350 or documentation of procedure(DOP); 9) Work hardening and work conditioning services provided in a facility that has not been approved for exemption by the Division; 10) Rehabilitation programs to include (a) outpatient medical rehabilitation and (b) chronic pain management / interdisciplinary pain rehabilitation; 11) All durable medical equipment (DME) in excess of$500 per item (either purchase or expected cumulative rental)and all transcutaneous electrical nerve stimulator(TENS)units; 12) Nursing home,convalescent,residential,and all home health care services and treatments; 13) Chemical dependency or weight loss programs; 14) Any investigational or experimental service or device for which there is early,developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that'is not yet broadly accepted as the prevailing standard of care;and 15) Physical and occupational therapy services;(a)-physical and occupational therapy services are those listed in the Healthcare Common Procedure Coding System (HCPCS) Level I code range for Physical Medicine and Rehabilitation, but limited to: (i) modalities, both supervised and constant attendance; (ii) therapeutic procedures,excluding work hardening and work conditioning; and(iii)other procedures,limited to the unlisted physical medicine and rehabilitation-procedure code. NOTE: Preauthorization is not required for the first two visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediately following: (i) the date of injury,or(ii)a surgical intervention previously approved by the payor. Page 5 of 5 Addendum Agreement-TIOPA