HomeMy WebLinkAboutContract 47186-P26 a
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CONTRACT NO.. l��
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ADDENDUM
To
Blaefistone 504 Program
Provider Agreement
This Addendum is entered into by and among X=T,MD("Member Provider"),Rockport Community
Network('Rockport"),and the City of Fort Worth ("City")on this day of
20
WHEREAS, Rockport and Member Provider entered into a Provider Agreement, effective A.uggst 25.
2014, (`Provider Agreement"), and desire that this Addendum apply to coveted 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
seting up a direct conhacted 504 providerpanel pursuant to Texas Labor Code Section 504.053.
WHMMAS,the City has determined that a workers'compensation health care aetwork certified wader
Taxes insurance Code Chapter '1305 is not available or praddcal 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.
Va EREAS, Rockport, Msmber Provider, grid 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).
VsWITMAS,Rockpmr,Member Wovider,and the City desire forthe terms Bad conditions of the Provider
Agreement to he 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,TI IEREFORE,for good and valuable consideration,the suffiaiemy and receipt of-which is hereby
acknowledged,the pax ties 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 408.073, 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 mattes_
2. The parties agree that the City will bear the financial responsibility for payment to Member Provides
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.
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3. When used in this Addendum,unless the content otherwise clearly requires,the following words and
terms shall have the meaning set froth below. All other defined terms shall have the meaning
ascribed to them is the Provider Agreement
"Payors"will be the City as they are responsible for payment of medical,benefits for
compensable.injuries and or iIInesses sustained by its injured workers according to the
Texas Workers Campensation Ac'L
q `BiacicStene" is the 504 Provider Panel established by the City of Fort Worth through
this and other direct contracts usingRockport as its contracting agent
°Provider Manual"means the$leck9tone 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 ofthe Texas Labor Code.
4. Nothing in this Addendtmn or the Provider Agreement shalt be interpreted to inue to the
benefit of a third party not a party to ibis contract. This contract may not be interpmted
to warm any statutory or common law defense, itnmmi ty, Including governmental and
soimmunity,i unity,or any limitation of liability,responsibility,or damage of any party
to this contract;party's agent,or party's employees otherwise provided by law.
5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates a
new rause of action.
b. All other teams of the Provider Agreement shall remain in force and unchanged_Any conflicts
between this Addendum and the Provider.Agreement shall be superseded by the urns y.ovidecr
herein.
IN WITNESS WHEREOF,itie parties hereto have executed this Addendum effective on tie day and year
fust written above.
For and on behalf of
nckStone
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Name: a i S 6QftT
Title:61551-5bta (11
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STA ITY ATTORNEY
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RQCUPCRT CUMMUNI.TYNSTWORK
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Name:7oharaalacci
Title:Sr.Vice President
Date: —7--1L4-1-
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ROCKPORTTM
MEDICAL GROUP AGREEMENT
ROCKPORT SELECTHEALTH NETWORK
This Medical Group Agreement ("Agreement"), is L DEFINITIONS
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 otherwise clearly requires, the following words and
SelectHealth Network (an exclusive provider terms shall mean:
network) and Stephenville Medical & Surgical
Clinic PA ("Member-Provider"), and will become I.1 "Ph sician"means a licensed Medical Doctor or
effective as of the date the provider is fully Doctor of Osteopathic Medicine, or group of same
credentialed by RHG. who desire to become a Member Provider with
RHG.
WHEREAS, RHG is engaged in the business of
developing and acting in an administrative capacity Pursuant to §10.42 of Texas Insurance Code 1305
in providing Occupational Injury and health provider regarding Network Contracts with Providers seeking
networks that offer direction of care while providing to participate in Texas Certified Workers'
savings to RHG clients and/or Payors. These Compensation Networks,
networks will offer greater coverage of services and
savings; and 1.2 "Qualified Participant" means an "employee" as
defined and used in the Texas Labor Code, the
WHEREAS, RHG has networks of contracted Network Act Section 1305 and the implementing
physicians, physician groups, hospitals and rules who sustained a work-related injury/illness that
providers of ancillary healthcare services is determined compensible by an employer and that
(collectively, the "Member Providers")to provide a participates in the Rockport United Network or
full-range of healthcare services. These services are Rockport SelectHealth Network through Rockport's
available for use by "Qualified Participants" as Client. Unless in an emergency or after business
defined in I.2 of this Agreement;and hours, initial services provided for the work-related
injury/illness require authorization by the Employer
WHEREAS, Member Provider desires to provide and/or network either in writing or by telephone.
medical care services to "Qualified Participants"
who are covered by Payor Agreements at the rates in I.3 "Client" means an insurance company, certified
Exhibit B and in locations listed in Exhibit C:and self-insured or governmental entity as those terms
are defined and used in the Texas Labor Code, the
WHEREAS, RHG has entered into Agreements. Network Act Section 1305 and the implementing
•and/or services with one or more Payors who rules. These CIients have entered into a Client
provide payment of claims for medical care rendered Agreement with RHG for the provision of healthcare
to Qualified Participants. services to Qualified Participants.
NOW, THEREFORE, in consideration of the 1.4 `'Payor" means an insurance carrier or network
premises,the mutual promises contained herein,and certified by an insurance carrier for its own benefit,
other good and valuable consideration, the receipt certified self-insured or governmental entity as those
and sufficiency of which are hereby acknowledged, terms are defined and used in the Texas Labor Code,
it is mutually agreed as follows: the Network Act Section 1305 and the implementing
rules who is responsible for payment of medical
benefits for on the job injuries and or illnesses
according to State and/or Federal Rules and
Regulations.
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Stephenville Medical and Surgical Center RSHNPHYEXCSS_TX_0 10 12014
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I.5 "CIient Agreement" means the agreement specialty to maintain their RHG classification as
between RHG and a Client, which agreement is such and be willing and able to treat Qualified
s made before, on or after the effective date of this Participants as needed or required..
h Agreement and which expresses the agreed upon
f contractual rights and obligations of the parties. I.9 "Emergency Medical or Mental Condition" is
Such Client Agreements will require Payors to pay defined as the sudden onset of a medical condition
Member Provider for Covered Services rendered to manifested by acute symptoms of sufficient severity,
Qualified Participants pursuant to this Agreement. including severe pain,that the absence of immediate
Furthermore,such Client Agreements shall authorize medical attention could reasonably be expected to
RHG to enter this Agreement and contractually bind result in:
Payors to the terms hereof unless there is a conflict (a)placing the patient's health or bodily functions in
with State and/or Federal rules and regulations. serious jeopardy;or
(b)serious dysfunction of any body organ or part as
1.6 "Member Provider" means any physician; defined in TIC 1305.004(13);and
physician group;hospital; surgery center; diagnostic (c)in the case of a mental health condition, one that
imaging center; laboratory; clinic; chiropractor; could reasonably present danger to the person
dentist; podiatrist; psychologist; social worker; experiencing the mental health condition or another
physical, occupational and speech therapist; etc. person as defined in TIC 1305.004(15).
licensed or certified to practice a healthcare
profession or licensed as a facility to offer healthcare 1.10 "Covered Services" are those healthcare and
services,in the state where services are rendered and health-related services provided to Qualified
who has executed a contract with RHG. Participants for treatment of a compensible, work-
related injury/illness as defined by either nationally
I.7 "Primary Treating Physician/Clinic" According recognized treatment guidelines and/or individual
to Texas law for certified workers' compensation treatment protocols that do not conflict with any
networks, the Network decides who will be a state and/or federal rules and regulations.
Treating Doctor.Therefore,a Member Provider who
is a Medical Doctor (MD) or a Doctor of 1.11 •"Bill and/or Claim Form'CMS 1500 (or other
Osteopathic Medicine (DO) that specializes in appropriate claim form or their successors)
Family Practice, General Practice, Occupational completed in accordance with the guidelines
Medicine or Internal Medicine as well as a physician established by the National Uniform Billing
that provides initial and/or follow-up care in Occ- Committee or CMS 1500 billing guidelines, and/or
Med or Urgent Care Clinics whose practice is state rules and regulations.
largely dedicated to caring for work related injuries
and illnesses is designated by RHG as a Primary U. MEMBER PROWDEI2 OBLIGATIONS
Treating Physician/Clinic (PTP). PTP agrees to
render medical care to Qualified Participants without 11.1 Services. Member Provider agrees to provide or
a scheduled appointment and must be available and arrange for all medically necessary medical care for
accesible to employees twenty-four (24) hours per- Qualified Participants who present themselves to
day, seven (7) days-per-week as per 28 TAC Member Provider. Member Provider agrees to
10.80(b)(1). Should a Qualified Participant need perform such services with the same standard of
medical attention outside of Member Provider's care, skill and diligence for all Qualified
normal business hours, Member Provider will be Participants. Member Provider agrees that it is their
available and/or make arrangements to have another sole responsibility to verify that the individual
Member Provider render care to Qualified presenting for care is a Qualified Participant.
Participant twenty.-four(24)hours-per-day,seven(7) Member Provider agrees to render healthcare
days-per-week. services to Qualified Participants at any and all
facility or practice locations listed in Exhibit "C".
1.8"Specialist Physician" means a Member Provider Member Provider shall make best efforts to ensure
who has met the credentialing requirements of RHG that services provided are consistent with nationally
to be a Specialist Physician, and to whom Primary recognized treatment guidelines (i.e. official
Treating Physicians/Clinics may refer for necessary Disability Guidelines (ODG), American
and authorized care other than primary treating Occupational and Environmental Medicine's
services. Specialists will need to maintain their (ACOEM) and /or state rules and regulations. i
f current board certifications for their particular
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Stephenville Medical and Surgical Center RSHNPHnXCSS TX 010I2014
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Member Provider agrees to comply with and be
bound by all State/Federal Rules and Regulations. H.6 Reports. For each encounter where Member
II.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
I Utilization Review Programs.RHG agrees to furnish specified by RHO, 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 11.7 Professional Requirements.
after business hours,initial services provided for the
work-related injury/iIIness require authorization by I.7.1 Licensure&Accreditation. Member Provider
the Employer and/or Network either in writing or by shall comply with all applicable federal, state and
telephone. The CIient 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 specifically of such current licensing, certification and/or
addressed by the treatment guidelines used by the accreditation shall be submitted promptly to RHO
CIient 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,
11.3 Non-Discrimination.Member Provider shall not permits and approvals as are required for the Iawful
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
observe, protect and promote the rights of Qualified warrants that it is currently accredited by the Agency
Participants. that governs like providers and is certified as a
!, provider under Title XVIII (Medicare) and when
1I.4 Medical Staff Participation. Certain medical appropriate, Title XIX (Medicaid) of the Social
specialties may not require hospital privileges such Security Act and that it shall maintain such
as Occupational Medicine,Pathology,Dermatology, accreditation and certification during the term of this
Allergy, and those Primary Treating Agreement. Member Provider shall immediately
Physicians/Clinics whose practice is dedicated to notify RHO of any action, investigation or
treating work-related injuries and illnesses. Where proceeding to revoke, suspend, restrict, or otherwise
appropriate, Physicians must maintain active, affect such accreditation or certifications.
unrestricted staff privileges with at Ieast one RHG
Member Provider hospital or Surgery Center. 11.7.2 Organization's Requirements. Member
Physician hereby consents to disclosure by such Provider shall use best efforts to comply with RHG's
facility to RHG of all data collected with respect to criteria 'for provider participation, including
Physician in connection with Physician's medical credentialing policies and procedures. Member
staff membership, including without limitation all Provider shall cooperate with RHOS periodic
applications for staff privileges and any renewals evaluation of qualifications. In addition. Member
thereof. Provider shall use best efforts to cooperate with
RHG's and/or state rules and regulations for the
11.5 Referrals. Except in a medical emergency or expeditious resolution of any grievance or
when authorized by RHG, Client, or its designated complaint.
representative, Member Provider agrees to .refer
Qualified Participants only to other Member 11.8 Notification to RHG. Member Provider
Providers,as defined in 1.6. represents and warrants that information provided
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Stephenviile Medical and Surgical Center RSH gPHYEXCSS *FX 0lOM14
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herein and in the RHG application is true and during normal business hours, upon prior five (5)
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 s
best efforts to provide written notice to RHO of any performance under this Agreement. Member
(i)suspension,reduction or loss of license to provide Provider further agrees to allow REG, Payor or a
healthcare services; (ii) denial, suspension, designated representative thereof; including the
restriction, reduction or termination of designated utilization review, quality management,
accreditation/certification; (iii) changes 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 for information of Qualified Participants for services
participation, (v) Member Provider's professional provided under the terms of this Agreement as
liability insurance if such insurance falls below the necessary to enable such party to perform Utilization
requirements of state law and (vi) Member Review and Quality Assurance activities in
Provider's billing or facility address. A failure to accordance with the applicable Utilization Review
give any notice required by this Section shall be a and Quality Assurance Program. In addition,
material breach of Member Providers obligations Physician agrees that in the event an examination
and responsibilities hereunder, regardless of the concerning the quality of healthcare services is
status,pendency or outcome of the event giving rise conducted by appropriate officials, as required by
to the obligation to give that notice, and may be federal,state,and/or Iocal 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
11.9 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 Iocal
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 U.11 Relationship of Parties. Member Provider and
Participants and shall comply with all applicable RHG understands and agrees that they are each an
state and federal laws. Member Provider shall independent legal entity. Nothing in this agreement
maintain such records for the length of time required shall be 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 shall be made available to each than that of independent parties contracting with
Member Provider and other health professionals each other solely to carry out the provisions of this
treating the Qualified Participant, and upon request, Agreement for the purposes recited in this
to the Payor, RHG or its designated representative Agreement. With regard to the provision of
for review at the rates approved by State law and as healthcare services, Member Provider acts as an
set forth in the current State Workers' Compensation independent entity and the Member Provider-pafient
Reimbursement Manual for Hospitals, if applicable. relationship shall in no way be affected.
Member Provider shall obtain a valid consent for the
release of the Qualified Participant's medical records II.12 Standards of Care. Member Provider agrees
to other providers, RHG, Payor, or its designated that all duties performed hereunder shall be
representative. RHG agrees that medical records of consistent with the proper practice of their
Qualified Participants shall be treated as confidential healthcare profession, and that such duties shall be
so as to comply with all federal and state laws and performed in accordance with the customary rules of
regulations regarding the confidentiality of patient ethics and conduct of the appropriate and applicable
records. The Member Provider's obligations under professional organizations and/or associations,as the
this Section 11.9 shall survive the termination of this case may be, and such other bodies, formal or
Agreement. informal, state, government or otherwise, or by
which they are subject to licensing/certification and
H.10 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 ail reasonable times conformance with the standards for their facilities as
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Stephenville Medical and Surgical Center RSENTHYEXCSS_TX_01012014 -
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established by the local/regional professional referral; including but not limited to the following:
healthcare community and applicable (i) Provider Search Provider Locator System (ii)
accreditingAicensing agencies. Member Provider Provider Directories (iii) Site-Specific Provider
agrees that,to the extent feasible,it shall utilize such Panels (lv) Customized Local Networks and (v)
additional allied health and other qualified personnel Client Service Provider Referral Service.
as are available and appropriate for effective and
efficient delivery of care. Member Provider shall I11.2 Credentialina. RHG will perform and/or
ensure that all such personnel are properly licensed delegate to qualified organizations credentialing of
and/or possess the necessary credentials to render each Member Provider. Credentialing may include
the services that they perform. verification of all information and documents
provided in the application for participation and
I1.13 Riaht to Use Member Provider's or Network's investigation, including but not limited to
Name. Member Provider agrees to allow RHG to verification with all state and national licensing and
list Member Provider's name, specialty, address, certifying bodies that apply to the services rendered
telephone number, and hours of operation in a by the Member Provider,such as JCAHO,AAAHC,
Member Provider directory, Provider Search, RHG NCQA, CLIA, URAL, etc. Inquiries may also be
Site-Specific Provider Panel(s), RHG website and/ made to current and previous professional liability
or other materials to help promote and assist Clients carriers, Medicare and Medicaid. RHG's
with Qualified Participants needing medical care for credentialing policies and procedures follow the
injuries/illnesses sustained. RHG agrees to allow American Accreditation Healthcare Commission
Member Provider to list RHG's name, address, and (URAL) standards for Workers' Compensation
telephone number on Member Provider's website or provider networks.
in other publications listing the health plans accepted
by Member Provider, In addition,Member Provider 111.3 Operational Functions. RHG shall utilize
agrees to post in waiting room and make available to systems to respond to Member Providers requests
Qualified Participant notice of Member Provider's for information and will provide clarification of
participation with RHG with name, address and policies concerning the operation of RHG's
telephone number and process for Qualified programs. Member Provider agrees to work in
Participants to resolve complaints. The Member cooperation with RHG to market the services of the
Provider is required to post, in Member Provider's Member Provider to Clients and/or Payors.
office, notice to employees on the process for
resolving workers' compensation health care RHG shall act as a liaison with the Member
network complaints. The notice must include the Providers and Clients and/or Payors to devote
Texas Department of Insurance's toll-free phone necessary time and effort to perform RHG's
number for filing a complaint and must list all responsibilities hereunder.
workers' compensation health care networks with
which the Member Provider contracts. IIIA Retaliatory Action. RHG 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
imposed pursuant to this Agreement may result in behalf of an Qualified Participant,reasonably filed a
termination of this Agreement by RHG. complaint against, or appealed a decision of RHG or
Payor, or requested reconsideration or independent
11.15 Antitrust Guidelines. Member Provider agrees review of an adverse determination.
to comply with all antitrust guidelines and
procedures promulgated by Federal and State III.5 Antitrust Guidelines. RHG agrees to comply
entities. with all antitrust guidelines and procedure
promulgated by Federal and State entities.
III. REIG's OBLIGATIONS
111.6 Audit Policy and Procedure Compliance. All
III.1 Marketing to Clients/PMors. RAG 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 I.3 and 1.4 for their access to RHG quality and Regulations.
Member Providers through specific referral
processes. RHG will market Member Providers for
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Stephenville Medical and Surgical Center RSHNPHYEXCSS TX_010120l4
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will be subject to the reimbursement rates
IV. REIMBURSEMENT,CLAIMS established in the Exhibit B of this Agreement_
SUBMISSION AND PAYMENT
All billing and reimbursement will be made in
1V.1 Reimbursement. RHG 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 for Payors to pay Member Provider the IV.3 Bill and/or Claim Forms. Claim forms are
jreimbursement 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 CMS 1500 (or
Member Provider agrees and acknowledges that other appropriate claim form or their successors)and
RHG is acting solely in an administrative capacity in must include Member Provider's usual and
providing a network of quality health services.RHG customary billed charges (not discounted rates) and
is not the claims paying agent and will not be liable appropriate codes, consistent with policies
for the payment of any amount owed by a Payor to established or approved by applicable state and/or
Member Provider in the event that Member Provider federal regulations. Member Provider must submit
is unable to collect such amount of money up to and claims to Payor not later than the 95`h day after the
including the insolvency of the Payor. Under no date an 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
IV.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 Aeainst Oualified
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 vdll not seek additional payments or
rendered.All claims will be paid,when appropriate, reimbursement for compensible 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 REG,the Payor nor the
defined as a clean claim by Medicare.RHG 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 RHG's provider network. The program, Member Provider agreesto 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 Payors
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-compensible
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 transfer of financial 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 RHG is acting solely
and/or a Member Provider as defined in section I.6 in an administrative capacity in providing a network
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Stephenville Medical and Surgical Center RSHNPHYExCSS_7) 01012014
' of quality health providers. RHG is not the claims alleged to have be caused by its employees or
paying agent and will not be liable for the payment , representatives, in the performance or omission of
of any amount owed by a Payor to Member Provider any act or responsibility under this Agreement. In
in the event that Member Provider is unable to the event that a claim is made against RHG,it is the
collect such amount of money up to and including intent of RHG to cooperate in the defense of said
the insolvency of Payor, claim. However, RHG shall have the right to take
any and all actions they believe necessary to protect
IV.S Payment of Claim Forms. RHG shall their interest.
administratively arrange for. the Payor or its
t designated representative to pay undisputed claims V.3 Indemnification of Member Provider. Member
which are accurate, complete and comply with the Provider will be responsible for its own acts or
Agreement within the time period mandated by state omissions and any and all claims,liabilities,injuries,
or federal law. suits and demands and expenses of all kinds which
may result or arise out of any alleged malfeasance or
IV.6 Erroneous Payment. In the event that a Payor neglect caused or alleged to have be caused by its
and/or its designated representative pays the employees or representatives, in the performance or
Member Provider (i) more than once, or (ii) an omission of any act or responsibility under this
incorrect amount,or(iii) an overpayment,the Payor Agreement. In the event that a claim is made against
or its designated representative may, at its sole Member Provider, it is the intent of Member
option and discretion, request the return of such Provider to cooperate in the defense of said claim.
amount from Member Provider The Member However, Member Provider shall have the right to
Provider will not unreasonably withhold take any and all actions they believe necessary to
reimbursement. If overpayment has been made protect their interest.
Member Provider shall reimburse such overpayment
within forty-five (45) days and/or follow State and VL TERM AND TERMINATION
Local Rules and Regulations. The Member Provider
may not contest payment of Claims after one VI.1 Term. The term of this Agreement shall be for
hundred eighty(180)days from the date of payment. one (1) year from the date hereof and shall be
All claims for overpayment or underpayment shall automatically renewed on an annual basis for
be resolved in accordance with State Law and /or successive twelve(12)month periods,unless sooner
Federal Rules and Regulations. terminated in accordance with Section VI.2.
V. INSURANCE AND INIDEMNMCATION VI.2 Termination, This Agreement may be
terminated sooner on the first to occur of the
V.1 Insurance Requirement. Member Provider shall following:
provide and maintain such policies of professional
liability insurance or a self-funded program. The VI.2.1 Termination by Member Provider. Member
amounts and extent of such insurance coverage or Provider may terminate this Agreement in the event
self-funded program shall be in the amounts of a material default or breach of RHG`s obligations
determined by community standards for relevant hereunder,upon ninety(90) days prior written notice
hospital/facilities. If such coverage is under a and the failure of RHG to cure such breach or
"claims-made" policy, Member Provider agrees to default within sixty (60) days of the notice. In
provide and maintain such insurance coverage or a addition, in the event of an "emergency situation",
"tail" policy in the same amounts following the Member Provider may terminate the Agreement
termination of this Agreement. Member Provider immediately with the acknowledgment by RHG that
shall promptly demonstrate evidence of insurability such an emergency condition does exist.
or self-funded program and that the required "Emergency Situation" shall mean an unforeseeable
insurance is paid and in force upon request of RHG event, not resulting from Member Provider`s act or
and/or meet the credentialing guidelines of RHG. omission, which materially affects Member
Provider's ability to continue the practice of
V.2 Indemnification of RHG. RHG will be medicine or to perform his obligations hereunder.
responsible for its own acts or omissions and any The network will provide notification to employees
aad 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
Page 7 of 14
Stephenville Medical and Surgical Center RSffNPHYEXCSS TX 010l2D14
effective date of termination as required by 28 TAC either party may terminate the Agreement with at
10.42(b)(6)(G). Ieast ninety (90) days prior written notice to the
other party; however, the party in breach may cure
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 revoked, (ii) terminate this Agreement without cause upon ninety
Member Provider is excluded from participation in (90)days prior written notice.
The Medicaid or Medicare programs, (iii) Member
Provider Iosses their JCAHO, NCQA, AAAHC, V1.2.5 Unforeseen Events_ In the event that either
URAC, CLIA or other applicable license, party's ability to perform their obligations under this
certification and/or accreditation, (iv) Member Agreement is substantially interrupted by war, 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 shall be
engages in any act, omission, demeanor or conduct relieved of those obligations for the duration of the
that is reasonably likely to be detrimental to patient interruption upon notice to the other party. In the
safety or to the delivery of quality patient care,or to event that the interruption is reasonably determined
lead to the provision of healthcare services below likely to persist for at least ninety (90) days, either
applicable standards, or (vi) ninety (90) days party may terminate this Agreement upon thirty(30)
following written notice by RHG of a material days prior written notice.
default or breach by Member Provider hereunder
and the failure of Member Provider to cure such VI.3 Effects of Termination_ Upon termination of
default or breach within sixty(60)days of the notice this Agreement, neither party shall have any further
(vii) Member Provider fails to meet RHG's or the obligation hereunder except for (i) obligations
State's credentialing requirements. RHG, however, accruing prior to the date of termination, including
may not terminate this Agreement in direct response without limitation, any obligation by Member
to Physician filing a reasonable complaint,on behalf Provider to continue to provide healthcare services
of a Qualified Participant against, or appealed a to Qualified Participants, and (ii) obligations,
decision of, the network, or requested promises or covenants contained herein which are
reconsideration or independent review of an adverse expressly made to extend beyond the.tern of this
decision. Agreement.
In the event RHG deems it necessary to terminate VIA Qualified Participant and Payor Notification.If
Member Provider's agreement based on the above applicable, upon the termination of this Agreement,
requirements RHG will notify Member Provider at by either party, Member Provider shall cooperate
least ninety (90) days before the effective date of with RHG to notify Qualified Participants and
termination. Payors of such termination.
Upon written notification from RHG, Member VII.CONTINUATION OF BENEFITS
Provider may request a review by RHG's advisory
review panel, not Iater than thirty (30) days after VII.1 Continuation of Benefits. If Member Provider
notification. RHG must then complete the review voluntarily terminates its contract with REG, upon
before the effective date of termination. Member Provider's request,Payor must continue to
reimburse Member Provider for a period not to
V1.2.3 Termination for Insolvency. This Agreement exceed 90 days at the Member Provider's contracted
shall terminate immediately in the event that either rate set forth in Exhibit B of this Agreement with
RHG or Member Provider voluntarily or RHG,for care of an Qualified Participant with a life-
involuntarily, liquidates, dissolves or becomes threatening condition or an acute condition for
subject to any proceeding for the rehabilitation or which discontinuing or disruption of care would
conservation of their financial affairs with written harm the Qualified Participant as per 28 TAC
notification_ 10.42(b)(A). Any disputes concerning continuity of
care shall be resolved through the complaint process
VI.2.4 Termination by Either Party. In case of under Insurance Code §1305.401 - §1305.405 and
material breach of the terms of this Agreement,
Page 8 of 14
Stephenville Medical and Surgical Center RSH NPHYEXCSS_TX_01012014
1 .
5
Subchapter G of Title 29, Part I (relating to amicable understanding cannot be reached are to be
Complaints). decided by the following method:
IX.1.1 Mediation through RHG. The Member
{ V11.2 Survival. The provisions of this Article VII Provider shall notify RHG in writing of the dispute
1 shall survive the termination of this Agreement or disagreement and shall provide all necessary
regardless of the cause - giving rise to such information to RHO. RHO shall use best efforts to
termination, as will sections 11.9, V.2, V.3, VI3, mediate the dispute within the rules and regulations
VIII, and IX. The provisions of this Article VII put forth by the State as reference in RHG's
supersede any oral or written agreement to the Provider Handbook.
contrary now existing or hereafter entered into
f between Member Provider and any Qualified IX.1.2 Arbitration. If the dispute cannot be solved
t Participant or any person acting on a Qualified by the mediation process described above,either the
Participant's behalf. Member Provider, RHO or Payor may elect to
submit the dispute to binding arbitration under the
VIII. CONFIDENTIALITY rules of the American Arbitration Association or any
k other method of arbitration mutually agreed upon by
All business, medical and other records relating to the parties. Arbitration will be conducted in
the operation of MG or Member Provider, Houston, Texas. Each party will be responsible for
including but not limited to, books of account, their own legal fees. The cost of the arbitration
general administrative records, policies and services will be the sole responsibility of the party
procedures, pricing information, terms of this requesting the arbitration.
Agreement and all information generated and/or
contained in management information systems IX.1.3 Provider Appeals.Except for termination due
owned by or pertaining to RHO or Member to contract expiration, Member Provider has the
Provider, and all systems, manuals, computer right to appeal his/her termination from the Network,
software and other materials, but excluding patient as follows:
charts,shall be and remain the sole property of RHG
or Member Provider respectively (collectively, the IX.1.3.1 RHO will provide notice to the Member
"Confidential Information"). RHG and Member Provider at least 90 days before the effective date of
Provider acknowledges that the Confidential a termination by RHO;
Information and all -other information regarding
RHG or Member Provider that is competitively IX.1.3.2 Upon receipt of the written notification of
sensitive is the property of RHO or Member termination, a Member Provider may request in
Provider and RHG or Member Provider may be writing a review by the Network's advisory review
damaged if such information was revealed to a third panel no later than 30 days after receipt of the
,party. Accordingly, RHO and Member Provider notification;
agrees to keep strictly confidential and to hold in
trust all Confidential Information. Upon termination IX.1.33 The Network will provide an advisory
of this Agreement by either party for any reason review panel that consists of at least three Providers
whatsoever, RHG and Member Provider shall of the same licensure and the same or similar
promptly return to the other all material constituting specialty as the Member Provider;
Confidential Information or containing Confidential
Information, and neither party will not thereafter IX.1.3.4 The Network must complete the advisory
use, appropriate, or reproduce such information or panel review before the effective date of the
disclose such information to any third party. RHG termination;
and Member Provider specifically agrees that under
no circumstances will either party discuss the terms IX.1.3.5 The Client,Payor, or RHO may not notify
and conditions of this Agreement, and in particular patients of the termination until the earlier of the
The pricing information herein. effective date of the termination or the date the
advisory review panel makes a formal
IX. MISCF11ANEOUS recommendation;
IX.1 Disputes. All disputes and difference between IX.1.3.6 If Member Provider terminates the contract,
the Member Provider and RHO upon which an the Network or RHG's Client will provide
E Page 9 of 14
Stephenville Medical and Surgical Center RSHNPHYEXCSS TX_01012014
f
I. notification of the termination to employees IX.7 Amendments. This Agreement may be
receiving care from the terminating provider. The amended as agreed to by both parties in writing upon
Network shall give such notice immediately upon thirty (30) days written notice of such proposed
receipt of the Member Provider's termination amendment.
request or as soon as reasonably possible before the
effective date of termination. IX.3 Severability. The invalidity or un-
enforceability of any term or condition hereof shall
IX.2 Non Exclusivity. Nothing in this Agreement in no way affect the validity or enforceability of any
shall be construed to restrict Member Provider or other term or provision.
RHG from entering into other contracts or
agreements to provide healthcare services to Payors 1X.9 Assignment. Member Provider may not assign
or other healthcare delivery plans, patients, and or otherwise transfer any right or delegate any duty
employer groups, of performance hereunder, in whole or in part
without the prior written consent of RHG_ A change
IX.3 Entire Agreement,emlent, This Agreement contains in ownership will not negate the prior contractual
the entire understanding of the parties and agreement without written notification to RUG.
supersedes any prior understandings and agreements, RHO retains the right to assign this Agreement, in
written or oral, respecting the subjects discussed whole or in part,to any entity with which RHG or its
herein. parent company or any of its subsidiaries is
affiliated,or with which it merges or consolidates.
1X.4 No Waiver. The waiver by either party of a
breach or violation of any provision of this IK10 Third Party Beneficiaries. Except for Payors
Agreement shall not operate as or be construed to be and the agents thereof, there are no third party
a waiver of any subsequent breach hereof, beneficiaries of this Agreement.
IX.S Regulatory Compliance. Member Provider, MI ' Captions. The captions and headings
sub-contracting providers, and RHG agree that each contained in this Agreement are for reference
shall comply with all applicable requirements of purposes only and shall not affect in anyway the
municipal, county, state and federal authorities, all meaning or interpretation of this Agreement.
municipal and county ordinances and regulations,
and all applicable state and federal statutes and IX.12 Execution of Counterparts. This Agreement
regulations, now or hereafter in force and effect, may be executed in any number of counterparts,
governing RHO, Member Provider, sub-contracting including facsimiles,.each of which shall be deemed
providers, the provision of services by Member to be an original as against any part whose signature
Provider or sub-contracting providers, and/or appears thereon, and all of which shall together
Payors, including but not limited to applicable constitute one and the same instrument.
requirements under any state or federal fair
employment practices, equal - employment IX.13 Partial. Invalidity. If any part, clause or
opportunity,or similar laws declaring discrimination provision of this Agreement is held to be void by a
in employment based upon race, color, creed, court of competent jurisdiction, the remaining
religion,sex, or national origin as illegal,and,Titles provisions of this Agreement shall not be affected
VI and VII of the Civil Rights Act of 1964,Section and shall be given construction, if possible, as to
202 of Executive Order 11246 as amended by permit it to comply with the minimum requirements
Executive Order 11375, Sections 503 and 504 or the of any applicable law, and the intent of parties
Rehabilitation Act of 1973 and Title IV of the hereto.
Vietnam Era Veterans Readjustment Assistance Act
of 1974, and Sections 1 and 3 of Executive Order
11625, or any applicable rule or regulation
promulgated pursuant to any such laws or orders.
IX.6 Governing Law. This Agreement shall be
governed by and construed in accordance with
applicable state law.
Page 10 of 14
Stephenville Medical and Surgical Center RSHNPHYEXCSS TX 01012014
IX.14 Financial Incentives.Neither a Client, Payor, IX.17 Official Notices. Any notice or
nor RHO may use financial incentive or make a communication required, permitted or desired to be
payment to a health care provider that acts directly given hereunder shall be deemed effectively given
or indirectly as an inducement to limit medically when personally delivered or mailed, return receipt
necessary services- The adoption of treatment and requested, or overnight express mail addressed as
return-to work guidelines and individual treatment follows:
protocols by RHO or Network is not in violation of
this section as pursuant to Insurance Code §1305-
304 and§10.83(a)of Chp 10 of Title 28 Part 1,
IX.15 Financial Disclosure Requirements. Member
Provider is required to file financial disclosures in
accordance with Labor Code §§408.023 and Member Provider or Representative/Designee:'
epresentative/Desiaee:
§§413.041. j ("Please Print)
�i I,
IX.16 Economic Profiling. Network must provide Name
written notice to Member Provider before the
Network conducts economic profiling, including Organization:. Stephenville- Medical & Surgical
utilization management studies or other proftling of Clinic
the provider or group of providers,
Address: I50 River North Blvd
City/State/Zip:Stephenville,TX 76401
Telephone:25�4�4-9/668-605,11
Fax:
Organization:
Rockport Community Network,Inc.
dba Rockport Healthcare Group.
Attu: Director of Network Development
50 BriarHoliow Lane,Suite 515W
Houston,TX 77027
Telephoiue:(713),621-9424
IN WITNESS WHEREOF, the undersigned will,be Fax:(713)621-9511
deemed.to have executed this Agreement as of the
date the provider is fully credentialed by RHG. 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.
For and on behalf of:
Rockpart Community Network,Inc. For and on behalf of:
dpa.�-ockport Healthcare Group
,{,0, Briiar HouovsDane,suite 515W Member Provider or Re resentative/Designee
110n3t ri 77027 ,
Signate. C.�J
Au/"
Douglas 3 a kham Name:: tri 4
President (Print) `
Date: L�
�_ 2}5- TIN:752136613
"1
Date: 7—l41'
Page I1 of 14
Stephenvi le Medical and Surgical Center RSHNP}lYF.XCSS TX 01012014
i
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
l Disability Guidelines(ODG) and/or American Occupational and Environmental Medicine's (ACOEM) guidelines)
J in the treatment of work-related injuries/illnesses for Qualified Participants,
G, RHG's Clients provide utilization Teview and quality improvement programs for Qualified Participants_ RHG shall
F 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 titne 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 procddures(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 (IICPCS) 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 12 of 14
i Stephenville Medical and Surgical Center RSHNPHYEXCSS TX 01012014
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EXIMBIT B
Reimbursement Schedule
I.Rockport SelectHealth Network-Texas Certified'Workers'Compensation Medical Care only
Provider fees for the programs listed above shall be reimbursed at the following:
All fees will be reimbursed at 90% (ninety percent)of the state's current Workers' Compensation
fees,rules and regulations or usual and customary allowables.
Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of
this Agreement,state rules and regulations and/or tate applicable Certified Network Benefit Flan.
I
I I/We accept the fees as outlined in this Exhibit B.
For and on behalf of For and an Behalf of:
(Name,address,etc.)
ROCEFORT COMMUNITY NETWORK,INC. Stephenville Medical and Surgical Clinic
i dba Rockport Healthcare Group 150 River North Blvd
5 Hollow Lane,Suite 515W 3tephetivMe.TX 76401 �
oast n .Te s 77)27"
fSignature
Douglas rkllam Printed_ e
President
Date TAY 752136613 Date �f
4
l '
Page 13 of 14
Stephenville Medical and Suigicat Center RSHN--dnXC55_iX_01012014
l
f
I
i
i
I
EXHIMIT C
Slgnatvre Wage
Physicians and locations where services are to be rendered byMember Provider
Member Provider agrees that the following physicians and practice locations listed.on attached Exhibit C
Spreadsheet and/or an equivalent spreadsheet provided by Member Provider,shall be inclusive of the signed
agreement and the signed rates in Exhibit B. By signing below,Member Provider or its Representative/Designee
allows Rockport Healthcare Group(RHO)and its representatives to use any and a]I of the attached information as
agreed to in the signed agreement.
I
i
I � '
I
For and on behalf of: For and on behalf of:
Rockport Community Network,Inc.
dba Rockport Healthcare Group Member Pr er or Re resentative/13esi�ea
6611riar Hollow Lane Suite 515W �
i Hous on 77027 Signature:
i
/ i+lames •
Douglasrkham (print) r
President V
Date: d //� '� Date.
i
Page 14 o 14
Stephenville Medical and Surgical Center PSHNPHYEXCSS•r%01012014
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