HomeMy WebLinkAboutContract 47186-P29 .ROCKPORT "' CAC
ITYSEETARYONTRNO.,
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'A.Wi�jlp lip ry,om.pony.
ADDENDUM
To
BlaelcStone:504.Frogram
Provider Agreement
This.Addenchun.is:entered into by and.arn6hk jefff&V:Rafus�mik.AD("%46nibefNovidarl' ) .Ro,ckport
:Community'Network ("Rodkporr), :and the City of Fort Worth ('U'VD :on this day of
20
wip-ME39, Rockport and Member Provider 'entered into. a Provider Agreement; effective
, (".Provi rre6menV desire,.that
thi.s. Pply:'to coved a
ges
that
uq_goyPtned_b tft.7ex4s.�pmir Code; rQqde :and'Teka Admihistratv Code.
WHEREAS,, Rockport -contracted with Merriber Provider-on behalf of the-City in the process of
setting up a direquontracted564 provid. panel pursuagi Sect gr Iq Texa-s]�aoor CD4e."S tion.M4,053.
WHEREAS,the,City has; letOrffitdO thO Ii-.W..oikers! compensation 1601 1 h care'n�&'_twork.certified.under
er
Texas Insurance. Code Chapter- .1305 is :not available or; -practical for, self-insured: workers'.
,cqpponAa#qn.p. jqgrqR needs,and,as-such,have elected to provide-sne&O'benefitsto injured waiker&by,
health care.vivvidert.
directly 0q.tilradint-w-A
W M- REAS
,i Rockpo4 'member-Pr cwider;.and ffie-City desire to executo.this Addendumii-I.-bidier'to
establish a diriect.,contract between Member,.P—rovider, and the:City--under'Tex-as Ldbor•Code;S absedrion
WHEREAS,'Rockport,Member'.Novldor,and the City Odslmf6r thetOi3jis-and.cd ditiobs.0 the:?
roy,id
er
Agreement-to -be the: same terms and %conditions T-diat apply .to the direct.contract between Member
y,*qt.MakeqV e.covered-.services.fbr Quafified;Patticipanti'needs to th-einjured
NOWTMOMORE'�for good and valuable considerafiaRIhe suftiency and recalpt:,of which.is-h eridby
acknowledged,.the.patties a
qr9e.as fqllows:
I. AlllerwAnd conditions oft–he.-ftoviderA. gred-.0, 1 ace hereby adopted by!*.I?pih Member Provider
and. .the City, with fill, consent:and a
greanent of Rockport, to. apply as a direct "ontmdual
ageement between.Member Provider andthe-City.:.Affrefe,rences-tozertified metworks;as wellas
the Texa Irisliranat.Code..Chapter 1305 acid Sections 408'021408.02.7 'and 4.13.04.1 of the
Texas Labor-Code . Ie hereby deleted as they-do not apply to a-Pr Pane. set"up .andel`.
section 5.04-053 of the, Tews Labd.r-Code. The- CityIs.Prdwdek M6fiud .(udder the
naive of
BlackStone) shall Instead apply to matter,s -ofnotice,billin Ili colnp 10%:
&:dis�ute4i�s6lutioi lai
preO*ization,and related matters:.
2. The.potits:.agree that t.ht.Q*ty.wi.H..beqLrthe fina.noi.alresponaibility-fdr,p4y*nttD.MeinbprProvider
under the ienns of the Novider A,gftem6nf subject'to the .4piplicabje,'Pid.v- 1d6r Nlkniial and the
provisions of theTexas Labor Code-and applicable -rules under the Texas- AdniWistrative. Code.
�,IqcXpq4t yvill.continue-to provide applicablenetwork administrative services.
PXIAZIL R2,_C`k(IRD yyy
"Al
Jeffrey Ratuznik, MD Provider Agreement.
3. When used in this Addendum, unless the content otherwise clearly requires, the following words and
terms shall have the meaning set forth below. All other defined terms shall have the meaning ascribed to
them in the Provider Agreement
"Payors" will be the City as they are responsible for payment of medical benefits for
compensable injuries and or illnesses sustained by its injured workers according to the Texas
Workers Compensation Act.
'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. Nothing in this Addendum or the Provider Agreement shall be interpreted to ingre to the benefit of
a third party not a party to this contract. This contract may not be interpreted to waive any statutory
or common law defense, immunity,including governmental and sovereign immunity,or any limitation
of liability, responsibility, or damage of any party to this contract;party's agent; or party's employee,
otherwise provided by law.
5. Nothing in this Addendum or the Provider Agreement waives sovereign immunity or creates anew cause
of action.
6. All other terms of the Provider Agreement shall remain in force and unchanged. Any conflicts between
this Addendum and the Provider Agreement shall be superseded by the terms provided herein.
IN WITNESS WHEREOF,the parties hereto have executed this Addendum effective on the day and year
first writtenabove.
For and on behalf of:
City of Fort Worth
Blackstone Provider Panel
Signature: ate:
Name: Su n A nis Assistant Ci1y Manager
APPROVED AS TO FORM AND LEGALITY:
Cis
Assi ant City Att rney
<
Attest ;S
�i
Mary/k.Kayser,City Secretary * PC_
2 s '` ,EXRI7A-
I
7eff`iey RatusxnLl� MD Provider� et�ament
ROCKPORT COIVINUI!ITTY{I!{.!
Signature:: _
•
Name:3o1ui PaoIacoi {'- 'c
Title:Sr.Vice President
----------- Date: r� --- -- —_.—__--�—
Mr,, D.U,R PROVIDER or
Roprosentative/Designee
Signature:
Name:Jeffrey R810011lc,NO
Title: Orthotoaedio Spine Sumon
Date:
TIN.47-17168
:s-
ROCKPORTTM
PHYSICIAN AGREE1vIENT
ROCKPORT UNITED NETWORK
ROCKPORT SELECTHEALTH NETWORK
This Physician Agreement('Agreement"),is entered I. DEFINITIONS
into by and between Rockport Community Network,
Inc., a Nevada Corporation, dba Rockport When used in this Agreement and unless the content
Healthcare Group ("RHG"), dba Rockport United otherwise clearly requires, the following words and
Network (a preferred provider network for terms shall mean:
Occupational Injuries and Illnesses), dba Rockport
SelectHealth Network Can exclusive provider I.1 "P i 'a "means a licensed Medical Doctor or
network)and Jeffrey Ratusznik MD.PA("Member Doctor of Osteopathic Medicine, or group of salve
Provider"), and will become effective as of the date who desire to become a Member Provider. with
the provider is fully credentialed by RHG. REG.
WHEREAS, RHG is engaged in the business of Pursuant to Title 28, Texas Administrative Code
developing and acting in an administrative capacity §10.42 regarding Nehvork Contracts with Providers
in providing Occupational Injury and health provider seeking to participate in Texas Certified Workers'
networks that offer direction of care while providing Compensation Networks,
savings to RHO clients and/or Payors. These
networks will offer greater coverage of services and I.2 "Qualified Participant" means an "employee" as
savings;and defined and used in the Texas Labor Code, the
Network Act Section 1305 and the implementing
WHEREAS, RHG has networks of contracted rules who sustained a-work-related injury/illness that
physicians, physician groups, hospitals and is determined compensable by a Client and that
providers of ancillary healthcare services participates in the Rockport United Network or
(collectively, the"Member Providers' to provide a Rockport SelectHealth Network through Rockport's
full-range of healthcare services. These services are Client. Unless in an emergency or after business
available for use by "Qualified Participants" as hours,initial services provided for the work-related
defined in I.2 of this Agreement;and injury/illness require authorization by the network
either in writing or by telephone.
WHEREAS, Member Provider desires to provide
medical care set-vices to "Qualified Participants" L3 "C'ent" means an insurance company, certified
who are covered by Payor Agreements at the rates in self-insured or governmental entity as those terms
Exhibit B and in locations listed in Exhibit C: and are defined and used in the Texas Labor Code, the
inclusive of the networks included in Exhibit D;and Network Act Section 1305 and the implementing
rules. These Clients have entered into a Client
WHEREAS, RHG has entered into Agreements Agreement with RHO for the provision of healthcare
and/or services with one or more Payors who services to Qualified Participants.
provide payment of claims for medical care rendered
to Qualified Participants. L4 "Payor" means an insurance carrier or network
certified by an insurance carrier for its own benefit,
NOW, THEREFORE, in consideration of the certified self-insured or governmental entity as those
premises,the mutual promises contained herein,and terms are defined and used in the Texas Labor Code,
other good and valuable consideration, the receipt the Network Act Section 1305 and the implementing
and sufficiency of which are hereby acknowledged, rules who is responsible for payment of medical
it is mutually agreed as follows: - benefits-for on the job injuries and or illnesses
according to State and/or Federal Rules and
Regulations,
! Page I of 15
Jeffrey Ratu milt,hM,PA 6-15-15 RUNPHY TX 050115
I.5 "Mient 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
made before, on or after the effective date of this Participants as needed or required..
Agreement and which expresses the agreed upon
contractual rights and obligations of the parties. 1.9 "Emergency Medical or Mental Condition" is
Such Client Agreements will require Payors to pay defined as the sudden onset of a medical condition
Member Provider far 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
I.6 "Member Provider" means any physician; defined in TIC 1305.004(13);and
physician group; hospital;surgery center;diagnostic (c)in the case of a merrtal 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(I5).
licensed or certified to practice a healthcare
profession or Iicensed as a facility to offer healthcare I.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 compensable, 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 (ND) or a Doctor of I.I1 "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
i and illnesses is designated by RHG as a Primary II. ME,A BER PROVIDER OBLIGATIONS
Treating Physician/CIinic (PTP). PTP agrees to
render medical care to Qualified Participants without II.1 Services. Member Provider agrees to provide or
! a scheduled appointment and must be available and arrange for all medically necessary medical care for
accessible 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)(I). 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".
I.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-'wiII-heed-to iimintain 'their * '' (ACOEM) and /o'r' state rules and regulations.
current board certifications for their particular-
Page 2 of 15
Jeffrey Ratasmk,MD,PA 6-15-16 RUNFHY 73 _050115
Member Provider agrees to comply with and be Qualified Participants only to other Member
bound by all State/Federal Rules and Regulations. Providers,as defined in I.6.
I.6 Reports. For each encounter where Member
I12 Treatment Guidelines. Member Provider agrees Provider provides services to a Qualified Participant,
to follow the treatment guidelines, return-to-work Member Provider sball report such encounter on an
guidelines and individual treatment protocols appropriate form and shall include statistical,
outlined in E-.d bit 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
Utilization Review Programs.RHO 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 II.7 Professional Requirements.
after business hours,initial services provided for the
work-related injury/illness require authorization by II.7.I Licensure&Accreditation. Member Provider
the carrier and/or Network either in writing or by shall comply with all applicable federal, state and
telephone. The Client and/or Payor may not deny local laws, rules and regulations governing like
treatment solely on the basis that a treatment for a providers and their provision of services. Evidence
compensable injury in question is not specifically of such current licensing, certification and/or
addressed by the treatment guidelines used by the accreditation shall be submitted promptly to RHO
Client and/or Payor. However, Member Provider upon request. Member Provider represents and
must demonstrate medical necessity to support warrants that it and each of its employees and
services rendered to Qualified Participants that are contracted service providers has obtained, and shall
outside of treatment guidelines. maintain throughout the term of this Agreement, all
necessary registrations, certifications, licenses,
11.3 Non-Discrimination.Member Provider shall not permits and approvals as are required for the lawful
differentiate or discriminate in the treatment of its provision of Member Provider services to Qualified
patients as to the quality of services delivered to Participants. Member Provider shall immediately
Qualified Participants because of race, sex, age, notify RHO of any revocation, suspension or
religion, national origin, place of residence, source restrictions, that would affect any certifications,
of payment or health status. Member Provider shall licenses or accreditations. Member Provider
observe,protect and promote the rights of Qualified warrants that it is currently accredited by the Agency
Participants. that governs IU e providers and is certified as a
provider under Title XVIII (Medicare) and when
II.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 least 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'&
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 RHG's 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, '1Vlember Provider agrees *to refer
Page 3 of 15
Jettiey Rattumik,MD,PA 6-15-16 RUNPHY TX 050115
IIS Notification to RHG. Member Provider 11.10 Inspection of Records and Operations. RHO,
represents and warrants that information provided Payor or a designated representative shall have the
herein and in the RHO application is true and right to inspect and audit, at all reasonable times
accurate in all respects and acknowledges that RHO during normal business hours, upon prior five (5)
is relying on the accuracy of such information in business days, any of Member Provider's medical
entering into and continuing the term of this records and operations reasonably pertaining to
agreement. In addition Member Provider shall use RHO Qualified Participants, services provided to
best efforts to provide written notice to RHO of any Qualified Participants, and to Member Provider's
(i)suspension,reduction or loss of license to provide performance under this Agreement. Member
healthcare services; (li) denial, suspension, Provider further agrees to allow RHG, Payor or a
restriction, reduction or termination of designated representative thereof, including the
accreditation/certification; (iii) changes in Federal designated utilization review, quality management,
Tax Identification Number(s), (iv)other information case management or peer review staff, to have
provided in its application or Exhibit C for reasonable access to medical records and
participation, (v) Member Provider's professional information of Qualified Participants for services
liability insurance if such insurance falls below the provided under the terms of this Agreement as
requirements of state law and (vi) Member necessary to enable such party to perform Utilization
Provider's billing or facility address. A failure to Review and Quality Assurance activities in
give any notice required by this Section shall be a accordance with the applicable Utilization Review
material breach of Member Providers obligations and Quality Assurance Program. In addition,
and responsibilities hereunder, regardless of the Physician agrees that in the event an examination
status,pendency or outcome of the event giving rise concerning the quality of healthcare services is
to the obligation to give that notice, and may be conducted by appropriate officials, as required by
grounds for termination of this Agreement. federal,state,and/or local law,RHO shall submit,in
a timely fashion,any required books and records and
II.9 Medical Records. Member Provider shall shall facilitate such examination. RHO and
maintain complete and timely medical records for Member Provider agree to assist one another with
Qualified Participants treated by Member Provider on-site inspection of facilities and records by
and its medical staff. Such records shall be prepared representatives of authorized federal, state and local
in accordance with accepted principles of practice, regulatory agencies
shall document all services performed for Qualified
Participants and shall comply with all applicable II.11 Relationship of Parties. Member Provider and
state and federal laws. Member Provider shall RHO understands and agrees that they are each an
maintain such records for the length of time required independent legal entity. Nothing in this agreement
by applicable state or federal law. Subject to all shall be construed or deemed to create a relationship
applicable privacy and confidentiality requirements, of employer and employee, principal and agent,
such medical records shall be matte available to each partnership or joint venture or any relationship other
Member Provider and other health professionals than that of independent parties contracting with
treating-the Qualified Participant, and upon request, each other solely to carry out the provisions of this
to the Payor, RHO or its designated representative Agreement for the purposes recited in this
for review at the rates approved by State law and as Agreement. With regard to the provision of
set forth in the current State Workers' Compensation healthcare services, Member Provider acts as an
Reimbursement Manual for Hospitals, if applicable, independent entity and the Member Provider-patient
Member Provider shall obtain a valid consent for the relationship shall in no way be affected.
release of the Qualified Participant's medical records
to other providers, RHO, Payor, or its designated 11.12 Standards of Care. Member Provider agrees
representative. RHO agrees that medical records of that all duties performed hereunder shall be
Qualified Participants shall be treated as confidential consistent with the proper practice of their
so as to comply with all federal and state laws and healthcare profession, and that such duties shall be
regulations regarding the confidentiality of patient performed in accordance with the customary rules of
records. The Member Provider's obligations under ethics and conduct of the appropriate and applicable
this Section II.9 shall survive the termination of this professional organizations and/or associations,as the
Agreement. case may be, and such other bodies, formal or
iafoirnal, state, 'goveinment or-oth6iwise; or-by
which they are subject to licensing/certification and
Page 4 of 15
Jeffrey Ratusmik,W.PA 6-15-16 RUNPHY TX 050115
control. Additionally, Member Provider shall defined in I.3 and L4 for their access to RHG quality
perform all medical and healthcare services in Member Providers through specific referral
conformance with the standards for their facilities as processes. RHO will market Member Providers for
established by the local/regional professional referral; including but not limited to the following:
healthcare community and applicable (1) Provider Search Provider Locator System (ii)
accrediting/licensing agencies. Member Provider Provider Directories (iii) Site-Specific Provider
agrees that,to the extent feasible,it shall utilize such Panels (iv) Customized Local Networks and (v)
additional allied health and other qualified personnel Client Service Provider Referral Service.
as are available and appropriate for effective and
efficient delivery of care. Member Provider shall 111.2 Credentialing. RHO 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
11.13 Right to Use Member Provider's or Network's investigation, including but not limited to
Name. Member Provider agrees to allow RHO to verification with all state and national licensing and
list Member Provider's name, specialty, address, certifying bodies that apply to the services rendered
telephone number, and hours of operation in a by the Member Provider,such as JCAHO,AAAHC,
Member Provider directory, Provider Search, RHG NCQA, CLIA, URAC, 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 (URAC) and/or NCQA standards for Workers'
telephone number on Member Provider's website or Compensation provider networks.
in other publications listing the health plans accepted
by Member Provider. In addition,Member Provider 111.3 Operational Functions. RHO shall utilize
agrees to post in waiting room and make available to systems to respond to Member Providers requests
Qualified Participant notice of Member Provider's for information and will provide clarification of
participation with 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. 111.4 Retaliaj=Action, RHG agrees not to engage
in any retaliatory action including termination of
11.14 Noncoms iance.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
1115 Antitrust Guidelines. Member Provider agrees review of an adverse determination.
to comply with all antitrust guidelines and
procedures promulgated by Federal and State IH.5 Antitrust Guidelines. RHG agrees to comply
entities. with all antitrust guidelines and procedure
promulgated by Federal and.State entities.
III, RIiG's OBLIGATIONS
111.6 Audit Policy and Procedure Compliance. All
II1.1MMarketink to Clients/P�ayors. RHG'shall enter "bili—audit requests by Payoff• shall' be done in
into agreements with Clients and/or Payors as
Page S of 15
Jeffrey RataszAk MD,PA 6-I5-16 RUNPHY TX 05D115
I accordance with the State Law and/or Federal Rules All services billed Under the Tax Identification
and Regulations. Number(s) indicated in this Agreement, any
Amendments, Exhibit A, Exhibit B, Exhibit C,
Applications or any updates regarding locations
and/or a Member Provider as defined in section I.6
IV. RED7BIIRSEMENT,CLAIMS will be subject to the reimbursement rates
SUBMISSION AND PAYMENT established in the Exhibit B of this Agreement.
IV.1 Reimbursement. RHO shall arrange and All billing and reimbursement will be made in
provide the Member Provider, locations and/or any accordance with Labor Code 408.027 and all other
additional Tax Identification Numbers as listed in applicable state rules and regulations.
Exhibit C for Payors to pay Member Provider the
reimbursement rates for,Covered Services rendered IV.3 Bill and/or Claim Forms. Claim forms are
to Qualified Participants pursuant to Exhibit B. required for all services. All claims must be
Member Provider agrees and acknowledges that submitted complete and accurate on CMS 1500 (or
RHO is acting solely in an administrative capacity in other appropriate claim form or their successors)and
providing a network of quality health services.RHO must include Member Provider's usual and
is not the claims paying agent and will not be liable customary billed charges (not discounted rates) and
for the payment of any amount owed by a Payor to appropriate codes, consistent with policies
Member Provider in the event that Member Provider established or approved by applicable state and/or
is unable to collect such amount of money up to and federal regulations. Member Provider must submit
including the insolvency of the Payor. Under no claims to Payor not later than the 950'day after the
circumstance will a Member Provides attempt to date on which services are provided to the Qualified
collect payment from a Qualified Participant for Participant, or as specified by state law. In
medical services rendered for a compensable,work accordance with Labor Code §408.027 and other
related injury/illness. applicable statutes and rules,billing and payment to
Member Provider will be made within forty-five
i IV.2 Reimbursement Rates.Member Provider is to (45) days of receipt of bills which are accurate and
be paid by the Payor in accordance with State Law complete, and otherwise in accordance with state
and/or rules and regulations at the rates established rules and regulations.
in Exhibit B. Member Provider hereby agrees that
i rates in Exhibit B,which may be amended from time IVA Limited Recourse Against Qualified
to time upon mutual written agreement,represent the Participants. Except as otherwise provided in this
total amount to be received and agrees to look solely Agreement (Section 1.10), Member Provider agrees
to the Payor for payment for such Covered Services. to seek payment from each Payor for Covered
f Payment will be made for Covered Services actually Services provided to its Qualified Participants, and
rendered.All claims will be paid,when appropriate, agrees that it will not seek additional payments or
only after submission of a complete and accurate reimbursement for compensable injuries from
claim. A complete and accurate claim shall be Qualified Participants. In addition, Member
j defined as a clean claim by Medicare.RHG does not Provider agrees that neither RHG,the Payor nor the
guarantee, represent, warrant or covenant regarding Qualified Participant shall be billed or ultimately
the selection or use of Member Provider's services held responsible for payment of services deemed not
by any Qualified Participant or Payor,or the number to be covered by the Payor or its designee. When
of patients, if any, which may result from Qualified Participant is covered by a state or
participation in RHG's provider network. The federally regulated Occupational Injury and Illness
obligation of a Payor to reimburse Member Provider program, Member Provider agrees to comply with
in accordance with Exhibit B for the provision of state and federal. regulations regarding holding
Covered Services to a Qualified Participant shall be Qualified Participants harmless for amounts not paid
conditioned upon a good faith determination by the by Payor for any reason,including Payor or network
Payor or its designated representative that (i) such insolvency. This provision does not preclude billing
I services are medically necessary, whether such it Non-Qualified Participant for a non-compensable
determinations are made before, on or after the injury.
provision of services to such Qualified Participant.
IV.Cl Transfdr of Risk. This Agtdement and any
subcontract within shall not be interpreted to involve
Page 6 of IS
3effreyRatusmi1c,14)PA 6-15-16 RUNPHY TX 050115
a transfer of financial risk for the provision of health out of any alleged malfeasance or neglect caused or
care services from Payor to RHG as defined under alleged to have be caused by its employees or
Insurance Code§1305.004(a)(26).Member Provider representatives, in the performance or omission of
agrees and acknowledges that RHG is acting solely any act or responsibility under this Agreement. In
in an administrative capacity in providing a network the event that a claim is made against RHG,it is the
of quality health providers. RHG is not the claims intent of RHG to cooperate in the defense of said
paying agent.and will not be liable for the payment claim. However, RHG shall have the right to take
of any amount owed by a Payor to Member Provider any and all actions they believe necessary to protect
in the event that Member Provider is unable to their interest.
collect such amount of money up to and including
the insolvency of Payor or the Nerivork. V.3 Indemnification of Member Provider. Member
Provider will be responsible for its own acts or
IV.5 Payment of Claim Forms. RHG shall omissions and any and all claims,liabilities,injuries,
administratively arrange for the Payor or its suits and demands and expenses of all kinds which
designated representative to pay undisputed claims may result or arise out of any alleged malfeasance or
which are accurate, complete and comply with the neglect caused.or alleged to have be caused by its
Agreement within the time period mandated by state employees or representatives, in the performance or
or federal law. omission of any act or responsibility under this
Agreement. In the event that a claim is made against
IV.6 Erroneous Payment. In the event that a Payor Member Provider, it is the intent of Member
and/or its designated representative pays the Provider to cooperate in the defense of said claim.
Member Provider (i) more than once, or (ii) an However, Member Provider shall have the right to
incorrect amount,or(iii)an overpayment,the Payor- take any and all actions they believe necessary to
or its designated representative may, at its sole protect their interest.
option and discretion, request the retain of such
amount from Member Provider The Member VI. TERM AND TERMINATION
Provider will not unreasonably withhold
reimbursement. If overpayment has been made VI.1 Term. The term of this Agreement shall be for
Member Provider shall reimburse such overpayment one (1) year from the date hereof and shall be
within forty-five (45) days and/or follow State and automatically renewed on an annual basis for
Local Rules and Regulations. The Member Provider successive twelve (12)month periods,unless sooner
may not contest payment of Claims after one terminated in accordance Nvith Section V1.2.
hundred eighty(180)days from the date of payment.
All claims for overpayment or underpayment shall VI.2 Tennination. This Agreement may be
be resolved in accordance with State Law and /or terminated sooner on the fust to occur of the
Federal Rules and Regulations. following:
V. INSURANCE AND INDEMNIFICATION VI.2.1 Termination by Member Provider. Member
Provider may terminate this Agreement in the event
V.1 Insurance Requirement. Member Provider shall of a material default or breach of RHG`s obligations
provide and maintain such policies of professional hereunder,upon ninety(90)days prior written notice
liability insurance or a self-funded program. The and the failure of RHG to cure such breach or
amounts and extent of such insurance coverage or default within sixty (60) days of the notice. In
self-funded program shall be in the amounts addition, in the event of an "emergency situation",
determined by community standards for relevant Member Provider may terminate the Agreement
hospital/facilities. Member Provider shall promptly immediately with the acknowledgment by RHG that
demonstrate evidence of insurability or self-funded such an emergency condition does exist.
program and that the required insurance is paid and "Emergency Situation" shall mean an unforeseeable
in force upon request of RHG and/or meet the event, not resulting from Member Provider's act or
credentialing guidelines of REG. 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
and all claims,liabilities,injuries,suits and demands of the terminating Member Provider• immediately
and expenses of all kinds which may result or arise upon receipt of'the Member Provider's termination
Page 7 of 15
le@iey Ratusu ik,NID,PA 6-15-16 RUNPHY TX 050115
i
request or as soon as reasonably passible before the VI.2.4 Termination by Either Party. In case of
effective date of termination as required by 28 TAC material breach of the terms of this Agreement,
10.42(b)(6)(0). either party may terminate the Agreement with at
least ninety (90) days prior written notice to the
VI.2.2 Termination by RHO. A Member Provider other party; however, the party in breach may cure
shall automatically be terminated on the date when: the breach within sixty (60) days of the notice, in
(i) Member Provider's license in the State where which case,the Agreement and applicable rates and
services are rendered is suspended or revoked, (ii) terms shall continue in effect. Either party may
Member Provider is excluded from participation in terminate this Agreement without cause upon ninety
the Medicaid or Medicare programs, (iii) Member (90)days prior written notice.
Provider loses their JCAHO, NCQA, AAAHC,
URAC, CLIA or other applicable license, VI.2.5 Unforeseen Events. In the event that either
certification and/or accreditation, (iv) Member party's ability to perform their obligations under this
Provider loses or experience a material reduction in Agreement is substantially interrupted by war, fire,
liability insurance and such insurance falls below the insurrection, riots,the elements, earthquake, acts of
requirements of State Law (v) Member Provider God, or other similar circumstances beyond the
engages in any act, omission, demeanor or conduct reasonable control of such party, the party shall be
that is reasonably likely to be detrimental to patient relieved of those obligations for the duration of the
safety or to the delivery of quality patient care,or to interruption upon notice to the other party. In the
lead to the provision of healthcare services below event that the interruption is reasonably determined
applicable standards, or (vi) ninety (90) days likely to persist for at least ninety (90) days, either
following written notice by RHO of a material party may terminate this Agreement upon thirty(30)
default or breach by Member Provider heretimder• days prior written notice.
and the failure of Member Provider to cure such
default or breach within sixty(60)days of the notice VI.3 Effects of Termination. Upon termination of
(vii) Member Provider fails to meet RHG's or the this Agreement, neither party shall have any further
State's credentialing requirements. RHG, however, obligation hereunder except for (i) obligations
may not terminate this Agreement in direct response accruing prior to the date of termination, including
to Physician filing a reasonable complaint,on behalf without limitation, any obligation by Member
of a Qualified Participant against, or appealed a Provider to continue to provide healthcare services
decision of, the network, or requested to Qualified Participants, and (ii) obligations,
reconsideration or independent review of an adverse promises or covenants contained herein which are
decision. expressly made to extend beyond the term of this
Agreement.
In the event RHO deems it necessary to terminate
Member Provider's agreement based on the above VIA Qualified Participant and Payor Notification.If
requirements RHO will notify Member Provider at applicable, upon the termination of this Agreement,
least ninety (90) days before the effective date of by either parry, Member Provider shall cooperate
termination. with RHO to notify Qualified Participants and
Payors of such termination.
Upon written notification from RHO, Member
Provider may request a review by RHG's advisory VII.CONTINUATION OF BE,
review panel, not later than thirty (30) days after
notification. RHO must then complete the review VII.1 Continuation of Benefits. If Member Provider
before the effective date of termination. voluntarily terminates its contract with RHO, upon
Member Provider's request, Payor must continue to
VI.2.3 Termination for Insolvency- This Agreement reimburse Member Provider for a period not to
shall terminate immediately in the event that either exceed 90 days at the Member Provider's contracted
REG or Member Provider voluntarily or rate set forth in Exhibit B of this Agreement with
involuntarily, liquidates, dissolves or becomes RHO,for care of an Qualified Participant with a life-
subject to any proceeding for the rehabilitation or threatening condition or an acute condition for
conservation of their financial affairs with written which discontinuing or disruption of care would
notification. harm the Qualified Participant as per 28 TAC
10.42(b) (5)(A.):Any disputes concerning continuity
of care shall be resolved through the complaint
Page 8 of 15
Jef cy Ratus=&-,MD,PA 6-15-I6 RUNPHY TX 050115
process under Insurance Code §1305.401 - IX.1 DisQutes. All disputes and difference between
§1305.405 and Subchapter G of Title 28, Part 1 the Member Provider and RHO upon which an
(relating to Complaints). amicable understanding cannot be reached are to be
decided by the following method:
VII.2 Survival. The provisions of this Article VII IX.1.1 Mediation through RHO. The Member
shall survive the termination of this Agreement Provider shall notify RHO in-writing of the dispute
regardless of the cause - giving rise to such or disagreement and shall provide all necessary
termination, as will sections II.9, V.2, V.3, VI.3, information to RHO. RHO shall use best efforts to
VIII, and IX. The provisions of this Article VII mediate the dispute within the rules and regulations
supersede any oral or written agreement to the put forth by the State as reference in RHG's
contrary now existing or hereafter entered into Provider Handbook.
between Member Provider and any Qualified
Participant or any person acting on a Qualified IX.1.2 Arbitration. If the dispute cannot be solved
Participant's behalf. by the mediation process described above,either the
Member Provider, RHO or Payor may elect to
VIII. CONFIDENTIALITY submit the dispute to binding arbitration under the
rules of the American Arbitration Association or any
All business, medical and other records relating to other method of arbitration mutually agreed upon by
the operation of RHO or Member Provider, the parties. Arbitration will be conducted in
including but not limited to, books of account, Houston, Texas. Each party will be responsible for
general administrative records, policies and their own legal fees. The cost of the arbitration
procedures, pricing information, terms of this services will be the sole responsibility of the party
Agreement and aI] information generated and/or requesting the arbitration.
contained in management information systems
owned by or pertaining to RHO or Member IX.1.3 Provider Appeals.Except for termination due
Provider, and all systems, manuals, computer to contract expiration, Member Provider has the
i software and other materials, but excluding patient right to appeal his/her termination from the Network,
? charts,shall be and remain the sole property of RHO as follows:
or Member Provider respectively (collectively, the
"Confidential Information"). RHG and Member IX.1.3.1 RHO will provide notice to the Member
i Provider acknowledges that the Confidential Provider at least 90 days before the effective date of
Information and all other information regarding a termination by RHG;
RHO or Member Provider that is competitively
sensitive is the property of RHO or Member IX.1.3.2 Upon receipt of the written notification of
j Provider and RHO or Member Provider may be termination, a Member Provider may request in
damaged if such information was revealed to a third writing a review by the Network's advisory review
party. Accordingly, RHO and Member Provider panel no later than 30 days after receipt of the
agrees to keep strictly confidential and to hold in notification;
trust all Confidential Information. Upon termination
of this Agreement by either party for any reason IX.1.3.3 The Network will provide an advisory
whatsoever, RHO and Member Provider shall review panel that consists of at least three Providers
promptly return to the other all material constituting of the same licensure and the same or similar
Confidential Information or containing Confidential specialty as the Member Provider;
Information, and neither party will not thereafter
use, appropriate, or reproduce such information or IX.1.3A The Network must complete the advisory
disclose such information to any third party. RHO panel review before the effective -date of the
and Member Provider specifically agree that under termination;
no circumstances will either party discuss the terms
and conditions of this Agreement, and in particular IX.1.3.5 The Client, Payor, or RHG may not notify
the pricing information herein. patients of the termination until the earlier of the
effective date of the termination or the date the
IX AffSCELLAIVEOUS advisory review panel makes a formal
recommendation; `
Page 9 of 15
Je9ieyRah=k INID PA 6-15-16 RUNPHY nC 050115
i
I
DC.1.3.6 If Member Provider terminates the contract,
the Network or RHG's Client will provide 1X.7 Amendments. This Agreement may be
notification of the termination to employees amended as agreed to by both parties in writing upon
receiving care from the terminating provider. The thirty (30) days written notice of such proposed
Network shall give such notice immediately upon amendment.
receipt of the Member Provider's termination
request or as soon as reasonably possible before the 1X.8 Severability. The invalidity or un-
effective date of termination. enforceability of any term or condition hereof shall
In no way affect the validity or enforceability of any
1X.2 Non-Exclusivity. Nothing in this Agreement other term or provision.
shall be construed to restrict Member Provider or
RING from entering into other contracts or IX.9 Assi ng ment. Member Provider may not assign
agreements to provide healthcare services to Payors or otherwise transfer any right or delegate any duty
or other healthcare delivery plans, patients, and of performance hereunder, in whole or in part
employer groups. without the prior written consent of RHO. A change
in ownership will not negate the prior contractual
1X.3 Entire Agreement. This Agreement contains agreement without written notification to RHG.
the entire understanding of the parties and RHO retains the right to assign this Agreement, in
supersedes any prior understandings and agreements, whole or in part,to any entity with which RHG or.its
written or oral, respecting the subjects discussed parent company or any of its subsidiaries is
herein. affiliated,or with which it merges or consolidates.
1X.4 No Waiver. The waiver by either party of a 1X.10 Third Party Beneficiaries. Except for Payors
breach or violation of any provision of this and the agents thereof, there are no third party
Agreement shall not operate as or be construed to be beneficiaries of this Agreement.
a waiver of any subsequent breach hereof.
1X.11 Ca tions. The captions and headings
IX.5 Regulatory Compliance. Member Provider, contained in this Agreement are for reference
sub-contracting providers, and RHG agree that each purposes only and shall not affect in anyway the
shall comply with all applicable requirements of meaning or interpretation of this Agreement.
municipal, county, state and federal authorities, all
municipal and county ordinances and regulations, 1X.12 Execution of Counterparts. This Agreement
and all applicable state and federal statutes and may be executed in any number of counterparts,
regulations, now or hereafter in force and effect, including facsimiles,each of which shall be deemed
governing RHG, Member Provider, sub-contracting to be an original as against any part whose signature
providers, the provision of services by Member appears thereon, and all of which shall together
Provider or sub-contracting providers, and/or constitute one and the same instrument.
Payors, including but not limited to applicable
requirements under any state or federal fair IX.13 Partial Invalidity. If any part, clause or
employment practices, equal employment provision of this Agreement is held to be void by a
opportunity,or similar laws declaring discrimination court of competent jurisdiction, the remaining
in employment based upon race, color, creed, provisions of this Agreement shall not be affected
religion,sex,or national origin as illegal,and,Titles and shall be given construction, if possible, as to
VI and VII of the Civil Rights Act of 1964,Section permit it to comply with the minimum requirements
I 202 of Executive Order 11246 as amended by of any applicable law, and the intent of parties
Executive Order 11375,Sections 503 and 504 or the hereto.
Rehabilitation Act of 1973 and Title N of the
Vietnam Era Veterans Readjustment Assistance Act
of 1974, and Sections 1 and 3 of Executive Order
11625, or any applicable rule or regulation
promulgated pursuant to any such laws or orders.
IX.6 Governigg Law. This Agreement shall be
governed liy*anti construed' in'" accbrdance' with
applicable state law.
Page 10 of 15
Jeffrey Ratuunik,MD,PA6.15-16 xumrY TX 050115
i
.1X.14 Financial.Incentives.Neither a Cliciit,Payor, LM 17 Oficial Notices. Any notice or
nor RHO may Iise, financial incentive or inake a: communication.required; permittedor desired to be
payimenf to a health care provider that acts-direct;iy given hereunder 'shall be deemed effectively.given
or itidireetly as an inducement to limit medically when personally delivered-or mallett,retum receipt
necessary nr��ices. The adoption of treatment and requested, or overnight express.nail addressed:as
return-towork gttidelittes grid indiYidual treatment: follows:
protocols by RHG ot•Nehvoik isnot in violation of
Ellis section as pursuant.to Insurance Code §1305.
304 and..§10:83:(a)cifChp:10`of Title;29.Pard.
IXIS '_Financial Disclosure;Rec{airernents.ivlember:
Provider is required 'to :Erle financial d.isclosafes:in.
accordance -with.. Labor t ole z4§4081023 .and' lvfeniberProvider;or Represent2tive/Desgneec
§§4I3:Q4,k, (Please`Print)
I7f.1:b 'E6pn6nii6..Prgfilhit Nehvork must provide Nariie:,JeffrevRaftisziiik,MD
written not- to lYjember Provider before the
Netivorl. conducts ecotuoriiic yrofilmg,, :including. Orgenizatrt,n;JeffreyRahisznik,MD,PA
utilizatton ihahagrpeg s,'tudies or other profiling of
the provider o group of providers. Address: 3 Old Hightivav'1.187
City%StatelZip,BuilesQn—TX 76028
Teleplione::.817-9.261663
FM 4174M-A660.
Organizaftoil
Rockport CoinmiulityNehvprk,,Inc,.
dba Rockport Healthcare ar600
Attn: Nets ek, Develop"nenE
50 Briar'HollowLane,Stih
u ; 5t51)�.
i HostonTX 77027
Telephone (7l3).629 9424'
Fac "(7 i3)b21-95.1
IN 1VITDtR$S `VHERBOF,_the undp pigned will be
deemed to have executed th's grcement as of the or to silclibther address,and to the;attentron:of'such
date'tlie provider is fullycfedentialed byR13G. other person(sj` br officer{s) as ether;part) may
designateby'w ittenNotice.
vor:and on beltidtofr
For;fl�nd.on:Uehfllf`of::
Roclport Comntunity.Netavoilt,Inca.
dbaRoctcportHealtlrcaieO.roup ayieinber.Pr v et or resentattvelDesrgnee:
U Brla nllowLane,Sutte515W l��'p�
13 oltst zr;, .. .:770 Sigrittttu' • v'�"t!
1
Name:Rffrevltatttsznik,lVID:
Dougl �iYlarkhflnl (Print)
Preside t TIN 47-17168'82:
-Lao Dates
Page i C ofa5:
Ieftey;gatpsxnik;\[D PA:6=15=16 KUNE.kIY TY_050E;1i
EXHIBIT A
STANDARDS AND GUIDELINES
UTILIZATION REVIEW AND QUALITY INIPROVEIVIENT PRO GPLABdS
RHG and its Clients require Member Providers to billow nationally recognized treatment guidelines (i.e. Official
Disability Guidelines(ODG) and/or American Occupational and Environmental Medicine's (ACOEM) guidelines)
in the treatment of work-related injuries/illnesses for Qualified Participants.
RHG's Clients provide utilization review and quality improvement programs for Qualified Participants. RHG shall
review each Clients Utilization Review and Quality Improvement Program in accordance with RHG's Credentialing
Standards and Guidelines as described in this Exhibit. Physician and/or Member Provider agrees to comply and be
bound by such programs and any state or federal rules and regulations,
Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written
notice to Physician and/or Member Provider.
The primary goals ofthe Utilization Review Programs shall be to:
1) Ensure and certifl,for the payment of benefits that healthcare services meet the definition of medical necessity
as defined by the network,Payor or the Payors designee;
2) Ensure that healthcare services are provided at the appropriate level of care;and
3) Ensure that healthcare services follow nationally recognized treatment guidelines that are evidenced-based and
outcome-focused.
Treatments and Services that Require Preauthorization;unless otherwise specified by the network:
1) In-patient hospital admissions including the principal scheduled procedures(s)and the length ofstay;
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$500 per item (either purchase or expected cumulative
rental)and all transcutaneous electrical nerve stimulator(TENS)units;
12) Nursing home,convalescent,residential,and all home health care services and treatments;
13) Chemical dependency or weight loss programs;
14) Any investigational or experimental service or device for which there is early, developing scientific or clinical
evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly
accepted as the prevailing standard of care;and
15) Physical and occupational therapy services;(a)physical and occupational therapy services are those listed in the
Healthcare Common Procedure Coding System (HCPCS) Level I code range for Physical Medicine and
Rehabilitation, but limited to: (i) modalities, both supervised and constant attendance; (ii) therapeutic
procedures,excluding work hardening and work conditioning;and(iii)other procedures,limited to the unlisted
physical medicine and rehabilitation procedure code.
16) Closed Formulary Drugs,as defined by 23 TAC Chapter 134,Subchapter F.
NOTE:Preauthorization is not required for the first two visits of physical or occupational therapy following the
evaluation when such treatment is rendered within the fust two weeks immediately following:(i)the date of injury,
or(ii)a surgical intervention previously approved by the payor.
Page 12 of 15
Jeffrey Ratusnuk,iyM,?A 6-15-16 RUNPHY TX 050115
E'XHIBIT 13'
RohnWit.s.chiolt,Schedule
lJRo6kpQft VujtcilMt�ork Mocltpbil Sdeeffe-afth jXehyork-Oecupatiolrnlliijuiynud Illn 9
Proviorleeg:r r the P Oamp$We'd above.shall be reimbursed at-the lollowing.-..
0 1.,
Aft fees wift :be, reimbursed at 85% .(Eiihty-dive percout) ofIlic states cudent Wd.tkqs"
.Compensation fees,rules-and xWilatloosorusual:and.Pustom.uy A(Imvibles*,
.Coverage: Coverage-fox,aUprocedurcs onthe fee sdli.0016 is stibiect.t6the.terms and conditions of
thIsAgreement,state rtiles,:.atid.,,regiilatioiiszan the qo�Rcable QOP.P.pat a ty
dloi IQ. g(Nu on,111ftess Benefit
7/We accept thelees-as'Outlined-Jn this-rifilbif B-:
Tor and on behnItoti jTor 6,44 on b6half of
ev -Stum,71
RO CKF ORT:C OTYLVIU..NL ITYNE,TWORK, m- iwu Se
dbaiR04poft1loaltlitire 21Old-Hikliway 1187
rhi il Hollow Luue,S.Wte.5!W Burleson:,TX 76028
..A
s'fs. 7
Dovgbtl.
Va�kha I
Presidcrit 6�_ 6
Title RTHOPAEOIC.'SPINE URGEON
Date t TV 471716882 Pate V4
RLTNPITX-Tv
r,,WIBIT:C
jofi4bjl*s SYcs 6 ki**ft are to be koind0led'.bey MMIi WrIlrovider.
T mber-P "Werit .0 1 n
The Afe rov iOe th t IhO fbil0whA&YSIORh�And/or PkaetW locations sittad Eibiblt C.,,
Acd
sliall be IncluMve of thesigned agreement and the.signed.ratos hil• xlllhift. B ngbet6yNfew.berProv,tdor 6rlt;-
R4reSCntAtiVeIDCSi n6e 116Vs R6Ckp6ltReAltlLCRre:Group(W an Iltikeprpol . yes f
.qsiid all-bf the:
bia,oivltlforiu.otlonasfi.gi-didfofnt,lilsslguddWgreeni.eiiti-
Lef 2e NA.
-_y.RatusgAk.'MD PA,
Practice Mine(1) p co$0"(2)
Jeffrey Ratusznik.MP,
,Pkys f qplitgble) pIlysician Ramp.(if Mplicable)
,�dou Nalfte(i
2 15 Old Ai pJi%fav 1-187
llliysiqil Address PfrgsicalAddress
BUrleson.,TX 76028
cit)G.State•Zip !ip.
NIA
)vWing Address(JU15ered) -MalftAddrOss;igAlvbi�iio
847-526-1663/81.7-2*034860
Phone NuitiberTfaix Nu a iber i Fwlwvn*:-
4-7 16882, ..........
A...........
.............
pb"Icift Add.rfts PEO O61 Adorem
ov.
.M&Uln9..Addra3s'(gdlftemt) UallhigAddressl!f diffierent)
Phone 14uiub.-ef thm.Nt6ber.
TWID,Numbe.r
Forandonbehalf.-of: r.0 .0
And. ii bahall0f;
Rockport C_6n)M'.u-u 1 ty Netivq'rlc,lk.
.djba-RoC'!lt,poA.HeWtheiio
5 O)i, I H olx0
'Lan�,S65, 13NY
,ao '7702 Signslfur.
i�lti tic:
tusmilt,mb
pougl .-Irldial.h, (Frin 0
EXHIBIT D
Workers' Compensation Networks(WCN)
f
Rockport may make this provider agreement available to other networks through delegation. As defined within the
Physician agreement,Member Providers agree to provide treatment for injured employees who obtain workers'
compensation health care service through these networks. The named networks are Ilsted below:
• Rockport SelectHealth Network
• Wellcomp Managed Care Services,Inc.,Plan Name:CompKey Plus
• Broadspire HCN
i
I
I
I
Page 15 of 15
Revised 050215 RUNPHY TX 050115