HomeMy WebLinkAboutContract 47186-P31 R O C K P O R T " CITY SECRETARY;,
A WellComp company CONTRACT NO..—,
ADDENDUM
To
B1ackStone 504 Program
Provider Agreement
This Addendum is entered into by and among Allen Kent, 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 January 27,
2102, ("Provider Agreement'), and desire that this Addendum apply to covered services that are
governed by the Texas Insurance Code,Texas Labor Code,and Texas Administrative Code.
WHEREAS, Rockport has contracted with Member Provider on behalf of the City in the process of
setting up a direct contracted 504 provider panel pursuant to Texas Labor Code Section 504.053.
WHEREAS, the City has determined that a workers' compensation health care network certified under
Texas Insurance Code Chapter 1305 is not available or practical for its self-insured workers'
compensation program needs and,as such,have elected to provide medical benefits to injured workers by
directly contracting with health care providers.
WHEREAS, Rockport, Member Provider, and the City desire to execute this Addendum in order to
establish a direct contract between Member Provider and the City under Texas Labor Code Subsection
504.053(b)(2).
WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider
Agreement to be the same terns and conditions that apply to the direct contract between Member
Provider and the City that make available covered services for Qualified Participants'needs to the injured
workers of the City.
NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby
acknowledged,the parties agree as follows:
1. All terms and conditions of the Provider Agreement are hereby adopted by both Member Provider
and the City, with full consent and agreement of Rockport, to apply as a direct contractual
agreement between Member Provider and the City.All references to certified networks as well as
the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413.041 of the
Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under
section 504.053 of the Texas Labor Code. The City's Provider Manual (under the name of
BlackStone) shall instead apply to matters of notice, billing, dispute resolution, complaints,
preauthorization,and related matters.
2. The parties agree that the City will bear the financial responsibility for payment to Member Provider
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.
Allen Kent, 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 fromtime 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: l l Lro1
Name: Sus n A nis Assistant Cit M------
A PnnQVE V,
na erAPPROVED AS TO FORM AND LEGALITY:
Assistant City o ey
Attest
Com. ••.
ary .Kayser, City Secretary '
W �
.............
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I
I ,
j Allen Kenn MD Provider Agreement
ROCKPOR.T COMMIti+IITX NETWORK
NRmec Rohit Pay�cci
Title:Sr.Vigo Eg sident
Date: O 1. 3 •!"1
MEiV BR PROVWVR or
Reps esentatiw./Aesignee
Mpawre:
Name;AUSKeg MD
Title. rit1
Dote., I .ge.
M.-42-1540250
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K P 0 RT
PHYSICIAN AGREEMENT
ROCEFORT SELECTMEALTH NETWORK
This Physician Agreement-("Agreement"), is entered L DEFINITIONS
into by and between Rockport Community Network,
Inc.; a Nevada Corporation, dba Rockport When used in this Agreement and unless the content
Healthcare Group ("RHO"), dba Rockport otherwise clearly requires, the following words and
Se;lectHeaM Network (an -exclusive provider terms shall mean,
network) and Allen S. Kent MD ("Member
Pt,ovider"), and will.become effective as of the date 1.1 "Physicianmeans a licensed Medical Doctor or
the provider is fully credentialed by RHG. Doctor of Osteopathic Medicine, or group of same
who desire to become a Member -Provider with
WHEREAS, RHG is engaged in the business of RHG,
developing and acting in an administrative capacity
,irlprovidmig Occupational Injury-and'health provider Pursuant to §10.42 of Texas Insurance Code 1305
n6tworks that offer direction of care-while.providing regarding Network Contracts with.Providers seeking
savings to RHO clients and/or Payors. These to participate: in Texas Certified Workers'
networks will offer greater coverage of services and Compensation Networks,
savings;and
1.2 "Qualified Participant" means an "employee".as
WHEREAS, RHG has networks of contracted defined -and used in the Texas Labor Code, the
physicians, physician groups, 'hospitals and Network Act Section 1.305 and The implementing
p!ovidem of ancillary healthcare services rules who sustained awark-related injury/iIiness that
(collectively,the "Member ProviderO) to provide a is determined compensIble by an employer and that
full-range of healthcare-services. These services are participates in the, Rockport 'United Network or
:available for use by "Qualified Participants" as Rockport SelectHealth Network through Rock-port's
d4ned in.1.2 of this Agreement,and Client. Unless in an emergency or after business
hours, initial services provided for the-work-related
WHEREAS, Member Provider desires to provide injuryJillness require authorization by the Employer
,medic-al care services to "Qualified Participants" and/or network either in writing or by-telephone.
who are covered by Payor Agreements at the rates'in
Exhibit B and in locations listed in Exhibit C-_and 1.3 "Client" means an insurance compa4y,
self-insured or governmental entity as those terms
'WHEREAS, RHG has entered into. Agreements are defined.and used in the Texas Labor Code,the
and/or smices with one or more Payors who Network Act Section 1305 and the implementing
provide payment of claims for medical care rendered rules. These Clients have entered into a Client
to Qualified Participants. Agreement with RHO for the provision of healthcare
services to Qualified Participants.
NOW, THEREFORE, in consideration of the
premises,the mutual-promises contained herein,and 1.4 Payor" means an insurance carrier or network
other good and valuable consideration, the receipt certified by an insurance carrier for its own benefit
and sufficiency of which are hereby acknowledged, certified self-insured or:governmental entity as those
it is mutually agreed as follows- terms are defined and used in the Texas Labor Code,
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.
Page 1 of A
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