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Contract 47186-P33
JAN/12/2017/THU 10:42 AM Dynamic Production FAX No, 8172880081 P, 002 RO KPORT � A WeilComp Company CITY SECRETARYCONTRACT NO._ /I � 33 ADDENDUM To 131ackStone 504 program Provider Agreement This Addendum is entered into by and among William Shmpard. LPC ("Member Provider"), Rockport Community Network ("Rockport'), and the City of Fort Worth ("City") on this day of .20 WIM AS, Rockport and Member Provider entered into a Provider Agreement, effective October 16, 2016, ("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. WHERPAS, the City has determined that a workers' compensation health care network certified utides 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). I WHEREAS,Rockport,Member Provider,and the City desire for the terms and conditions of the Provider Agreement to be the same terms and conditions that apply to the direct contract between Member Provider and the City that make available covered services for Qualified Participants'needs to the injured workers of the City. NOW,THERF—FORE, for good and valuable consideration,the sufficiency and receipt of which is hereby acknowledged,the parties agree as follows: 1. All terms and conditions ofthe 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 Agteement 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, Ir s d University Counseling Center 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. 'B1ackStone" 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 totime 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 inµre 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 inthis Addendum or the Provider Agreement waives sovereign immunity or creates a new cause of action. 6. All other terms of the Provider Agreement shall remain in force and unchanged. Any conflicts between this Addendum and the Provider Agreement shall be superseded by the terms provided herein. IN 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 BlackstoneFnis, 1 Signature: Date: O )7 Name: Su n istant Ci1y Manager APPROVED AS TO FORM AND LEGALITY: Assis t City orne G Atte U, is 7G' a K. Kayser City Secret .Z 1 . JAN/12/2017/TRU 10:43 AM Dynamic Production FAX No. $172880081 P. 004 1 UniversitY Counseling Cotter Provider Agreement ROMORT CC}NM3fJNTrYNRTWORK ..y Sfgnatsxre• -- _ Name:Johns psalaaoi 7Ytle:Sr-VigaP—j IdCrn D4101 © � MEMBER PROVIDER or Re pre8 ontAt1V61b a BfiglnC 8 I�Eame:Virilliam 6he»nard.L_PQ Title:,dWArefrr apt'e TINs80-0133804 3 i M611 P 23g7 ROCKPORT " A VVelICOMP Company W YSICIAN AGREEMNT ROCICPORT CONtAUNTTY NETWORK This Physician Agreement("Agreement"),is entered into by and between Rockport Community Network, 1.1 "Physician'means a licensed Medical Doctor or Ine.,hereln known as "Rockport", a Nevada Doctor of Osteopathic Medicine, or group of same Corporation, and University Counseling Center who desire to become a Member Provider with ("Member Provider"), and will become effective as ROCKPORT. of the date the provider is firlly crede rtialed by ROCKPORT. Puisuant to Title 28, Teras Administrative Code §10.42) regarding Network Contracts with Providers WHEREAS, ROCKPORT is engaged in the seeking to participate in Tongs Certified Workers' business of developing and acting in an Compensation Networks, administrative capacity in providing Occupational Injury and health provider networks that offer 12 TIWORd Payde- AL " means err °`employee" as 'direction of care while. providing savings to defined and used in the Texas Labor Code, the lz0('-KPORT elieuts and/or Payors.Theso notworks Network Acr Section 1305 and the implementing will offer greater coverage of services and savings; rules who sustained a work-related injuryfiillness that and is determined compensable by a Client and that participates in the Rockport Community Network WEEREAS, ROCKPORT has networks of througb Rockport's Client Unless in an emergency contracted physicians, physician groups, limpitats or after business hours, initial services provided for and providers of ancillary healthcare services the work-related Wtuylillnew regtrire authorization (collectively,the"Member Providers")to provide a by the network either in writing or by telephone. trill-range of healthcare services. These services are available for use by "Qualified PaIdolpants" as 1.3 ''Chen" means an insurance company, certified { defined i i 1,2 ofthis Agreement;and self-insured or governmental entity as those terms are defined and used in the Texas Labor Code, the WFIEI2EAS, iVieiuber Provider desires to provide Network Act Section 130x' and the implementing medical cage services to "Qualified Participants" rules. These Clients have entered into a Client —--— --—rvho drff'dverezI-by ''ayor Agiei!MCztts at'tlie fate37jff_—_-AgTedcndnt•with ROCISPORT'fdr,YIiU-pron5ion of - Exhibit B and in locations listed in Exhibit C: and healthcare sei vices to Qualified Participants. inclusive of the networks included in Exhibit D;and 1.4 "Payor" means an insurance carrier or network WUREAS, ROCKPORT has entered into certijlad by ab insurance carrier for its own benefit, Agreements and(or services with one or more Payors certified self-insured or govemtental entity as those who provide payment of claims for medical care terms are defined and used in the Texas Labor Code, rendered to Qualified Participants. the Network Act Section 1305 and the implementing rules who is responsible for payment of medical NOW, THEREFORE, in consideration of the benefits for bn the job injuries and or illnesses pramises,the mutual promises contained herein,and according to State and/or Federal Rides and ether good and valuable consideration, the receipt Regulations. and sufficiency of which are hereby acknowledged, it is mutually agreed as follows: I5 "CIient Agreement_" means the agreement between ROCKPORT and a Client, which X. D)El@'WITIONS agreement is made before, on or after the effective date of this Agreement and which expresses the When used in this Agreement and unless the content agreed upon contractual rigbU and obligations of the otherwise clearly requires,the following words and parties. Such Client Agreements will require Payors terms shall mean: to pay Member provider for Covered Services i Fego i of IS — ' Unlversla Counsaling Centrs B-SLifi RCNPFIX_77L0620i6 M y„ S AUG/15/2016/MON 03:29 PM FAX No. 8172880081 P. 003 Aug-10-2016 08:21 AM . ••.... 3144 rendered to Qualified Participants pursuant to this manifested by anufe symptoms of mnfficient soveiity, Agreement. Fmthennore, such Client Agreements including severe pain,that the absence of immed(ate shall authorize ROCKPORT to enter this Agreement medical attention could reasonably be expected to and contractually bind Payors to the terms hereof result in: unless there is a conflict with State and/or Federal (a)placing the patient's health or bocilly functions in piles and regulations. serious jeopardy;or (b)serious dysfiinctlon of W body organ or part as L6 "Member Provider" mesas any physician; defined in TIC 1305.004(13);and physician group;hospital;surgery center;diagnostic (e)in the case of a wenfd health condition,one that imaging center, laboratory; clinic; chiropractor; could reasonably present datlger 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 prof elon or licensed as a facility to ofY&healthcare I.10 "Covered Services" are those healthcare and services,in the state where services are rendered acid health-related services provided to Qualified who has executed a contract with ROCKPORT. Participants for treattntent of a compensable, work- related injuryfi lness as defined by either nationally 17 "Primm-y Imatiog Phy51ci n/ int " According recognized treatment grrldelines and/or individual to Texas law for certified workers' oompewation treatment protocols that do not conflict with any networks, the Network decides who will be a state and/or federal rules and regulatlons. 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 Practioe, Occupational completed in accordance with the guidelines I Medicine or Imernal Medicine as well as a physlcian established by the National Uniform Billing that provides initial and/or follow-up care in Occ- Comiaittee or CMS 1500 billing g ftdelir cs, and/or Med or Urgeni Care Clinics whose practice is state rules and regulations. largely,dedicated to caring for work related injuries and illnesses is designated by ROCKPORT as a II. MEMBER PROVIDER OBlLIGA'1;')NS Primary Treating Physician/Clinic (PTP). P'I`P agrees to render medical carr' to Qualified IL I Services. Member Provider agrees to provide or Participarrts without a scheduled appointment and arrange for all medically necessary:medical care for must be available tand accessible to employees Qualified Participants who present themselves to twenty-four(24)hours-per-day,seven(7) days-per- Member Provider. Member Pro'Yide:r agrees to weak as per 28 TAC 10.80(b)(1).Should a Qualified perform such services with the same standard of —Parairnpant"need_niedicai`afterifio`n "outs vs`_. ___cafe, skill sulci- 3il'sgenee"->`'ir alr fled – -------- Member Provider's normal business hours,Member Participants. Member Provider agrees that it is their Provider will be available and/or melee arraugmnoots sole responsibility to verify that the individual to have another Member Provider reader care to presenting for care is a Qualified Participant, Queliied Participant twenty-four (24) hours-per- Member Provider agrees to render healthcare day,seven(7)daysim-week services to Qualified Participants at any pad all facility or practics locations listed in Exhibit "C". 1.8"Specialist PhysieW means a Member Provider Membar Provider shall make best efforts to ensure who has met the credentialing roquirerrlents of that services provided are consistent with nationally RoCltl'ORT to be a Specialist Physician, and to recognized treatment gtridelines (i.e. Official whom Primary Treating Physiclana/Ctiniea nay Disability Guidelines (01)0), American refer for necessary and authorized care other than OccupatloW and Erivirorimental Medicine's primary treating services. Specialists twill need to (ACOEM) and /or state rules and regulations. maintain their current board certifications for their Member provider agrees to comply with and be particular specialty to maintain their ROCKPORT bound by all State/1?ederal Rules and Regulations. classification as such end be willing and able to treat Qualified Participants as needed or required.. 1I.2 Member Provider agrees to follow the treatment giiidelines, return-to-work I.9 "Emergency Medical or Me,WQMdition" is guidelines a11d indlvidual treatment protocols defined as the sudden onset of a medical condition outlined in Exhibit A of this Agreement,provided in Unlversity Cvumd iAg Cellryge?or rsa 8-9.16 3iCNp�kY_TX ae301B i I 3 AUG/15/2015/MON 03:29 PM FAX No. 8172880081 P. 004 Aug-10.2016 08:21 AM . •... .. 4/44 ROCKPORT's Provider Landbook and/or Clients' specified by ROCICPORT, Client or its designated Utilization Xevlew Programs. ROCKPORT agrees representative, and requested information is not to furnish Member Provider or catrs3 Payor to prohibited by stata and/or federal rules and furnish to Member Provider, and Member Provider regulations, agrees to abldc by, the list of any treatments and services that require preauthorization and by any 11.7 Professional Regidrements. procedures to obtain preauthorization. Unless in an emergency or after business hours, initial sm-vieos 11.7.1 Licensure&Aeore itati n. Member Provider provided for the work-related inji"Allness require shall comply with all applicable federal, state and authorization by the carrier and/or Network either in local laws, riles and regulations governing like writing or by tnlophone- The Client and/or Payor providers and their provision of services, Evidence may not deny treatment solely on the basis that a of such current licensing, certification and/or treatment for a compensable it&y in question is not accreditation shall be submitted promptly to spacffically addressed by the treatment guidelines ROCKPORT upon request. Member Provider used by the Client and/or Payor.However,Member represents and warrants that it and each of its Provider must demonstrate medical necessity to employees and contracted service providers has support services rendared to Qualified Participants obtained, and shall maintain throughout the term of that are outside of treatment guidelines. this Agreement, all necessary registrations, certifications, licenses, permits and approvals as are 113 Non-Discriminati n.Member Provider-shall not required for the lawful provision of Member differentiate or discriminate in the treatment of its Provider services to Qualified Participants.Member patients as to the quality of seivicas delivered to Provider shall immediately notify ROCKPORT of Qualified Participants because of race, sex, age, any revocation, suspension or re-trictions, that religion, national origin, place of residence, source would affect any ei�Tdfteations, licenses or of payment by health status. Member Provider shall accreditation. Member Provider warrants that it is observe,protect and promote the rights of Qualified currently accredited by the Agency that governs I&e Participants. providers and is certified as a provider under Title XVIII (Medicare) and when appropriate, Title XLX 11.4 Medical 5= Participedga. Certain medical (Medicaid) of the Social Security Act and that it specialties may not require hospital privileges such shall maintain such accreditation and certification as Occupational Medicine,Pathology,Dermatology, during the terra of this Agreement Member Allergy, and those Primary Treating Provider shall immediately notify ROCKPORT of Physicians/Clinlrs whose practice is dedicated to any action, investigation or proceeding to revoke, treating work-related injuries and illnesses, Where suspend, restrict, or otherwise affect such appropriate, Physicians must maintain active, accreditation or certifications. unrestri`fc z-_-- -'prrvt eges-•1•Vit--af- easf—one ROCKPORT Member Provider hospital or Surgery 11.7.2 Organization's Regzrirements. Member Center. Physicim hereby consents to disclosure by Provider shall use best efforts to comply with such facility to ROCKPORT of all data collected ROC12ORTs criteria for provider participation, with respect to Physician in connection with including credentialing policies and procedures, Physician's medical staff membership, includitrg Member Provider shall cooperate with without limitation all applications for staff privileges ROCKPORI"s periodic evaluation of qualifications. and any renewals thereof: In addition, Member Provider shall use best efforts to cooperate with ROCI{PORT's and/or state rules II.5 Referrals. Except in a medical emergency or and regulations for the expeditious resolution of any when authorized by ROCKPORT, Client, or its grievance or complaint. designated representative, Member Provider agrees to refer Qualitled Participants only to other Member II.$ Notification to ROCKPORT. Member Provider Providers,as defined in L6. represents and warrants that information provided 1,6 RD=. For each encounter where Member herein mid in the ROCKPORT application is true Provider pmvides services to a Qualified Participant, and accurate in all respects and acknowledges that Member Provider shall report such encounter on an ROCKPORT is relying on the accuracy of such appropriate form and shall inchido statistical, information in entering into and continuing the term descriptive medical land patient data and identifying of this agreement. In addition Member Provider information, if and to the extern that reports are shall use best efforts to provide written notice to Page 3 of Ss v0emity cmimseiing ceiver s-9.16 RCNPFTY_7�06zoi6 AUG/15/2016/MON 03:30 PM FAX No. B172880081 P. 005 Aug-10.2016 03:22 AM . •----- 5/44 ROCKPORT of any(i)suspension,reduction or loss Participants, and to Member Providers performance of license to provide healthcare services; (ii)denial, under this Agreenterit Member Provider fi •rher suspension, restriction, reduction or termination of agrees to alloW ROCKPORT,Payor or a designated accreditation/ceatificatdon; Ci�i) obanoes In Federal representative thereof; including the designated Tax Identification Number(s).(iv)other information utilization review, quality marragt cera, case provided in its application or Exhibit C for management or peer review staff,to have reasonable participation, (w) Member Providers professional access to medical records and information of liability insurance if such insurance AM$ below the Qualified Participants for services provided under requirements of state law and (vi) Member the terms of this Agreement as necessary to enable Provider's billing or facility addirm. A fkfiit,tra to such party to perform Utilization Rr;vIew and give any notice required by this Section shall be a Quality Assurance aafivities is a000rdance with the material breach of Member Providers obligations applicable Utilization Review and Quality and responsibilities hereunder, regardless of the Assurance Program. In addition, Physician agrees status,pendettoy or outcome of tie event giving rise that in the a reut an examination concerning the to the obligation to give that notice, and may be quality of healthcare services is conducted by grounds for termination of this Agreement. appropriate officials, as required by federal, state, and/or local law, ROCKPORT shall submit, in a IM9 Medical Records, Member Provider shall timely fashion, any required books and mcords and maiuWA complete and timely medical records for shall faollitate such examination ROCKPORT and Quallfled Participants treated by Member Provider Member Provider agree to assist one another with and its medical staff. Such records shall be prepared on-site inspection of facilites and records by in accordance with accepted prindples of prmrtice, represaatatives of authorized federal,state and local shall document ell services performed for Qualified regulatory agencies participants and shall comply with all applicable state and federal laws. Member Provider shell 11.11 'ons ' of Parti3s, Member Provider and maintain such records for the length of time required ROCKPORT understands and agrees that they are by applicable state or federal law. Subject to all each an independent legal entity. Nothing in this applicable privacy and confide3fdality requirements, agreement shall be construed or deemed to create a such medical records shall be made available to each relationship of employer and employee, principal Member Provider and other health professicnats and agent, partnership or joint venture or any treating the Qualified Participatrt, and upon request, relationship other than that of independent parties to the Payor. ROCKPORT or its deslgnated contracting with each other solely to carry out the representative for review at the rates approved by provisions of this Agreement for the purposes Stitt law and as set forth in the current State recited in this Agreement. With regard to the Worker's'Compensation Reimbursement:Manual for provision of healthcare services. Member Provider ------- --- I' ;if"appTicabTe.--1VIetnBei Provider shaI1_— WN as an'i�epeiraea entity and Yhe-ivlerTer . ...------ obtain a valid consent for the release of the Qualified Provider-patient relstiox ship shall in ho way be Participant's medical records to other providers, affected, ROCKPORT, Payor, or its designated representative. ROCKPORT agrees that medical H.12 Standards of Care. Member Provider agrees records of Qualified Participants shall be treated as that all duties performed hereuurder shall 6e confidential so as to comply with all federal and consistent with the proper p=tioe of their state laws and reguleons regarding the healthcare profession,and that such duties shall be confidentiality of patient records. The Member performed in accordance with the customary rules of Provider's obligations tm&r this Section II-9 shell ethics and conduct of the appropriate and applicable survive the termism ton of this Agreement. professional organizations and/or associations,as the case may be, and such other bodies, format or I1-10 Inspection of E.ecords end Operationsinformal, state, gov'er=ent or oth"IK or by ROCKPORT, Payor or a designated representative which they are subject to licensing/certification and shall have the right to inspect and audit, at all control, .Additl=ally, Member Provider shall reasonable times during normal business hours,upon perforin all medical and healthcare services in prior five (5) business days, any of Member conformance with the standards for their facilities as Provider's medical records and operations established by the local/regional professional reasonably pertaining to ROCKPORT Qualified healthcare community and applicable Participants, services provided to Qualified accrediting/licensing agencies, Mernber Provider rw 4 or is j Qnivw tryCamWingCot=8.9•L6 RCNPHY 7N.662016 AUG/15/2016/MON 03:30 PM PAX No. 8172880081 P. 006 Au9-10.2016 08:23 AM . •-•-•• 6/44 agrees that,to the extent feasible,it shall utilize such not limited to the following: 0) provider Search additional allied health and other qualified personnel provider Locator System (ii) Provider Directories as are available and appropriate far effective and (ii) Site-8pecifte Provider Panels (iv) Customized efficient delivery of care, Member Provider shall Local Networks and (v) Client Service Provider ensure that all such persormel are properly licensed Referral Service. and/or possess the necessary credentials to reader the services that they perform. lu) Credentialin2. ROCXPORT will perform and/or delegate to quali$cd organlauions IL 13 Right to Use Member Provider a or X"- ork's cred=daling of each Member Provider. Name. Member Provider agrees to allow Credentlaling 1riay include verification of all ROCKPORT to list Member Provider's name, information and documents provided in the specialty, address, telephone number, and hours of application for participation and irNestigatiorb operation in a Member Provider directory,Provider including but not limited to verification with all state Search, ROCKPORT Site-Specific Provider and national licensing and certifying bodies that Panel(s), ROCKPORT website and/ or other apply to the services rerid=A by the Member materials to help promote and assist Clients with Provider,such as YCAHO,AAAHC,NCAA, CLIA, Qualified Participants needing madiml care fur URAL, etc, Inquiries may also be made to current injuiieshllnesses sustained. ROCKPORT agrees to and previous professional liability carriers,Medicare allaw Member Provider to list IZOCKPORT's name, and Medicaid.R.00KPORT's eredetrtlaling policies address, and telephone murlber on Member and procedures follow the American Accreditation lhovider's website or in other publications listing the Healthcare Commission (URAL) and/or NCQA health plans accepted by Member Provider. In standards for Workers' Compensation provider addition,Member Provider agrees to post in waiting networks. room and make. available to Qualified Participant notioe of Member Fmvidcr's participation with 11I.3 Operational Fimct3ons. ROCKPORT shall ROCICPORT with name, address and telephone - utilize systems to respond to Member Providers nconber and process for Qualified Participants to requests for ir►fortnation and will provide resolve complaints. The Member Provider is clarification of policies concerning the operation of required to post;in Member Provider's office,notice ROCKYORT's programs. Member Provider agrees to employees on the process for resolving workers' to work in cooperation with ROCKPORT to market compensation health care network complaints. The the services of the Member Provider to Clients andf notice must include the Texas Department of or Psyors. Insurance's toll-free phone nE=ber ;For filing a complaint and must list all workers' compensation ROCKPORT shall act as a liaison with the Member health care networks with which the Member Providers and Clients and/or Payors to devote _--�...___-provider contracts:--—- _.__.---•---..__ _. -neoess`ary Tame aric�ffurt�a perti>riti XDC1T0RT's — responsibilities heremder, U.14Non-compliance.Member Provider understands that failure to comply with any of the requirements 111.4$etslj&,t=Action.ROCTSPORT agrees not to imposed pL=iaut to this Agreement may result in engage in any retaliatory action including tarnination of this Agreement by ROCKPORT. termination of contract or refusal to renew a contract against Member Pravidar, because Member II.15 ,Antltrust Guidelines. Member Provider agrees Provider, on behalf of an Qualified Participant, to comply with all antitrust guidelines and reasonably filed a complaint against, or appealed a procedures promulgated by Federal and State decision of ROCKPORT or Payor, or requested entities. reconsideration or independent review of an adverse determination.. 11L ROCATORT's OBLIGATIONS 111.5 Anthrctst Guidelines. ROCKPORT agrees to III.1 Marloeting to Clients/Payors. ROCKPORT comply with all antitrust guldefts and procedure shall enter into agreements -with Clients and/or promulgated by Federal and State entities. Payors as defined in 1.3 and I.4 for their access to ROCKPORT quality Membcr Providers through IIIb Audit Poligy and Procedwe Compliance. All specific referral processes. ROCKPORT will bill audit requests by Payor shall be done in market Member Providers#or referral,including but Page 5 of l5 t4itvcniryCouoee&gCemitr3-9-16 RCNM7Y,.P )6 i AUG/15/2016/MON 03:31 PM FAX No, 8172880081 P. 007 Aug-10-2015 08:23 AM . ...... 7/44 4 accordance with the State Law and/or Federal Rules All services billed under the Tait Identification and Regulations. Number(s) indicated in this Agreement, any Amendments, Exhibit A, Exhiblt D, Exhibit C, Applications or arty updates regarding locations IV, lftEllt7[BURSEIVMENT,CLAIMS and/or a Member Provider as defined in section 1.6 WBMISSION AND PAYMENT will be subject to the relinbursement rates established in the Exhibit B of this Agteemerit. IV.1 Reimbiu cement. ROCKPORT shall artange and provide the Member provider, locations and/or All billing and reimbursement will be made in any additional Tax Identification Numbers as listed accordance with Labor Code 408.027 and all other In Exhibit C for payors to pay Member Provider the applicable state Hiles and regulations. reimbursement rates For Covered Sft-Roes rendered to Qwatfled Participants pursuant to Paclubit B. IV-3 Bill and/or Claim Forms, Claim forms are Member Provider agrees and acknowledges that required for all services. All claims must be ROCKPORT is acting solely in an administrative submitted complete and accurate on CMS 1500(or capacity in providing a network of duality hrlth other appropriate claim form or their successors)and services.ROCKPORT is not the claims paying agent must include Member Provider's usual and and will not be liable for the payment of any amount customary billed charges(not discounted rates) and owed by a Payor to Member Provider to the event appropriate codes, consistent with policies that Member Provider is unable to collect such established or approved by applicable state and/or amourit of mo ney up to and including the insolvency federal regulations. Member Provider must subinit of the Payor. Under no circumstance Vvilh a Member claims•to payor not later than the 95°h day after the Provider attempt to collect payment from a Qualified date on which scrviam are providad to the Qualified Participant for medioal servicas rendered for a Pardoipaat, or as specified by state law, In compensable,work-related Wury/illness. accordance with Labor Code §403.027 and other applicable statutes and tules,billing and payment to IV2 Reit a &�N.Mambar provider Is to Member Provider will be made within forty-five be paid by the Payor in accordance with State La-vy (45)clays of receipt of bills which are accurate and and/or rules end ragulativas at the rates established complete, and otherwise in accordance with state in Exhibit B. Member Provider hereby agrees that rules and reg dations. rms in Exhibit B,which may be amended from time ' to time upon mutual written agreement,represent the TVA Limited Recourse A.cjng Qualified total ainount to be received and agrees to look solely EgWWA= Except as otherwise provided in this to the Payor for payment for such Covered Services. Agreement(Section L10), Member Provider agrees Pa meat will be made for Covered Services actually to sNk_a ntent from each Pyr for Covered _ _ - - Ciaime will be paid,w�ieri appiopr�ate, ---6ervioes provided to its Qualified Putidpants, end — —only after submission of a complete *od accurate agrees that it will not seek additional payments or claim. A complete and accurate; claim shall be reimbursement for compensable injuries from defined as a clean claire by Medicare.ROCYPORT Qualified Participants. In addition, Member does not guarantee, represent, warrant or covenant Provides aglecs that nelther ROCKPORT,the Payor rogarding the selection or use of Member Provider's nor the Qualified Participant shall be billed or services by any Quali£ed Pardripant or payor,or the ultlmately held responsible for payment of services number of patients, if any, whioh may result from deemed not to be covered by the Payor or its pardelpation in ROCKPdRT's provider network. designee.When Qualified Participant is covered by a The obligation of a Payor to reimburse Member state or federally regulated Occupational Injury and Provider in accordance with ByJiibit B for the Illness program,Member Provider agrees to comply provision of Covered Services to a Qaahfled with state and federal regulations regarding holding Participant shall be conditioned upon a good Nth Qualified Participants harmless for amounts not paid determination by the Payor or its designated by Payor for any reason,including Payor or tletwork representative that (i) such services are medloally insolvency. This provision does not preclude billing necessary, whether such determinations are made a bion-Qualified Partycip=for a non-compensable before, on or after the provisiwa of services to such injury. Qualified Participant, 1VA.1 Transfer of Risk. This Agreement and any subcontract within shall not be interpreted to involve prga 6 cr 15 Un[veteity Cauaxiiag Canner 6�9-16 RLNP�fY 17i�,o67oib i _ AUG/15/2015/MON 03:31 PM FAX No. 8172880081 P. 008 Aug-10-2016 08:24 AM . •----- 8/44 a transfer of financial risk for the provision of health demands and expenses of all kinds which may result care services from Payor to ROCKPORT as defined or anis® out of any alleged malfeasance or neglect umder insurance Code §1305,004(a)(26). Member calmed or alleged to have be caused by its employee$ Provider agrees and acknowledges fhat ROCKPORT or representatives,in the performance or omission of is acting solely in an administrative aepacity in stay act or responsibility under this,Agreement. In providing a ner,,vork of quality health providers. the event that a claim is made against ROCKPORT, ROCKPORT is not the claims paying agent and will it is the intent of ROCKPORT to cooperate in the not be liable for the payment of any amount owed by defense of said claim.However,ROCIYORT shall a Payor to Member Provider in the event that have the right to take any and all actions they believe Member Provider is unable to collect stitch amount of necessary to protect their interest money up to and including the insolvency of Payor or the Network V.3 In;domnificatl2u of Momber Provider. Member Provider will be responsible for its own acts or IV.5 Payment of Claim Forms. ROCKPORT shall ❑missions 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 acctu'afe, complete and comply with the neglect caused or alleged to have be caused by its Agreernwit 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 TV,6 , goneous Pavment. fn 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 clash. Member provider (i) more than once, or (ii) an However, Member Provider shall have the right to incorrect amotuit; or(iia)an overpaymm%tho Payor take any and all actions they believe necessary to or its designated representative may, at its sole protect their intorost. option and discretion, request the rowrn of such amount from Member Provider The Member V1. TERiVI AND TERMINATION Provider will not tiweasonably withhold reimbursement. If overpayment has been Made VI.I _TerM. The term of this Agreement shall be for Member Provider shall reimbnse such overpaytmect one (1) year from the date hereof and shall be within forty-five(.45) days and/or follow 5tt,.te and automatically renewed on an annual basis for Looal Rules and Regulations. The Member Provider successive twelve(12)month periods,tmless sooner may not contest payment of Claims after one terminated in accordance with Section V1.2. hundred aloty(180)days from the data of payment All claims for overpayment or underpayment shall___ V1.2 TemT-&ation. This Ao°reement_ may be _ be resolved in accordance with State�.aw and•T ieiimiziated sooner on the first to occur Federal Rules and Regulations, following: V. INSUPANCE AND INDENE IFICATION VI.2.1 Te_mLination by Member Providerk, Member Provider may terminate this Agreement in the event V.1 Tnsuuance Requirement. Member Provider shall of a material default or breaoh of ROCKPORT's provide and maintain such policies of professional obligations hereunder, upon ninety (90) days prior liability insurance or a self-funded program. The written notice and the failure of ROCKPORT to cure arnolints and extent of such insurance coverage or such breach or default within sixty(60)days of the self Arrided progr= shall be in the amounts notice. In addition, in the event of an "emergency detmTnined by community standards for relevant situation", Member provider may tetmiuiate the hospital/facilities, Member Provider shall promptly Agreement immediately with the acknowledgment demonstrate evidence of insurability or self-funded by FOCKPORT that such an emergency condition program and that the required insurance is paid and does exist, "Emergency Situation" shall mean an in force upon request of ROCKPORT and/or meet %unforeseeable event, not resulting from Member the eredentivEng guidelines of ROCKPORT. Provider's act or omission,which materially affects Member Provider's ability to continue the practice of V.2 Tndeimification of ROCKPORT.ROCKPORT medicine or to perform his obligations hereunder. will be responsible for its own acts or omissions and The network will provide notification to employees any and all claims, liabilities, injuries, sults and of the terminating Member Provider immediately Paige 7 oP 15 UhImmityC01109C DS Center 3-9-16 RCNPIiY_T]�Ob7Ar6 AUG/15/2016/MON 03; 31 PM FAX No. 8172880081 P. 009 Aug-10-2016 08:25 AM . --- 9/44 upon receipt of the Member Provider's ternnination conservation of their financial affairs with written request or as soon as reasonably possible before the notification. effective date of teiminatlon as required by 28 TAC 10.42(b)(6)(G). VI,24 Termin j n by Either Pari. In case of material breach of tate terms of chis Agreement, V12.2 T-mmiln4on by.ROCKPORT. A Member either patty may terminate the Agreement with at Provider shall automatically be terminated on the least ninety (90) days prior written notice to the date when:(1)Member Provider's license in the State other parly;however, the party in breach may cure where services are rendered is suspended or revoked, the breach within sixty (60) days of the notice, in (li)Member Provider is excluded from participation which case,the Agreement and applicable rates and in the Medicaid or Medic-art programs, (W)Member teens shall continue in affect. Either party may Provider loses their JCAIJO, NCQA, A AAPIC, terminate this Agreement without cause upon ninety URAC, CLIA or other applicable license, (90)days prior written notice. certification and/or accreditation, (iv) Member Provider loses of experience a mate4al reduction in VL2,$ Unforeseen Events_ In the event that either liability insurance and such insurance falls below the party's ability to perforin their obligations under this requirements of State Law (v) Member Provider Agreement is substantially interrupted by war, fire, ewgages in any act, omission, demeanor or conduct insurrection,riots,the elements, earthquake, acts of that is reasonably likely to be detrimental to patient Gad, or other similar circumstances beyond the safety or to the delivery of quality patient care,or to reasonable control of such party, the parry shall be lead to the provision of healthcare services below relieved of those obligatiom for the duration of the applicable standards, or (vi) ninety (90) days interruption upon notice to the other party. In the following written notice by ROCKPORT of a event that the interruption is reasonably determined material default or breach by Member Provider likely to persist for at least ninety(90) days, either hereunder and the failure of Member Provider to party may terminate this Agreement upon thirty(3 0) care such default or breach Withitr sixty(60)days of days prior written notice. the notice (vii) Member Provider fails to meet ROCKPORT's or the, State's oredentialing V1.3 Effects of Termination, Upon termination of requirements. ROCKPORT, however, may not this Agreement,neither party shall have auy fiu-rher terminate this Agreement in dlreat response to obligation hereunder except for (i) obligations Pbysician filing a reasonable coraplain%on behalf of aocraing prior to the date of terznirmtion, inclading a Qualified Participant against, or appealed a without Iitnitation, any obligation by Member decision of, the network, or requested Provider to continue to provide healthcare services reconsideration or independent review of an adverse to Qualified Participants, and (ii) obligations, - --.--------deaf--_--------- •-------- -••--•- -..__.— FrQmises_�conants��ntaine�iterei>,_vthi --- -._.----._. expressly made to extend beyond the term of this In the eveat ROCKPORT deems it necessary to Agreement. terminate Member Provider's agreement based on tate above requirements ROCKPORT will notify VI.4 QualifiedPartigjDantand PavorNotifcation.If Member Provider at least»inety(90)days before the applicable,upon the termination of this Agreement, effective date o,Ctstrnination, by either party, Member Provider shall cooperate with ROCKPORT to notify Qualified Participants Upon written notification from 13.0CK1'OXT, and Payors of such termination. Member Provider may request a revie8v by ROCKPORT's advisory review panel,not later than VII.CONTINUTION OF BENEFITS thirty (30) days after notification. ROCKPORT must then complete the review before the effective VIZI Continuation of Benefits,If Member Provider dam of termination. voluntarily terminates its contract With ROCKPORT, upon Member Provider's request, VI.2.3 Termination for Insolvency. This Agreement Payor must continue to reuuburse Member Provider shall terminate imrtxediately in the event that either for a period not to exceed 90 days at the Member ROCKPORT or Member Provider voluntarily or Provider's contracted rate set forth in Exhibit D of involuntarily, liquidates, dissolves or becomes this Agreement with ROCKPORT, for care of an subject to any proceeding for the rehabilitation or Qualified Participant with a life-threatening condition or an acute condition for which iUniversity Counseh&Center 8-9-16 pego 8 of 15 RCNPHY Tx 062016 AUG/15/2016/MON 03;32 PM FAX No. 8172880081 P. 010 AUg-IU-L01b 02b AM . --..-- 10/44 discontinuing or disruption of care would harm the Agreement,and in particular the pricing information QualifiedPartieipatlt as per 28 TAC 10.42(b)(5)(A). herein. Any disputes concerning contimrlty of cafe shall be resolved through the complaint process under IX. MMCKLLANEOVS Insurance Code §1303.401 - §1305.405 and Subchapter (I of Title 28, Part 1 (relating to IX.I.DismMes. All disputes and difference between Complaints). the Member Provider and ROCKPORT upon whicii an amicable understanding cannot be reached are to be decided by the follow[r1g method: VIi 2 �, The provisions of this Article VII shall survive the termination of this Agreement Z,1.1 Mediation through ROCKPORT. The regardless of the cause - giving Ase to such Member Provider shall notify ROCKPORT in terminatioxL as will sections II.9, V.2, V.3, VL3, writing of the dispute or disagreemerrt awl shall VIII, and IX The provisions of flus Article VII provide all necessary information to ROCKPORT. supersede any oral or written agreement to the ROCKPORT shall use best efforts to mediate the oontiaty now existing or hereafter entered into dispute within the rules and regulations put f6rth by between Member Provider and any Qualified the State as reference in ROCKPORT's Provider Participant or any person actjrig on a Qualified Handbook Participants behalf. IX.1.2 Arbitration,, 1f the dispute cannot be solved VIII. Co"MENTIALITY by the mediation process described above,either the Member Provider,ROCKPORT or Payor may elect All business, medical and other moords relating to to submit the dispute to binding arbitration under the the opandotr of ROCKPORT or Member Provider, rules of the American Arbitration Association or any including but not limited to, books of account, other method of arbitration mutually agreed upon by general admiuistr&uve records, policies end the parties. Arbitration will be conducted in procedures, pricing information, terms of this' Houston,Texas. Each party will be responsible for Agreement and all information generated arid/or their own legal fees. The cost of the arbitration contained in management information systems services will be the sole responsibility of the party owned by or pertaining to ROCKPORT or Member requesting the arbi %tion. Provider, and all systems, manuals, computer software sad other materials, but excludirig patient IX.13 Provider Anneals.Except fbr termination due charts, shall be and remain the sole property of to contract expiration, Member Provider has the ROCKPORT or Member Provider respectively right to appeal his/her termination from the Network, (collectively, the aConfIdetltial Information'). as follaws; __ __.—_�_1�DG�T(�'G>�1'-sad-member�prorrctler-acknowlEdges'•---•-•------._. -_ ._. _._ -•- ----•--..__-_._...._--- •-, that the Confidential Infen=tlon and all other 1X.13.1 ROCKPORT will provide notice to the infortnaiion regarding ROCKPORT or Member Member Provider at least 90 days before the Provider fiat is cornpetitsvely sensitive is the effective date of a termination by ROCKPORT, property of ROWORT or Member Provider and ROCKPORT or Member Provider may be damtaged IX.1.3.2 Upon receipt of the written notification of if such information was revealed to a third party. termination, a Member provider may request in Accordingly, ROCKPORT and Member Provider writing a review by the Network's advisory review agrees to keep strictly confidential and to hold in panel no later thea 30 days after receipt of the trust all Confidential Information.Upon tmmination notification; of this Agreement by either parry for any reason whatsoever, ROCKPORT and Member Provider IX.1.3.3 The Network will provide an advisory shall promptly return to the other all material review panel that consists of at least three Providers constitutrr g Cocfidentiel Information or containing of the same Iicensure and the same or simflar Confidential Information,and neither party will not specialty as the Member Provider; thereafter use, appropriate, or reproduce such informafion or disclose such information to any third IX.I.3.4 The Network must complete tbn advisory party. ROCKPORT and Member provider panel review before the effective date of the apeciflcally agree that under no circumstances will termination; either party discuss the terms and conditions of this page 9 of is Uravemicy coum,61 g Cabter 6.9.16 RCNPHY 77C 042016 I s AUG/15/2016/YON 03:32 PM FAX No, 8172880081 P, 011 Aug-10-2016 68:26 AM . •....• 11/44 1X.1.3.5 The Client,Payor,or ROCKPORT may not 11625, or any applicable rule or regulation notify patients of the termination until the earlier of promulgated pursuant to any such Taws or orders, the effective date of the terarAwtion or the date the advisory review panel makes a formal 1X,6 CrM!M ne T.aw_ 7l'ltis Agreement shall be reovr=endaton; governed by and construed in accordance with applicable state law. IX.1.3.6 If Merober Provider terminates the conh'act, the Network or ROCISPORT'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 &hall give such notice Immediately upon amendment. receipt of the Member Provider's termination request or as soon as reasonably possible before the 1X.8 •ersbili The invalidity or un- eftbctive date of termination. enforceability of any term or condition hereof shall In no way affect the validity or enforceability of any DC-7 Non-Exclusivity, Nothing in this Agreement other term or provision. shall be construed to restrict Member provider or ROCKPORT from entering into other contracts or IX.9 Assipment, Member Provider may not assign agreements to provide healthcare services to Payors or otherwise t rosier any right or delegate any dory or other healthcare delivery plans, patients, and of performance hereunder, in whole or in part employer groups, without the prior written consent of ROMORT, A. change in ownership will not negate the prior IX3 Enfire Aopment This Agreement contains contractual agreement without written notification to the entire understanding of the parties and ROCKPORT. ROCKPOMT retains the right to supersedes any prior understandings and agreements, assign this Agreement, in whole or in par#, to any written or oral, respecting the subjects discussed entity with which ROCKPORT or its parent herein. company or any of its subsidiaries is affiliated, or with which it merges or consolidates. IX.4 No Waiver. The waiver by either party of a breach or violation of any provision of this 1X.10 Third Va ciariqs. Except for Payors Agreement shall tat operate as or be construed to be and the agents ther'eoZ there are no third party a.waiver of any subsequent breach hereof beneficiaries of this Agreement. IX,5 Reggulatory Compliance. Member Provider, lX11 Caotiom The captions and headings _ Y sub-contracting providers, and ROCKPORT agree _ _ contained in this Agreement era for rale notice thahall t-eater scomply w th all applicable purposes only and shall not affect in anyway the requirements of mturicipal, county,state and federal meaning or in*erprotarion of'this Agreement authorities,all municipal and county ordinances and regulations, and all applicable state and federal IX.12 Execution of Counterparts. This Agreement statutes and regulations, now or hereafter in force may be executed in any munber of cmix1terparts, and effect, governing ROCKPORT, Member including facsimiles,each of which shall be deemed Provider,sub-cgntracting providers,the provision of to be an original as against any part whose signature services by Member Provider or sub-contracting appears thereon, and all of which shall together providers,and/or Payors,including but not limited to oonstitute one and the same instrument applicable requirements under any state or federal fair employment practices, equal employment IX.13 Partial Invalidity. If any part, chaise 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 jurisdiotioN the rciiminlgg Teligioi-4 sex,or national ori&as illegal,and,Titles provisions of this Agreement shall not be affected VI and V1I of the Civil Rights Act of 1964,Section and shall be given eonstrtwtion, if possible, as to 202 of VxeCntivr Order 11246 as amended by permit it to comply with the miniantm requirements Executive Order 11375,Sections 503 and 504 or the of any applicable law, and the intent of pares Rehabilitation Act of 1973 and Title IV of the hereto. Vietnam Fra Veterans Readjustment Assistatrcc Act of 1974, and Sections 1 and 3 of Executive Order Page 10 of 15 Untvasity Cotuueling Center 8-9-16 RCNFHY TX 063016 AUG/15/2016/MON 03:32 PM PAX No. 8172880081 P. 012 Aug-10.2016 08;27 AM . ------ 12/44 IL-14 tinancPal.Incentives.Neither a Client,payor, IX.17 Official Noticws Any notice or nor ROCKPORT msy use financial incentive or communication required,permitted or desired to be make a payment to a health care provider that acts given hereunder shall. be deemed effectively even directly or ind ready as an induoemeht to limit when personally delivered or malled,return receipt inedfoally necessary services. The adoption of requested, or overnight express mall addressed as treatment and return-to-work guidelines and follows: individual treatment protocols by ROCKPORT or Network is not fn vlola4on of this section as pursuant to Insurance Code §1305. 304 and M=bar Frovider or Representa&e/Designee: §1 D.83(z)of Clop 10 of Title 28 Part 1. (Please print) IDL 15 1'inanoial Disclosure Requirements. Member Name: �r!�+.��4 0 u' Provider is required to file financial disclosures in accordance with Labor Cody §§408.023 and Organization: 1L ntyrrsity Counseling Center §§413.041. 1}(.16 Bo omic Profiding. Network roust provide Address: 1533 Merrimac Circle Scute 101 written notice to Member provider bafore the City:/State/Zip:Felt Warth_TX 76107 Network conducts economic profiling, including utilization management studies or other profiling of Telephone:817-810.0030 the provider or group of providers. Fax: 817-877.3562 Organization: IN WITNESS WHEREOF, the undersigned will be WellComp Managed Care Serviq s,Inc. deemed to have executed this Agreement as of the One Upper New Jars Bldg,)l,4 Floor date the provider is fully credentialed by par8ippany,Netiv 7er5ey 07054 ROCKPORT. Ater:Michael Krasvh7,Gmaral Counsel,SVP or to such other address,and to the attention of such other person(s) or officer(s) as either party may deslgYaate by written notice. Vov and on behalf of: Rockport Cominunity NetworX,We- _..,,_.. ._... _ For and on behalf of- - - - 761 Old aticory Blvd S e,300 are ttivp a, 7 Member Provider or l�epresetttatfvefl)esS ec 17b1r$7a8 rkharrr �, ?' �/ Presider Name.. 4v/r�t� w' FF((,,., (pant) Date; `�'lU'(�2 TLis 80-0133804 Date: 1'S— / Page lrofl5 Untveniry Counseling Center 9-9-16 RCNPH1l 1'X_Od20t6 AUG/15/2016/MON 03:33 PM FAX No• 8172880081 P. 013 Aug-10-2016 08:27 AM , • 13/44 I EXHIBIT A ST.A,NDA,"S AND GUIDELINES UTILIZATION REVIEW AND QUALITY IM11RO-V EMENT FROGRANIS ROCKPORT and its Clients require Member Providers to follow nationally rcoognlmd treatancat gWdeliuos(i,a. Official ]Disability Cloidelines(ODO) and/or American occupational and Environmental Medioine's (ACOEM) guidelines)is the treatment of work-related injuries/illnesses for Qualified Participants. 1tOCIUO"'s Clients provide utilizidion review said quality improvement programs for Qualified Participants, ROCKPORT shall review each Clients Utilization Review and Quality Improvement Program is accordance with ROORPORT's Credentialing Standards and Ouidejitaes 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 Guidellnes for Utilization Review Programs may be amended from time to time uport written notice to Physician and/or Member Provider, The primary goals of the Utilization Review Programs shall be to: s) Ensure and ecrt]>;y for t}ae payment of benefiss that healthcare services meet the definition of medical necessity as dof'med by the network,Payor or the Payors designee; 2) Ensure that healthcare services are provided at the appropriate level of cars;and 3) $risme that healthcare services follow nationally recognized treatment guidelines that are evidenced-based and outcome-focused. Treatments and Services that Requh'e Preauthorization;unless otherwise specified by the[reta;vrk: 1) In-patient hospital admissions including the principalsohedulcdproccdores(s)and%aIgrgthofstay; 2) Cutpatimt surgical orambulatwy surgioal services; 3) Spinal surgery,as provided by Texas Tabor Code§408.026,- 4) 408.026;4) All psychological testing and psychotherapy,repeat interview's,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,diseograma,or surface alactromyograms; 3) Unless otherwise speclfled,repeat individual diagnostic study,with a fee established in the current Medical Fee Guideline of greater than$350 or dooumentat3on of procedure(DOP); 9) 'W=k herdening and work conditioning services provided in a facility that has not been approved for exemption ------ — — --by-rho-DbAslon;..___— 10) rehabilitation programs to inclade(a) outpatient medical rehaWitation and (b)chronic pain management I Werdisoiplinaty pain rehabilitation; 11) All durable-medical equlpment(DME) iia w4cess o;C$500 per item (either purchase or expected cumulative rmatal)and all transcutaneous electrical nerve stirnulator(=S)units; 12)Nursing home,convalescent,residential,and all horns health oars services and treatments; 13) Chemical dependency or weight loss programs; 14) Any investigational or experimental servioe or device for which there is oarly,developing scientific or clinical evidence deartonstrad:ng the potential efficacy of the treatment, service, or device but that It not yet broadly accepted as the prevailing standard of care;and 15) Physical and occupailenal thorapy services;(a)physical and occupational therapy services are those tilted in the Heaitheate Common Procedure Coding System (HCPCS) Level I code range for Physical Medicine and Reitabilttation, but limiud to: (i) modalitim, both supervised and constant affxvianre; (il) therapeutic procedures,excluding work bardening and work conditioning•,and(iii)other procedures,lhnfted to the unlisted physical medicine and rebabilitAtionprocoduro coda 1S) Closed Formulary Mugs,as defined by 28 TAC Chapter 134,Subchapter F. 'NOTE�z Fres lhorizatlon is not required for the first two visits of physical or occuparional therapy fallowing the evaluation when such treatment is rendered within the fust two weeks immediately following;(i)the date of injury. or(il)a surs3ical intervention previously approved by the payor. paae 12 of 13 UoivereiryCounselingCenter 8-9.16 7rcNi+FTY;r7C 06a0r6 I AUG/15/2016/MON 03:33 PM FAX No• 8172880081 P. 014 Aug-10-2016 08:28 AN . ---•-• 14/44 VOMIT R Reimbursement Schedule 1.kockport Community Network,and its affiliates.-Occupational Injury and Illness Provider fees for the programs listed above shall bs reimbursed at the followirW, All fees will be reimbursed at 85% (Nighty five percent) of the swe's current Workers' Compensation fees,rules and regulations of usual and watomary allowablw. Coverage: Coverage for all procedures on the fee Schedule,is subject to the teams and conditions of this Agreement,state rules and regulations and/or the applicable Oocupatiol-Al Injury or Illness Benefit Plan. ISI'We accept the fees as outlined in this Exhibit B. For and on behalf4of-, — - For and on behaif of, (Name,address,etc.) ROC"ORT CON IS�Mn NMT'SVOIUZ ,INC. University Coursel wx Center 1333 Merrimac Circle Suite 101 7 Eod 312Lth.TX 75107 anttVo Tl�l I Signature �� � � Z—zLfi ,9 Dough$J.4ax<< ata Printed Name 0w(c""¢ President Title C w AJ--e/.tr- Date___,_ TIN SO-0133804 Date Ad.'a 13 a£SS University Counseling Comer 8-9-16 TtCNpFTi'_T1�DKto14 AUG/15/2016/MON 03; 33 PM FAX No. 8172880081 P. 015 Aug-10.2016 08:28 AM . ------ 15/44 EXHIBIT C Physicians and/or locations where services Are to be rendered by Member Provider j Tbc Member Provider agrees that the following pbysiclans and/or prxctice locations listed on attached Exhibit C, i sha11 be:luclusive of the signed agreement and the signed rates In Exhibit B. By signing below Member Provider or It8 Itopresentnttvo/l)esignea allows Rockport 11eolt2tcaro Group(ROCXFOR17 Rud its roprrsrata'tivns to use am nAd as of the belong Wormetion as agreed to in this signed agreement, University Counseling Conte Practice Name(1) Practice Name(7) William R(Rab l Sht tpard I,PC Physician Name(if applicable) Physician Name(if applicable) 1533 Mt rrimu Circle Suite I01 Physical Address Physical Address Fort Worth.TX 76107 City,State Zip City,Stato Zip Mailing Address(if different) Mailing Address(if different) 6717-810-00301917-977-3563 Phone Number/Fax Number Phone Number/Fax Number 80-0133804 Tax ID Number Tax ID Number PmaCice Name(3) practice Name(4) Physician Name(if applicable) Physician Name(if applicable) Physical Address Physical Address City,state zip City,state Zip (if difr-erent) ------ - - -- -- - --- - -- Phone Number/Fax Ntnnber Phone Number/Fax Number Tax 1D Number Tax ID Namber For and oft behalf 4 For and on behalf oh Aoc pari Community Network,Inc. Member Provider or Represi mtaq've/A -761 Old kSidory Blvd.Ste,300 Bre oa r- 37027 4 signature: 'J4/ Don gg ast Tyl`tcllsui (pent) Pros don jj Data., 3"l(0 Date: Ngo 14 of 13 University Counseling Center 84-16 RCNPHY TX 062016 AUG/15/2016/MON 03:33 PM FAX No, 8172880081 P, 016 Aug-10-2016 08:29 AM . ...... 16/44 EXHIBIT D Workers'Compellsation Networks(WM Rockport may make this provider agreement available to other networla through dekpiiox. As defined within the Physician agreement,member Providers agree to provide treatment for hjured employees who obtain workers' compensation health care service through these networks. The named networks are listed below: • Rockport Commuxdty Network • Wtllcemp Managed Care Services,Inc.,Plan Name:CompKey plus • 19r08d9p1Te$CN Pagc 13 of 13 Revinl062016 RCN?RY TX 062016