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HomeMy WebLinkAboutContract 47186-P35 R C C K P Q R T 'm CITY SECRETARY` CONTRACT N0., �1� A WelICOTTtp:Campany ADDENDUM To BlackStone 504 Program Provider Agreement This Addendum is entered into by and among Fort Worth Brain and Spine Institute("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 March 18, 2013, ("Provider A,greement'% 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 terms and conditions that apply to the direct contract between Member Provider and the City that make available covered services for Qualified Participants'needs to the injured workers of the City. NOW,THEREFORE,for good and valuable consideration,the sufficiency and receipt of which is hereby acknowledged,the parties agree as follows: 1. All terms and conditions of the Provider Agreement are hereby adopted by both Member Provider and the City, with full consent and agreement of Rockport, to apply as a direct contractual agreement between Member Provider and the City.All references to certified networks as well as the Texas Insurance Code, Chapter 1305 and Sections 408.023, 408.027, and 413.041 of the Texas Labor Code are hereby deleted as they do not apply to a Provider Panel set up under section 504.053 of the Texas Labor Code. The City's Provider Manual (under the name of Blackstone) shall instead apply to matters of notice, billing, dispute resolution, complaints, preauthorization,and related matters. 2. The parties agree that the City will bear the financial responsibility for payment to Member Provider 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. Fort Worth Brain& Spine Institute 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 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 written above. For and on behalf of: City of Fort Worth Blackstone Provider Panel Signature: Date: C) Name: Su n A nis Assistant Ci1y Manage APPROVED AS TO FORM AND LEGALITY: IS C. Mcb1,110 AsE ijtaAt City Att rney O�frORT�2 Attested-BY:Q a K.Kayser,City Secretary k * e r i i�vr�Wesith l3raltY ant(Spine Institute RO�I�O��_�€1)YJNI�'�.N�,�f'Vt►C?ZtK ' I�rtte:,��i3i'fff'ao Acci . Title;•Se''Y ?-resident MOM.LR-FRO..V-XD 1 L of Rep7resent�itive/Des�nee Tile> ftiE1'2 _ _ bate.: • �`,1.�1':.5�-114.1 ' • � . I 3 ( 59.4 b3 �.N ROCKPORTT11 MEDICAL GROUP AGREEMENT ROCKPORT UNITED NETWORK ROCKPORT SELECTHEALTH NETWORK This Medical Group Agreement ("Agreement"), is I. DEFINITIONS entered into by and between Rockport Community Network, Inc., a Nevada Corporation, dba Rockport When used in this Agreement and unless the content Healthcare Group ("RHG"), dba Rockport United otherwise clearly requires, the following words and Network (a preferred provider organization for terms shall mean: Occupational Injuries and Illnesses), dba Rockport SelectHealth Network (an exclusive provider 1.1 "Physician"means a licensed Medical Doctor or network) and Fort Worth Brain and Spine Doctor of Osteopathic Medicine, or group of same Institute ("Member Provider"), and will become who desire to become a Member Provider with effective as of the date the provider is fully RHG. credentialed by RHG. Pursuant to §10.42 of Texas Insurance Code 1305 WHEREAS, RHG is engaged in the business of regarding Network Contracts with Providers seeking developing and acting in an administrative capacity to participate in Texas Certified Vorkers' in providing Occupational Injury and health provider Compensation Networks, networks that offer direction of care while providing savings to RHG clients and/or Payors. These I.2 "Qualified Paxticinant" means an "employee" as networks will offer greater coverage of services and defined and used in the Texas Labor Code, the savings;and Network Act Section 1305 and the implementing rules who sustained a work-related injury/illness that WHEREAS, RHG has networks of contracted is determined compensible by an employer and that physicians, physician groups, hospitals and participates in the Rockport United Network or providers of ancillary healthcare services Rockport SelectHealth Network through Rockport's (collectively, the "Member Providers") to provide a Client. Unless in an emergency or after business full-range of healthcare services. These services are hours, initial services provided for the work-related available for use by "Qualified Participants" as injury/illness require authorization by the Employer defined in I.2 of this Agreement; and and/or network either in writing or by telephone. WHEREAS, Member Provider desires to provide I.3 "Client" means an insurance company, certified medical care services to "Qualified Participants" self-insured or governmental entity as those terms who are covered by Payor Agreements at the rates in are defined and used in the Texas Labor Code, the Exhibit B and in locations listed in Exhibit C:and Network Act Section 1305 and the implementing rules. These Clients have entered into a Client WHEREAS, RHG has entered into Agreements Agreement with RHG 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. I.4 "Pavor" 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 Page 1 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012 according to State and/or Federal Rules and and authorized care other than primary treating Regulations. services. Specialists will need to maintain their I.5 "Client Agreement" means the agreement current board certifications for their particular between R4G and a Client, which agreement is specialty to maintain their RHG classification as made before, on or after the effective date of this such and be willing and able to treat Qualified Agreement and which expresses the agreed upon Participants as needed or required.. contractual rights and obligations of the parties, Such Client Agreements will require Payors to pay I.9 "Emergency Medical or Mental Condition" is Member Provider for Covered Services rendered to defined as the sudden onset of a medical condition Qualified Participants pursuant to this Agreement. manifested by acute symptoms of sufficient severity, Furthermore, such Client Agreements shall authorize including severe pain,that the absence of immediate RHO to enter this Agreement and contractually bind medical attention could reasonably be expected to Payors to the terms hereof unless there is a conflict result in: with State and/or Federal rules and regulations. (a)placing the patient's health or bodily functions in serious jeopardy;or I.d "Member Provider" means any physician; (b) serious dysfunction of any body organ or part as physician group; hospital; surgery center; diagnostic defined in TIC 1305.004(15); and imaging center; laboratory; clinic; chiropractor; (c) in the case of a mental health condition, one that dentist; podiatrist; psychologist; social worker; could reasonably present danger to the person physical, occupational and speech therapist; etc. experiencing the mental health condition or another licensed or certified to practice a healthcare person as defined in TIC 1305.004(13). profession or licensed as a facility to offer healthcare services, in the state where services are rendered and I.10 "Covered Services" are those healthcare and who has executed a contract with RHO. health-related services provided to Qualified Participants for treatment of a compensible, work- I.7 "Primary Treating Physician/Clinic" According related injury/illness as defined by either nationally to Texas law for certified workers' compensation recognized treatment guidelines and/or individual networks, the Network decides who will be a treatment protocols that do not conflict with any Treating Doctor. Therefore, a Member Provider who state and/or federal rules and regulations. is a Medical Doctor (MD) or a Doctor of Osteopathic Medicine (DO) that specializes in I.11 'Bill and/or Claim Form" CMS 1500 (or other Family Practice, General Practice, Occupational appropriate claim form or their successors) Medicine or Internal Medicine as well as a physician completed in accordance with the guidelines that provides initial and/or follow-up care in Occ- established by the National Uniform Billing Med or Urgent Care Clinics whose practice is Committee or CMS 1500 billing guidelines, and/or largely dedicated to caring for work related injuries state rules and regulations. and illnesses is designated by RHO as a Primary Treating Physician/Clinic (PTP). PTP agrees to II. MEMBER PROVIDER OBLIGATIONS render medical care to Qualified Participants without a scheduled appointment and must be available and II.1 Services. Member Provider agrees to provide or accesible to employees twenty-four (24) hours-per- arrange for all medically necessary medical care for day, seven (7) days-per-week as per 28 TAC Qualified Participants who present themselves to 10.80(b)(1). Should a Qualified Participant need Member Provider. Member Provider agrees to medical attention outside of Member Provider's perform such services with the same standard of normal business hours, Member Provider will be care, skill and diligence for all Qualified available and/or make arrangements to have another Participants. Member Provider agrees that it is their Member Provider render care to Qualified sole responsibility to verify that the individual Participant twenty-four(24)hours-per-day,seven(7) presenting for care is a Qualified Participant. days-per-week. Member Provider agrees to render healthcare services to Qualified Participants at any and all I.8 "Specialist Physician" means a Member Provider facility or practice locations listed in Exhibit "C". who has met the credentialing requirements of RHG Member Provider shall make best efforts to ensure to be a Specialist Physician, and to whom Primary that services provided are consistent with nationally Treating Physicians/Clinics may refer for necessary recognized treatment guidelines (i.e. Official Page 2 of 14 Fort Worth Drain and Spine Institute 02212013 RUNPHY TX_01-2012 Disability Guidelines (ODG), American I1.5 Referrals. Except in a medical emergency or Occupational and Environmental Medicine's when authorized by RHG, Client, or its designated (ACOEM) and /or state rules and regulations. representative, Member Provider agrees to refer 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 1.6. 11.2 Treatment Guidelines. Member Provider agrees to follow the treatment guidelines, return-to-work II.6 Reports. For each encounter where Member guidelines and individual treatment protocols Provider provides services to a Qualified Participant, outlined in Exhibit A of this Agreement, provided in Member Provider shall report such encounter on an RHG's Provider Handbook and/or Clients' appropriate form and shall include statistical, Utilization Review Programs.RHG agrees to furnish descriptive medical and patient data and identifying Member Provider or cause Payor to furnish to information, if and to the extent that reports are Member Provider, and Member Provider agrees to specified by RHG, Client or its designated abide by,the list of any treatments and services that representative, and requested information is not require preauthorization and by any procedures to prohibited by state and/or federal rules and obtain preauthorization. Unless in an emergency or regulations. after business hours, initial services provided for the work-related injury/illness require authorization by 11.7 Professional Requirements. the Employer and/or Network either in writing or by telephone. The Client and/or Payor may not deny II.7.1 Licensure&Accreditation. Member Provider treatment solely on the basis that a treatment for a shall comply with all applicable federal, state and compensible injury in question is not specifically local laws, rules and regulations governing like addressed by the treatment guidelines used by the providers and their provision of services. Evidence Client and/or Payor. However, Member Provider of such current licensing, certification and/or must demonstrate medical necessity to support accreditation shall be submitted promptly to RHG services rendered to Qualified Participants that are upon request. Member Provider represents and outside of treatment guidelines. warrants that it and each of its employees and contracted service providers has obtained, and shall 11.3 Non-Discrimination.Member Provider shall not maintain throughout the term of this Agreement, all differentiate or discriminate in the treatment of its necessary registrations, certifications, licenses, patients as to the quality of services delivered to permits and approvals as are required for the lawful Qualified Participants because of race, sex, age, provision of Member Provider services to Qualified religion, national origin, place of residence, source Participants. Member Provider shall immediately of payment or health status. Member Provider shall notify RHG of any revocation, suspension or observe, protect and promote the rights of Qualified restrictions, that would affect any certifications, Participants. licenses or accreditation's. Member Provider warrants that it is currently accredited by the Agency 1I.4 Medical Staff Participation. Certain medical that governs like providers and is certified as a specialties may not require hospital privileges such provider under Title XVIII (Medicare) and when as Occupational Medicine, Pathology, Dermatology, appropriate, Title XIX (Medicaid) of the Social Allergy, and those Primary Treating Security Act and that it shall -maintain such Physicians/Clinics whose practice is dedicated to accreditation and certification during the term of this treating work-related injuries and illnesses. Where Agreement. Member Provider shall immediately appropriate, Physicians must maintain active, notify RHG of any action, investigation or unrestricted staff privileges with at least one RHG proceeding to revoke, suspend, restrict, or otherwise Member Provider hospital or Surgery Center. affect such accreditation or certifications, Physician hereby consents to disclosure by such facility to RHG of all data collected with respect to I1.7.2 Organization's Requirements. Member Physician in connection with Physician's medical Provider shall use best efforts to comply with RHG's staff membership, including without limitation all criteria for provider participation, including applications for staff privileges and any renewals credentialing policies and procedures. Member thereof. Provider shall cooperate with RHG's periodic evaluation of qualifications. In addition, Member Provider shall use best efforts to cooperate with Page 3 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY_Tx 01-2012 i RHG's and/or state rules and regulations for the records. The Member Provider's obligations under expeditious resolution of any grievance or this Section II.9 shall survive the termination of this complaint. Agreement. I1.8 Notification to RHG. Member Provider 11.10 Inspection of Records and Operations. RHG, represents and warrants that information provided Payor or a designated representative shall have the herein and in the RHG application is true and right to inspect and audit, at all reasonable times accurate in all respects and acknowledges that RHG during normal business hours, upon prior five (S) 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 RHG Qualified Participants, services provided to best efforts to provide written notice to RHG 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; (ii) 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,RHG shall submit, in a timely fashion,any required books and records and II.9 Medical Records. Member Provider shall shall facilitate such examination. RHG 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 11,11 Relationship of Parties. Member Provider and state and federal laws. Member Provider shall RHG 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 made 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, RHG 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, RHG, Payor, or its designated 11.12 .Standards of Care. Member Provider agrees representative. RHG 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 Page 4 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY_TX_O1-2012 I ethics and conduct of the appropriate and applicable procedures promulgated by Federal and State professional organizations and/or associations,as the entities. case may be, and such other bodies, formal or informal, state, government or otherwise, or by III. RHG's OBLIGATIONS which they are subject to licensing/certification and control. Additionally, Member Provider shall III.1 Marketing to Clients/Payors. RHG shall enter perforin all medical and healthcare services in into agreements with Clients and/or Payors as conformance with the standards for their facilities as defined in 1.3 and 1.4 for their access to RHG quality established by the local/regional professional Member Providers through specific referral healthcare community and applicable processes. RHG will market Member Providers for accrediting/licensing agencies. Member Provider referral; including but not limited to the following: agrees that,to the extent feasible,it shall utilize such (i) Provider Search Provider Locator System (ii) additional allied health and other qualified personnel Provider Directories (iii) Site-Specific Provider as are available and appropriate for effective and Panels (iv) Customized Local Networks and (v) efficient delivery of care. Member Provider shall Client Service Provider Referral Service. ensure that all such personnel are properly licensed and/or possess the necessary credentials to render III.2 Credentialins. RHG will perform and/or the services that they perform. delegate to qualified organizations credentialing of each Member Provider. Credentialing may include II.13 Right to Use Member Provider's or Network's verification of all information and documents Name. Member Provider agrees to allow RHG to provided in the application for participation and list Member Provider's naive, specialty, address, investigation, including but not limited to telephone number, and hours of operation in a verification with all state and national licensing and Member Provider directory, Provider Search, RHG certifying bodies that apply to the services rendered Site-Specific Provider Panel(s), RHG website and/ by the Member Provider, such as JCAHO,AAAHC, or other materials to help promote and assist Clients NCQA, CLIA, URAC, etc. Inquiries may also be with Qualified Participants needing medical care for made to current and previous professional liability injuries/illnesses sustained. RHG agrees to allow carriers, Medicare and Medicaid. RHG's Member Provider to list RHG's name, address, and credentialing policies and procedures follow the telephone number on Member Provider's website or American Accreditation Healthcare Commission in other publications listing the health plans accepted (URAC) standards for Workers' Compensation by Member Provider. In addition, Member Provider provider networks. agrees to post in waiting room and make available to Qualified Participant notice of Member Provider's III.3 Operational Functions. RHG shall utilize participation with RHG with name, address and systems to respond to Member Providers requests telephone number and process for Qualified for information and will provide clarification of Participants to resolve complaints. The Member policies concerning the operation of RHG's Provider is required to post, in Member Provider's programs. Member Provider agrees to work in office, notice to employees on the process for cooperation with RHG to market the services of the resolving workers' compensation health care Member Provider to Clients and/or Payors. i network complaints. The notice must include the Texas Department of Insurance's toll-free phone RHG shall act as a liaison with the Member number for filing a complaint and must list all Providers and Clients and/or Payors to devote workers' compensation health care networks with necessary time and effort to perform RHG's which the Member Provider contracts. responsibilities hereunder. II.14 Noncompliance. Member Provider understands IIIA Retaliatory Action. RHG agrees not to engage that failure to comply with any of the requirements in any retaliatory action including termination of imposed pursuant to this Agreement may result in contract or refusal to renew a contract against termination of this Agreement by RHG. Member Provider, because Member Provider, on behalf of an Qualified Participant,reasonably filed a II.15 Antitrust Guidelines. Member Provider agrees complaint against, or appealed a decision of RHG or to comply with all antitrust guidelines and Payor, or requested reconsideration or independent review of an adverse determination. Page 5 of 14 FortWorth Brain and Spine Institute 02212013 RUNPHY TX_01-2012 Covered Services to a Qualified Participant shall be III.5 Antitrust Guidelines. RHG agrees to comply conditioned upon a good faith determination by the with all antitrust guidelines and procedure Payor or its designated representative that (i) such promulgated by Federal and State entities. services are medically necessary, whether such determinations are made before, on or after the III.6 Audit Policy and Procedure Compliance. All provision of services to such Qualified Participant, bill audit requests by Payor shall be done in 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. REIMBURSEMENT,CLAIMS will be subject to the reimbursement rates SUBMISSION AND PAYMENT established in the Exhibit B of this Agreement. IV.1 Reimbursement. RHG 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 RHG is acting solely in an administrative capacity in other appropriate claim form or their successors) and providing a network of quality health services. RHG 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 95'h day after the circumstance will a Member Provider 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 compensible, 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 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 S. Member Provider hereby agrees that 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 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 compensible injuries from claim. A complete and accurate claim shall be Qualified Participants. In addition, Member 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 Page 6 of 14 Fort Worth Brain and Spine Institute 022120I3 RIJNPHY_TX_01-2012 Qualified Participants harmless for amounts not paid "claims-made" policy, Member Provider agrees to by Payor for any reason, including Payors provide and maintain such insurance coverage or a insolvency. This provision does not preclude billing "tail" policy in the same amounts following the a Non-Qualified Participant for a non-compensible termination of this Agreement. Member Provider injury, shall promptly demonstrate evidence of insurability or self-funded program and that the required IV.4.1 Transfer of Risk. This Agreement and any insurance is paid and in force upon request of RHG subcontract within shall not be interpreted to involve and/or meet the credentialing guidelines of RHG. a transfer of financial risk for the provision of health care services from Payor to REG as defined under V.2 Indemnification of RHG. RHG will be Insurance Code §1305.004(a)(26). Member Provider responsible for its own acts or omissions and any agrees and acknowledges that RHG is acting solely and all claims, liabilities, injuries, suits and demands in an administrative capacity in providing a network and expenses of all kinds which may result or arise of quality health providers. RHG is not the claims out of any alleged malfeasance or neglect caused or paying agent and will not be liable for the payment alleged to have be caused by its employees or of any amount owed by a Payor to Member Provider representatives, in the performance or omission of in the event that Member Provider is unable to any act or responsibility under this Agreement. In collect such amount of money up to and including the event that a claim is made against RHG, it is the the insolvency of Payor. intent of RHG to cooperate in the defense of said claim. However, RHG shall have the right to take IV.5 Payment of Claim Forms. RHG shall any and all actions they believe necessary to protect administratively arrange for the Payor or its their interest. designated representative to pay undisputed claims which are accurate, complete and comply with the V.3 Indemnification of Member Provider. Member Agreement within the time period mandated by state Provider will be responsible for its own acts or or federal law. omissions and any and all claims, liabilities,injuries, suits and demands and expenses of all kinds which IV.6 Erroneous Payment. In the event that a Payor may result or arise out of any alleged malfeasance or jand/or its designated representative pays the neglect caused or alleged to have be caused by its Member Provider (i) more than once, or (ii) an employees or representatives, in the performance or incorrect amount, or (iii) an overpayment, the Payor omission of any act or responsibility under this or its designated representative may, at its sole Agreement. In the event that a claim is made against option and discretion, request the return of such Member Provider, it is the intent of Member amount from Member Provider The Member Provider to cooperate in the defense of said claim. Provider will not unreasonably withhold However, Member Provider shall have the right to reimbursement. If overpayment has been made take any and all actions they believe necessary to Member Provider shall reimburse such overpayment protect their interest. within forty-five (45) days and/or follow State and Local Rules and Regulations. The Member Provider VI. TERM AND TERMINATION may not contest payment of Claims after one hundred eighty(180)days from the date of payment. VI.1 Term. The term of this Agreement shall be for All claims for overpayment or underpayment shall one (1) year from the date hereof and shall be be resolved in accordance with State Law and /or automatically renewed on an annual basis for Federal Rules and Regulations. successive twelve (12)month periods, unless sooner terminated in accordance with Section VI.2. V. INSURANCE AND INDEMNIFICATION VI.2 Termination. This Agreement may be V.1 Insurance Requirement. Member Provider shall terminated sooner on the first to occur of the i provide and maintain such policies of professional following: liability insurance or a self-funded program. The j amounts and extent of such insurance coverage or V1.2.1 Termination by Member Provider. Member iself-funded program shall be in the amounts Provider may terminate this Agreement in the event determined by community standards for relevant of a material default or breach of RHG's obligations hospital/facilities, If such coverage is under a hereunder,upon ninety(90)days prior written notice Page 7 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY TX_01-2012 and the failure of RHG to cure such breach or Upon written notification from RHG, Member default within sixty (60) days of the notice. In Provider may request a review by RHG's advisory addition, in the event of an "emergency situation", review panel, not later than thirty (30) days after Member Provider may terminate the Agreement notification. RHG must then complete the review immediately with the acknowledgment by RHG that before the effective date of termination. such an emergency condition does exist. "Emergency Situation" shall mean an unforeseeable VI.2.3 Termination for Insolvency. This Agreement event, not resulting from Member Provider's act or shall terminate immediately in the event that either omission, which materially affects Member RHG or Member Provider voluntarily or Provider's ability to continue the practice of involuntarily, liquidates, dissolves or becomes medicine or to perform his obligations hereunder. subject to any proceeding for the rehabilitation or The network will provide notification to employees conservation of their financial affairs with written of the terminating Member Provider immediately notification. upon receipt of the Member Provider's termination request or as soon as reasonably possible 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)(G). either party may terminate the Agreement with at least ninety (90) days prior written notice to the VI.2.2 Termination by RHG. 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 losses 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 RHG of a material party may terminate this Agreement upon thirty (30) default or breach by Member Provider hereunder 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 RHG deems it necessary to terminate Member Provider's agreement based on the above VIA Qualified Participant and Payor Notification.If requirements RHG will notify Member Provider at applicable, upon the termination of this Agreement, least ninety (90) days before the effective date of by either party, Member Provider shall cooperate termination. with RHG to notify Qualified Participants and Payors of such termination. Page 8 of 14 Fort Worth Brain and Spine institute 02212013 RUNPHY TX O1-2012 I trust all Confidential Information. Upon termination VII.CONTINUATION OF BENEFITS of this Agreement by either party for any reason whatsoever, RHO and Member Provider shall VII.1 Continuation of Benefits. If Member Provider promptly return to the other all material constituting voluntarily terminates its contract with RHO, upon Confidential Information or containing Confidential Member Provider's request, Payor must continue to Information, and neither party will not thereafter reimburse Member Provider for a period not to use, appropriate, or reproduce such information or exceed 90 days at the Member Provider's contracted disclose such information to any third party. RHO rate set forth in Exhibit B of this Agreement with and Member Provider specifically agrees that under RHO,for care of an Qualified Participant with a life- no circumstances will either party discuss the terms threatening condition or an acute condition for and conditions of this Agreement, and in particular which discontinuing or disruption of care would the pricing information herein. harm the Qualified Participant as per 28 TAC 10.42(b) (A). Any disputes concerning continuity of IX. MISCELLANEOUS care shall be resolved through the complaint process under Insurance Code §1305.401 - §1305.405 and IX.I Disputes. All disputes and difference between Subchapter G of Title 28, Part 1 (relating to the Member Provider and RHO upon which an 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 throuirh RHO. The Member shall survive the termination of this Agreement Provider shall notify RHG 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 RHG. 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 i 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 RHG 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 all 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 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"). RHO and Member IX.1.3.1 RHO will provide notice to the Member Provider acknowledges that the Confidential Provider at least 90 days before the effective date of Information and all other information regarding a termination by RHO; RHO or Member Provider that is competitively i sensitive is the property of RHO or Member IX.1.3.2 Upon receipt of the written notification of 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 4 party. Accordingly, RHG and Member Provider panel no later than 30 days after receipt of the agrees to keep strictly confidential and to hold in notification; Page 9 of 14 j Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012 I requirements under any state or federal fair IX.1.3.3 The Network will provide an advisory employment practices, equal employment review panel that consists of at least three Providers opportunity, or similar laws declaring discrimination of the same licensure and the same or similar in employment based upon race, color, creed, specialty as the Member Provider, religion, sex, or national origin as illegal, and, Titles VI and VII of the Civil Rights Act of 1964, Section IX.1.3.4 The Network must complete the advisory 202 of Executive Order 11246 as amended by panel review before the effective date of the Executive Order 11375, Sections 503 and 504 or the termination; Rehabilitation Act of 1973 and Title IV of the Vietnam Era Veterans Readjustment Assistance Act IX.1.3.5 The Client, Payor, or RHO may not notify of 1974, and Sections 1 and 3 of Executive Order patients of the termination until the earlier of the 11625, or any applicable rule or regulation effective date of the termination or the date the promulgated pursuant to any such laws or orders. advisory review panel makes a formal recommendation; IX.6 Governing Law. This Agreement shall be governed by and construed in accordance with IX.1.3.6 If Member Provider terminates the contract, applicable state law. the Network or RHG's Client will provide notification of the termination to employees IX.7 Amendments. This Agreement may be receiving care from the terminating provider. The amended as agreed to by both parties in writing upon Network shall give such notice immediately upon thirty (30) days written notice of such proposed receipt of the Member Provider's termination amendment. request or as soon as reasonably possible before the effective date of termination. IX.8 Severability. The invalidity or un- enforceability of any term or condition hereof shall IX.2 Non-Exclusivity. Nothing in this Agreement in no way affect the validity or enforceability of any shall be construed to restrict Member Provider or other term or provision: RHO from entering into other contracts or agreements to provide healthcare services to Payors IX.9 Assignment. Member Provider may not assign or other healthcare delivery plans, patients, and or otherwise transfer any right or delegate any duty employer groups. of performance hereunder, in whole or in part without the prior written consent of RHG. A change IX.3 Entire ALxreement. This Agreement contains in ownership will not negate the prior contractual the entire understanding of the parties and agreement without written notification to RHO. supersedes any prior understandings and agreements, RHO retains the right to assign this Agreement, in written or oral, respecting the subjects discussed whole or in part,to any entity with which RHO or its herein. parent 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 IX.10 Third Party Beneficiaries. Except for Payors Agreement shall not operate as or be construed to be and the agents thereof, there are no third party a waiver of any subsequent breach hereof. beneficiaries of this Agreement. IX.5 Regulatory Compliance. Member Provider, IX.11 Captions. The captions and headings sub-contracting providers, and RHO agree that each contained in this Agreement are for reference shall comply with all applicable requirements of purposes only and shall not affect in anyway the municipal, county, state and federal authorities, all meaning or interpretation of this Agreement. municipal and county ordinances and regulations, and all applicable state and federal statutes and IX.12 Execution of Counterparts. This Agreement regulations, now or hereafter in force and effect, may be executed in any number of counterparts, governing RHG, Member Provider, sub-contracting including facsimiles, each of which shall be deemed providers, the provision of services by Member to be an original as against any part whose signature Provider or sub-contracting providers, and/or appears thereon, and all of which shall together jPayors, including but not limited to applicable constitute one and the same instrument. Page 10 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012 l I I IX.13 Partial Invalidity. If any part, clause or IX.17 Official Notices. Any notice or provision of this Agreement is held to be void by a communication required, permitted or desired to be court of competent jurisdiction, the remaining given hereunder shall be deemed effectively given provisions of this Agreement shall not be affected when personally delivered or mailed, return receipt and shall be given construction, if possible, as to requested, or overnight express mail addressed as permit it to comply with the minimum requirements follows: of any applicable law, and the intent of parties hereto. IX.14 Financial Incentives. Neither a Client, Payor, nor RHG may use financial incentive or make a payment to a health care provider that acts directly Member Provider or Representative/Designee: or indirectly as an inducement to limit medically (Please Print) necessary services. The adoption of treatment and return-to-work guidelines and individual treatment Name: protocols by RHG or Network is not in violation of this section as pursuant to Insurance Code §1305. Organization:Fort Worth Brain and Spine Institute 304 and §10.83(a)of Clip 10 of Title 28 Part 1, IX.15 Financial Disclosure Requirements. Member Address: 1325 Pennsylvania,Ste 890 Provider is required to file financial disclosures in City/State/Zip:Fort Worth,TX 76014 accordance with Labor Code §§408.023 and §§413.041. Telephone:(817) 878-5333 1X.16 Economic Profiling. Network must provide Fax: written notice to Member Provider before the Network conducts economic profiling, including Organization: utilization management studies or other profiling of Rockport Community Network,Inc. the provider or group of providers. dba Rockport Healthcare Group Attn: Director of Network Development 50 Briar Hollow Lane,Suite 515W Houston,TX 77027 Telephone:(713)621-9424 Fax: (713)621-9511 IN WITNESS WHEREOF, the undersigned will be or to such other address, and to the attention of such deemed to have executed this Agreement as of the other person(s) or officer(s) as either party may date the provider is fully credentialed by RHG, designate by written notice. For and on behalf of: For and on behalf of: Rockport Community Network,Inc. dba Rockport Healthcare Group Member Provider or Repr s t ve/Designee 50 Briar Hollow Lane,Suite 515W Houston,f;�k Signature• Name: . eW!\ - Mark C.Neer cL � {{ (Print) Sr.Vice Preside t,Ne rk Dev lopment TIN: ! "j 4� `-1 I r al Date: Date: Z I ko l I Page 11 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY_TX_01-2012 I I f EY-=IT A STANDARDS AND GUIDELINES UTILIZATION REVIEW AND QUALITY IMPROVEMENT PROGRAMS RHO and its Clients require Member Providers to follow 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. RHO's Clients provide utilization review and quality improvement programs for Qualified Participants. RHO shall review each Cliegts 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 jbound by such programs and any state or federal rules and regulations. Such Standards and Guidelines for Utilization Review Programs may be amended from time to time upon written notice to Physician and/or Member Provider. The primary goals of the Utilization Review Programs shall be to: 1) Ensure and certify for the payment of benefits that healthcare services meet the definition of medical necessity as defined by the network,Payor or the Payors designee; 2) Ensure that healthcare services are provided at the appropriate level of care;and 3) Ensure that healthcare services follow nationally recognized treatment guidelines that are evidenced-based and outcome-focused. Treatments and Services that may Require Preauthorization: 1) In-patient hospital admissions including the principal scheduled procedures(s)and the length of stay; 2) Outpatient surgical or ambulatory surgical services; 3) Spinal surgery, as provided by Texas Labor Code§408.026; 4) All psychological testing and psychotherapy, repeat interviews, and biofeedback; except when any service is part of a preauthorized or exempt rehabilitation program; 5) All external and implantable bone growth stimulators; 6) All chemonucleolysis; 7) All myelograms,discograms,or surface electromyograms; 8) Unless otherwise specified,repeat individual diagnostic study,with a fee established in the current Medical Fee Guideline of greater than$350 or documentation of procedure(DOP); 9) Work hardening and work conditioning services provided in a facility that has not been approved for exemption by the Division; 10) Rehabilitation programs to include (a) outpatient medical rehabilitation and (b) chronic pain management / interdisciplinary pain rehabilitation; 11) All durable medical equipment (DME) in excess of$500 per item (either purchase or expected cumulative rental)and all transcutaneous electrical nerve stimulator(TENS)units; 12) Nursing home,convalescent,residential,and all home health care services and treatments; 13) Chemical dependency or weight loss programs; 14) Any investigational or experimental service or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care;and 15) Physical and occupational therapy services;(a)physical and occupational therapy services are those listed in the Healthcare Common Procedure Coding System (HCPCS) Level I code range for Physical Medicine and Rehabilitation, but limited to: (i) modalities, both supervised and constant attendance; (ii) therapeutic procedures,excluding work hardening and work conditioning;and(iii)other procedures, limited to the unlisted physical medicine and rehabilitation procedure code. NOTE: Preauthorization is not required for the first two visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediately following: (i)the date of injury, or(ii)a surgical intervention previously approved by the payor. Page 12 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPEY TX 01-2012 it i EXHIBIT B Reimbursement Schedule I.Rockport United Network/Rockport SelectHealth Network-Occupational Injury and Illness Provider fees for the programs listed above shall be reimbursed at the following: All fees will be reimbursed at 100% (one hundred percent) of the state's current Workers' Compensation fees, rules and regulations or usual and customary allowables with the following hardcoded exceptions: 99201 $65. 99214 $156. 99202 $110. 99215 $210. 99203 $158. 72010 $120. 99204 $241. 72040 $54. 99205 $300. 72050 $73. 99211 $30. 72070 $50. 99212 $65. 97002 $62. 99213 $107. 97750 $50. Coverage: Coverage for all procedures on the fee schedule is subject to the terms and conditions of this Agreement,state rules and regulations and/or the applicable Occupational Injury or Illness Benefit Plan. I/We accept the fees as outlined in this Exhibit B. For and on behalf of: For and on behalf of: (Name,address,etc.) ROCKPORT COMMUNITY NETWORK,INC. Fort Worth Brain and Spine Institute dba Rockport Healthcare Group 1325 Pennsylvania,Ste 890 50 Briar Hollow Lane,Suite 515W Fort Worth, TX 76014 Houston,Texas 77027 L� Signature `,, ,n (�,, Mark C.Neer Printed a ��t \1 V lk- -Z Sr.Vice President,Netw k Dev opment Title !{ Date le h TIN Date i i Page 13 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY TX 01-2012 i EXHIBIT C Signature Page Physicians and locations where services are to be rendered byMember Provider Member Provider agrees that the following physicians and practice locations listed on this Exhibit C shall be inclusive of the signed agreement and the signed rates in Exhibit B. By signing below,Member Provider or its Representative/Designee allows Rockport Healthcare Group(RHG)and its representatives to use any and all of the attached information as agreed to in the signed agreement. Fort Worth Brain and Spine Institute Fort Worth Brain and Spine Institute Practice Name Practice Name(2) Brent Alford,MD Samir Lapsiwala,MD Physician Name(if applicable) Physician Name(if applicable) 1325 Pennsylvania Ave,Ste 890 1325 Pennsylvania Ave. Ste 890 Physical Address Physical Address Fort Worth,TX 76104 Fort Worth,TX 76104 City,State Zip City,State Zip Mailing Address(if different) Mailing Address(if different) (8 17)878-5333/«\—+) �'I %-S33y (817)878-5333 / '%--'d'S33Li Phone Number/Fax Number Phone Number/Fax Number 57-1141121 57-1141121 Tax ID Number Tax ID Number Practice Name(3) Practice Name(4) Physician Name(if applicable) Physician Name(if applicable) Physical Address Physical Address City, State Zip City,State Zip I Mailing Address(if different) Mailing Address(if different) Phone Number/Fax Number Phone Number/Fax Number Tax ID Number Tax ID Number For and on behalf of: For and on behalf of: Rockport Community Network,Inc. dba Rockport Healthcare Group Member Provider or Repres live esignee 50 Briar Hollow Lane,Suite 515W Houston,TX 77027 Signature: Name: {� Marls C.Neer (print) Sr.Vice Pres dent,Ne rk D velopment Date Date: du i Page 14 of 14 Fort Worth Brain and Spine Institute 02212013 RUNPHY TX_01-2012 1