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HomeMy WebLinkAboutResolution - 6228 - Contract - Southwest Medical IPA - Preferred Physician Network - 03_11_1999Resolution No.6228 Item No. 18 March 11, 1999 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock BE and is hereby authorized and directed to execute for and on behalf of the City of Lubbock, a contract to provide a preferred physician network, by and between the City of Lubbock and Southwest Medical IPA, and related documents. Said contract is attached hereto and incorporated in this resolution as if fully set forth herein and shall be included in the minutes of the City Council. Passed by the City Council this 11th day of March , 1999. F << , PArVEMMIA ATT46� Kayt e arnell City kdretary APPROVED AS TO CONTENT: Mary Andre s Managing Director of Human Resources APPROVED AS TO FORM: William de Haas Competition and Contracts Manager/Attorney rkb1ccdocs11999 physiciannetwork.res March 11, 1999 Resolution No. 6228 Item No. 18 March 11, 1999 IPA PHYSICIAN PARTICIPATION AGREEMENT THIS AGREEMENT ("Agreement") is made and entered into by and between City of Lubbock and Southwest Medical IPA ("RA'� effective as of December 1, 1998. RECITALS A. City of Lubbock is engaged in the business of marketing, negotiation and administering a network of health care providers and organizations to payers of health care services. B. IPA desires to enter into an Agreement with City of Lubbock to provide or arrange, through its affiliated physicians, certain health care services for eligible individuals enrolled in health benefit plans by participating in one or more City of Lubbock provider panels. THEREFORE, the parties agree as follows: 1. DEFINITIONS 1.1. "Agreed Fees" means the reimbursement amounts agreed to under each Payer Agreement for Covered Services. 1.2. "Enrollee" means any person who is eligible for Plan coverage and whose sponsor has a contract with City of Lubbock. The term "Enrollee" shall include an Enrollee's dependents to whom coverage is automatically extended or for whom coverage has been purchased under a Plan and whose sponsor has a contract with City of Lubbock. 1.3. "Covered Services" means medically necessary health care or medical services for which benefits are payable under a Payer's Plan. 1.4. "Medically Necessary" means those health care services, in accordance with applicable utilization management policies of City of Lubbock and/or a Payer, are: 1.4.1. appropriate for the symptoms and diagnosis or treatment of the Covered Person's condition, illness, disease, or injury; 1.4.2. provided for the diagnosis, or the direct care and treatment of the Covered Person's condition, illness, disease or injury; 1.4.3. in accordance with current standards of good medical practice; 1.4.4. not primarily for the convenience of the Enrollee or the Participating Provider; and 1.4.5. the most appropriate supply or level and location of service that can safely be provided to the Enrollee. -1- Medically Necessary decisions or disputes shall be reviewed and resolved by a physician or Medical Director for the particular Payer Plan, or shall otherwise be settled following the dispute resolution procedures of the Agreement as set forth in Exhibit A. For Hospital stays, this means that acute care as an inpatient is necessary due to the kind of services the Enrollee is receiving or the severity of the Enrollee's condition and that safe and adequate care cannot be received as an outpatient or in a less intense medical setting. The determination as to medical necessity shall be made solely to determine whether Covered Services are eligible for payment under a Plan and shall have no implication or precedential effect on any issue as to professional malpractice. 1.5. "Emergency" Means an accidental injury or sudden onset of illness which, at the time of the injury or onset of illness and from the view of a reasonably prudent person, is life -threatening or presents a serious threat to the enrollee's continued health. In the event an enrollee requires emergency services, provider shall render such services in accordance with applicable law before beginning enrollee verification. Provider will notify Payer on the next regular business day after the emergency services are provided to obtain verification of eligibility and authorization of or continued treatment. If such verification is obtained and an authorization code issued, Payer shall pay for all covered services, including emergency services rendered to enrollee. Any dispute regarding the provision of emergency services will be reviewed and resolved by a physician or the Medical Director of the Payer Plan, or will be settled following the dispute resolution procedures or the Agreement. 1.6. "Group provider" means a licensed physician or other licensed/certified health care professional in the State of Texas who: (a) practices his or her profession through a Group; (b) is employed by, a member of, associated with or otherwise represented by a Group; (c) is authorized by a Group to provide or arrange for health care services pursuant to this Agreement; (d) has completed a Participation Application; (e) has been approved by City of Lubbock as a Panel Participation Provider; and, (f) has agreed to be bound by and abide by the terms and conditions of the Agreement or is otherwise bound to comply with the terms and conditions of this Agreement through provider's professional association with Group. 1.7. "Network Participant" means a physician -hospital organization, physician organization, hospital, physician, dentist or other provider of health care goods or services that has entered into a Participation Agreement with City of Lubbock. A roster of Payer's Network Participants is set forth Exhibit B, attached hereto, and shall be updated by Payer periodically. " Health Agreement; City of Lubbock & Southwest Medical IPA" 2 1.8. "Non -covered Services" means all health care or medical services that are not Covered Services, either as specifically identified in a Payer's benefit plan or by determination by appropriate review process as elective or other wise not covered. 1.9. "Participating Physician" means a doctor of medicine, podiatry, or osteopathy who is duly licensed to practice his/her specialty in the State of Texas and who has entered into a Participation Agreement with IPA. 1.10. "Participating Provider" means a Participating Physician, group practice, Participating Provider, or other provider of health care goods or services that has entered into a Participation Agreement with IPA. A roster of IPA's current Participating Providers is set forth in Exhibit B, attached hereto, and shall be updated by IPA periodically to reflect new Participating Providers. 1.11. "Plan" means the medical benefits program that a Payer maintains and funds on behalf of the Enrollees. 1.12. "Payer" means an employer or third -party Payer that has entered into a Payer Agreement with City of Lubbock and shall also include, when the context requires, any third -party administrator of a Plan. Those payers will have access to covered services. 1.13. "Payer Agreement" means a non-capitated agreement for the provision of health care services to a Payer's Enrollee by Participating Provider. 1.14. "Provider Manual" means a manual provided by Payers to health care professionals containing rules, policies, procedures, and programs governing the administration of Payer's Health Plan, including, but not limited to, utilization management and quality assurance programs, eligibility verification procedures, claim procedures, grievance and dispute resolution procedures. 1.15. "UR/QM Plan" means the utilization review and quality management plan, as established and amended from time to time by City of Lubbock or by an individual payer, intended to monitor Network Participants' utilization of resources and quality of service provided to Enrollees. 2. PARTICIPATING PROVIDER OBLIGATIONS 2.1 Provision of Service. Subject to the Participating Provider's medical specialty, practice, available facilities and service capability, each Participating Provider agrees to provide or arrange for the provision of services for Enrollees with the same standard of care, skill and diligence customarily exercised by similar physicians and licensed health care professionals in the community in which such services are rendered. The " Health Agreement; City of Lubbock & Southwest Medical IPA" 3 services to be provided under this Agreement are set forth and described in the applicable Payer Reimbursement Attachment to this Agreement and incorporated herein by reference. Participating Provider agrees to make such Services available and accessible to Enrollees in the same manner, in accordance with the same standards, and with the same access and availability as provided or arranged for Provider's other patients. Participating Providers shall not discriminate against any Enrollee in the provision of services on the basis of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, health status, physical handicap, income, source of payment or participation in a prepaid Health Plan. Any Participation Provider may close his or her practice at any time upon written notice. 2.2 Applications and Credentialing. Participating Providers agree to adhere to the NCQA credentialing and recredentialing policies, criteria and procedures. Each Provider shall provide all information and copies of all documentation pertaining to such Provider's Participation Application to the IPA. City of Lubbock will not list a Provider in directories of Participating Providers until such provider is credentialed and approved to participate by the IPA in accordance with the NCQA Credentialing Program. Each Provider hereby authorizes IPA to investigate and verify Provider's status with regard to privileges, licensure, board certification, accreditation, professional liability insurance, experience, and peer review actions as necessary. Provided, however, Group and Participating Providers shall not be required by this provision, or any other provision of this Agreement, to disclose information which is immune, privileged or otherwise protected from disclosure under applicable law. Each Provider, and any health care professional publicized by Group and Participating Providers in rendering Services shall maintain all applicable professional licensing, certifications and accreditations required under applicable law for the type of Service rendered, including continuing professional education, at all times during the term of the Agreement. Participating Providers shall notify IPA immediately of material changes or inaccuracy in their Participation Application and credentialing information. IPA acknowledges that City of Lubbock enters into this Agreement in reliance on the truth and accuracy of the information, representations and documentation contained in each Providers Application. IPA agrees that City of Lubbock shall have the right to terminate a Participating Provider's participation under this Agreement immediately in the event any material information or representation in a Participating Provider's Participation Application is discovered to be false, inaccurate, incomplete or omitted. 2.3 Privileges. Each Participating Provider agrees to maintain active medical staff or clinical privileges in a Panel participating hospital or health care facility, or in a non -Panel hospital or health care facility approved in writing in advance by City of Lubbock, and maintain all necessary qualifications and standards for such privilege throughout the term of this Agreement. " Health Agreement; City of Lubbock &c Southwest Medical IPA" 4 2.4 Physician Coverage. IPA shall require its Participating Physicians to provide or arrange coverage so that Covered Services are available and accessible twenty-four hours a day, seven days a week for Enrollees requiring urgent or emergency service. 2.5 Utilization Management. IPA shall require its Participating Providers to abide by and comply with each Health Plan's Utilization Management Program established to authorize Services and review the Medical Necessity and appropriateness of Services provided to Enrollees. These programs generally require pre -authorization for admissions, out -patient services and referrals, concurrent and retrospective review of provided Covered Services, and Case Management. Group and each Participating Provider acknowledge failure to comply with applicable Utilization Management Program requirements may result in a reduction or denial of benefits payable under a Payer's Health Plan. Quality Management. Each Participating Provider rendering Services shall be solely responsible for the quality of Services rendered to Enrollees. Payers will implement Quality Management Programs to monitor the quality, availability and accessibility of protocols and standards of care. Group and each Participating Provider agree to cooperate in resolving quality matters and to comply with the Quality Programs of Payers. Group or a Participating Provider's failure to satisfactorily resolve quality matters may result in termination of the Agreement upon proper notice to Group or the termination of an individual Participating Provider's Panel participation. The Medical Director of the IPA and/or the Quality Management Committee of the IPA will be involved in the Utilization Management and Quality Management process. 2.6 Standard of Care and Scope of Services. Participating Providers shall provide Covered Services to Enrollees in a manner similar to those services provided to any other patient within the usual and customary range of its facilities and personnel. No Participating Provider shall be obligated to provide any service that such Provider does not provide to other patients in the course and scope of its usual and customary business operations. Participating Providers may add or delete any service to this scope of business operations at any time upon at least thirty (30) days prior notice to City of Lubbock. If, in the sole judgment of the Provider, a satisfactory provider/patient relationship does not exist with a particular enrollee, that enrollee will be required to obtain another Provider through whatever mechanism is provided for the transfer of patients in the Payer benefit plan. 2.7 Insurance. At all times during the term of this agreement, Group and each Participating Provider shall, at his or her sole cost and expense, maintain such policies of comprehensive general liability and professional liability insurance " Health Agreement; City of Lubbock & Southwest Medical IPA" 5 at limits of coverage as required by City of Lubbock to insure Group, each Participating Provider, their employees and agents, and their business operations, against any claims or damages arising by reason of personal injury or death, occasioned directly or indirectly, in connection with the performance or non-performance of this Agreement and any Service under this Agreement by Group, a Participating Provider or their respective employees and agents acting within the scope of their duties and responsibilities pursuant to this Agreement. Primary Care Physicians shall maintain professional liability insurance in the minimum amount of two hundred thousand dollars ($200,000) for each claim and six hundred thousand dollars ($600,000) in the aggregate of all claims per policy year. Specialty Care Physicians shall maintain professional liability insurance in the minimum amount of five hundred thousand dollars ($500,000) per claim and one million dollars ($1,000,000) in the aggregate of all claims per policy year. Written evidence of required insurance coverages and compliance with City of Lubbock insurance requirements shall be provided to City of Lubbock upon request. IPA, Group, or Participating Provider shall notify City of Lubbock thirty (30) days prior to any termination, material modification or cancellation of any insurance coverage required under this section of the Agreement. 2.8 Duty to Inform. IPA and its Participating Providers shall make best efforts to notify City of Lubbock within ten (10) business days of any change in the information contained in the application for Participating Providers or any other information related to the IPA or its Provider's participation in the Network. Such information includes, but is not limited to: (a) any change in Group's name, ownership or business organization; (b) the addition of Participating Providers to the Group and withdrawal of Participating Providers set forth in Exhibit B to this Agreement; (c) any lapse, material change or reduction in any liability insurance coverage required by this Agreement for Group and individual Participating Providers; (d) the revocation, suspension, restriction, termination or voluntary relinquishment of any licenses, certifications or accreditations required by this Agreement for Group and Participating Providers; (e) any restriction, suspension, revocation or voluntary relinquishment of a Participating Provider's medical staff membership or clinical privileges at any health care facility; (f) any professional disciplinary investigation or proceeding brought against a Participating Provider or any disciplinary action taken against a Participating Provider by Group, the Texas Board of Medical Examiners, a peer review body, or any other State or Federal regulatory or licensing board, agency or body, and provide documentation of resolution of the investigation or proceeding; (g) any action taken to restrict, suspend or revoke the Group's or any individual Participating Provider's Medicare or Medicaid program participation status; or (h) Group's insolvency, the filing of a petition in bankruptcy or of receivership against Group or any determination that Group is bankrupt, order appointing a receiver for Group or order approving a petition seeking Group's reorganization under Federal bankruptcy law. " Health Agreement; City of Lubbock & Southwest Medical IPA" 3. NETWORK OBLIGATION 3.1 Negotiation of Payer Agreements. In the event this agreement is entered into with or through a marketing agent the following will apply: At all times during the term of this Agreement, City of Lubbock shall use its best efforts to identify potential Payers, to market all Participating Providers to such Payer, and to negotiate in good faith with such Payers. If, after reviewing a proposal for a Payer Agreement, City of Lubbock elects not to enter into that Payer Agreement, the IPA or any IPA Provider may enter into a contract or contracts with any or all such Payers. IPA reserves the right not to participate in any given Payer Agreement without penalty and may continue to participate in existing or future Agreements. 3.2 Nondisclosure. City of Lubbock shall not disclose IPA's or any Participating Providers schedule of charges or any other information provided to City of Lubbock to any third party, with the exception of disclosures to potential Payers pursuant to the authorization set forth in the agreement unless required by law. 3.3 Payer Information. City of Lubbock shall furnish IPA with a written summary of the terms and conditions of each executed Payer Agreement proposed to utilize IPA's Panel of Providers at least 30 days prior to effective date of such agreement. Information will include but is not limited to the Payer's name and address, the name and telephone number of the Payer's Plan representative, the Agreed Fees, and other information City of Lubbock deems relevant. City of Lubbock shall provide a copy of the Payer Agreement upon request by IPA. In addition, Payer will provide IPA with detailed information or policies regarding utilization review, peer review and quality management, grievance procedures, provider manuals, and all billing and claims submission requirements within the same time frame. 3.4 Negotiations with Payers. City of Lubbock shall ensure that each Payer Agreement includes the same or similar language addressing the following items, and shall further insure that Payer agreements do not conflict with other provisions of the agreement between City of Lubbock and the IPA: 3.4.1 Payer shall specify the Covered Services under its Plan. Payer shall notify City of Lubbock and IPA of any amendment(s) to its Plan at least ninety (90) days prior to the effective date of such amendment. 3.4.2 Payer shall be responsible, at its sole expense, for establishing and maintaining identification and verification procedures which IPA and its Participating Providers shall use in verifying Enrollees' eligibility for Plan coverage. City of Lubbock will insure, by contract provision, that Payers provide such plans. Payer shall furnish each enrollee with an " Health Agreement; City of Lubbock & Southwest Medical IPA" 7 identification card, setting forth, at a minimum, payer's name; a toll -free telephone number for eligibility and coverage questions; and the address for submitting provider's claims. Payer shall instruct its enrollees to present this identification card when obtaining services from provider. If Payer fails to furnish an identification card complying with this paragraph, Payer shall be obligated to pay provider's usual and customary charges for any services rendered to enrollees. If enrollee does not present ID card at time services are provided, Payer or enrollee shall be obligated to pay provider's usual and customary charges for services. 3.4.3 If coverage is verified under the Payer's verification procedure, Payer shall be responsible for payment of the Agreed Fees, regardless of whether such verification is in error, unless it can be shown that Provider has actual knowledge of Enrollee's ineligibility. If Providers cannot obtain timely pre -certification or authorization for services, i.e., unreasonable delays in telephone access or decisions regarding authorization, a complaint may be initiated through the Plan's grievance procedure to insure that action will be taken to improve this situation. 3.4.4 Network Participants shall have the right to interim bill Payers for hospital stays in excess of thirty (30) days. 3.4.5 Payer shall designate each Participating Provider as a preferred provider under its Plan. 3.4.6 Payer shall provide in its Plan financial incentives to Enrollees to utilize Network Participants. Such incentives shall comply with any criteria adopted by City of Lubbock and IPA. 3.4.7 In the case of HMO Payers, if Covered Services are not available through the Payers provider panel within a reasonable time period, upon request of a Network Participant, Payer shall allow referral to a provider outside the Payer's provider panel within a reasonable time period and shall fully reimburse the non -panel provider at the usual and customary or other agreed upon rate. Before the Payer may deny such a referral, the request shall be reviewed by a specialist of the same or similar specialty as the type of provider to whom a referral is requested. 3.4.8 Payer shall maintain the confidentiality of the terms of the Payer Agreement, each Network Participant's fee schedule, and all medical records. Payer shall be responsible for obtaining Enrollees' consent for the release, if required, of medical information required by Payer or City of Lubbock. " Health Agreement; City of Lubbock & Southwest Medical IPA" 8 3.4.9 The termination of the Payer Agreement shall not affect Payer's obligation to pay for (a) Covered Services provided by Participating Providers prior to the termination date and (b) Covered Services for a continuous course of acute treatment provided by a Participating Provider subsequent to such termination date to Enrollees who were properly under the care of a Participating Provider prior to such termination. 3.5 Utilization Review and Peer Review. City of Lubbock shall not interfere in any manner with the provision of health care or medical services by a Network Participant. The determinations of the UR/QM Plan shall be made solely to determine whether Covered Services are eligible for payment under a Plan and shall in no way be substituted for any Participating Provider's professional judgment. All City of Lubbock utilization review information regarding IPA or its Participating Providers that can be shared with IPA or its utilization or peer review committee under a legal privilege shall be provided to IPA, subject to conditions as may be necessary to preserve such privilege. A copy of the pre -certification process is attached hereto as Exhibit C. With respect to any peer review activities conducted by City of Lubbock for its Participating Providers, City of Lubbock shall adhere to the provisions of the Texas Medical Practice Act relating to the peer review privilege and will cooperate in good faith with the peer review committees of the Participating Providers. 3.6 Termination of Payer Agreement. Notwithstanding anything herein to the contrary, Network, upon the decision of its Board of Directors or its designee, shall have authority to terminate any Payer Agreement. In the event of such termination, Network will make reasonable efforts to give IPA at least (90) days' prior written notice of the effective date of termination, unless Payer is in breach of the Agreement. Network shall notify IPA immediately for any notice that a Payer is in breach of the Agreement. 3.7 Network Participant Relations. Network agrees that it will not permit its agents or employees to disparage or discourage any Enrollee from seeking care from any Network Participant. 3.8 Insurance. Throughout the term of this contract, payer shall maintain, at payer's sole cost and expense, policies of insurance or self-insurance providing coverage for payer's general liability combined single limit in the aggregate amount of $1,000,000 and professional liability in the minimum amount of $300,000 per claim, $600,000 aggregate, as may be necessary to protect payer or payer's employees, agents or representatives in the discharge of its or their responsibilities and obligation under this contract. " Health Agreement; City of Lubbock & Southwest Medical IPA" 9 4. REIMBURSEMENT AND BILLING. City of Lubbock will insure that Payer Agreements include the following provisions and obligations by specific language in each agreement. 4.1 Billing. Each participating Provider shall submit an itemized claim for Covered Services using the HCFA-1500 billing form, or a form containing equivalent information. Claims shall be submitted within forty-five (45) days following the provision of services, excepting that claims submitted later than that time will not be automatically rejected and Provider may give reasonable explanation for the delay in submission of claims. Clean claims will be paid by Payer within 30 days of receipt. A "clean claim" for purpose of this agreement is one that is submitted in accordance with Payer's directions, and that does not involve coordination of benefits, third - party liability, or subrogation. 4.2 Payer Reimbursement. IPA and each Participating Provider shall accept as payment in full for Covered Services rendered to Enrollees under this Agreement the reimbursement and/or compensation set forth in the applicable Payer's Reimbursement Attachment, attached hereto and incorporated herein as an Exhibit D less any applicable amounts for Co -payments, Coinsurance and Deductibles. Providers will be paid for Medically Necessary Covered Services only as described and/or defined in this Agreement, the designated Payer's Reimbursement Attachment, or the Payer Agreement and/or Health Plan. Except for co -payments and/or deductibles owed by Enrollees, payer shall agree to pay the Agreed Fees to Provider for Covered Services within forty- five (45) days or less of the date Payer receives a claim that satisfies the Payer's definition of a complete claim. Within fifteen (15) days of receipt, Payers shall be required to determine whether a claim is complete and request any information necessary to make such claim a complete claim. Payers shall apprise Network Participants of the status of any claim upon request and endeavor to resolve promptly any incomplete claim. If Payer fails to deny a claim within the 15 day period, Payer waives right to deny the claim. If Payer does not pay a claim within the 45 day period, the Payer will be required to pay 8% on all unpaid amounts with such amount occurring monthly until paid in full. Payer's failure to comply with such payment requirements may result in termination of such Payer Agreement. 4.3 Non -covered Services. Provider may bill the enrollee usual and customary fees for non -covered services that are requested or authorized by the enrollee. Provider will use best effort to advise the patient of services that might not be covered under a given benefit plan prior to rendering such services; however, if a service provided is later determined to be non -covered by the plan but has been authorized or requested by the enrollee, payment will be the " Health Agreement; City of Lubbock & Southwest Medical IPA" to responsibility of the enrollee. It is the responsibility of the Provider to insure that adequate documentation is available to show that the services were in fact requested by the enrollee. 4.4 Coordination of Benefits and Subrogation. Each Payer "Plan" will specify which party is responsible for coordination of benefits. IPA and Participating Providers will assist and cooperate with Payers in coordinating benefits for Covered Services with responsible Payers. Regardless, the Provider is entitled to collect reimbursement from all sources without limitation up to the usual and customary amount of charges. If Payer elects to exercise rights under subrogation, Payer must make payment to IPA or Participating Provider in accordance with the Provider Agreement while pursuing those rights. If the Payer is a secondary Payer for a Medicare beneficiary, nothing in this agreement will be construed to prohibit a Provider from collecting co - payments or deductible amounts regardless whether the secondary Payer is required to make any payment on a claim. 4.5 Overpayment and Underpayments. a. Request for Adjustment of Payment. Either party shall be entitled to request an adjustment of payment if, within 180 days from the date of payment, it notifies the other party in writing of the overpayment or underpayment and provides documentation substantiating such claims. b. Payment Disputes. The parties shall work cooperatively and in good faith to attempt to resolve payment issues on an informal basis within 90 days of the first notification of a request for an adjustment of payment, pursuant to paragraph above. If this is unsuccessful, then any disputes concerning claims of overpayment or underpayment shall be resolved in accordance with Plan. c. Payments Final. Except for those payments that have been submitted to dispute resolution or arbitration in accordance with the foregoing, all payments shall be final. d. Paying Adjustments. If the Parties determine that Plan has underpaid Provider, Plan shall pay the underpaid amount to provider within 30 days of said determination. If the parties determine that Plan has overpaid Provider, Provider shall reimburse Plan for the overpayment within 30 days of said determination. No offsets or deductions without permission. In no event shall Plan offset overpayments against, or deduct overpayment from, any other payment it owes to Provider unless Provider expressly permits Plan to do so. " Health Agreement; City of Lubbock & Southwest Medical IPA" 11 4.6 Explanation of Benefits Forms. EOB or similar statements must identify membership in the network to obtain discounted fees. Participating Providers have the right to rely on membership cards, members lists and telephone authorization to verify coverage and benefits for Enrollees. 4.7 Secondary Network. Neither City of Lubbock nor any individual Payer or associated network will be permitted to sell or otherwise provide access to City of Lubbock or the IPA list of Participating Providers through the use of "bundling", "wrap -around PPG's", "shadow PPG's", "silent PPO's", or similar arrangements. In the event such a practice is discovered, the Participating Provider or IPA may terminate the agreement with the particular Payer or Network immediately and without notice or penalty. 5. RELATIONSHIP OF THE PARTIES 5.1 Independent Contractors. The parties acknowledge that each is an independent contractor and not an agent, employee, officer, partner or joint venturer of the other. Neither parry nor any of their respective officer, agents, representatives or employees shall be construed to be an officer, agent, representative or employee of the other party. The provisions of this Agreement are not intended to create, nor shall be construed to create, any relationship between the parties other than that of independent entities contracting with each other solely for the purpose of effecting the provisions of this Agreement. 5.2 No Assumption of Liability. Each party will use reasonable care and due diligence in performing this Agreement. Each party shall be responsible for any claims, actions, liabilities or damages arising under this Agreement out of their acts or omissions. Neither party assumes any liability for any acts or omissions of the other party or the acts or omissions of such other party's officers, employees, agents, or representatives arising under the Agreement. Neither party shall be liable or assumes any responsibility for defending, or the expense of defending, the other party, its officers, employees, agents or representatives against any claim or legal action, or in any dispute resolution, administrative or regulatory proceeding arising under this Agreement out of such party's acts or omissions. 6. MEDIAL RECORDS AND CONFIDENTIALITY 6.1 Participating Providers shall maintain the usual and customary records, in accordance with all applicable federal and state statutory and regulatory requirements, as amended from time to time, for each Covered Person in the same manner as for other patients. Such records shall, at all times, remain the exclusive personal property of the Participating Provider. " Health Agreement; City of Lubbock & Southwest Medical IPA" 12 6.2 Upon prior written notice to IPA, City of Lubbock or Payer shall have the right to inspect or receive copies of the medical, administrative, and accounting records maintained by Provider pertaining to the billing and rendering of covered services to that Payer's enrollees, subject to the confidentiality and other limitations of state and federal law, Provider's policies and procedures governing access to records, and the confidentiality clause of the Agreement. 6.3 Plan or Payer shall conduct inspections pursuant to this section only at a mutually convenient time during Provider's business hours. 6.4 Plan or Payer shall be responsible for obtaining written releases by enrollees authorizing the release of medical information by Provider, and shall, notwithstanding any other provision in this Agreement, indemnify and hold harmless Provider and IPA for any liability in connection with the requested release. Payer or Plan agrees to reimburse reasonable copy and shipping charges Provider incurs to furnish information the Payer requests. 6.5 Except as specifically provided for in this agreement, IPA and Participating Providers and Network/Payer will consider all information provided by the other party as confidential and proprietary business information. Providers agree to use best efforts to assure that its employees or agents release no confidential information regarding the Plan, this agreement or any activities between Provider and the Plan to any person, party, organization, or association, unless required by law to do so. 7. TERM AND TERMINATION 7.1 Term. The effective date of this Agreement is December 1, 1998. Thereafter, this Agreement shall be renewed automatically for additional one (1) year term(s), unless earlier terminated pursuant to the appropriate provisions of this Section. 7.2 Termination. Notwithstanding Section 6.1, either party to this Agreement may, with or without cause, unilaterally terminate this Agreement at any time upon ninety (90) days prior written notice to the other party. 7.3 Termination by Either Party. Either party, upon decision of its Board of Directors of its designee, may terminate this Agreement immediately upon the dissolution or bankruptcy of the other party. 7.4 Termination for Cause. Either party may terminate this Agreement for cause due to a material breach by the other party by providing the breaching party thirty (30) days advance written notice of termination, specifying the nature of the breach, and allowing the party in default an opportunity to cure the breach within such period. City of Lubbock may terminate the IPA or " Health Agreement; City of Lubbock & Southwest Medical IPA" 13 Participating Provider's participation under this Agreement due to a material breach by such provider by providing the Provider and IPA thirty (30) days advance written notice of the termination of his participation, specifying the nature of the breach, and allowing the Provider an opportunity to cure the breach within such period. Failure of a party to this Agreement or a Provider to comply with or perform any duty or obligation under this Agreement shall constitute a material breach. If the notified party or Provider cures the breach within the notice period, the Agreement shall continue in effect. If a notified party, to include a Provider, fails to cure the breach within the notice period, this Agreement will terminate on the designated notice termination date. Upon a timely request before the date of termination, the Provider will be entitled to a review of the proposed termination conducted in accordance with the terms of the appropriate section of this Agreement. 7.5 Immediate Termination. Notwithstanding the above section, there are instances when City of Lubbock may terminate this Agreement immediately upon notice to IPA. Immediate termination may be justified when it can be shown that the health or safety of a patient is in imminent danger, or if there is reason to believe that fraud or malfeasance has been committed by the IPA or a Participating Provider. 7.6 Termination Review. Upon a timely request by the IPA or a Group or the Participating Provider prior to the date of termination, City of Lubbock will provide a review of the termination by the City of Lubbock Termination Review Panel. One member of the Termination Review Panel will be a Provider in the same or similar specialty or profession as the terminated Provider, if such a Provider is available and qualified to serve on the City of Lubbock Review Panel. The Group or Participating Provider may present relevant written materials to the Panel prior to its review. The decision of the Panel, which is not binding upon City of Lubbock, will be provided in writing to the IPA and Group or terminated Participating Provider and considered by the Review Panel in its review of the termination. 7.7 Continuing Treatment. Upon termination of the Agreement, each Participating Provider shall continue to provide Covered Services and each Payer shall continue to pay each Participating Provider in accordance with this Agreement until (a) such Enrollee's care is transferred to another Participating Provider, (b) the current course of hospitalization or treatment is completed, or (c) for a period of thirty (30) days, whichever occurs first. City of Lubbock and Payer agree to promptly inform Enrollees that the IPA, Group or Participating Provider is no longer a Network Participant. IPA and its Participating Providers agree to promptly inform Enrollees orally that the IPA or a Provider is no longer a Network Participant whenever contacted by an Enrollee by telephone or in person. IPA and its Participating Providers will use best efforts to assist City of Lubbock in the transfer of Enrollees to other Network Participants, however, it shall be the primary responsibility of City " Health Agreement; City of Lubbock & Southwest Medical IPA" 14 of Lubbock or the Payer to arrange for transfer of patients, and Payer agrees to reimburse any care provided after the effective date of termination at Provider's usual and customary rates. 8. GENERAL PROVISIONS 8.1 Waiver. The waiver of any breach of this Agreement by either party shall not constitute a continuing waiver or a waiver of any subsequent breach of either the same or of any other provision of the Agreement. 8.2 Amendment. This Agreement may be amended only by a written agreement signed by both parties. In the event the Agreement must be amended to comply with applicable Federal or State law or regulatory action, will not require the consent of City of Lubbock or IPA and will be effective on the appropriate date of the action. 8.3 Assignment. This Agreement shall not be assigned or transferred by either party without the prior written consent of the other party. 8.4 Severance of Invalid Provisions. The invalidity or unenforceability of any terms or provisions of the Agreement shall in no way affect the validity or enforceability of any other terms or provisions. 8.5 Governing Law and Venue. This Agreement shall be construed and governed by the laws or the state of Texas. Venue for any suit, action or proceeding arising out of this Agreement shall be Lubbock County, Texas. 8.6 Notices. Any notice required to be given pursuant to the terms and provisions of this Agreement shall be in writing and shall be sent by certified mail, return receipt requested, postage prepaid, or by personal delivery, to the addresses set forth on the signature page of this Agreement. Such notice shall be deemed received three (3) days following date of postage or upon the date of personal delivery, whichever applies. 8.7 Headings. Headings, captions and titles in this Agreement are for ease of reference only, are not part of this Agreement, and shall not affect, limit or define the terms and provisions of this Agreement. 8.8 Entire Agreement. This Agreement constitutes the entire understanding between the parties and supersedes all communications, either oral and written, regarding the subject matter of this Agreement. No further sections. IN WITNESS WHEREOF, the undersigned have executed this Agreement to be effective as of the date set forth below: " Health Agreement; City of Lubbock & Southwest Medical IPA" 15 r THIS AGREEMENT EFFECTIVE ON: necenher 1. 1998 City of Lubbock: ,�� ir- Vfifidy-Siaon-, A EST: I �WL �" Kayt i Darnell, City Secreta APPROVED AS TO CONTENT: Mary AndWs, Managing Director of Human Resources APPROVED AS TO FORM: *U� William de Haas, Competition and Contract Manager Southwest Medical IPA: Name:��, Title: P(M-. � " Health Agreement; City of Lubbock & Southwest Medical IPA" 16 EXHIBIT A CLAIMS REVIEW AND APPEAL PROCEDURES Steel Upon denial of claim for Benefits, re -file the claim for review in writing with the Plan Administrator. The review must be filed no later than sixty (60) days after Provider receives written notification of the denial of the claim for benefits or within sixty (60) days after the claim has been deemed denied. Attach any pertinent documents relating to the claim and submit any issues and comments in writing. CtTn Z The claim will receive a full and fair review. If the claim is denied when it is reviewed, the Plan Administrator must provide written notice of this denial within sixty (60) days after the Plan Administrator's receipt of written claim for review. The sixty- (60) day period may only be extended if there are special circumstances that are communicated in writing within the sixty- (60) day period. If there is an extension, a decision shall be made as soon as possible, but not later than one hundred and twenty (120) days after the receipt by the Plan Administrator of the claim for review. The Plan Administrator's decision on the claim for review shall be communicated in writing and shall include specific references to the pertinent Plan provisions on which the denial was based. Step 3 If the Plan Administrator denies the claim after review and you feel the decision is incorrect, the claim will be sent to the plan's Insurance Provider for final determination on payment. Request to appeal the Plan Administrator's decision must be in writing within thirty (30) days after receipt of written notification of the denial of the review. All pertinent documents relating to the denial and written issues and comments must be submitted to the Insurance Provider with the claim denial from the Plan Administrator. An explanation must be attached specifically stating why the Plan Administrator's decision is not in line with the plan stipulations. Step 4 The Insurance Provider will give the claim full and fair review in accordance to the Plan's level of benefits, provider contracts, and applicable insurance law. The Insurance Provider must provide you with a written notice of their decision within sixty (60) days after the written receipt of appeal. There may be times when this sixty- (60) day period may be extended. This extension may only be made, however, where there are special circumstances that are communicated in writing within the sixty- (60) day period. If there is an extension, a decision shall be made as soon as possible, but not later than one hundred and twenty (120) days after the receipt of the written appeal. The Insurance Provider's decision on the appeal shall be communicated in writing and shall include specific references to the pertinent Plan provisions on which the decision was based. The City of Lubbock Group Health Plan is a fully insured plan. The Insurance Providers decision on any appeal will be the final determination of payment. IPA Physicians EXH►.IBIT B TPA Yes Specialty Last Name First Name Title Practice Address 1 city 1 State I Tax ID # Allergy/Immunol Beck Suzanne M.D. 4005 24th Street Lubbock TX 75-2447770 AlleWimmunol Mamlok Robert J. M.D. 3806 21st Street Suite 311 Lubbock TX 75-2321758 Anesthesiology Boyd Robert M.D. P.O. Box 64488 Lubbock TX 75-1968998 Anesthesiology Brown Cynthia M.D. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology Brown Byron M.D. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology CoWn Jeffrey M.D. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology Danchak R. Michael M.D. 3420 22nd Place Lubbock TX 75-2624017 Anesthesiology Davis William M.D. 350a 22nd Place Lubbock TX 75-2624017 Anesthesiology Evans Lary D.U. 3420 22nd Place Lubbock TX 75-2624017 Anesthesiok)gy Fmcher Cecil D.O. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology Hauler Stephen M.D, 3508 22nd Place Lubbock TX 75.2624017 Anesthesiology Hicidh Randall S. M.D. 3420 22nd Place Lubbock TX 75-2624017 Anesthesiology Holmes Stephen M.D. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology Latour Jonathan M.D. a50822nd Place Lubbock TX 75-2624017 Anesthesiology Anesthesiology Anesthesiology McCabe Menard Miller H. Ralph Greg S. M.D. M.D. M.D. 3508 22nd Place 4102 24th Street #507 3420 22nd Place Lubbock Lubbock Lubbock TX TX TX 75-2624017 75-2273200 75-2604017 Anesthesiology Sardella Paul A. M.D. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology Schaub Lowry M.D. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology Strickland Michael M.D. 109 N. Norwich Lubbock TX 75 2243990 Anesthesiology Thornton Stanley M.D. 3508 22nd Place Lubbock TX 75-2624017 Anesthesiology Cardiology Wilson Bomo Lawrence R. Mounir Y. M.D. M.D. 3420 22nd Place 3506 21st Street Suite 507 Lubbock Lubbock TX TX 75-2624017 75-2651583 Cardiology Cardiology Cardiology Grattan Hurd Karkoutly James Gardiner Howard Ayman M.D. M.D. M.D. 3506 21st Street, Suite 507 3506 21st Street, Suite 507 4001 21st Street Lubbock Lubbock Lubbock TX TX TX 75-2651583 75-2651583 75-1841070 Cardiology Levine Marc M.D. 3514 21st Street Lubbock TX 75-1523371 Cardiology Maddoux Gerry M.D. 3506 21st Street, Suite 507 Lubbock TX 75-2651583 Cardiology Madonna John M.D. 3514 21st Street Lubbock TX 75-1523371 Cardiology Moss James M.D. 3514 21st Street Lubbock TX 75-1523371 Cardiology Overlie Paul M.D. 3514 21st Street Lubbock TX 75-1523371 Cardiology Rizo-Patron Carlos M.D. 3514 21st Street Lubbock TX 75-1523371 Cardiology Rogers Matthew M.D. 3514 21st Street Lubbock TX 75-1523371 Cardiology Cardiology Shoukfeh Walter M.F. Paul M.D. M.D. 3514 21st Street 3514 21st Street Lubbock Lubbock TX TX 75-1523371 75-1523371 Cardiology Wey Robert M.D. 3506 21st Street, Suite 507 Lubbock TX 75-2651583 Cardiology Wilkins Charles M.D. 3514 21 st Street Lubbock TX 75-1523371 Cardiology Las John M.D. 3514 21st Street Lubbock TX 75-1523371 Dermatology Lehman Michael M.D. 3715 21 st Street Lubbock TX 75-1390475 Dermatology Long David M.D. 3715 21 st Street Lubbock TX 75-1390475 Dermatology Paulger Brent M.D. 2202 Ithaca Avenue Lubbock TX 76-0553283 Dermatology Family Practice Way Chandler Barbara H. Sarah M.D. M.D. 4102 24th Street Suite 201 5203 79th Street Lubbock Lubbock TX TX 75-1972408 75-2249190 Family Practice Ordonez Robert M.D. 3621 22nd Street Lubbock TX 75-1784427 Gastroenterolog Batra Subhash C. M.D. 2424 50th Street, Suite 201 Lubbock TX 75-2624584 Gastroenterolog Block Steven C. M.D. 3610 24th Street Lubbock TX 75-2147436 Gastroenterolog Ganga Usha M.D. 3610 24th Street Lubbock TX 75-2147436 Gastroenterolog Ghandour Elias M.D. 3801 19th Street, Suite 115C Lubbock TX 75-2384892 Gastroentemlog Gastroenterolog Gastroenterolog Kensing McCarthy Narendran Kelly P. Justin Kumarapillai M.D. M.D. M.D. 3610 24th Street 3819 24th Street 3712 22nd Street Lubbock Lubbock Lubbock TX TX TX 75-2147436 75-2438687 75-1735633 Gastroenterolog Gastroenterolog Paragas Jr. Phipps _ Pablo D. Ted L. M.D. M.D. 3610 24th Street 3610 24th Street Lubbock Lubbock TX TX 75-2147436 75-2147436 Gastroenterolog Shaver William M.D. 3702 21at Street Lubbock TX 75-2436866 Gastroenterolog Snodgrass Priscilla Carter M.D. 3610 24th Street Lubbock TX 75-2147436 Gastroenterolog Williams William C. M.D. 3610 24th Street Lubbock TX 75-2147436 Hemetology/Onc Vugdn Davor M.D. 3702 21st Street #104 Lubbock TX 75-2380470 Infectious Disea Costa Henry M.D. 4404-C 19th Street Lubbock TX 75-2353617 Infectious Disea Infectious Disea Duriex Martinelli Dennis Lawrence M.D. M.D. 4404 19th Street Suite C 4404 19th Street Suite C Lubbock Lubbock TX TX 75-2353617 75-2353617 Internal Medicine Rohra Lakhu M.D. 4102 24th Street Suite 410 Lubbock TX 75-1768981 Internal Medicine Villalona Guillermo E. M.D. 2602 Avenue Q Lubbock TX 216-11-0732 Nephrology Alpar Andy M.D. 4110 22nd Place Suite 200 Lubbock TX 75-2186541 Nephrology Myers W. Duke M.D. 1607 W. Loop 289 Lubbock TX 75-2385542 Nephrology Newsom Gary D. M.D. 1607 W. Loop 289 Lubbock TX 75-2385542 Nephrology Nephrology Stanbaugh Wheeler Glen C.J. M.D. M.D. 1607 W. Loop 289 4110 22nd Place Lubbock Lubbock TX TX 75-2385542 75-2186541 Neurology Chuang H.S. M.D. 3612 22nd Place Lubbock TX 75-1667430 Neurology Dihenla Bhupesh M.D. 4102 24th Street, Suite 500 Lubbock TX 75-2716190 Neurology Gordon William H, M.D. 3802 21st Street, Suite A Lubbock TX 75-1330638 Neurology Gordon, Jr. William M.D. 3802 21st Street Ste A Lubbock TX 75-1330638 Neurology Hutton Tam M.D. 4102 24th Street Suite 500 Neurology Williams Benjamin M.D. 4102 24th Street, Suite 500 Lubbock TX Neurosurgery George Richard M.D. 3506 21 st Street Lubbock TX Neurosurgery Smith Harold M.D. '3506 21st Street, Ste 401 Lubbock TX 75-2515635 77-0283805 75-2712096 75-2712096 OBIGYN Sears Kathleen M.D. 6630 Quaker Ave Lubbock TX 75-1913347 Oncology Oncology-Gynec Martinez Phillips Rodolto Benny M.D. M.D. 3702 B 20th Street 3621 22nd Street Suite 101 Lubbock Lubbock TX TX 75-2638688 75-1806498 Ophthalmology Allison Kevin M.D. 4003 22nd Street Lubbock TX 75-2363599 Ophthalmology Boop James M.D. 3008 50th Street, Suite F Lubbock TX 75-2719168 Ophthalmology Boothe William D. M.D. 4020 21st Street Suite 3 Lubbock TX 75-2086553 Ophthalmology Gandhi Sham M.D. 710 W. Main Crosbyton TX 75-1778282 Ophthalmology Gandhi Sham M.D. 3602 23rd Street Lubbock TX 75-1778282 Ophthalmology Lamberts David M.D. 4003 22nd Street Lubbock TX 75-2086932 Ophthalmology Shihab Zuhalr M.D. 4003 22nd Street Lubbock TX 75-2193164 Ophthalmology Streit John M.D. 4014 22nd Place Lubbock TX 75-2600320 Opthalmology Khater Timothy M.D. 4020 21st Street, Suite 5 Lubbock TX 351-52-1201 Orthopedic Surg Ananthakdshnan C.V. M.D. 4102 24th Street Suite 407 Lubbock TX 75-1696000 Orthopedic Surg Carr Robert V. M.D. 4102 24th Street Suite 300 Lubbock TX 75-2277544 Orthopedic Surg Cons Stephen M.D. 3601 22nd Street Lubbock TX 75-2339654 Orthopedic Surg Dewitt Owen M.D. 4102 24th Street, Suite 300 Lubbock TX 75-2277544 Orthopedic Surg Orthopedic Surg Orthopedic Surg Gill Pal Scioli G.S. Dilip Mark M.D. M.D. M.D. 3601 22nd Place 3601 A 22nd Place 4102 24th Street Suite 300 Lubbock Lubbock Lubbock TX TX TX 75-1667517 T 75-1535169 75-227754-4 Orthopedic Surg Seay Gaylon M.D. 3802 22nd Street Lubbock TX 75-1824574 Orthopedic Surg Sisco Ted M.D. 3601 22nd Street Lubbock TX 75-2339654 Orthopedic Surg Smitherman Bryan M.D. 4104 24th Street, #300 Lubbock TX 75-2277544 Orthopedic Surg Theo John Paul M.D. 4102 24th Street Suite 300 Lubbock TX 75-2277544 Orthopedics Burke James M.D. 3801 19th Street #102 Lubbock TX 75-1830690 Orthopedics Casler Travis M.D. 2601 21st Street Lubbock TX 75-1677923 Orthopedics Crawford Kevin M.D. 3601 22nd Street Lubbock TX 75-2339654 Orthopedics Orthopedics Orthopedics Gill Hall King G.S. Harry Robert M.D. M.D. M.D. 3601 22nd Place 3601 21st Street 3801 19th Street Lubock Lubbock Lubbock TX TX TX 75-2037844 75-1830690 Orthopedics Nordyke Mark D. M.D 4102 24th Street, Suite 301 Lubbock TX 75-2164600 Orthopedics Wilson Joseph M.D. 4102 24th Street #300 Lubbock TX 75-2277544 Otolaryngology Kint C.M. M.D. 4511 University Lubbock TX 75-1845009 Otolaryngology Mehdiabadl Rustam M.D. 3506 21st Street Suite 501 Lubbock TX 75-1502271 Otolaryngology Neat Tom M.D. =1 22nd Street Lubbock TX 75-1761323 Ototaryngology Scolaro Phillip M.D. 3702 21st Street Suite 300 Lubbock TX 75-2310928 Otolaryngology Ullom William S. M.D. 3623 22nd Place Lubbock TX 75-1402222 Otolaryngology Ward SanilOn3 D.O. 3719 22nd Street Lubbock TX 74-2339505 Otofaryngology Winter Mark M.D. 3805 22nd Street Lubbock TX 75-1782791 Otolaryngology, Pershall Kim M.D. 4122 22nd Place Suite C Lubbock TX 75-2518327 Otolarynology Marchbanks John M.D. 3623 22nd Place Lubbock TX 75-1774864 Pediatrics Pang Suat Chang M.D. 3804 C 21st Street Lubbock TX 75-1968945 Plastic Surgery Rowley Milton M.D. 3519 22nd Place Lubbock TX 75-1611848 Plastic Surgery Rowley Jane M. M.D. 3519 22nd Place Lubbock TX 75-2624210 Pukrrcanary Chekuru htaldu M.D. 3621 22nd Street Suite 400 Lubbock TX 75-2487162 Pulmonary Johnson Mark M.D. 3621 22nd Street Suite 400 Lubbock TX 75-2487162 Pulmonary Smith Gary M.D. 3621 22nd Street Suite 400 Lubbock TX 75-2487162 Pulmonary Terrell Kenneth M.D. 3621 22nd Street Suite 400 Lubbock TX 75-2487162 Pulmonary Wertz Rodney M.D. 3621 22nd Street Suite 400 Lubbock TX 75-2487162 Radiology Munoz Otto M.D. 3813 22nd Street Rheumatology Sushan Naga M.D. 3506 21st Street, Ste 201 Surgery Chambers Clint M.D. 3505 21st Street #601 surgery Kahn Dan M.D. 4014 22nd Place Suite 11 Lubbock TX 75-2640271 Lubbock Tx 75-2578995 Lubbock TX 75-2496630 Lubbock TX 75-1793194 Surgery Mangold David M.D. 3702 21st Street Suite 203 Lubbock TX 75-1625913 Surgery Woolam Gerald M.D. 3702 21st Street Suite 203 Lubbock Thoracic & Cardi Bricker Donald L M.D. 3420 22nd Place Lubbock Burt N. M.D. 3420 22nd Place Lubbock Thoracic & Cardi Fowler TX TX TX 75-1625913 75-1444134 75-1444134 Thoracic & Cardi Hansen H. Andrew M.D. 3601 21st Street Lubbock TX 75-2781362 Thoracic & Cardi Harman P. Kent M.D. 3420 22nd Place Lubbock TX 75-1444134 Thoracic & Cardi Robertson Donald I M.D. 3420 22nd Place Lubbock TX 75-1444134 Thoracic & Cardi Thomas Malcolm M.D. 3606 21st Street Suite 202 Lubbock TX 75-1376176 Thoracic & Cardl Wilcott R. I M.D. 3420 22nd Place Lubbock TX 75-1444134 Urobgy Avant Lynn M.O. 4102 22nd Place Lubbock TX 75-1514281 Urology Beck Howard M.D. 4102 22nd Place Lubbock TX 75-1514281 Urology Britton Carl M.D, 3502 82nd Street Lubbock TX 75-2772595 Urology Brothers Jorge M.D. 707 South 1st Muleshoe TX 75-2500477 Urology Brothers Jorge M.D. 3417 20th Street Lubbock TX 75-2500477 Urology Brothers Jorge M.D. 103 John Dupre Ave Levelland TX 75-2500477 Urology Snodgrass W.T. M.D. 3606 21st Street Suite 207 Lubbock TX 75-1517198 Urology Stalcup Obie M.D. 707 South 1st Muleshoe TX 75-1697783 Urology Stalcup Obie M.D. 3417 20th Street Lubbock TX 75-1697783 Urology Vallabhan Girish M.D. 4102 22nd Place Lubbock TX 75-1514281 Urology-Pediatri Snodgrass Warren M.D. 3606 21st Street Suite 207 Lubbock TX 75-1517198 EXHIBIT C 0 Immicaw Precertification Process: Intracorp's preadmission certification program is designed for easy accessibility. Plan members simply call a toll -free number to notify Intracorp of a hospital admission. The review then continues through each step and concludes when the patient is discharged. Intracorp's approach to preadmission certification incorporates three components: review of procedure and medical necessity, length -of -stay determination and negotiation of the treatment plan and alternative care. Our objective is to provide focused health care management while maintaining high quality, cost-effective patient care. Our professional staff evaluates each admission request and addresses questionable or negotiable medical necessity issues. The following is a typical chronology of the utilization management review process: Patient, family member or treating provider telephones Intracorp with a request for preadmission certification or procedure approval. Intracorp evaluates the case intensity and performs a needs assessment. Intracorp creates an on-line plan member/patient file to record all relevant demographic and medical information. Supported by on-line expert systems and accepted medical guidelines, Intracorp assesses the medical necessity of the case and negotiates appropriate alternatives, if needed, The review specialist then assesses the appropriateness of the proposed setting. If medical necessity and/or treatment setting cannot be confirmed, the case is referred to an on -site board -certified physician advisor. The physician advisor contacts the attending physician to discuss and negotiate an appropriate treatment plan. If agreement cannot be reached and clinical guidelines are still not met, the case is noncertified. Intracorp advises providers by telephone, and the patient in writing of the noncertification of an admission or extended stay. This automatically generated letter informs the patient that benefits may be reduced if he or she receives or continues to receive, medical care as an inpatient. The letter also outlines appeal procedures. Throughout the entire process, Intracorp emphasizes negotiation with the treating provider and applies sound medical judgment at every stage. This process continues until the patient is discharged or until medical guidelines are no longer met by the patient's condition or treatment plan. Intracorp's review specialists maintain regular contact with the treating provider to ensure the patient retrains in the acute care setting only as long as medically necessary. Concurrent Review Process: Once a certified admission occurs, continued stay review monitors medical treatment and recovery to determine the necessity of continued inpatient care. Intracorp's continued stay review process is telephonic and concurrent. For each certified admission, the review specialist enters the admission date and the number of days certified in the patient file. A computer -generated report alerts a review specialist to confirm discharge. If the patient has not been discharged, the review specialist contacts the treating provider to discuss prognosis and current treatment plan, and to negotiate possible treatment plan alternatives. The review specialist compares the information obtained from the treating provider with established guidelines and applies professional judgment to assess if the treatment plan is appropriate. If guidelines for continued stay are met, the review specialist continues the certification and sets a target date to recontact the treating provider to follow-up. If guidelines are I not met, and the review specialist is unable to negotiate alternate treatment options with the treating provider, the review specialist refers the case to a physician advisor for peer -to -peer discussion with the treating provider. The review specialist always attempts to speak with the treating provider, unless the provider has delegated the responsibility to a staff member. Notification All continued stay reviews are internal check points. If additional days are certified, Intracorp notifies the physician or hospital staff member verbally at the time of review. To preserve the patient -physician relationship, the physician verbally informs the patient of the outcome of the continued stay review. In the cases of noncertifieation, Intracorp verbally notifies the treating provider or hospital staff member at the time of review and then sends an automatically generated letter to the hospital, treating provider, patient and claims payer. This letter is mailed within 24 hours of the review decision. If an electronic data interface (E©1) is in place, the claims payor may receive the information electronically. Discharge Planning Process: Intracorp's review specialists identify discharge planning needs during the pre -admission certification and continued stay review process using our expert case management identification system, Infer. Once discharge planning needs are identified, the case is referred to case management for further intervention. Case management involvement can range from arranging post -discharge rehabilitation needs to more extensive care coordination and management. Intracorp's case managers use their clinical skills, working knowledge of CMSA's Standards of Practice, and extensive set of guidelines and resource tools to ensure that high quality, cost effective care is given to each patient. Denial Process: Review specialists review all cases for medical necessity and appropriateness of treatment setting using our on-line clinical guidelines and their own experience and judgment. Cases that meet guidelines are certified promptly without undue delay or use of unnecessary costly medical resources. If a case fails to meet guidelines and the review specialist is not successful in negotiating an appropriate alternative treatment plan with the treating provider, the case is automatically referred to a board certified physician advisor for secondary review. Our physician advisor then calls the treating physician for peer -to -peer discussion of the case. After obtaining additional information about the case, the physician advisor attempts to negotiate an appropriate medical treatment plan. In the rare instance that agreement cannot be reached with the treating provider, the physician advisor recommends non -certification. Criteria Used in UR Process: Procedure Necessity Guidelines Statistics indicate that up to 25 percent of all surgical procedures are considered unnecessary. I= Additional documentation suggests that many of these procedures are based on the physician's individual preferences and exhibit significant regional variation. To decrease unnecessary surgery, remove subjectivity from the decision making process and increase review effectiveness, CCOG developed Procedure Necessity Guidelines (PNG) to identify available alternatives that can equally resolve symptoms and improve quality of life without surgery. When an appropriate proven alternative is available, PNG enables the nurse to suggest and approve alternative care with demonstrated positive results. Infer Review specialists apply these proprietary, expert guidelines throughout the utilization management processes for the early identification of patients who may benefit from case management services. In addition to early identification, Intracorp's Infer system determines the level of case management that is appropriate for the individual case (i.e., telephonic Mon - site). Internal research shows that factors such as medical history, current level of care provided, complications, psychosocial aspects and others can be used as criteria to more accurately predict the potential benefits of case management services. Review specialists access Psychlnfer® for the early identification of mental health/substance abuse cases that may benefit from case management. Milliman & Robertson Review specialists access these on-line guidelines when responding to questions regarding proposed Iength of stay, appropriateness and medical necessity. Developed by Milliman & Robertson (M&R), a leading actuarial consulting firm, the following guidelines reflect the most efficient treatment practices achieved by HMOs. They have been widely accepted by both medical groups and the managed care industry. Intracorp uses the following M&R components; M&R Optimal Recovery Guidelines Optimal Recovery Guidelines (ORGs) provide day-by-day treatment plans for patients under age 65 with no significant oomorbidities or complications. They are based on the CPT (procedure) and ICD-4 (diagnosis) codes relevant to the patient's condition and planned treatment. ORGs provide the equivalent of medical guidelines, length -of -stay guidelines and outpatient procedure/treatment alternatives for uncomplicated medical, surgical and pediatric admissions. They also include guidelines for extending an admission. Intracorp has modified this criteria by adding "bridge" days to each guideline when medically necessary. This modification guarantees more effective management of the patient from the hospital to the home, especially in situations where an aftercare benefit or system is not in place. Mental HealthlSubstance Abuse Review Review specialists use our own proprietary Level -of -Care Guidelines in the mental health/substance abuse review process. The guidelines suggest the most appropriate setting — such as inpatient, outpatient, partial hospitalization, residential or rehabilitation facilities -- for a multitude of mental health and substance abuse diagnoses. Review specialists use the guidelines as a screening tool to allow for consistent evaluation of the appropriateness of the level of care and planned treatment. Outpatient Procedure Necessity Intracorp applies exclusive and proprietary medical guidelines to arrive at rational, consistently applied recommendations on the medical necessity of the outpatient procedures and high -cost tests. In developing medical standards of care, Intracorp considered patient care quality and safety, up to -date standards of medical practice and optimal use of resources. To determine which outpatient procedure categories are aggressively reviewed, Intracorp considers the overall financial impact, potential for overutilization and necessity. Nigh -Risk Pregnancy Screening Intracorp developed a proprietary screening system to identify potential high -risk pregnancies. Intracorp's medical directors, physician advisors, obstetrical nurses, and outside medical consultants, developed risk identification screening questions. These questions are continually enhanced and updated based on the latest statistical data analysis and research. We also employ M& R criteria for obstetrical review. In addition, after a high -risk pregnancy is identified we use Infer, our expert system, to direct the case to our case management department for assessment.