HomeMy WebLinkAbout20122166.tiff RESOLUTION
RE: APPROVE PARTICIPATING AND PPO CONSULTANT PROVIDER AGREEMENT
AND AUTHORIZE CHAIR TO SIGN - ROCKY MOUNTAIN HOSPITAL AND MEDICAL
SERVICE, INC., dba ANTHEM BLUE CROSS AND BLIJE SHIELD
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Participating and PPO Consultant
Provider Agreement between the County of Weld, State of Colorado, by and through the Board
of County Commissioners of Weld County, on behalf of the Department of Public Health and
Environment, and, Rocky Mountain Hospital and Medical Service, Inc., dba Anthem Blue Cross
and Blue Shield with terms and conditions being as stated in said agreement, and
WHEREAS, after review, the Board deems it advisable to approve said agreement, a
copy of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Participating and PPO Consultant Provider Agreement
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Public Health and Environment,
and Rocky Mountain Hospital and Medical Service, Inc., dba Anthem Blue Cross and Blue
Shield be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 15th day of August, A.D., 2012.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST:-3c.�,�
Sean P. n ay, Chair
Weld County Clerk to the Board �
William rcia, Pro- e
Deputy CI 4 to th Board f' \'! !+O� x^^-
a. • rbara Kirkmeyer
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APPROVEDAASS T• " �•- ' ; J
R" Ovid E. Long•
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Date of signature: q -`J /
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53-15-3 '- Cu. 44 ).- 2012-2166
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,��, � . Memorandum
TO: Sean Conway, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health & Environment
DATE: July 30, 2012
SUBJECT: Participating and PPO Consultant Provider
Agreement with Anthem Blue Cross Blue
Shield
Enclosed for Board review and approval is an agreement for Anthem Blue Cross and Blue Shield
Participating and PPO Consultant Provider Agreement between Rocky Mountain Hospital and
Medical Service, Inc., d.b.a. Anthem Blue Cross and Blue Shield (Anthem BCBS) and the Board
of County Commissioners of Weld County on behalf of the Weld County Department of Public
Health and Environment (WCDPHE).
The agreement allows for WCDPHE to receive periodic payment for the provision of Covered
Services to enrollees under Anthem BCBS, a Colorado insurance company for their PPO and
Indemnity members. This agreement has been specifically created for Local Public Health
Agencies (LPHA) for submitting immunization and family planning claims and coverage of
preventive services with the Health Reform Act. This is not for new services, but services that
we have historically provided for immunizations and family planning. This also coincides with
the ACA RIZO grants pursuing and preparing LPHA's to be able to submit claims electronically
and get better reimbursement for services.
Reimbursement for all Covered Services provided by Weld County Department of Public Health
& Environment is made by Anthem BCBS on a fee-for-service basis.
The agreement shall commence upon signature of this Agreement by Anthem Blue Cross and
Blue Shield and will stay in effect until cancelled by either party.
2012-2166
ANTHEM BLUE CROSS AND BLUE SHIELD
PARTICIPATING AND PPO CONSULTANT PROVIDER AGREEMENT
THIS AGREEMENT is made and entered into, by and between Rocky Mountain Hospital and
Medical Service, Inc., d.b.a. Anthem Blue Cross and Blue Shield (Anthem BCBS), located at 700
Broadway, Denver, Colorado 80273-0002 and Weld County Department of Health and Q j�Environment(Consultant Provider) located at
In order to support the operational efficiencies regarding the implementation this Agfeem nt, Fsit5
Anthem BCBS reserves sole discretion in determining the effective date of this Agreement. The
effective date is not to exceed ninety (90) days after the date this Agreement is fully executed. This
Agr ent 7abe effective (as determined by Anthem BCBS upon execution)
e
ti7
WITNESSETH:
WHEREAS, Anthem BCBS operates as a Colorado insurance company; and
WHEREAS, Consultant Provider is a duly licensed health care provider in the State of Colorado,
whose license is without limitation or restriction; and
WHEREAS, Anthem BCBS and Consultant Provider desire to enter into an agreement whereby
Consultant Provider shall provide Consultant Services, and arrange for and coordinate the
provision of other health care services, to Members in a manner that preserves and enhances
patient dignity; and
NOW, THEREFORE, the parties agree as follows:
ARTICLE I. DEFINITIONS
A. "Affiliate" means any entity which owns or is owned by Anthem BOBS directly or indirectly,
and any entity which is under common ownership directly or indirectly, by Anthem
Insurance Companies, Inc. Upon execution of this Agreement, Anthem BCBS shall
provide to Consultant Provider a current list of Affiliates. This list will be updated not less
than quarterly and a copy will be provided to Consultant Provider upon request.
B. "Claim" means a complete billing, or an adjustment to such a billing, for health care
services that is submitted by Consultant Provider on the CMS1500 form, or a form
approved by Anthem BCBS, or through a method of automated transmission developed
for direct entry into Anthem BCBS's Claim processing system.
C. "Clean Claim" shall have the meaning set forth in 10-16-106.5 (2), C.R. S. and related
regulations, as amended from time to time.
D. Contractual Adjustment" means any portion of a charge for a Covered Service in excess
of the Maximum Benefit Allowance. Contractual Adjustments shall be absorbed by the
Consultant Provider and shall not be charged to the Member or Anthem BCBS.
E. "Cost Share" means an amount which a Member is required to pay for Covered Services
under the terms of the applicable Membership Certificate. Such payment may be referred to
PARPPO CON.01-2008 I we.a en., ne
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as an allowance, coinsurance, copayment, deductible, penalty or other Covered
Person/Member payment responsibility, and may be a fixed amount or a percentage of
applicable payment for Covered Services rendered to the Member.
F. "Covered Services" means those Medically Necessary and preventive health care services
that are benefits of Anthem BCBS Membership as described and limited in the applicable
Membership Certificate, as the same may be amended from time to time. Services are
Covered Services only if they are performed, arranged and authorized in accordance with
the terms, limitations and exclusions set forth in the applicable Anthem BCBS Membership
Certificate.
G. "Emergency" means a medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent lay person, with an average knowledge
of health and medicine, could reasonably expect the absence of immediate medical
attention to result in (1) serious jeopardy to the health of the individual (or unborn child); (2)
serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or
part. "Emergency Services" means those services necessary to screen for, diagnose or
stabilize an Emergency medical condition.
H. "Health care provider" means a person licensed or certified in this state to practice
medicine, pharmacy, chiropractic, nursing, physical therapy, podiatry, dentistry, optometry,
occupational therapy, or other health arts. "Health care provider" also means an
ambulatory surgical center, a licensed pharmacy or provider of pharmacy services, and a
professional corporation or other corporate entity consisting of licensed health care
providers as permitted by the laws of the State.
"Material Change" means a change to this Agreement that decreases the health care
provider's payment or compensation, changes the administrative procedures in a way that
may reasonably be expected to significantly increase the provider's administrative
expense, replaces the maximum allowable cost list used with a new and different
maximum allowable cost list by a person or entity for reimbursement of generic
prescription drug claims, or adds a new category of coverage.
A material change does not include:
(a) a decrease in payment or compensation resulting solely from a change in a published
fee schedule upon which the payment or compensation is based and the date of
applicability is clearly identified in this Agreement;
(b) a decrease in payment or compensation resulting from a change in the fee schedule
specified in this Agreement for pharmacy services such as a change in a fee schedule
based on average wholesale price or maximum allowable cost;
(c) a decrease in payment or compensation that was anticipated under the terms of this
Agreement and where the amount and date of applicability of the decrease is clearly
identified herein;
(d) an administrative change that may significantly increase the provider's administrative
expense, the specific applicability of which is clearly identified herein;
(e) changes to an existing prior authorization, precertification, notification, or referral
program that do not substantially increase the provider's administrative expense; or
PARPPO CON:01-2008 7 Weld County Department of Health and Environment,03/2012 akr,
(f) changes to an edit program or to specific edits; however, the health care provider shall
be provided notice of the changes pursuant to state law and the notice shall include
information sufficient for the health care provider to determine the effect of the change.
J. "Maximum Benefit Allowance" means the maximum amount of reimbursement allowed for
a Covered Service as determined by Anthem BCBS.
K. "Medically Necessary" or "Medical Necessity" shall mean health care services that a
physician, exercising prudent clinical judgment, would provide to a patient for the purpose
of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms,
and that are:
(a) in accordance with generally accepted standards of medical practice;
(b) clinically appropriate, in terms of type, frequency, extent, site and duration, and
considered effective for the patient's illness, injury or disease; and
(c) not primarily for the convenience of the patient, physician, or other health care provider,
and not more costly than an alternative service or sequence of services at least as likely to
produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of
that patient's illness, injury or disease.
For these purposes, "generally accepted standards of medical practice" means standards
that are based on credible scientific evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community, Physician Specialty Society
recommendations and the views of [Physicians] practicing in relevant clinical areas and
any other relevant factors . The above definition of "Medically Necessary" / "Medical
Necessity"shall be inapplicable to the extent that a different definition is required by a self-
funded group, a government contract or any applicable law or regulation.
L. "Member" means any subscriber or dependent who is entitled to benefits under a
Membership Certificate including an HMO Colorado Member accessing their point-of-
service option that is underwritten by Anthem BCBS. The term Member shall include PPO
Members. The PPO Program (PPO) is a preferred provider Plan which delivers services
through a network of physicians, hospitals, or a hospital and its medical staff, under
contract to provide care to Plan Members at negotiated fees for service (allowables). PPO
Members are also Members who have coverage or other health service benefits through a
self-funded group or trust, employer Plan, or other insuring entity with whom Anthem
BCBS has any contractual arrangement, including other Blue Cross and Blue Shield
Plans.
M. "Membership Certificate" means any contract between Anthem BCBS and a subscriber
(Member), between Anthem BCBS and a group (employer) for the benefit of a Member,
between Anthem BCBS and a Federal Employee Program subscriber, or a contract issued
by other Blue Cross and Blue Shield Plans and administered by Anthem BCBS (including
national accounts), whereby Anthem BCBS agrees to pay Consultant Provider for all or
part of Covered Services rendered to Members in accordance with the terms of such
contract. The contract may be wholly or partially underwritten by Anthem BCBS or may be
wholly or partially self-insured by the group. The term Membership Certificate or Group
Master Contract shall include certificates and contracts for PPO.
PARPPO CON-01-2008 3 Weld County Department of Health and Environment,03/2012 akr,
N. "Participating Hospital" means a hospital which has entered into a written agreement with
ANTHEM BCBS to provide certain Covered Services to Members.
O. "Participating Provider" means a health professional, institutional health care provider or
any other entity that has entered into a written agreement with A BCBS to provide certain
Covered Services to Members upon appropriate referral by the Member's Consultant
Provider and/or ANTHEM BCBS. A non-participating Provider is a provider who has not
entered into such an agreement.
P. "Physician Specialty Society" means a United States medical specialty society that
represents diplomats certified by a board recognized by the American Board of Medical
Specialties.
Q. "Plan" means: (1) Anthem BCBS; (2) an Affiliate as designated by Anthem BCBS; (3) any
Blue Cross and Blue Shield Plan; and/or (4) a self-funded account which is administered in
whole or in part by Anthem BCBS, an Affiliate or any Blue Cross and Blue Shield Plan.
R. "Point-Of-Service (POS) Plan" means a health care Plan offering eligible POS Plan
Members choice and flexibility in their health care delivery wherein care is coordinated
through a pre-selected Primary Care Provider.
S. "Point-Of-Service (POS) Plan Member" means any person entitled to benefits under an
Anthem BCBS POS Plan Membership Certificate.
T. "Primary Care Provider (PCP)" means a duly licensed health care provider who has
entered into a written agreement with Anthem BCBS to provide Covered Services to POS
Plan Members, and to coordinate and arrange for the provision of other health care
services to POS Plan Members who have selected him/her as their primary health care
provider.
U. "Provider Manual" means the policy and procedure manual prepared by Anthem BCBS,
setting forth the basic policies and procedures to be followed by Consultant Provider in
carrying out the terms and conditions of this Agreement. The terms of this manual shall be
part of this Agreement.
V. "Quality Improvement/Management" means programs, processes and procedures which
may include, without limitation, evaluation of the quality, effectiveness and efficiency of the
use of health services, (including but not limited to improved health outcomes) procedures
and facilities on a prospective, concurrent or retrospective basis. A description of Anthem
BCBS's Quality Improvement/Management is included in the Provider Manual.
W. "Utilization Management" means programs, processes and procedures which may include,
without limitation, evaluation of the necessity, appropriateness, and efficiency of the use of
health services, procedures, and facilities on a prospective, concurrent, or retrospective
basis. A description of Anthem BCBS's Utilization Management is included in the Provider
Manual.
ARTICLE II. OBLIGATIONS OF CONSULTANT PROVIDER
A. Laws and Regulations. Consultant Provider shall abide by all applicable federal and state
laws and regulations in effect during the term of this Agreement.
PARPPO CON:01-2008 4 Weld County Department of Health and Environment,03/2012 akr,
B. Covered Services. Consultant Provider shall provide to Members those needed Covered
Services which Consultant Provider commonly performs within the scope of his/her
practice and license. Consultant Provider shall render such services to Members in the
same manner, in accordance with the same standards, and within the same time
availability as to his/her other patients.
C. Non-Covered Services. In the event Consultant Provider recommends that a Member
receive services and PCP knows that such services are not Covered Services, Consultant
Provider shall inform the Member prior to the provision of such services: (1) that the
services recommended are not Covered Services, (2) that Anthem BCBS will not pay for
or be liable for such services, and (3) that the Member will be financially liable to the
Consultant Provider for such services. If Consultant Provider fails to provide the Member
with the above information, then Consultant Provider may not collect payment from the
Member for any non-Covered Services performed by Consultant Provider.
D. Admissions. Any non-Emergency inpatient admission of, or use of an outpatient surgery
facility by, a Member must be approved in advance by Anthem BCBS. The sole
responsibility for obtaining any required pre-authorization rests with the provider, and not
with the Member. However, this provision is not intended to relieve Member of any
responsibility under the Membership Certificate. The procedures governing
preauthorization, including the appropriate length of any hospital stay, are set forth in the
Provider Manual.
E. Authorization.
1. Except in a Medical Emergency, Consultant Provider agrees to obtain Anthem
BCBS authorization in advance for all services requiring authorizations. Consultant
Provider must follow the required authorization procedures set forth in the Provider
Manual. However, this provision is not intended to relieve Member of any
responsibility under the Membership Certificate. Authorizations are based on
information available at the time requested and do not guarantee eligibility or
payment.
2. In the event services required by a Member are not available from Consultant
Providers, other providers may be utilized with the prior approval of Anthem BCBS,
as described in the Provider Manual.
F. Required Coverage . Consultant Provider shall make necessary and appropriate
arrangements to ensure the availability of Covered Services to Members on a 24-hour-per-day,
seven-day-per-week basis, which arrangements may include directing Members to contact 911 in
the event of an emergency during the hours Consultant Provider's clinic is closed. Consultant
Provider shall, if standard procedure in his or her area of practice, maintain weekly appointment
hours which are sufficient and convenient to serve Members and shall maintain on-call service
capability, to the extent standard procedure for Consultant Provider's other clinics, with other
Participating Provider(s) to perform appropriate and cost effective evaluation and treatment of
referred Members when Consultant Provider is unavailable. To the extent Consultant Provider
does utilize other providers to provide covering arrangements, and that provider does not
participate with HMOC, Consultant Provider shall guarantee that such provider shall cooperate
with and accept the findings of HMOC's peer review procedures as they relate to services
provided to Members and shall require covering provider to follow the administrative procedures
described in the Provider Manual. Consultant Provider further guarantees that covering provider
shall accept HMOC's reimbursement, as set forth in this Agreement, for Covered Services as
PARPPO CON:01-2008 5 Weld County Department of Health and Environment,03/2012 akr,
payment in full except for Copayments. In addition, Consultant Provider shall assure that the
covering provider shall comply with the provisions of paragraphs C., D., and I. of this Article II.
Consultant Provider hereby agrees to indemnify and hold harmless Members and HMOC against
any charges, except Cost Share Amounts, for Covered Services or charges in excess of HMOC's
reimbursement for Covered Services rendered by providers who are covering on behalf of
Consultant Provider. This indemnification does not include Covered Services provided to
Members as a result of Member's utilization of the local 911 service.
G. Collection of Cost Shares. Consultant Provider shall not require of any Member an
advance deposit toward payment for services, except to the extent of reasonably
anticipated charges for deductibles, co-payments, co-insurance, or non-Covered Services.
In the event that other payment for such permissible deposits is made to Consultant
Provider, Consultant Provider shall refund overpayments to the Member without delay.
H. Hold Harmless. Consultant Provider hereby agrees that in no event, including, but not
limited to nonpayment by Plan, Plan insolvency or breach of this Agreement, shall
Consultant Provider bill, charge, collect a deposit from, seek compensation, remuneration
or reimbursement from, or have any other recourse against Member or persons other than
Plan acting on their behalf for services provided pursuant to this Agreement. This
provision shall not prohibit collection of Cost Shares in accordance with the terms of the
applicable Membership Certificate or collection of payment for non-Covered Services.
Consultant Provider further agrees that (1) this provision shall survive the termination of
this Agreement regardless of the cause giving rise to termination and shall be construed to
be for the benefit of the Member, (2) this provision supersedes any oral or written contrary
agreement now existing or hereafter entered into between Consultant Provider and any
Member or person acting on his behalf and (3) this provision is not intended to apply to
services provided after this Agreement has been terminated. Any modification, addition, or
deletion to the provisions of this paragraph shall become effective on a date no earlier
than 30 days after the Commissioner of Insurance has received written notice of such
proposed changes.
1. In the case of a Member whose Membership Certificate is not underwritten by
Anthem BCBS or an Affiliate, Consultant Provider's cause of action, if any, shall lie
strictly with the Plan sponsor of said Member's Plan.
2. If a reduction in or denial of payment is imposed for failure of the Member to comply
with Utilization Management as specified in the Member's Membership Certificate,
Consultant Provider agrees that Anthem BCBS and Plan are not responsible for the
amount of such reduction or denial. However, Consultant Provider may seek
payment from the Member for such amount. If a reduction in or denial of payment is
imposed for failure of Consultant Provider to comply with Plan's Utilization
Management, as set forth in the Provider Manual, Consultant Provider agrees that
Anthem BCBS, Plan, and Member are not responsible for the amount of such
reduction or denial.
3. Consultant Provider may seek payment from the Member for health services which
are not Covered Services in the Member's Membership Certificate. However, if the
health services provided are not Covered Services because Plan has deemed
such services to be not Medically Necessary, Consultant Provider may seek
payment from Member for such services: a) only if the Member has requested the
health services to be provided notwithstanding Plan's determination related thereto;
b) only if Consultant Provider has provided to Member notice in writing, prior to the
PARPPO CON:01-2008 6 Weld County Department of Health and Environment,03/2012 akr,
rendition of the services, of the approximate cost said Member will incur; and c)
Member has agreed in writing to the rendition of the service after completion of (a)
and (b) hereof. In such event, Consultant Provider may bill the Member at its
customary rate for such services.
4. This hold harmless Section shall survive termination of this Agreement, regardless
of the reason for termination, including insolvency of the Plan, and shall be for the
benefit of Members.
Records and Reports.
1. Consultant Provider shall maintain such records and provide, without charge, such
medical, financial and administrative information to Anthem BCBS as may be
necessary for compliance by Anthem BCBS with state and federal law, as well as
for Anthem BCBS program management purposes. ANTHEM BCBS shall have
access, at reasonable times upon demand and reasonable notice, to the books,
records, and papers of Consultant Provider relating to the health care services
provided to Members, to the cost thereof, and to monies received by Consultant
Provider from Members for Covered Services. Anthem BCBS shall also have the
right to inspect Consultant Provider's facilities pursuant to Anthem BCBS's
Utilization and Quality Management Program at reasonable times and on
reasonable notice. For purposes of this provision, reasonable shall be a minimum
of 72 hours advance notice.
2. Consultant Provider shall maintain a medical record for each Member in
accordance with standards adopted by Anthem BCBS. Medical records of
Members shall be treated as confidential so as to comply with all federal and state
laws and regulations regarding the confidentiality of patient records.
J. Professional Requirements. Consultant Provider warrants that s/he is the holder of valid
licenses to practice medicine and prescribe medications in the State of Colorado, and
agrees to notify Anthem BCBS immediately in the event that there is any restriction,
suspension or other change in the status of either of such licenses. Consultant Provider
warrants that s/he is certified/credentialed by an Anthem BCBS Participating Hospital to
perform any specialty services s/he renders to Members in an outpatient or inpatient
setting, and must immediately notify Anthem BCBS of any change in such certification,
credentialing, or other hospital privileges.
K. Insurance. Consultant Provider shall procure and maintain such policies of general and
professional liability (malpractice) insurance as shall be necessary to insure Consultant
Provider and PCP's employees against any Claim or Claims for damages arising by
reason of personal injuries or death occasioned, directly or indirectly, in connection with
the performance of any service by Consultant Provider. The amount and extent of such
insurance coverage shall be subject to the approval of Anthem BCBS and shall not be less
than $1,000,000 per incident and $3,000,000 in aggregate. Consultant Provider shall
provide memorandum copies of such insurance coverage to Anthem BCBS upon request.
PCP shall also immediately notify Anthem BCBS of any policy cancellation or any
changes in the coverage required by this paragraph.
L. Administration.
PARPPO CON:01-2008 7 weld County Department of Health and Environment,0312012 akr,
1. Consultant Provider agrees to abide by the terms of the Provider Manual, and to
participate in and comply with Plan's Quality Improvement/Management and
credentialing standards as applicable. Consultant Provider warrants that it currently
meets Plan's credentialing standards as described in the Provider Manual and that it
has all licenses required to provide health services in accordance with the applicable
licensing provisions of the laws and regulations of the state in which it operates.
Consultant Provider agrees to cooperate with Anthem BCBS in the development and
implementation of action plans arising under Quality Improvement/Management.
2. If Consultant Provider fails to follow the procedures set forth in the Provider
Manual, Anthem BCBS may not cover the services rendered and the provisions of
paragraph H. of this Article shall apply. Failure to follow the procedures set forth
in the Provider Manual may also result in termination of this Agreement
3. Consultant Provider shall submit claims to Anthem BCBS on form CMS 1500 or its
equivalent or in a HIPAA compliant electronic format. Claims shall be submitted
within 365 days of the date services are rendered for all services rendered to
Members covered by Anthem BCBS plans. Requests made by Anthem BCBS for
additional information shall be completed and returned by Consultant Provider within
thirty (30) days. For purposes of coordination of benefits, in the event, Anthem BCBS
is not the primary payor, Consultant Provider shall submit claim to Anthem BCBS not
later than 365 days following receipt by Consultant Provider of an explanation of
benefits from the primary payor and other payors. If a claim is not received by
Anthem BCBS within the above time periods such claims shall be deemed to be
waived and shall not be the financial responsibility of Member or Anthem BCBS.
4. Consultant Provider agrees to participate in and cooperate with Anthem BCBS in
developing and implementing innovative methods for delivering services that
promote quality care and cost effectiveness.
5. Consultant Provider agrees to cooperate and participate in Anthem BCBS's
complaint and grievance procedure, and to make a good faith effort to comply with
the decisions of Anthem BCBS's Member complaint and grievance committee. If
Consultant Provider determines that s/he cannot in good faith comply with a
decision of this committee, Consultant Provider shall notify Anthem BCBS and
Anthem BCBS shall make alternative arrangements for effectuating the decision.
The Member Complaint and Grievance Procedure are set forth in the Provider
Manual.
6. Consultant Provider shall permit Anthem BCBS to use Consultant Provider's name
and address in mailings, publications, and other printed material issued by Anthem
BCBS.
7. Consultant Provider may close office to new patients upon 60 days written notice to
Anthem BCBS. The notice shall state the reason(s) for closing the office to new
patients. "New Patients" shall mean patients who have not been seen by
Consultant Provider in the 3 years prior to the date notice is provided to Anthem
BCBS. Changing category of coverage or from one Person or Entity to another
does not make a patient a new patient. A closed office cannot discriminate against
health carriers.
PARPPO CON:01-2008 8 Weld County Department of Health and Environment,03/2012 akr,
M. Coordination of Benefits and Subrogation.
1. Consultant Provider shall assist in establishing procedures for identification of
Members (1) who have work-related injuries or illness, (2) who have other
coverage which may be coordinated with Anthem coverage, or (3) who have been
injured in an accident. Consultant Provider shall notify Anthem whenever
Consultant Provider has reason to believe a Member may be entitled to coverage
under any other health benefit Plan and shall assist Anthem in obtaining
information for the coordination of benefits when a Member holds such other
coverage.
2. Consultant Provider agrees to notify Anthem of any facts that might give rise to
Anthem subrogation rights based on third party liability, and to execute and provide
documents that may reasonably be required or appropriate for the purpose of
pursuing reimbursement or payment from other payers.
3. In no event will Anthem's payment obligation to Consultant Provider exceed the
compensation specified in Attachment A, and any calculation of such
compensation shall include amounts payable from other coverage.
N. Network Participation: Participation in all Anthem BCBS networks shall not be a condition
of participation in any Anthem Colorado network. Anthem BCBS shall not require
Consultant Provider to participate in a capitated fee arrangement in order to participate in
a provider network in which Consultant Provider is compensated on a fee for service
basis. Anthem BCBS shall not require Consultant Provider to participate in a Medicare
Advantage or Medicaid network in order to participate in commercial provider networks.
Anthem BCBS shall not require Consultant Provider to participate in all Anthem BCBS's
commercial provider networks.
O. Credentialinq Information. Consultant Provider agrees to cooperate with and provide
information to Anthem BCBS, or its agent, for the purposes of credentialing PCP as part of
the provider network as applicable. Consultant Provider shall also provide updates to that
information at specified time intervals or upon material changes in information previously
provided by PCP, for recredentialing purposes as applicable. Failure to submit the
information or to meet either the initial credentialing or recredentialing criteria may, at
Anthem BCBS's sole discretion, result in termination of this Agreement.
P. Federal Health Care Contract Compliance Consultant Provider warrants and represents
that at the time of entering into this Agreement, as well as at any time while this Agreement
is in force, neither it nor any of its employees, contractors, subcontractors or agents are
ineligible persons identified on the General Services Administrations' List of Parties
Excluded from Federal Programs (available through the Internet at http://epls.arnet.gov)
and the HHS/OIG List of Excluded Individuals/Entities (available through the Internet at
www.dhhs.gov/progorg/oig). In the event the Consultant Provider or any employees,
subcontractors or agents thereof becomes an ineligible person after entering into this
Agreement or otherwise fails to disclose its ineligible person status, the Consultant
Provider has an obligation to (1) immediately notify the Company of the Consultant
Provider's status as an ineligible person and (2) within ten days of Consultant Provider
PARPPO CON:01-2008 9 Weld County Department of Health and Environment,00/2012 akr,
receiving such notice, Consultant Provider will remove such individual from responsibility
for, or involvement with, the Consultant Provider's business operations related to the
federal government healthcare contracts. Anthem BCBS shall have the right to
immediately terminate this Agreement in the event it receives notification of the Consultant
Provider's ineligible person status. Consultant Provider agrees to hold Anthem BCBS
harmless from any and all costs, expenses, judgments, Claims and liability arising out of
Consultant Provider's breach of this warranty provision with respect to Federal Health
Care contract compliance.
Q. Notice of Action. Consultant Provider shall immediately send written notice to Anthem
BCBS of any legal, governmental, or other action involving Consultant Provider which
could materially impair the ability of Consultant Provider to carry out any of its duties and
obligations under this Agreement, including, by way of example only, loss of insurance,
Medicare/Medicaid or other regulatory sanctions, loss of license, etc.
R. Notice of Use of Subcontractors. Consultant Provider shall use its best efforts to provide
Anthem BCBS with thirty (30) days prior notice of any subcontractors with which
Consultant Provider may contract to perform Provider's duties and obligations under this
Agreement. Provider shall require such subcontractors to abide by the terms and
conditions of this Agreement. Consultant Provider agrees that Anthem may contract
directly with any Providers rather than relying on the subcontracting arrangements entered
by Consultant Provider.
S. Consultant Provider agrees, when Medically Necessary, to refer a PPO Member to another
PPO network Provider unless otherwise directed in writing by the PPO Member, or unless
there is no PPO network Provider for the services required. Consultant Provider shall
notify Member in advance when referring to a non-PPO provider for additional services
T. Patients Rights. Consultant Provider will not discriminate in the treatment of Members or
delivery of services to Members, either in the quality, quantity or type of services rendered
or in any other manner, on the basis of race, color, sex, disability, handicap, sexual
orientation, age, religion, national origin, ancestry, Vietnam-era veteran's status, place of
residence, health status, need for health services or source of payment for services
rendered. Consultant Provider will observe, protect and promote the rights of Members as
patients.
U. Consultant Provider shall notify Anthem BCBS in writing within 20 days of any of the
following events:
1. Change in ownership.
2. Change in business or billing address.
3. Commencement of any legal, governmental, or administrative action that might
materially impair its ability to provide services to Members under the terms of this
Agreement.
ARTICLE III. OBLIGATIONS OF ANTHEM BCBS
A. Anthem BCBS shall ensure that Plan provides a means of identifying Covered
Person/Members either by issuing a paper or plastic identification document to the
Covered Person/Member or by a telephonic, paper or electronic communication to
Consultant Provider. This identification need not include all information necessary to
determine Covered Person/Member's eligibility at the time a Health Service is rendered,
PARPPO CON:01-2008 I0 Weld County Department of Health and Environment,03/2012 akr,
but shall include information necessary to contact Plan to determine Covered
Person/Members' eligibility and the applicable Health Benefit Plan. Consultant Provider
acknowledges and agrees that possession of such identification document or ability to
access eligibility information telephonically or electronically, in and of itself, does not
qualify the holder thereof as a Covered Person/Member unless Consultant Provider has
received verification of eligibility within two business days prior to providing a Covered
Service, nor does the lack of an identification document mean that the person is not a
Covered Person/Member.
B. Anthem BCBS shall adhere to all applicable federal and state laws and regulations in
effect during the term of this Agreement.
C. Anthem BCBS shall review and authorize all hospital admissions and shall perform
concurrent monitoring of hospitalized Members.
D. Anthem BCBS shall reimburse or cause Plans to reimburse Consultant Provider directly
for Covered Services in accordance with the terms of Attachment A less any applicable
payments required of Member or other coverage.
E. Plan Payment Time Frames. Anthem, Plan or their designee and Consultant Provider shall
comply with the requirements of the Colorado prompt payment legislation, as may be
applicable, for payment of Clean Claims for Covered Services. In the event the Colorado
prompt payment legislation is not applicable, Anthem shall require Plans or their designees
to use best efforts to make payment or arrange for payment for all Clean Claims for
Covered Services submitted by Consultant Provider within 90 days of receipt, exclusive of
Claims that have been suspended due to the need to determine the extent of Plan's
payment liability, if any, because of issues such as coordination of benefits, subrogation,
eligibility for coverage, or medical necessity.
F. Offsets, Payment Corrections and Right of Recovery. Consultant Provider shall refund to
Plan all duplicate or erroneous payments, including but not limited to credit balances,
regardless of the cause. Nothing in this Section shall be construed to limit Consultant
Provider's rights pursuant to Plan's procedures for provider-carrier dispute resolution.
For claims subject to CRS 10-16-704 (4.5), as amended from time to time, Anthem may
adjust such claims within twelve months from the date of the original explanation of benefits,
which included the erroneous or duplicate payment. Anthem may retroactively adjust claims
based on coordination of benefits with federally funded health plans, including Medicare,
Medicaid or the Federal Employees Health Benefit Plan within three years of the date of
service. Anthem shall not retroactively adjust claims based on eligibility if Provider received
verification of eligibility within two business days prior to providing a Covered Service. Upon
notice by Provider of an underpayment by Anthem to Provider, Anthem shall correct its error
and pay Provider any amount due, provided such erroneous payment has been identified
and notice of the error has been provided to Anthem within twelve months from the date of
the original explanation of benefits which included the erroneous payment.
For claims not subject to CRS 10-16-704 (4.5), as amended from time to time, Anthem
may adjust such claims, provided such erroneous payment has been identified and notice
of the error has been provided to Provider. Upon notice by Provider of an underpayment
by Anthem to Provider, Anthem shall correct its error and pay Provider any amount due,
provided such erroneous payment has been identified and notice of the error has been
PARPPO CON:01-2008 I I Weld County Department of Health and Environment,03/2012 akr,
provided to Anthem within twelve months from the date of the original explanation of
benefits which included the erroneous payment.
Nothing in this Section shall be construed to limit Provider's rights pursuant to Anthem's
procedures for provider-carrier dispute resolution.
G. Anthem BCBS, at its sole cost and expense, may procure and maintain for the term of this
Agreement such policies of comprehensive general liability, professional liability, and other
insurance as necessary to insure Anthem BCBS, and its agents, servants and employees
acting within the scope of their duties, against any Claim for damages arising in
connection with the performance by Anthem BCBS of services pursuant to this
Agreement. This provision does not in any way limit or waive Participating Provider's
liability for professional services rendered to Members.
H. Any data or information pertaining to the diagnosis, treatment, or health of any Member or
applicant obtained from such person or from any provider by Anthem BCBS shall be held
in confidence and shall not be disclosed to any third person except in connection with
utilization review or reports, or unless an appropriate release has been obtained, or to the
extent required or permitted by law, or as provided in Anthem BCBS's Membership
Certificate.
Anthem BCBS shall periodically provide Consultant Provider with a current list of Anthem
BCBS's Consultant Providers, either in hard copy or on Anthem BCBS's website at
www.anthem.com.
J. Anthem BCBS shall recognize Consultant Provider's right to refuse to treat a Member for
appropriate professional reasons.
K. Anthem BCBS agrees to encourage PPO Members to use services of PPO network
Providers through benefit design and marketing efforts.
ARTICLE IV. UTILIZATION AND QUALITY MANAGEMENT PROGRAM
A. The Utilization and Quality Management Program is established by Anthem BCBS and
implemented by Anthem BCBS in conjunction with Consultant Providers to authorize and
monitor the quality and utilization of Covered Services provided to Members and to ensure
current credentialing of Consultant Providers. The Utilization Management and Quality
Improvement Programs are described in the Provider Manual.
B. Anthem BCBS, through its Utilization and Quality Management Program, shall review on a
prospective, concurrent and/or retrospective basis the quality of care, appropriateness of
care, level of care, and utilization of Covered Services provided to Members. Consultant
Provider shall cooperate with Anthem BCBS in conducting utilization and quality
management review, shall respond to inquiries from Anthem, and shall provide access to
Members' medical records consistent with Article II, I., all within such reasonable time
frames as may be established by Anthem BCBS. Failure to respond within a reasonable
time frame may result in termination of this Agreement.
C. Consultant Provider agrees to abide by the terms of the Provider Manual, and to participate
in and comply with Plan's Quality Improvement/Management and credentialing standards.
Consultant Provider warrants that it currently meets Plan's credentialing standards as
described in the Provider Manual and that it has all licenses required to provide health
PARPPO CON:01-2008 12 Weld County Department of Health and Environment,03/2012 akr,
services in accordance with the applicable licensing provisions of the laws and regulations of
the state in which it operates. Consultant Provider agrees to cooperate with Anthem BCBS
in the development and implementation of action Plans arising under Quality
Improvement/Management.
ARTICLE V. COMPENSATION
A. This Agreement shall commence on the date shown in the opening recitals and shall
remain in effect until terminated by either party as provided herein.
B. Consultant Provider shall accept the compensation provided under this Agreement as full
and final compensation for Covered Services provided to Members. Consultant Provider
shall collect any outstanding Cost Share amounts in accordance with the terms of the
applicable Membership Certificate or collection of payment for non-Covered Services from
the Member except as limited by the other provisions of this Agreement. Remaining
balances shall be treated as Contractual Adjustments by Consultant Provider and shall not
be billed to or collected from the Member.
ARTICLE VI. TERM AND TERMINATION
A. This Agreement shall commence on the date shown in the opening recitals and shall
continue until terminated by either party.
B. This Agreement may be terminated by either party at any time upon a minimum of 90 days'
advance written notice of termination to the other party. Termination shall be effective at
the end of the calendar month in which the 90-day notice requirement expires, or at the
end of any subsequent calendar month specified in the notice. This Agreement does not
create any continuing economic or other expectational rights.
C. This Agreement shall terminate automatically and immediately: (1) if either party commits
any act or conduct for which its license(s), permit(s), or any governmental or board
authorization(s) or approval(s) necessary for business operations are lost or voluntarily
surrendered; (2) if either party makes any material misstatements or omissions on any
documents which it submits to the other party; (3) if Consultant Provider fails to maintain the
minimum standards of quality set forth in Quality Improvement/Management beyond the time
parameters established in any corrective action/rehabilitation Plan set forth in Quality
Improvement/Management; (4) if Consultant Provider fails to provide credentialing
information that Anthem BCBS requires of all of its Providers in the region; (5) if Anthem
BCBS receives notification of Consultant Provider's ineligible person status; (6) if either
party's liability insurance coverage as required by this Agreement lapses for any reason; or
(7) upon notice by Anthem BCBS, if Anthem BCBS reasonably believes that Consultant
Provider's conduct or inaction jeopardizes the well-being of patients. Termination is effective
upon receipt of the notice of termination sent in accord with paragraph H.
D Termination With Cause/Default. If either party defaults in the performance of its
obligations under this Agreement, then the non-defaulting party shall give the defaulting
party written notice of the default. The defaulting party shall then have 15 days to cure any
financial default, and 45 days to cure any other default to the satisfaction of the non-
defaulting party. If the default is not cured within the required time, then the non-defaulting
party shall give the defaulting party a final notice of termination and this Agreement shall
PARPPO CON:01-2008 13 Weld County Department of Health and Environment,03/2012 akr,
terminate at the end of the calendar month in which such notice is given, or at the end of
any subsequent calendar month if specified in the notice.
E. Upon termination as described in paragraphs B., C., or D. above, the rights of each party
hereunder shall terminate, provided, however, that such action shall not release
Consultant Provider or Anthem BCBS from their obligations with respect to:
1. Payments and/or settlements accrued to either party prior to termination;
2. Consultant Provider's agreement not to seek compensation from Member for
Covered Services provided prior to termination; and
3. Consultant Provider shall, upon termination of this Agreement for reasons other than
the grounds set forth in the termination for default Section of this Agreement,
continue to provide and be compensated for Covered Services to Members under
the terms and conditions of this Agreement for 60 days after the effective date of
such termination. If coverage is terminated for any reason other than nonpayment of
premium, fraud, or abuse, Consultant Provider shall continue to provide and be
compensated for Covered Services to Members under the terms and conditions of
this Agreement until such Members are discharged from the hospital or any inpatient
facility. For purposes of this Section, "discharge" shall mean the Member's physical
release from the Hospital or in-patient facility.
F. In the event this Agreement is terminated for any reason, Anthem BCBS shall have the
right to offset against any monies owed to Consultant Provider by Anthem BCBS any or all
sums owed by Consultant Provider to Anthem BCBS. Any sums that are owed to Anthem
BCBS by Consultant Provider that are not satisfied by offset shall be paid by Consultant
Provider within 60 days of the date Consultant Provider is notified, by invoice or otherwise,
that such sums are owing.
G. Any notice of termination shall be sent by facsimile or certified mail, postage prepaid to
Anthem BCBS at:
Anthem Blue Cross and Blue shield
Mail Code CO0105-0568
700 Broadway
Denver, Colorado 80273-0002
Attention: Network Management
Fax: 303-831-5833
and to Consultant Provider at: Weld County Department of Health and Environment
1555 N 17`h Avenue
Greeley CO 80631
H. Anthem BCBS agrees to notify Members affected by the termination of this Agreement
prior to such termination, as required by applicable law.
PARPPO CON:01-2008 14 Weld County Department of Health and Environment,03/2012 akr,
ARTICLE VII. AMENDMENTS, MODIFICATIONS AND MATERIAL CHANGES
A. Amendments and Modifications.
1. Except as set forth below, no change or modification of this Agreement shall be
valid or binding upon the parties hereto, nor shall any waiver of any term or
condition be deemed a waiver of such term or condition in the future, unless such
modification, change or waiver shall be in writing signed by the parties hereto.
2. Anthem BCBS may disclose a change or modification to the Agreement, without
requiring a signed amendment, in order to conform to the requirements of statute,
regulation, or interpretation by court or government agency having jurisdiction
thereof.
3. Except as stated above in subsection A.2., this Agreement may be amended only in
writing signed by both parties. Notwithstanding the foregoing, and not including any
"Material Changes" as further described below, Anthem BCBS may amend the
Provider Manual, claims adjudication logic (such as, but not limited to, bundling),
Quality Improvement/Management or Utilization Management, by giving notice of
such amendment to Consultant Provider at least forty-five (45) days in advance of the
effective date of the amendment. If Consultant Provider decides not to accept the
amendment, Consultant Provider shall provide, within thirty (30) days of Consultant
Provider's receipt of such amendment, written notice of its objection to Anthem BCBS
and such notice of objection shall constitute Consultant Provider's notice of
termination under the Termination Without Cause Section of this Agreement. Prior to
the effective date of such termination, the proposed amendment shall not go into
effect as to Consultant Provider. Failure of Consultant Provider to object to an
amendment in writing to Anthem BCBS within the time frames described herein shall
constitute acceptance of the Amendment.
B. Material Changes.
Anthem BCBS reserves the right to amend its policies and procedures (incorporated by
reference herein) by providing Consultant Provider with a written description of the material
change at least ninety (90) days prior to the date that the material change becomes
effective (the "Notice Period") on a form entitled "Notice of Material Change to Contract."
The date that the Anthem BCBS sends the material change notice by U.S. mail shall be
referred to as the "Notice Date," and it shall mark the beginning of the Notice Period.
If the Consultant Provider does not object to this material change, in the manner described
below, the material change will become effective at the end of the Notice Period.
However, if Consultant Provider objects to the material change, Consultant Provider may
terminate this Agreement rather than complying with the material change terms.
If the health care provider objects in writing to the material change within fifteen days and
there is no resolution of the objection either party may terminate the contract upon written
notice of termination provided to the other party not later than sixty (60) days before the
effective date of the material change.
PARPPO CON:01-2008 15 Weld County Department of Health and Environment,0312012 akr,
If Consultant Provider gives Anthem BCBS notice of Consultant Provider's intent to
terminate the Agreement, as described above, Anthem BCBS has the right to notify
Consultant Provider that Anthem BCBS will not implement the material change as to
Consultant Provider. If Anthem BCBS chooses to exercise this option, its notice to
Consultant Provider must be in writing and given within sixty (60) days of the Notice Date.
If Anthem BCBS gives Consultant Provider this notice, then this Agreement will not
terminate, and the material change will not be applied to Consultant Provider.
C. Non Material Changes.
If a change to the contract is administrative only and is not a material change, the change
shall be effective upon at least fifteen (15) days' notice to the health care provider. All
other notices shall be provided pursuant to the contract.
ARTICLE VIII. MISCELLANEOUS PROVISIONS
A. Dispute Resolution — Pursuant to 1 CCR 101-1 and except for the following: disputes
related to claims of medical malpractice; disputes between Consultant Provider and
Members; or, the Termination Without Cause Section of this Agreement, if any dispute
arises out of or relates to this Agreement, Consultant Provider shall follow the applicable
Provider Appeal procedure related to the subject matter of the dispute. In the event such
appeal fails to resolve the dispute, Anthem BCBS and Consultant Provider shall meet to
attempt to resolve the dispute. If such efforts are unsuccessful, the complaining party shall
provide written notice to the other party describing the dispute within twenty (20) days of
the meeting. If a party intends to litigate the dispute, such party shall notify the other party,
in writing, of its intent to litigate at least thirty (30) days before filing a cause of action. The
parties hereby consent to jurisdiction of the courts in the State of Colorado for injunctive,
specific enforcement, or other relief.
B. Independent Contractors. Anthem BCBS and Consultant Provider are separate and
independent entities. The relationship between Anthem BCBS and Consultant Provider is
purely contractual. Neither Anthem BCBS nor any employee thereof shall be deemed to
be the agent, employee or other representative of Consultant Provider, nor shall
Consultant Provider be deemed to be an agent, employee or other representative of
Anthem BCBS. In the performance of this Agreement and in rendering medical services as
provided herein, Consultant Provider shall at all times act as an independent contractor.
C. Excuse of Non-Performance. Consultant Provider and ANTHEM BCBS shall be excused
from performance under this Agreement if for any period either is prevented from
performing any obligations pursuant hereto, in whole or in part, as a result of any Act of
God, war, civil disturbance, court order, third party labor dispute or other cause beyond its
reasonable control, including shortages or fluctuations in electrical power, heat, light or air
conditioning, and such non-performance shall not be a ground for default.
D. Notice. Any notice relating to this Agreement, shall be deemed given upon (1) mailing,
certified mail, postage prepaid, to a party's address of record, or (2) two business days
after properly completed facsimile transmission, provided such facsimile is also sent
regular mail, postage prepaid, to a party's address of record.
PARPPO CON 01-2008 16 Weld County Department of Health and Environment,03/2012 akr,
E. Successors, Assignment and Delegation of Duties. Except as provided herein, neither this
Agreement nor any interest or obligation of any party herein shall be assigned without the
written consent of all parties. The parties hereby expressly agree that Anthem BCBS may,
at its sole discretion, assign all of its rights, interests and obligations under this Agreement
to any successor organization of Anthem BCBS. This Agreement shall not create any
right, or cause of action in, or on behalf of any person other than Anthem BCBS, its
assignees, or Consultant Provider. Anthem BCBS shall provide thirty (30) days advance
written notice of any assignment, and the assignment shall become effective thirty (30)
days after such notice.
F. Waiver.
1. Waiver of breach/violation: The waiver by either party of a breach or violation of
any provision of this Agreement shall not be construed as a waiver of any
subsequent breach thereof.
2. Waiver of Law: Contract shall not require as a condition of contracting that Health
Care Provider waiver of forego any right or benefit to which the Health Care
Provider may be entitled.
G. Paragraph Headings. The paragraph and section headings used in this Agreement are for
reference only. They are not to be used by themselves for the purpose of interpreting
provisions of the Agreement.
H. Governing Law. The laws of the State of Colorado shall apply to any matter or dispute
arising out of this Agreement.
Entire Agreement. This Agreement, including the Provider Manual and all attachments
hereto, contains all the terms and conditions agreed upon by the parties regarding the
subject matter of this Agreement. This Agreement replaces and supersedes any prior
Agreement between Anthem BCBS and Consultant Provider except with respect to any
rights and obligations incurred there under which continue beyond the effective date of this
Agreement. Consultant Provider agrees that by executing this Agreement, it waives the
notice requirements for termination contained in any prior Agreement. Any prior
agreements, promises, negotiations or representations of or between the parties, either
oral or written, relating to the subject matter of this Agreement, which are not expressly set
forth in this Agreement are null and void. The summary disclosure form is for informational
purposes only, is not an attachment to this Agreement and does not constitute a term and
condition of this agreement.
J. Non-Exclusivity. Nothing contained in this Agreement shall be construed to preclude
either party from entering into reimbursement arrangements with parties outside this
Agreement.
K. Use of Names/Service Marks. Anthem BCBS may include Consultant Provider name in
lists or other notifications of Consultant Providers. Consultant Provider may identify
himself as an Anthem BCBS Consultant Provider. Except as provided in this paragraph,
neither Anthem BCBS nor Consultant Provider shall use the other party's name, symbols,
trademarks or service marks in promotional material or otherwise without the prior written
consent of the other party.
L. Association Service Mark. Consultant Provider acknowledges that this Agreement
constitutes an agreement between Consultant Provider and Anthem BCBS. Anthem
BCBS is an independent corporation operating under a license with the Blue Cross and
PARPPO CON:01-2008 17 Weld County Department of Health and Environment,03/2012 akr,
Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans,
(the Association) permitting Anthem BCBS to use the Blue Cross and Blue Shield Service
Mark in Colorado, and that Anthem BCBS is not entering into this Agreement as the agent
of the Association. Consultant Provider further acknowledges and agrees that it has not
entered into this Agreement based upon representations by any person other than Anthem
BCBS and that no person, entity, or organization other than Anthem BCBS shall be held
accountable or liable to Consultant Provider for any of Anthem BCBS's obligations to
Consultant Provider created under this Agreement. This provision shall not create any
additional obligations whatsoever on the part of Anthem BCBS other than those
obligations created under other provisions of this Agreement.
M. Medical Care Decisions. Notwithstanding any other Section in this Agreement and
regardless of any benefit or coverage exclusions or limitations associated with a Membership
Certificate, Consultant Provider shall not be prohibited from discussing fully with Members
any issues related to the Member's health including recommended treatments, treatment
alternatives, treatment risks and the consequences of any benefit coverage or payment
decisions made by Plan or any other person. Consultant Provider is encouraged to, in good
faith, express disagreement it has with an Anthem BCBS decision regarding a Membership
Certificate decision, whether such disagreement is communicated to Anthem BCBS, to a
Member, to a regulator or to a law enforcement agency. Nothing in this Agreement shall
prohibit the Consultant Provider from disclosing to the Member the general methodology by
which Consultant Provider is compensated under this Agreement, provided no dollar
amounts or other specific terms of the payment arrangement are mentioned to the Member.
Plan shall not refuse to allow or to continue the participation of any otherwise eligible
Provider, or refuse to compensate Consultant Provider in connection with services rendered
solely because Consultant Provider has in good faith communicated with one or more of its
current, former or prospective patients regarding the provisions, terms or requirements of a
Membership Certificate as they relate to the health needs of such patient.
FURTHERMORE,
Consultant Provider or any individual Provider or group of Providers covered by this
Agreement shall not be prohibited from protesting or expressing disagreement with a
medical decision, medical policy or medical practice of Plan or an entity representing or
working for Plan (e.g., a utilization review company). Plan or an entity representing or
working for Plan shall not be prohibited from protesting or expressing disagreement with a
medical decision, medical policy, or medical practice of Consultant Provider covered by
this Agreement. Plan shall not terminate this Agreement because Consultant Provider
expresses disagreement with a decision by Plan or an entity representing Plan to deny or
limit benefits to a Member or because Consultant Provider assists a Member to seek
reconsideration of Plan's decision, or because Consultant Provider discusses with a
current, former or prospective Member any aspect of Member's medical condition, any
proposed treatments or treatment alternatives, whether covered by Plan or not, policy
provisions of the Plan, or Consultant Provider's recommendation regarding selection of a
health Plan based on the Consultant Provider's personal knowledge of the health needs
of such Member.
N. Contracting Party. If Consultant Provider is a partnership, corporation, or any other entity
other than an individual professional provider, all references herein to "Consultant Provider"
shall also mean and refer to each provider of such entity individually who has applied for and
been accepted by Plan for such purposes.
PARPPO CON'.01-2008 18 Weld County Department of Health and Environment,03/2012 akr,
O. Survival of Terms. A term for compensation/payment shall not survive termination of a
contract, except for a state continuation requirement or by agreement.
P. Disclosure to Third Parties. A contract shall not preclude its use or disclosure to a third party
for the party for the purpose of enforcement or by the law. All confidentiality agreements
shall apply to third party.
Q. Confidentiality. The parties acknowledge that as a result of this Agreement, each may have
access to certain trade secrets and other confidential and proprietary information of the
other. Each party shall hold such trade secrets and other confidential and proprietary
information, including the terms and conditions of this Agreement, in confidence and shall
not disclose such information, either by publication or otherwise, to any person without the
prior written consent of the other party except as may be required by law and except as may
be required to fulfill the rights and obligations set forth in this Agreement. With respect to
Anthem BCBS, such confidential and proprietary information shall include, without limitation,
the Attachments/Exhibits. Anthem BCBS and Consultant Provider on behalf of itself an its
providers affirm a positive duty to maintain the confidentiality of the financial terms of this
Agreement, except where disclosures is required by law, necessary or appropriate in
connection with any audit of Anthem BCBS by or on behalf of any group obtaining services
through Anthem BCBS or necessary to administer this Agreement, or Consultant Providers'
attorneys, accountants, actuaries or agents, or where all parties consent to such disclosures
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by the following
authorized officers.
CONSULTANT PROVIDER ANTHEM BLUE CROSS AND BLUE SHIELD
BY: BY:
Signature 'g re
PRINTED PRINTED
NAME: Sean P. Conway NAME: Janet Pogar
TITLE: Chair, Board of Weld TITLE: R.V.P., Provider Engagement and
County Commissioners Contracting
DATE: AUG 1 5 2012 DATE: 10.1 1
TAX l D#846000813
o7D/o? -c>2%6
PARPPO CON:01-2008 19 Wetd County Department of Health and Environment,0312012 akr,
ANTHEM BLUE CROSS AND BLUE SHIELD
PARTICIPATING AND PPO CONSULTANT PROVIDER AGREEMENT
LIST OF ATTACHMENTS/ADDENDUM
ATTACHMENT
Reimbursement Schedule A
Consultant Provider Listing B
PARPPO CON:01-2008 20 Weld County Department of Health and Environment,00/2042 akr,
ANTHEM BLUE CROSS AND BLUE SHIELD
PARTICIPATING AND PPO CONSULTANT PROVIDER AGREEMENT
ATTACHMENT A
REIMBURSEMENT SCHEDULE
Indemnity/Participating
Payment to Consultant Providers is based on fee-for-service reimbursement. Anthem BCBS shall
reimburse Consultant Provider the lesser of billed charges or 115% of the current Medicare fee
schedule Anthem BCBS has implemented for Covered Services.
Immunizations are paid 100% of AWP (Average Wholesale Price).
All payments by Anthem BCBS shall be net of any applicable deductible, coinsurance, or
copayment requirements.
Therapy Codes (97001-97799) shall be reimbursed the lesser of billed charges or an all inclusive
rate of$70.00 per visit. Except for codes 97597-97606 which are paid at your contracted rate.
Unlisted Therapeutic Procedure 97139 will be reimbursed at a flat fee of$5.00, unless it is billed
with another therapy service, in which case it will be included in the $70.00 per visit.
Lab codes as indicated in the Provider Manual are reimbursed at lesser of billed charges or at
100% of the Medicare fee schedule. Anthem BCBS will allow any lab procedures performed in-
office that are not indicated on this list at 42% of the Medicare fee schedule.
Radiology codes are reimbursed at the lesser of billed charges or your contracted rates.
Medicare reimburses certain radiology codes using a flat fee. For those codes, Anthem will follow
Medicare and reimburse using a flat fee. High-end outpatient diagnostic imaging performed in-
office (to include but not be limited to MRI, MRA, PET Scan, CT/CAT, and related services and
supplies) will not be allowed unless specifically outline in your contract.
Sleep Studies (in-office) not specifically outlined in your contract will not be allowed. Sleep Studies
billed with a modifier 26 will be reimbursed according to your contracted rates.
HCPCS codes for DME and supplies are paid at 80% of the Medicare fee schedule.
Allergy Immunotherapy: CPT code 95165 is paid at 100% of the Medicare fee schedule
Non-Invasive Vascular Diagnostic Studies: CPT Codes 93875 — 93990 are paid at 100% of the
Medicare fee schedule
Allergy Testing: CPT Codes 95004 — 95075 are paid at 100% of the Medicare fee schedule.
Nerve Conduction Tests: CPT Codes 95900 — 95904 are paid at 100% of the Medicare fee
schedule.
Health and Behavior Assessment: CPT Codes 96150 — 96155 are paid at 100% of the Medicare
fee schedule.
Determination of Refractive State: CPT Code 92015 is reimbursed at flat fee of$20.00.
PARPPO CON:01-2008 21 Weld County Department of Health and Environment,03/2012 akr,
Reimbursement will be made according to Anthem BCBS's medical/reimbursement policies for
Covered Services including, but not limited to, policies regarding multiple surgical procedures,
surgical assistance, global surgical service, coding and unbundling, and other billing and
reimbursement practices.
All payments by Anthem shall be the net of any applicable copayments, coinsurance or deductible
amounts.
PPO
For Covered Services rendered to PPO Members or Federal Employee Program Members, the
payment shall be the lesser of billed charges or 115% of the current Medicare fee schedule
Anthem BCBS has implemented for Covered Services.
Immunizations are paid 100% of AWP (Average Wholesale Price).
All payments by Anthem BCBS shall be net of any applicable deductible, coinsurance, or
copayment requirements.
Therapy Codes (97001-97799) shall be reimbursed the lesser of billed charges or an all inclusive
rate of$70.00 per visit. Except for codes 97597-97606 which are paid at your contracted rate.
Unlisted Therapeutic Procedure 97139 will be reimbursed at a flat fee of$5.00, unless it is billed
with another therapy service, in which case it will be included in the $70.00 per visit.
Lab codes as indicated in the Provider Manual are reimbursed at lesser of billed charges or at
100% of the Medicare fee schedule. Anthem BCBS will allow any lab procedures performed in-
office that are not indicated on this list at 42% of the Medicare fee schedule.
Radiology codes are reimbursed at the lesser of billed charges or your contracted rates.
Medicare reimburses certain radiology codes using a flat fee. For those codes, Anthem will follow
Medicare and reimburse using a flat fee. High-end outpatient diagnostic imaging performed in-
office (to include but not be limited to MRI, MRA, PET Scan, CT/CAT, and related services and
supplies) will not be allowed unless specifically outline in your contract.
Sleep Studies (in-office) not specifically outlined in your contract will not be allowed. Sleep Studies
billed with a modifier 26 will be reimbursed according to your contracted rates.
HCPCS codes for DME and supplies are paid at 80% of the Medicare fee schedule.
Allergy Immunotherapy: CPT code 95165 is paid at 100% of the Medicare fee schedule
Non-Invasive Vascular Diagnostic Studies: CPT Codes 93875 — 93990 are paid at 100% of the
Medicare fee schedule
Allergy Testing: CPT Codes 95004 -95075 are paid at 100% of the Medicare fee schedule.
Nerve Conduction Tests: CPT Codes 95900 - 95904 are paid at 100% of the Medicare fee
schedule.
Health and Behavior Assessment: CPT Codes 96150 — 96155 are paid at 100% of the Medicare
fee schedule.
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Determination of Refractive State: CPT Code 92015 is reimbursed at flat fee of$20.00.
Reimbursement will be made according to Anthem BCBS's medical/reimbursement policies for
Covered Services including, but not limited to, policies regarding multiple surgical procedures,
surgical assistance, global surgical service, coding and unbundling, and other billing and
reimbursement practices.
All payments by Anthem shall be the net of any applicable copayments, coinsurance or deductible
amounts.
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ANTHEM BLUE CROSS AND BLUE SHIELD
PARTICIPATING AND PPO CONSULTANT PROVIDER AGREEMENT
ATTACHMENT B
CONSULTANT PROVIDER LISTING
Weld County Department of Health and Environment
Tax I.D. #'s - 846000813
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