HomeMy WebLinkAbout20122165.tiff RESOLUTION
RE: APPROVE CONSULTANT PROVIDER AGREEMENT AND AUTHORIZE CHAIR TO
SIGN - HMO COLORADO, INC.
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 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 HMO Colorado, Inc., 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 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 HMO Colorado, Inc., 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: 617-
Sean P. n y, Chair
Weld County Clerk to the Board
lac
William F arcia, Pr -T
BY: J
Deputy CI-.I to the':oard � E1
._ cts Barb a Kirkmeyer
•
AP.� • . D A Ifrmea
111111 ';utter avid E. Long
t.0 .ttorney � yD ��.;
• •ougl.s Radem-cher
Date of signature: 0-J- I1)-
0 Yi9 -TcaW 1—C n „ �, W�I3 2012-2165
�I l�l t� HL0039
Memorandum
r
4 r TO: Sean Conway, Chair
Board of County Commissioners
z , FROM: Mark E. Wallace, MD, MPH, Director
{yZ Department of Public Health & Environment
1 y
DATE: July 30, 2012
SUBJECT: HMO Colorado, Inc., Consultant Provider
Agreement
Enclosed for Board review and approval is an agreement for HMO Colorado, Inc 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 HMO
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 Blue
Shield HMO Colorado, Inc. and will stay in effect until cancelled by either party.
2012-2165
HMO COLORADO, INC.
CONSULTANT PROVIDER AGREEMENT
THIS AGREEMENT is made and entered into, by and between HMO Colorado, Inc. (HMOC)
located at 700 Broadway, Denver, Colorado 80273-0002 and Weld County Department of Health
and Environment (Consultant Provider or Consultant) located at 1555 N 17th Avenue Greeley CO
80631
In order to support the operational efficiencies regarding the implementation of this Agreement,
HMOC 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 II exe uted. This
Agree ent shall be effective (as determined by HMOC upon execution) fr 7 ( 2'e
20
WITNESSETH:
WHEREAS, HMOC operates a health maintenance organization pursuant to the laws of the State
of Colorado; 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, HMOC and Consultant Provider desire to enter into an agreement whereby
Consultant Provider shall provide Covered 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 HMOC directly or indirectly, and any
entity which is under common ownership directly or indirectly, by Anthem Insurance
Companies, Inc_ Upon execution of this Agreement, HMOC 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 CMS 1500 form, or a form
approved by HMOC, or through a method of automated transmission developed for direct
entry into HMOC Claim's 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 HM0C Maximum Benefit Allowance. Contractual Adjustments shall be absorbed by
the Consultant Provider and shall not be charged to the Member or HMOC.
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
CONSUL TANT 01/2008 I We d Cn my Depadr-ort of Haa,,and Envy-men,03/2012,ekr
/ ? 47/6
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 HMOC 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 HMOC 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.
"HMOC Maximum Benefit Allowance" means the maximum amount of reimbursement
allowed for a Covered Service as determined by HMOC.
J. "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;
CONSULTANT 01/2008 2 Weld County Department of Health and EnvornmentO3/2012,akr
(e) changes to an existing prior authorization, precertification, notification, or referral
program that do not substantially increase the provider's administrative expense; or
(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.
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 a person eligible for benefits under an HMOC Membership Certificate,
which is defined herein. For purposes of this Agreement, Member includes participants in
an employer's self-funded employee benefit Plan for which HMOC acts in some
administrative capacity, as well as persons covered by other insurance Plans or entities
with whom HMOC may have a contractual agreement to allow such persons to use the
HMOC network of participating physicians or Consultant.
M. "Membership Certificate" means a contract between HMOC and a group (employer) for the
benefit an employee health Plan (including any conversion certificate issued to a Member
of the group after termination of employment), between HMOC and the Federal Employee
Health Benefits Program, or a contract issued by other Blue Cross and Blue Shield Plans
and administered by HMOC, (including national accounts), whereby HMOC agrees to pay
Consultant Provider a specified amount for Covered Services rendered to eligible
Members in accordance with the terms of such contract. The contract may be wholly or
partially underwritten by HMOC, or may be wholly or partially self-insured by the group.
N. "Participating Hospital" means a hospital which has entered into a written agreement with
HMOC 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 HMOC to provide certain
Covered Services to Members, upon appropriate referral by the Member's Consultant
Provider and/or HMOC. A non-Participating Provider is a provider who has not entered
into such an agreement.
CONSULTANT 01/2008 3 Weld County Department of Health and Envernment03/2012,akr
P. "Plan" means: (1) HMOC; (2) an Affiliate as designated by HMOC; (3) any Blue Cross and
Blue Shield Plan; and/or (4) a self-funded account which is administered in whole or in part
by HMOC, an Affiliate or any Blue Cross and Blue Shield Plan.
Q. "Primary Care Provider" means a duly licensed health care provider who has entered into
a written agreement with HMOC to provide specified Covered Services to Members, and
to coordinate and arrange for the provision of other health care services to Members who
have selected him or her as their Primary Care Provider.
R. "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.
T. "Provider Manual" means the policy and procedure manual prepared by HMOC, which
may be amended solely at HMOC's option from time to time, 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.
U. "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 HMOC's
Quality Improvement/Management is included in the Provider Manual.
V. "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 HMOC'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.
B. Covered Services. Consultant Provider agrees to provide, within the scope of Consultants
practice, Covered Services to Members. Authorization procedures are set forth in the
Provider Manual. Consultant Provider shall provide to Members only those Authorized
Covered Services. If Consultant Provider provides services beyond those authorized by
the authorization, HMOC may not pay Consultant Provider for those services. The
Consultant Provider agrees to provide Covered Services to Members in accordance with
this Agreement and HMOC's Utilization Management and Quality Improvement programs,
as more fully set forth in the Provider Manual.
C. Non-Covered Services. In the event Consultant Provider recommends that a Member
receive services, knowing that such services are not Covered Services, or provides
services not authorized, Consultant Provider shall inform the Member prior to the provision
of such services: (1) that the services recommended are not Covered Services, (2) that
HMOC 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
CONSULTANT 01/2008 4 Weld County Department of Health and Envornment03/2012,akr
collect payment from the Member, for any non-covered or unauthorized services
performed by Consultant.
D. Admissions. Any non-Emergency inpatient admission of, or use of an outpatient surgery
facility by, a Member must be approved in advance by HMOC. 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 HMOC
authorization in advance for all services requiring authorizations. Consultant must
follow the required authorization procedures set forth in the Provider Manual.
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 HMOC, 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
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. Cost Share Amounts. HMOC may require Members to pay Cost Shares for certain
Covered Services. It is the responsibility of Members to pay such Cost Share amounts
directly to the provider of service. Consultant Provider agrees to collect applicable Cost
Share amounts from Members.
CONSULTANT 01/2008 5 Weld County Department of Health and Envornment03/2012,akr
H. Hold Harmless. Consultant hereby agrees that in no event, including, but not limited to
nonpayment by Plan, Plan insolvency or breach of this Agreement, shall Consultant 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 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 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 HMOC
or an Affiliate, Consultant's cause of action, if any, shall lie strictly with the Plan
sponsor of said Member's Membership Certificate.
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 agrees that HMOC and Plan are not responsible for the amount of such
reduction or denial. However, Consultant 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 agrees that HMOC, Plan, and Member are not
responsible for the amount of such reduction or denial.
3. Consultant 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 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 has provided to Member notice in writing, prior to the 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 may bill the Member at its customary rate for
such services.
4. This hold harmless Section shall survive termination of this Agreement with respect
to health services rendered under this Agreement during the time this Agreement is
in effect, 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 HMOC as may be necessary
for compliance by HMOC with state and federal law, as well as for HMOC program
management purposes. HMOC shall have access, at reasonable times upon
CONSULTANT 01/2008 6 Weld County Department of Heath and Envornment03/2012,akr
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. HMOC shall also have the right to inspect Consultant Provider's facilities
pursuant to HMOC'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 HMOC. 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. Provision of Services and Professional Requirements.
1. Consultant Provider shall accept as patients, without regard to health status or
health care needs, those Members who have been referred by their Primary Care
Provider. Consultant Provider agrees (a) not to differentiate or discriminate in the
treatment of his patients or in the quality of services delivered to Members 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, and
(b) to observe, protect and promote the rights of Members as patients. All Covered
Services required or provided hereunder shall be of good quality and shall meet
the accepted standards of professional medical and surgical practices prevailing in
the community at the time such services are rendered.
2. 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
HMOC 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 HMOC Participating Hospital to perform any
specialty services Consultant renders to Members in an outpatient or inpatient
setting, and must immediately notify HMOC 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 his or her 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 HMOC 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 HMOC upon request. Consultant shall
also immediately notify HMOC of any policy cancellation or any changes in the coverage
required by this paragraph.
L. Administration.
1. Consultant Provider agrees to cooperate with HMOC and comply with all policies in
all matters of administration. Consultant Provider agrees to abide by the terms of the
Provider Manual, and to participate in and comply with Plan's Quality
CONSULTANT 01/2008 7 Weld County Department of Health and Envernment03/2012,akr
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 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 HMOC 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,
HMOC may not cover the services rendered and the provisions of paragraph H. of
this Article II 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 HMOC on form CMS 1500 or its equivalent
or in a HIPAA compliant electronic format. Claims shall be submitted within one
hundred eighty (180) days of the date services are rendered for all services rendered
to Members covered by HMO plans. Requests made by HMOC for additional
information shall be completed and returned by Consultant Provider within thirty (30)
days. For purposes of coordination of benefits, in the event HMOC is not the primary
payor, Consultant Provider shall submit claim to HMOC not later than one hundred
eighty (180) 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 HMOC within
the above time periods such claims shall be deemed to be waived and shall not be the
financial responsibility of Member or HMOC.
4. Consultant Provider agrees to participate in and cooperate with HMOC 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 HMOC's complaint and
grievance procedure, and to make a good faith effort to comply with the decisions of
HMOC'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 HMOC and HMOC shall make alternative
arrangements for effectuating the decision. The Member complaint and grievance
procedure is set forth in the Provider Manual.
6. If a Member persists in a course of conduct that interferes with the establishment
and maintenance of a satisfactory Physician-patient relationship or the rendering of
effective medical care, Consultant Provider shall follow the Member Non-
Compliance/Disenrollment Policy described in the Provider Manual. Such a course
of conduct, as well as non-payment of Cost Share amounts or charges for non-
Covered Services or prior services, may be justifiable reasons for HMOC to initiate
termination or transfer procedures against a Member in accordance with the terms of
that policy.
7. Consultant Provider agrees that HMOC may use Consultant Provider's name,
address, phone number, type of practice, and an indication of his willingness to
accept additional Members in HMOC's roster of Participating Providers and other
HMOC materials.
8. Consultant Provider may close office to new patients upon 60 days written notice to
HMOC. The notice shall state the reason(s) for closing the office to new patients.
CONSULTANT 01/2008 8 Weld County Department of Health and Envomment00/2013,akr
"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 HMOC. 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.
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 HMOC coverage, or (3) who have been injured in an
accident. Consultant Provider shall notify HMOC whenever Consultant has reason
to believe a Member may be entitled to coverage under any other health benefit Plan
and shall assist HMOC in obtaining information for the coordination of benefits when
a Member holds such other coverage.
2. Consultant Provider agrees to notify HMOC of any facts that might give rise to
HMOC 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 payors.
3. In no event will HMOC's payment obligation to Consultant 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 HMOC networks shall not be a condition of
participation in any HMOC network. HMOC 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. HMOC shall not
require Consultant Provider to participate in a Medicare Advantage or Medicaid network in
order to participate in commercial provider networks. HMOC shall not require Consultant
Provider to participate in all HMOC's commercial provider networks.
O. Credentialinq Information. Consultant Provider agrees to cooperate with and provide
information to HMOC, or its agent, for the purposes of credentialing him as part of the
provider network as applicable. Consultant Provider shall also provide updates to that
information at specified intervals for recredentialing purposes as applicable. Failure to
submit the information or to meet either the initial credentialing or recredentialing criteria
may, at HMOC'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 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. HMOC shall have the right to immediately terminate this Agreement in the event
CONSULTANT 01/2008 9 Weld County Department of Health and Envornment03/2012,akr
it receives notification of the Consultant Provider's ineligible person status. Provider agrees
to hold HMOC 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 Actions. Consultant Provider shall immediately send written notice to HMOC 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
HMOC with thirty(30) days prior notice of any subcontractors with which 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. Provider agrees that
HMOC may contract directly with any Providers rather than relying on the subcontracting
arrangements entered by Provider.
S. Consultant Provider shall notify HMOC 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 HMOC
A. HMOC 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, 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. HMOC shall adhere to all applicable federal and state laws and regulations in effect during
the term of this Agreement.
C. HMOC shall review and authorize all hospital admissions. HMOC shall perform concurrent
monitoring of hospitalized Members.
D. For all Covered Services provided by Consultant Provider hereunder, HMOC shall pay to
Consultant Provider the compensation set forth in Attachment A, less any applicable
payments required of Member or other coverage.
CONSULTANT 01/2008 10 Weld County Department of Health and EnvornmentO3/3012,akr
E. Plan Payment Time Frames. HMOC, 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, HMOC 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. For claims subject to CRS 10-16-704
(4.5), as amended from time to time, HMOC may adjust such claims within twelve months
from the date of the original explanation of benefits, which included the erroneous or duplicate
payment. HMOC 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. HMOC shall not retroactively adjust
claims based on eligibility if Consultant Provider received verification of eligibility within two
business days prior to providing a Covered Service. Upon notice by Consultant Provider of an
underpayment by HMOC to Consultant Provider, HMOC shall correct its error and pay
Consultant Provider any amount due, provided such erroneous payment has been identified
and notice of the error has been provided to HMOC 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, HMOC may
adjust such claims, provided such erroneous payment has been identified and notice of the
error has been provided to Consultant Provider. Upon notice by Consultant Provider of an
underpayment by HMOC to Consultant Provider, HMOC shall correct its error and pay
Consultant Provider any amount due, provided such erroneous payment has been identified
and notice of the error has been provided to HMOC 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 Consultant Provider's rights pursuant to
HMOC's procedures for provider-carrier dispute resolution.
G. HMOC, 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 HMOC, 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 HMOC of services pursuant to this Agreement. This provision does not
in any way limit or waive Consultant liability for professional services rendered under this
Agreement.
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 HMOC shall be held in
confidence and shall not be disclosed to any third person except in connection with
utilization review or unless an appropriate release has been obtained or to the extent
required or permitted by law, or as provided in HMOC's Membership Certificate.
HMOC will comply with the notice requirements of C.R.S. 10-16-705(7) and related
regulations, as amended from time to time.
CONSULTANT 01/2008 I I Weld County Department of Health and Envornment00/2012,akr
ARTICLE IV. UTILIZATION AND QUALITY MANAGEMENT PROGRAM
A. The Utilization and Quality Management Program is established by HMOC and
implemented by HMOC 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. HMOC, 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 HMOC in conducting utilization and quality management
review, shall respond to inquiries from HMOC, and shall provide access to Members'
medical records consistent with Article II, I., all within such reasonable time frames as may
be established by HMOC. 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
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 HMOC in the
development and implementation of action Plans arising under Quality
Improvement/Management.
ARTICLE V. COMPENSATION
A. Consultant Physician shall be compensated by HMOC as set forth in Attachment A.
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. The term of this Agreement shall commence on the date shown in the opening recitals and
shall continue until terminated by either party as provided herein.
B. This Agreement may be terminated by either party at any time upon giving 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-days 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.
CONSULTANT 01/2008 12 Weld County Department of Health and Envornment03/2012,akr
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 HMOC requires of all of its Providers in the region; (5) if HMOC 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 HMOC, if HMOC
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. Article VI.
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 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 HMOC 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, HMOC shall have the right to
offset against any monies owed to Consultant Provider by HMOC any or all sums owed by
Consultant Provider to HMOC. Any sums that are owed to HMOC 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. In the event of termination of this Agreement, Consultant Provider shall provide HMOC, to
the extent authorized by Members who have been enrolled with Consultant Provider under
CONSULTANT 01/2008 13 Weld County Department of Health and Envornment03/2012,akr
HMOC, copies of information and records concerning such Members that HMOC may
request or make such information and records available to HMOC for copying. Consultant
Provider reserves the right to retain originals of such records and information.
H. Any notice of termination shall be sent by facsimile or certified mail, postage prepaid:
to HMOC at: HMO Colorado, Inc.
Mail Stop CO0105-0568
700 Broadway
Denver, Colorado 80273-0002
Attention: Provider Engagement & Contracting
Fax: (303) 831-5833
and to Consultant Provider at: Weld County Department of Health and Environment
1555 N 17th Avenue
Greeley CO 80631
HMOC agrees to notify Members affected by the termination of this Agreement prior to
such termination, as required by applicable law.
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. HMOC 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, HMOC 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 HMOC 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 HMOC within the time frames described herein shall constitute acceptance of
the Amendment.
CONSULTANT 01/2008 14 Weld County Department of Health and Envornment03/2012,akr
B. Material Changes.
HMOC 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 HMOC 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.
If Consultant Provider gives HMOC notice of Consultant Provider's intent to terminate the
Agreement, as described above, HMOC has the right to notify Consultant Provider that
HMOC will not implement the material change as to Consultant Provider. If HMOC 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 HMOC 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. HMOC and Consultant Provider are separate and independent
entities. The relationship between HMOC and Consultant Provider is purely contractual.
CONSULTANT 01/2008 15 Weld County Department of Health and Envornment03/2012,akr
Neither HMOC 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 HMOC. 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 HMOC 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 termination or default.
D. Notice. Any notice relating to this Agreement, other than notice of termination, shall be
deemed sufficiently given and served for all purposes if and when sent by regular mail,
postage prepaid, addressed to each party at their addresses of record. Any notice of
termination 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.
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. HMOC is Affiliated with Rocky Mountain Hospital and Medical
Service, Inc. d/b/a Anthem Blue Cross and Blue Shield. The parties hereby expressly agree
that HMOC may, at its sole discretion, assign all of its rights, interests and obligations under
this Agreement to any successor organization of HMOC or Anthem BCBS. This Agreement
shall not create any right, or cause of action in, or on behalf of any person other than
HMOC, its assignees, or Consultant Provider. HMOC 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 waive 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 HMOC and Consultant Provider except with respect to any rights and
obligations incurred there under which continue beyond the effective date of this
CONSULTANT 01/2008 16 Weld County Department of Health and Envornment03/2012,akr
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. HMOC may include Consultant Provider's name in lists or
other notifications of Consultant Providers. Consultant Provider may identify itself as an
HMOC Consultant Provider. Except as provided in this paragraph, neither HMOC 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 HMOC, that HMOC is an
independent corporation operating under a license with the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans (the
Association) permitting HMOC to use the Blue Cross and Blue Shield Service Mark in
Colorado. HMOC is not entering into this Agreement as the agent of the Association.
Consultant Provider further acknowledges and agrees that Consultant has not entered into
this Agreement based upon representations by any person other than HMOC and that no
person, entity, or organization other than HMOC or its assignee shall be held accountable or
liable to Consultant for any of HMOC's obligations created under this Agreement. This
provision shall not create any additional obligations whatsoever on the part of HMOC or its
assignee, 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 HMOC decision regarding a Membership Certificate decision,
whether such disagreement is communicated to HMOC, 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. 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 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
CONSULTANT 01/2008 17 Weld County Department of Health and EnvornmentO3/2012,akr
working for Plan shall not be prohibited from protesting or expressing disagreement with a
medical decision, medical policy, or medical practice of Consultant Provider. 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. Health Insurance Portability and Accountability Act of 1996, P.L. 104-191 (HIPAA)
Compliance. At such time as the Health Insurance Portability and Accountability Act of
1996 (HIPAA) becomes effective, both parties agree to comply with HIPAA as it pertains to
performance of their respective obligations hereunder.
O. 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.
P. Survival of Terms. A term for compensation/payment shall not survive termination of a
contract, except for a state continuation requirement or by agreement.
Q. 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.
R. 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 HMOC, such
confidential and proprietary information shall include, without limitation, the
Attachments/Exhibits. HMOC 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 HMOC by or on behalf of any group obtaining services through HMOC 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 HMO COLORA , C.
BY: BY:
Signature Signature
CONSULTANT 01/2008 I S Weld County Department of Health and Envornmen'0LZ012,ekr
PRINTED Sean P. Conway PRINTED: Janet Poaar
TITLE: Chair, Board of Weld TITLE: R.V.P., Provider Enaaaement &
County Commissioners Contracting
++
DATE: AUG 1 5 Z012 DATE: 10 f(b
TAX ID# 846000813
CONSULTANT 01!2008 19 Weld County Department of Health and Enyomment0312012,akr
HMO COLORADO, INC.
CONSULTANT PROVIDER AGREEMENT
LIST OF ATTACHMENTS
ATTACHMENT
Compensation Schedule A
Consultant Providers B
CONSULTANT 01/2008 20 Weld County Department of Health and Envornment03/2012,akr
HMO COLORADO, INC.
CONSULTANT PROVIDER AGREEMENT
ATTACHMENT A
COMPENSATION SCHEDULE
Payment to Consultant Provider is based on fee-for-service reimbursement. HMOC shall reimburse
Consultant Provider the lesser of billed charges or 115% of the current Medicare fee schedule
HMOC has implemented for Covered Services.
Payment by HMOC will be net of any applicable Member Cost Share requirements.
Immunizations are paid 100% of AWP (Average Wholesale Price).
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. HMOC 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, HMOC 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.
Compensation shall be made according to HMOC's medical/reimbursement policies for Covered
Services, including, but not limited to, policies regarding multiple surgical procedures, surgical
CONSULTANT 01/2008 21 Weld County Department of Health and Envornment0012012,akr
assistance, global surgical services, coding and unbundling, and other billing and reimbursement
I practices.
HMO COLORADO, INC.
CONSULTANT PROVIDER AGREEMENT
ATTACHMENT B
CONSULTANT PROVIDERS
Weld County Department of Health and Environment
Tax I.D. #'s - 846000813
CONSULTANT 01/2008 22 Weld County Department of Health and Envornment03/2012,akr
Hello