HomeMy WebLinkAbout20172017RESOLUTION
RE: APPROVE ANCILLARY SERVICES AGREEMENT AND AUTHORIZE CHAIR TO SIGN
- CIGNA HEALTHCARE OF 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 an Ancillary Services 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 Cigna
Healthcare of Colorado, Inc., commencing July 1, 2017, with further 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 Ancillary Services 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 Cigna Healthcare of 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 10th day of July, A.D., 2017, pro nunc tunc July 1, 2017.
ATTEST: datA44) 4deo;
Weld County Clerk to the Board
BY:C9- Q -i c
puty Clerk to the Board
APPR•. DAASST
y A ttorney
Date of signature: "1 ( @Co ( I
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
EL�
Julie A. Cozad, Chair
Steve Moreno, Pro -Tern
Sean P. Conway
2017-2017
HL0049
Chloe Rempel
From:
Sent:
To:
Subject:
Attachments:
Tanya Geiser
Tuesday, May 8, 2018 1:48 PM
Kimberly Dewey; Chloe Rempel
FW: Documents Pending Final Signatures
20172017.pdf; 20173877.pdf; 20173954.pdf; 20181094.pdf; 20181095.pdf
Hello ladies, I have a status update for each below:
Tanya
Ext 2122
From: Kimberly Dewey
Sent: Tuesday, May 8, 2018 9:58 AM
To: Tanya Geiser <tgeiser@weldgov.com>
Cc: Chloe Rempel <crempel@weldgov.com>
Subject: Documents Pending Final Signatures
Hello,
This email serves as a status update for documents from the Commissioner's agenda that are pending final
signatures from various sources. When final signatures are obtained, please remember to send a copy to the
Clerk to the Board's Office to ensure the Commissioner's final resolution is signed, the resolution is distributed,
and the complete document is finalized. The query included items pending as of today's date, so there are
items from recent agendas that understandably may not have final signatures yet.
2017-2017 — Approve Ancillary Services Agreement — Cigna Healthcare we will NOT be getting anything back;
Cigna lost the original contract in July of last year and when they finally found it, after months of delaying us
when we followed -up, refused to sign the version that we signed because they said it was out of date. A new
Cigna contract (see below: 2018-1095) was executed and sent to them in April.
2017-3877 - Task Order Contract for Women's Wellness Connection Clinical Services I believe I have this in a
small stack and will get it to you.
2017-3954 — Task Order Contract #1 Prevention of Infertility and Management of STI I believe I have this in a
small stack and will get it to you.
2018-1094 - Contract #6 for Nurse Home Visitor Program Issue with CDHS; at this time CDHS is refusing to
sign, saying that the contract we executed (that they sent to us) had two typos in it and they want us to execute
a new copy. I have been working with Esther the last few days on this one.
2018-1095 - Agreement for Ancillary Services — Cigna Healthcare Sent to Cigna in April; pending return from
Cigna
Thank you,
Kim Dewey
Deputy Clerk to the Board
Weld County
1150 O Street
Greeley, CO 80631
1
C'th1 l,D*fi�30
Memorandum
TO: Julie A. Cozad, Chair
Board of County Commissioners
FROM: Mark E. Wallace, MD, MPH
Executive Director
Department of Public Health & Environment
DATE: June 28, 2017
SUBJECT: Ancillary Services Agreement with Cigna
Healthcare of Colorado
For the Board's approval is an Ancillary Services Agreement ("Agreement") between Cigna
Healthcare of Colorado, Inc. ("Cigna") and the Weld County Department of Public Health and
Environment ("WCDPHE").
The invitation from Cigna to become a participating provider came from Cigna employer and
customer feedback, expressing a need to have coverage for services we provide. We are
committed to improving the health and well-being of patients who may experience health
disparities that result from a variety of factors, including geographic availability, communication
barriers, and cultural differences. We have been contracted with Blue Cross Blue Shield since
November 1, 2012, primarily for immunizations. It has reduced the costs incurred by the county
to keep our Weld county citizens immunized.
This agreement will allow WCDPHE to receive payment from Cigna for the provision of covered
services received by their members. Reimbursement for all covered services provided by the
WCDPHE is made. by Cigna on a fee -for -service basis. This is not for new services, but services
that we have historically provided for immunizations and family planning, and that are listed on
our fee schedule that is approved annually by the Board. This agreement shall commence on July
1, 2017, or upon signature by both parties.
This agreement was approved for placement on the Board's agenda via pass -around dated June
26, 2017. I recommend approval of the Ancillary Services Agreement with Cigna Healthcare of
Colorado, Inc.
2017-2017
I-11- OO
Ancillary Services Agreement
This Ancillary Services Agreement ("Agreement") is between Cigna Healthcare of
Colorado, Inc. ("Cigna") and Weld County Board of County Commissioners on behalf of
Weld County Department of Public Health and Environment ("Provider") and is
effective on July 1, 2017 (the "Effective Date").
SECTION 1. DEFINITIONS
1.1
Administrative Guidelines
means the rules, policies and procedures adopted by Cigna or a Payor to be followed
by Provider in providing services and doing business with Cigna and Payors under
this Agreement.
1.2 Benefit Plan
means a certificate of coverage, summary plan description or other document or
agreement which specifies the health care services to be provided or reimbursed for
the benefit of a Participant.
1.3 Cigna Affiliate
means any subsidiary or affiliate of Cigna Corporation.
1.4 Coinsurance
means a payment that is the financial responsibility of the Participant under a Benefit
Plan for Covered Services that is calculated as a percentage of the contracted
reimbursement rate for such services or, if reimbursement is on a basis other than a
fee -for -service amount, as a percentage of a Cigna determined fee schedule or as a
Cigna determined percentage of actual charges.
1.5 Copayment
means a payment that is the financial responsibility of the Participant under a Benefit
Plan for Covered Services that is calculated as a fixed dollar amount.
1.6 Covered Services
means those health care services for which a Participant is entitled to receive coverage
under the terms and conditions of the Participant's Benefit Plan.
1.7 Deductible
means a payment for Covered Services calculated as a fixed dollar amount that is the
financial responsibility of the Participant under a Benefit Plan prior to qualifying for
reimbursement for subsequent health care costs under the terms of a Benefit Plan.
1.8 Medically Necessary/ Medical Necessity
means services and supplies that satisfy the Medical Necessity requirements under the
applicable Benefit Plan. No service is a Covered Service unless it is Medically
Necessary.
1.9 Participant
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means any individual, or eligible dependent of such individual, whether referred to as
"Insured", "Subscriber", "Member", "Participant", "Enrollee", "Dependent", or similar
designation, who is eligible and enrolled to receive Covered Services.
1.10 Participating Provider
means a hospital, physician or group of physicians, or any other health care
practitioner or entity that has a direct or indirect contractual arrangement with Cigna
to provide Covered Services with regard to the Benefit Plan covering the Participant.
1.11 Payor
means the person or entity obligated to a Participant to provide reimbursement for
Covered Services under the Participant's Benefit Plan and which Cigna has agreed
may access Provider's services under this Agreement.
1.12 Quality Management
means the program described in the Administrative Guidelines relating to the quality
of Covered Services provided to Participants.
1.13 Utilization Management
means a process to review and determine whether certain health care services
provided or to be provided are Medically Necessary and in accordance with the
Administrative Guidelines.
SECTION 2. DUTIES OF PROVIDER
2.1 Provider Services.
Provider shall provide Covered Services to Participants upon the terms and conditions
set forth in this Agreement and the Administrative Guidelines.
2.2 Standards.
Provider shall provide Covered Services with the same standard of care, skill and
diligence customarily used by similar providers in the community, the requirements of
applicable law, and the standards of applicable accreditation organizations. Provider
shall provide Covered Services to all Participants in the same manner, under the same
standards, and with the same time availability as offered to other patients. Provider
shall not differentiate or discriminate in the treatment of any Participant because of
race, color, national origin, ancestry, religion, sex, marital status, sexual orientation,
age, health status, veteran's status, handicap or source of payment. Provider shall
assure that all health care providers who perform any of the services for which the
Provider is responsible under this Agreement maintain all necessary licenses or
certifications required by state and federal law. Provider shall immediately restrict,
suspend, or terminate any such health care provider from providing services to
Participants under this Agreement if such provider ceases to meet the
licensing/certification requirements or other professional standards described in this
Agreement.
2.3 Insurance/Application for Participation Information.
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Provider shall maintain general and professional liability coverage in a form and
amount acceptable to Cigna, give Cigna evidence of such coverage upon request and
provide Cigna with immediate written notice of a material modification or termination
of such insurance. Provider shall also notify Cigna in writing within 30 days of any
material change in the information contained in Provider's application for
participation with Cigna.
2.4 Administrative Guidelines.
Provider shall comply with the Administrative Guidelines. Some or all Administrative
Guidelines may be communicated in the form of a provider reference manual, in other
written materials distributed by Cigna to Provider and/or at a website identified by
Cigna. Administrative Guidelines may change from time to time. Cigna will give
Provider advance notice of material changes to Administrative Guidelines.
2.5 Quality Management.
Provider shall comply with the requirements of and participate in Quality
Management as specified in the Administrative Guidelines.
2.6 Utilization Management.
Provider shall comply with the requirements of and participate in Utilization
Management as specified in this Agreement and the Administrative Guidelines.
Payment may be denied for failure to comply with such Utilization Management
requirements, and Provider shall not bill the Participant for any such denied payment.
Cigna's Utilization Management requirements include, but are not limited to, the
following: a) precertification must be secured from Cigna or its designee for those
services and procedures for which it is required as specified in the Administrative
Guidelines; b) Provider must provide Cigna or Cigna's designee with all of the
information requested by Cigna or its designee to make its Utilization Management
determinations within the timelines specified by Cigna or its designee in such request;
and c) Provider will refer Participants to and/or use Participating Providers for the
provision of Covered Services except in the case of an emergency or as otherwise
required by law.
2.7 Records.
Provider shall maintain medical records and documents relating to Participants as
may be required by applicable law and for the period of time required by law.
Medical records of Participants and any other records containing individually
identifiable information relating to Participants will be regarded as confidential, and
Provider and Cigna shall comply with applicable federal and state law regarding such
records. Provider will obtain Participants' consent to or authorization for the
disclosure of private and medical record information for any disclosures required
under this Agreement if required by law. Upon request, Provider will provide Cigna
with a copy of Participants' medical records and other records maintained by Provider
relating to Participants. These records shall be provided to Cigna at no charge and
within the timeframes requested by Cigna and will also be made available during
normal business hours for inspection by Cigna, Cigna's designee, accreditation
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organizations, or to any governmental agency that requires access to these records.
This provision survives the termination of this Agreement.
2.8 Cooperation with Cigna and Cigna Affiliates.
Provider shall cooperate with Cigna in the implementation of Cigna's Participant
appeal procedure. Provider shall also cooperate with Cigna and Cigna Affiliates in
implementing those policies and programs as may be reasonably requested by Cigna
or a Cigna Affiliate for purposes of Cigna's or the Cigna Affiliate's business operations
or required by Cigna or a Cigna Affiliate to comply with applicable law or
accreditation requirements.
SECTION 3. DUTIES OF CIGNA
3.1 Payors, Benefit Plan Types, Notice of Changes to Benefit Plan Types.
Cigna may allow Payors to access Provider's services under this Agreement for the
following Benefit Plan types: a) Benefit Plans where Participants are offered a network
of Participating Providers and are required or given the option to select a Primary
Care Physician; b) Benefit Plans where Participants are offered a network of
Participating Providers and are not required or given the option to select a Primary
Care Physician; and c) Benefit Plans where Participants are not offered a network of
Participating Providers from which they may receive Covered Services. Benefit Plans
may include workers' compensation plans. Cigna will give Provider advance notice if
Cigna changes this list of Benefit Plan types for which Payors may access Provider's
services under this Agreement.
3.2 Benefit Information.
Cigna will give Provider access to benefit information concerning the type, scope and
duration of benefits to which a Participant is entitled as specified in the Administrative
Guidelines.
3.3 Participant and Participating Provider Identification.
Cigna will establish a system of Participant identification and will identify
Participating Providers to those Payors and Participants who are offered a network of
Participating Providers. However, Cigna makes no representations or guarantees
concerning the number of Participants that will be referred to Provider as a result of
this Agreement and reserves the right to direct Participants to selected Participating
Providers and/or influence a Participant's choice of Participating Provider.
SECTION 4. COMPENSATION
4.1 Payments.
Payments for Covered Services will be the lesser of the billed charge or the applicable
fee under Exhibit A , subject to the Administrative Guidelines and minus any
applicable Copayments, Coinsurance and Deductibles. The rates in this Agreement
will be payment in full for all services furnished to Participants under this Agreement.
Provider shall submit claims for Covered Services at the location identified by Cigna
and in the manner and format specified in this Agreement and the Administrative
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Guidelines. Claims for Covered Services must be submitted within 90 days of the date
of service or, if Payor is the secondary payor, within 90 days of the date of the
explanation of payment from the primary payor. Claims received after this 90 day
period may be denied except as provided in the Administrative Guidelines, and
Provider shall not bill Cigna, the Payor or the Participant for those denied services.
Amounts due and owing under this Agreement with respect to complete claims for
Covered Services will be payable within the timeframes required by applicable law.
4.2 Underpayments.
If Provider believes a Covered Service has been underpaid, Provider must submit a
written request for an appeal or adjustment with Cigna or its designee within 180 days
from the date of Payor's payment or explanation of payment. The request must be
submitted in accordance with Cigna's dispute resolution process set out in the
Administrative Guidelines. Requests for appeals or adjustments submitted after this
date may be denied for payment, and Provider will not be permitted to bill Cigna, the
Payor or the Participant for those services.
4.3 Copayments, Coinsurance and Deductibles.
Provider may charge Participants applicable Copayments, Coinsurance and
Deductibles in accordance with the process set out in the Administrative Guidelines.
4.4 Limitations On Billing Participants.
Provider shall not bill, charge, collect a deposit from, seek compensation,
remuneration or reimbursement from, or have any recourse against Participants or
persons other than the applicable Payor for Covered Services or for any amounts
denied or not paid under this Agreement due to Provider's failure to comply with the
requirements of Cigna's or its designee's Utilization Management Program or other
Administrative Guidelines, failure to file a timely claim or appeal. This provision does
not prohibit collection of any applicable Copayments, Coinsurance and Deductibles.
This provision survives termination of this Agreement, is intended to be for the benefit
of Participants, and supersedes any oral or written agreement to the contrary now
existing or hereafter entered into between Provider and a Participant or persons acting
on the Participant's behalf. Modifications to this section will become effective no
earlier than the date permitted by applicable law.
4.5 Billing Patients Who Cease to Be Participants.
Provider may bill a patient directly for any services provided following the date that
patient ceases to be a Participant, and Payor has no obligation to pay for services for
such patients.
4.6 NonMedically Necessary Services.
Provider shall not charge a Participant for a service that is not Medically Necessary
unless, in advance of providing the service, Provider has notified the Participant that
the particular service will not be covered and the Participant acknowledges in writing
that he or she will be responsible for payment for such service.
4.7 Reimbursement of Amounts Collected In Error.
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If Provider collects payment from a Participant when not permitted to collect under
either this Agreement or the Administrative Guidelines, Provider must repay the
amount within 2 weeks of a request from Cigna or the Participant or of the date
Provider has knowledge of the error. If Provider fails to make the repayments, then
Cigna may (but is not obligated to) reimburse the Participant the amount
inappropriately paid and then withhold this amount from future payments.
4.8 Overpayments.
Provider shall refund to Cigna any excess payment made by a Payor to Provider if
Provider is for any reason overpaid for health care services or supplies. Cigna may, at
its option, deduct the excess payment from other amounts payable, and Provider will
be notified of any such deduction as specified in the Administrative Guidelines.
4.9 Audits.
Upon reasonable notice and during regular business hours, Cigna or its designee will
have the right to review and make copies of all records maintained by Provider with
respect to all payments received by Provider from all sources for Covered Services
provided to Participants. Cigna or its designee will have the right to conduct audits of
such records and may audit its own records to determine if amounts have been
properly paid under this Agreement. Any amounts determined to be due and owing
as a result of such audits must be promptly paid or, at the option of the party to whom
such amounts are owed, offset against amounts due and owing by such party
hereunder. This provision survives the termination of this Agreement.
4.10 Coordination of Benefits.
Certain claims for Covered Services are claims for which another payor may be
primarily responsible under coordination of benefit rules. Provider may pursue those
claims in accordance with the process set out in the Administrative Guidelines. When
a Participant's coverage under a Benefit Plan is secondary, Payor will pay an amount
no greater than that which, when added to amounts payable from other sources under
applicable coordination of benefits rules, equals 100% of the reimbursement for
Covered Services under this Agreement, but may be less as determined by the terms of
the Participant's Benefit Plan.
4.11 Applicability of the Rates.
The rates in this Agreement apply to all services rendered to Participants in the Benefit
Plan types covered by this Agreement, including services covered under a
Participant's in -network or out -of -network benefits, and whether the Payor or
Participant is financially responsible for payment.
4.12 Excluded Services.
This Agreement excludes services that Cigna has elected to obtain under an
arrangement between Cigna or a Cigna Affiliate and a national or regional vendor or
provider or a capitated provider, except as otherwise agreed by Cigna. Provider will
not be reimbursed and will not bill Participants for any such excluded services. If
Cigna notifies Provider that it no longer chooses to exclude a particular service from
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this Agreement, that service will no longer be excluded and those services will be
reimbursed as specified in Exhibit A .
4.13 Provider Facilities.
This Agreement shall specifically exclude those services rendered at Provider facilities
other than those facilities agreed upon and utilized as of the Effective Date unless
otherwise agreed in writing by Cigna.
SECTION 5. TERM AND TERMINATION
5.1 Term of This Agreement.
This Agreement begins on the Effective Date and continues from year to year unless
terminated as set forth below.
5.2 How This Agreement Can Be Terminated.
Either Provider or Cigna can terminate this Agreement at any time by providing at
least 60 days advance written notice. Either Provider or Cigna can terminate this
Agreement immediately if the other becomes insolvent. Cigna can terminate this
Agreement immediately (or upon such longer notice required by applicable law, if
any) if Provider no longer maintains the licenses required to perform its duties under
this Agreement, Provider is disciplined by any licensing, regulatory, accreditation
organization, or any other professional organization with jurisdiction over Provider, or
if Provider no longer satisfies Cigna's credentialing requirements. Upon termination
of this Agreement for any reason, the rights of each party terminate, except as
provided in this Agreement. Termination will not release Provider or Cigna from
obligations under this Agreement prior to the effective date of termination.
5.3 Services Upon Termination.
If this Agreement is terminated without cause, Provider shall continue to provide
Covered Services for those Participants suffering from a chronic condition requiring
continuity of care for whom an alternative means of receiving necessary care was not
arranged at the time of such termination. Provider shall continue to provide Covered
Services to such Participants so long as the Participant retains eligibility under a
Benefit Plan, until the earlier of completion of such services or the assumption of
treatment by another provider. Payment for Covered Services provided to any such
Participant after termination of this Agreement shall be in accordance with the terms
of the Participant's Benefit Plan. If, after termination of this Agreement, Provider
determines that Cigna has not used due diligence to arrange for alternative care,
Provider may terminate the provider -patient relationship. Provider has no obligation
under this Agreement to provide services to individuals who cease to be Participants.
SECTION 6. GENERAL PROVISIONS
6.1 Confidentiality.
As a result of this Agreement, Provider may have access to certain of Cigna's
confidential and proprietary information. Provider shall hold such information,
including the terms of this Agreement, in confidence and will not use or disclose such
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information to any person without the prior written consent of Cigna except as may be
required by law. This provision does not prohibit communications necessary or
appropriate for the delivery of health care services, communications about coverage
and coverage appeal rights or any other communications specifically protected under
applicable law. This provision survives the termination of this Agreement.
6.2 Independent Parties.
Provider is an independent contractor. Cigna and Provider do not have an employer -
employee, principal -agent, partnership, or similar relationship. Nothing in this
Agreement, including Provider's participation in Quality Management and Utilization
Management programs, nor any coverage determination made by Cigna or a Payor, is
intended to interfere with or affect Provider's independent judgment in providing
health care services to its patients.
6.3 Internal Dispute Resolution.
Disputes that might arise between the parties regarding the performance or
interpretation of the Agreement must first be resolved through the applicable internal
dispute resolution process outlined in the Administrative Guidelines. In the event the
dispute is not resolved through that process, either party can request in writing that
the parties attempt in good faith to resolve the dispute promptly by negotiation
between designated representatives of the parties who have authority to settle the
dispute. If the matter is not resolved within 60 days of such a request, either party
may initiate arbitration by providing written notice to the other. With respect to a
payment or termination dispute, Provider must submit a request for arbitration within
12 months of the date of the letter communicating the final decision under Cigna's
internal dispute resolution process unless applicable law specifically requires a longer
time period to request arbitration. If arbitration is not requested within that 12 month
period, Cigna's final decision under its internal dispute resolution process will be
binding on Provider, and Provider shall not bill Cigna, Payor or the Participant for any
payment denied because of the failure to timely submit a request for arbitration.
6.4 Arbitration.
If the dispute is not resolved through Cigna's internal dispute resolution process, the
controversy shall be resolved through binding arbitration. The arbitration shall be
conducted in 60 days in accordance with the American Health Lawyers Association
Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which
to the extent of the subject matter of the arbitration, shall be binding not only on all
parties to the agreement, but on any other entity controlled by, in control of or under
common control with the party to the extent that such affiliate joins in the arbitration,
and judgment on the award rendered by the arbitrator may be entered in any court
having jurisdiction thereof. Each party shall assume its own costs, but the
compensation and expenses of the mediator and any administrative fees or costs shall
be borne equally by the parties. The decision of the arbitrator shall be final, conclusive
and binding, and no action at law or in equity may be instituted by either party other
than to enforce the award of the arbitrator. The parties intend this alternative dispute
resolution procedure to be a private undertaking and agree that an arbitration
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conducted under this provision shall not be consolidated with an arbitration involving
other hospitals or third parties, and that the arbitrator shall be without power to
conduct an arbitration on a class basis. Judgment upon the award rendered by the
arbitrator may be entered in any court of competent jurisdiction.
6.5 Material Adverse Change Amendments.
For amendments that are a material adverse change in the terms of this Agreement,
Cigna can amend this Agreement by providing 90 days advance written notice except
if a shorter notice period is required to comply with changes in applicable law. The
change will become effective at the end of the 90 day notice period or, if applicable, the
shorter notice period required to comply with changes in applicable law. If Provider
objects to the material adverse change and notifies Cigna of its intent to terminate
within 30 days of the date of the notice of amendment, the termination will be effective
at the end of the 90 day notice of the material adverse change or, if applicable, at the
end of the shorter notice period required to comply with changes in applicable law,
unless Cigna agrees to retract the amendment, in which case the Agreement will
remain in force without the proposed amendment.
6.6 All Other Amendments.
For amendments that are not material adverse changes in the terms of this Agreement,
Cigna can amend this Agreement by providing 30 days advance written notice to
Provider. Alternatively, both parties can agree in writing to amend this Agreement.
6.7 Assignment and Delegation.
Neither Cigna nor Provider may assign any rights or delegate any obligations under
this Agreement without the written consent of the other party; provided, however,
that any reference to Cigna includes any successor in interest and Cigna may assign its
duties, rights and interests under this Agreement in whole or in part to a Cigna
Affiliate or may delegate any and all of its duties to a third party in the ordinary
course of business.
6.8 Sale of Business/Change in Management.
If, during the term of this Agreement, Provider desires (i) to sell, transfer or convey its
business or any substantial portion of its business assets to another entity, whether
through a stock or asset transaction, or (ii) enter into a management contract with
another entity, Provider shall so advise Cigna in writing at least 120 days prior to the
sale, transfer or contract effective date. Provider warrants and covenants that this
Agreement will be part of the transfer, and will be assumed by the new entity and that
the new entity will honor and be fully bound by the terms and conditions of this
Agreement unless the new entity already has an agreement with Cigna or a Cigna
Affiliate, in which case Cigna, in its sole discretion, will determine which Agreement
will prevail. Notwithstanding the above, if Cigna, in its sole discretion, is of the
opinion that the Agreement cannot be satisfactorily performed by the assuming entity
or does not want to do business with that entity for whatever reason, Cigna may
terminate this Agreement by giving Provider 60 days written notice, notwithstanding
any other provision in the Agreement.
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6.9 Use of Name.
Provider agrees that Cigna may include descriptive information about Provider in
literature distributed to existing or potential Participants, Participating Providers and
Payors. That information will include, but not be limited to, Provider's name,
telephone number, address, and specialties. Provider may identify itself as a
Participating Provider with respect to those Benefit Plan types in which Provider
participates with Cigna. Provider's use of Cigna's name or a Cigna Affiliate's name, or
any other use of Provider's name by Cigna will be upon prior written approval or as
the parties may agree.
6.10 Notices.
Any notice required under this Agreement must be in writing and sent by United
States mail, postage prepaid, to Cigna and Provider at the addresses below. Cigna
may also notify Provider by sending an electronic notice with automatic receipt
verification to Provider's e-mail address below. Either party can change the address
for notices by giving written notice of the change to the other party in the manner just
described.
6.11 Governing Law/Regulatory Addenda.
Applicable federal law and the law of the jurisdiction where Provider is domiciled
governs this Agreement. One or more regulatory addenda may be attached to the
Agreement setting out provisions that are required by law with respect to Covered
Services rendered to certain Participants (i.e. Participants under an insured plan).
These provisions are incorporated into this Agreement to the extent required by law
and as specified in such Addenda.
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6.12 Waiver of Breach/Severability/Entire Agreement/Copy of Original Agreement.
If any party waives a breach of any provision of this Agreement, it will not operate as a
waiver of any subsequent breach. If any portion of this Agreement is unenforceable
for any reason, it will not affect the enforceability of any remaining portions. This
Agreement, including any exhibits to this Agreement, contains all of the terms and
conditions agreed upon and supersedes all other agreements between the parties,
either oral or in writing, regarding the subject matter. A copy of this fully executed
Agreement is an acceptable substitute for the original fully executed Agreement.
AGREED AND ACCEPTED BY:
Weld County Board of County Commissioners on behalf of the
Weld County Department of Public Health and Enviroment
Address: 1555 North 17th Avenue, Greeley, CO 80631
Email Address: NA
By:
Printed Name: Julie Cozad
Title: Chair, Board of County Commissioners
Date Signed: July 10, 2017
Federal Tax ID: 84-6000813
National Provider Identifier: 1174515258
Cigna HealthCare of Colorado, Inc.
Address: 8505 East Orchard Road 2T1
Greenwood Village, CO 80111
Attention: AVP of Provider Contracting
By:
Printed Name:
Title:
Date Signed:
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Qoti-aOn
ADDENDUM TO ANCILLARY AGREEMENT FOR THE STATE OF COLORADO
The provisions set forth in this Addendum are being added to the Agreement to comply with
legislative and regulatory requirements of the State of Colorado regarding provider contracts
with providers rendering health care services in the State of Colorado. To the extent that such
Colorado laws and regulations are applicable and/or not otherwise preempted by federal
law, the provisions set forth in this Addendum shall apply and, to the extent of a conflict with
a provision in the Agreement, shall control. The provisions set forth in this Addendum do not
apply with regard to Covered Services rendered to Participants covered under self -funded
plans.
(1) The definition for Emergency Services, if any, shall comply with Colorado laws
and regulations to the extent applicable.
(2) Provider shall receive payments for Covered Services as set forth in the
Agreement. Colorado law prohibits the use of financial disincentives or the
withholding of full compensation to Provider because of the number or type of
referrals made by Provider to Participating Providers in accordance with
applicable Utilization Management requirements concerning the provision of
Covered Services to Participants.
(3)
Pursuant to the requirements of Section 10-16-704 (4.5), Colorado Revised
Statutes, to the extent applicable:
With respect to services reimbursed on a fee -for -service basis, if Provider
believes Provider has been underpaid for a Covered Service Provider must
submit a written request for an appeal or adjustment with Cigna or its designee
within 12 months after the date of the original payment or explanation of
benefits.
With respect to services reimbursed on a fee -for -service basis, Payor may only
retroactively adjust reimbursement made to Provider during the 12 month
period after the date of the original explanation of benefits.
Adjustments to claims related to coordination of benefits with federally funded
health benefit plans, including Medicare and Medicaid, shall be made within 36
months after the date of service.
(4) Neither Provider nor Cigna shall be prohibited from protesting or expressing
disagreement with a medical decision, medical policy or medical practice of
Provider or Cigna.
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(5)
Cigna shall not terminate the Agreement because: a) Provider expresses
disagreement with Cigna's decision to deny or limit benefits to a Participant or
assists the Participant to seek reconsideration of Cigna's decision; or b)
Provider discusses with a current, former or prospective patient any aspect of
the patient's medical condition, any proposed treatments or treatment
alternatives, whether covered by Cigna or not, policy provisions of a plan or
Provider's personal recommendation regarding selection of a health plan based
on the Provider's personal knowledge of the health needs of such patients.
(6) In the event of termination of the Agreement and to the extent applicable, the
provisions of Section 10-16-705(4) of the Colorado Statutes shall apply.
(7) Agreements for less than 2 years in duration may be terminated without cause
by Cigna or Provider with 90 days advance written notice to the other party.
Notwithstanding the foregoing, to the extent that the Agreement provides for a
longer notification period with respect to termination of the Agreement by
Provider or Cigna, such longer notification period will apply.
(8) Agreements for 2 or more years in duration may be terminated without cause
in accordance with the terms set forth in the Agreement.
(9) Cigna can terminate the Agreement immediately (or upon such longer notice
required by applicable law, if any) if Provider no longer maintains the licenses
required to perform his/her duties under the Agreement, Provider is
disciplined by any licensing, regulatory, accreditation organization, or any
other professional organization with jurisdiction over Provider, or if Provider
no longer satisfies Cigna's credentialing requirements.
(10) Cigna or Provider can terminate the Agreement if the other becomes insolvent.
(11) Any termination notice must be in writing and sent by United States mail,
postage prepaid, to Cigna at the addresses below. Cigna may also notify
Provider by sending an electronic notice with automatic receipt verification to
Provider's e-mail address. Either party can change the address for notices by
giving written notice of the change to the other party in the manner just
described.
Cigna HealthCare of Colorado, Inc. Attention: Manager of Contracting
8505 East Orchard Road
2T1
Greenwood Village, CO 80111
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(12) Payment terms shall not survive the termination of the Agreement except as
required by law or as agreed upon by Provider.
(13) Cigna shall provide Provider with at least 90 days written notice of the
effective date of a Material Change to the Agreement. Such notice will be
conspicuously entitled "NOTICE OF MATERIAL CHANGE TO CONTRACT."
"Material Change" means a change to an Agreement that: a) decreases the
provider's payment or compensation; b) changes the administrative procedures
in a way that may reasonably be expected to significantly increase the
providers administrative expense; c) 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 drugs; or d) 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 the Agreement; b) a decrease in payment or compensation
resulting from a change in an 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 the Agreement, if the amount and date of applicability of
the decrease is clearly identified in the Agreement; d) an administrative change
that may significantly increase the provider's administrative expense, the
specific applicability of which is clearly identified in the contract; e) changes to
an existing prior authorization, precertification, notification or referral program
that do not substantially increase the provider's administrative expense; or
changes to an edit program or to specific edits.
If Provider objects in writing to the material change within 15 days and there is
no resolution of the objection, Cigna or Provider may terminate the Agreement
upon written notice to the other party but no later than 60 days prior to the
effective date of the material change.
If Provider does not object to the material change within 15 days, the change
shall be effective as specified in the notice.
If the material change is the addition of a new category of coverage and
Provider objects within 15 days, the material change shall not be effective and
Cigna may not terminate Provider for this reason.
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Notwithstanding anything in this section, Cigna may modify the Agreement by
operation of state or federal law or regulation and Cigna may make such
notification to Provider by any reasonable means.
(14) Intermediary Contracts. If Provider is an Intermediary as defined by C.R.S.A.
§ 10-16-102(25.5) and 3 Colo. Code of Regs. § 4.2-15(IV)(B), or any other
applicable law, Provider as an Intermediary agrees to the following:
(a) If contracted to perform utilization management, utilization review,
provider credentialing, administration of health insurance benefits, setting or
negotiation of reimbursement rates, payment to providers, network
development, disease management programs, or any other program subject to
Section 10-16-705(6.5) C.R.S., Intermediary shall comply with the same
standards, guidelines, medical policies, and benefit terms as Cigna.
(b) If contracted to perform utilization management, utilization review,
provider credentialing, administration of health insurance benefits, setting or
negotiation of reimbursement rates, payment to providers, network
development, disease management programs, or any other program subject to
Section 10-16-705(10.5)(a) C.R.S., Intermediary shall indicate the name of
Intermediary and the company for which it is conducting the work when
making any payment to a health care provider on behalf of Cigna.
(c) Intermediary will comply, and shall require Subcontracted Providers to
comply, with all of the applicable requirements of Section 10-16-705, C.R.S.
(d) Cigna is responsible for ensuring that Subcontracted Providers have the
capacity and legal authority to furnish Covered Services.
(e) Cigna has the right to approve or disapprove participation status of
Subcontracted Providers in its own or a contracted network for the purpose of
delivering Covered Services to its Participants.
(f) Intermediary shall provide Cigna with copies of Subcontracted
Providers' contracts in accordance with Applicable Law and Cigna shall
maintain copies of all such contracts.
(g) As applicable, Intermediary shall transmit utilization documentation
and claims paid documentation to Cigna. Cigna shall monitor the timeliness
and appropriateness of payments made to providers and health care services
rendered to Participants.
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(h) As applicable, Intermediary shall maintain books, records, financial
information, and documentation of services provided to Participants at the
Intermediary's place of business in the State of Colorado.
(i) Intermediary agrees to allow the Commissioner of the Division of
Insurance for the State of Colorado access to the Intermediary's books,
records, financial information and any documentation of services provided to
Participants as necessary to determine compliance with the law.
(j) Cigna shall have the right, in the event of Intermediary's insolvency, to
require the assignment to Cigna of the provisions of a Subcontracted
Provider's contract addressing the provider's obligations to furnish Covered
Services.
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Cigna HealthCare
Exhibit C
Fee Schedule and Reimbursement Terms
This is an Exhibit to an Agreement between:
Provider: Weld County Department of Public Health and Enviroment
CIGNA Party: CIGNA HealthCare of Colorado, Inc.
Effective Date: July 1, 2017
This Rate Exhibit:
Applies to: Weld County Department of Public Health and Environment
Federal Tax ID: 84-6000813
National Provider Identifier: 1174515258
Effective Date: July 1, 2017
I. DEFINITIONS
CIGNA Standard Fee Schedule means the standard CIGNA fee schedule in effect at the
time of service and applicable to this Agreement for certain Covered Services provided to
Participants. The CIGNA Standard Fee Schedule is subject to change. For workers'
compensation Benefit Plans, the CIGNA Standard Fee Schedule shall not exceed the state
fee schedule.
CIGNA Resource Based Relative Value Scale or CIGNA RBRVS means the methodology
designated by CIGNA to produce the allowable fee for certain Covered Services rendered
to Participants that uses the components of Relative Value Units (RVU's), geographic
practice cost indices (GPCI's), conversion factor and base relativity factors, as defined by
CIGNA.
II. FEE FOR SERVICE REIMBURSEMENT
A. Except as otherwise provided below, Covered Services will be reimbursed at the lesser
of billed charges or the CIGNA RBRVS allowable fee, less applicable Copayments,
Deductibles and Coinsurance. The CIGNA RBRVS allowable fees are updated by
CIGNA periodically to reflect new information regarding RVU's, GPCI's, conversion
factor, and the addition of new codes and services. The GPCI locality used for this
Agreement is Colorado .
B. CIGNA will apply the following base relativity factors in its CIGNA RBRVS
calculation to the services specified below:
CPT4 Procedure Code Group
Base Relativity Factor
Surgery Codes
115 %
Evaluation & Management Codes
115 %
Medicine Codes
115 %
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C. The following services are excluded from the reimbursement methodology described
above, and such Covered Services will be reimbursed at the lesser of billed charges or
the fee listed below, less applicable Copayments, Deductibles and Coinsurance:
Procedure Code
(s)/Modifiers
Description
Maximum Allowable Fee
59400
Routine obstetric care including
antepartum care, vaginal delivery (with or
without episiotomy, and/or forceps) and
postpartum care
$2,050.00
59510
Routine obstetric care including
antepartum care, cesarean delivery and
postpartum care
$2,050.00
59610
Routine obstetric care including
antepartum care, vaginal delivery (with or
without episiotomy, and /or forceps) and
postpartum care, after previous cesarean
delivery
$2,050.00
59618
Routine obstetric care including
antepartum care, cesarean delivery and
postpartum care, following attempted
vaginal delivery after previous cesarean
delivery
$2,050.00
D. The following services are excluded from the reimbursement methodology described
above, and such Covered Services will be reimbursed at the lesser of billed charges or
the applicable fee under the CIGNA Standard Fee Schedule, less applicable
Copayments, Deductibles and Coinsurance.
1. Injectable drugs, immunizations, immunization administration, vaccines, toxoids;
physical therapy, pathology, radiology and laboratory services and routine
venipuncture as defined within the Current Procedural Terminology (CPT) coding
system and published by the American Medical Association and as defined within
the Healthcare Common Procedure Coding System (HCPCS) and published by the
Centers for Medicare & Medicaid Services.
2. All procedure codes for Covered Services for which reimbursement has not been
established above, including but not limited to those for unlisted procedures as
well as new Current Procedural Terminology (CPT), Healthcare Common
Procedure Coding System (HCPCS) and/or American Society of Anesthesiologists
(ASA) procedure codes, until such time as the applicable RVU's have been loaded
into the appropriate claims systems.
E. Notwithstanding anything to the contrary set forth above, those services that are
excluded from this Agreement under the Excluded Services section of the Agreement
shall not be reimbursed and Participants shall not be billed for such services.
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