Common use of Provider Contracts Clause in Contracts

Provider Contracts. 7.2.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH upon request, at the time and location requested by TDH. All standard formats of provider contracts must be submitted to TDH for approval no later than 60 days after the effective date of this contract, unless previously filed with TDH. HMO must submit 1 paper copy and 1 electronic copy in a form specified by TDH. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.4. 7.2.1.1 TDH has 15 working days to review the materials and recommend any suggestions or required changes. If TDH has not responded to HMO by the fifteenth day, HMO may execute the contract. TDH reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH or the requesting agency. Provider contracts requested in response to public information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDH. TDH retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health services under this contract. TDH may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systems, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program. HMO must provide copies of the TDH/HMO Contract to the provider upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDH/HMO contract could result in liability for money damages, and or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO. 7.2.8.3 [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇ ▇ecipient for a covered service. 7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH of the change in writing. If TDH does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which are required by TDH or by changes in state or federal law are effective immediately. 7.2.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a recipient to TDH for referral to THHSC. 7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider contracts.

Provider Contracts. 7.2.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH HHSC upon request, at the time and location requested by TDHHHSC. All standard formats of provider contracts must be submitted to TDH HHSC for approval no later than 60 days after prior to the effective date of this contract, unless previously filed with TDHHHSC. HMO must submit 1 one paper copy and 1 one electronic copy in a form specified by TDHHHSC. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH HHSC for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V5, Statutory and Regulatory Compliance, and the provisions contained in Article Section 3.2.4. 7.2.1.1 TDH HHSC has 15 working days to review the materials and recommend any suggestions or required changes. If TDH HHSC has not responded to HMO by the fifteenth day, HMO may execute the contract. TDH HHSC reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article Section 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH HHSC or the requesting agency. Provider contracts requested in response to public information a Public Information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of free-of-charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDHHHSC. TDH HHSC retains the authority to reject or require changes to any contract that do does not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH HHSC reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health care services under this contract. TDH HHSC may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systemssystem, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which that substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH HHSC STAR program. HMO must provide copies of the TDHHHSC/HMO Contract to the provider [Provider] upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider [Provider] is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDHHHSC/HMO contract could result in liability for money damages, and or and/or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO. 7.2.8.2.1 [Provider] understands and agrees that the HMO's Medicaid enrollees are not to be held liable for the HMO's debts in the event of the entity's insolvency in accordance with 42 C.F.R. Section 438.106(a). Page 72 of 173 7.2.8.3 [Provider] understands and agrees TDH HHSC is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇ ▇ecipient a Medicaid recipient for a covered service. 7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH HHSC of the change in writing. If TDH HHSC does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which that are required by TDH HHSC or by changes in state or federal law are effective immediately. 7.2.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH HHSC and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH HHSC or its authorized agent(s), THHSCHHSC, HCFACMS, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of free-of-charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a Medicaid recipient to TDH HHSC for referral to THHSCHHSC. 7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDHHHSC. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's [Provider's] free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider [Provider] contracts.

Provider Contracts. 7.2.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH upon request, at the time and location requested by TDH. All standard formats of provider contracts must be submitted to TDH for approval no later than 60 days after the effective date of this contract, unless previously filed with TDH. HMO must submit 1 paper copy and 1 electronic copy in a form specified by TDH. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.43.2. 7.2.1.1 TDH has 15 working days to review the materials and recommend any suggestions or required changes. If TDH has not responded to HMO by the fifteenth day, HMO may execute the contract. TDH reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH or the requesting agency. Provider contracts requested in response to public information a Public Information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of free-of-charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDH. TDH retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health care services 1999 Renewal Contract Bexar Service Area August 9, 1999 under this contract. TDH may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systemssystem, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program. HMO must provide copies of the TDH/HMO Contract to the provider [Provider] upon request. [Provider] ) understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider [Provider] is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, contract or any violation of the TDHTDR/HMO contract could result in liability for money damages, and or and/or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO.. 1999 Renewal Contract Bexar Service Area August 9, 1999 7.2.8.3 [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇▇▇▇ ▇ecipient a Medicaid recipient for a covered service. 7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH of the change in writing. If TDH does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which are required by TDH or by changes in state or federal law are effective immediately. 7.2.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of free-of-charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a Medicaid recipient to TDH for referral to THHSC. 7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's [Provider's] free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider [Provider] contracts.

Provider Contracts. 7.2.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH upon request, at the time and location requested by TDH. All standard formats of provider contracts must be submitted to TDH for approval no later than 60 days after the effective date of this contract, unless previously filed with TDH. HMO must submit 1 paper copy and 1 electronic copy in a form specified by TDH. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.43.2. 7.2.1.1 TDH has 15 working days to review the materials and recommend any suggestions or required changes. If TDH has not responded to HMO by the fifteenth day, HMO may execute the contract. TDH reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to 1999 Renewal Contract Harr▇▇ ▇▇▇vice Area 64 August 9, 1999 investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH or the requesting agency. Provider contracts requested in response to public information a Public Information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of free-of-charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDH. TDH retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health care services under this contract. TDH may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systemssystem, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract 1999 Renewal Contract Harr▇▇ ▇▇▇vice Area 65 August 9, 1999 provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program. HMO must provide copies of the TDH/HMO Contract to the provider [Provider] upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider [Provider] is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDH/HMO contract could result in liability for money damages, and or and/or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO. 7.2.8.3 [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇ ▇ecipient edicaid recipient for a covered service. 7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH of the change in writing. If TDH does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which are required by TDH or by changes in state or federal law are effective immediately. 7.2.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human 1999 Renewal Contract Harr▇▇ ▇▇▇vice Area 66 August 9, 1999 Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of free-of-charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a Medicaid recipient to TDH for referral to THHSC. 7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's [Provider's] free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider [Provider] contracts.

Provider Contracts. 7.2.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH upon request, at the time and location requested by TDH. All standard formats of provider contracts must be submitted to TDH for approval no later than 60 days after the effective date of this contract, unless previously filed with TDH. HMO must submit 1 paper copy and 1 electronic copy in a form specified by TDH. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.43.2. 7.2.1.1 TDH has 15 working days to review the materials and recommend any suggestions or required changes. If TDH has not responded to HMO by the fifteenth day, HMO may execute the contract. TDH reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH or the requesting agency. Provider contracts requested in response to public information a Public Information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of free-of-charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDH. TDH retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health care services 1999 Renewal Contract ▇▇▇▇▇▇ Service Area August 9, 1999 57 under this contract. TDH may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systemssystem, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program. HMO must provide copies of the TDH/HMO Contract to the provider [Provider] upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider [Provider] is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDH/HMO contract could result in liability for money damages, and or and/or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO.. 1999 Renewal Contract ▇▇▇▇▇▇ Service Area August 9, 1999 7.2.8.3 [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇▇▇▇ ▇ecipient a Medicaid recipient for a covered service. 7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH of the change in writing. If TDH does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, approved and will become effective. Modifications, additions or deletions which are required by TDH or by changes in state or federal law are effective immediately. 7.2.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of free-of-charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a Medicaid recipient to TDH for referral to THHSC. 7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's [Provider's] free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider [Provider] contracts.

Provider Contracts. 7.2.1 7.3.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH TDHS upon request, at the time and location requested by TDHTDHS. All standard formats of provider contracts must be submitted to TDH TDHS for approval no later than 60 days after the effective execution date of this contract, unless previously filed with TDHTDHS. HMO must submit 1 paper copy and 1 electronic copy in a form specified by TDHTDHS. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH TDHS for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.4. 7.2.1.1 TDH 7.3.1.1 TDHS has 15 working days to review the materials and recommend any suggestions or required changes. If TDH TDHS has not responded to the HMO by the fifteenth day, HMO may execute the contract. TDH TDHS reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 7.3.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract 7.9 relating to Primary Care Providers. 7.2.3 7.3.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH TDHS or the requesting agency. Provider contracts requested in response to public information a Public Information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of free-of-charge to the requesting agency. 7.2.4 7.3.4 The form and substance of all provider contracts are subject to approval by TDHTDHS. TDH TDHS retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and TDHS/HMO CONTRACT August 11, 1999 54 61 responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH 7.3.5 TDHS reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health services under this contract. TDH TDHS may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 7.3.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 7.3.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within the HMO's existing claims processing 56 Dallas Service Area Contract 63 systemssystem, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 7.3.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 7.3.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR TDHS STAR+PLUS program. HMO must provide copies of the TDHTDHS/HMO Contract to the provider [Provider] upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider [Provider] is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDHTDHS/HMO contract could TDHS/HMO CONTRACT August 11, 1999 55 62 result in liability for money damages, and or and/or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 7.3.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO. 7.2.8.3 7.3.8.3 [Provider] understands and agrees TDH TDHS is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇ ▇ecipient a Medicaid recipient for a covered service. 7.2.8.4 7.3.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH TDHS of the change in writing. If TDH TDHS does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which are required by TDH TDHS or by changes in state or federal law are effective immediately. 7.2.8.5 7.3.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH TDHS and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH TDHS or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of free-of-charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a Medicaid recipient to TDH TDHS for referral to THHSC. 7.2.8.6 7.3.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR STAR+PLUS Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDHTDHS. 7.2.8.7 7.3.8.7 HMO is prohibited from imposing restrictions upon the provider's [Provider's] free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR STAR+PLUS managed care plans with whom Provider [Provider] contracts.

Provider Contracts. 7.2.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH upon request, at the time and location requested by TDH. All standard formats of provider contracts must be submitted to TDH for approval no later than 60 days after the effective date of this contract, unless previously filed with TDH. HMO must submit 1 paper copy and 1 electronic copy in a form specified by TDH. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.43.2. 7.2.1.1 TDH has 15 working days to review the materials and recommend any suggestions or required changes. If TDH has not responded to HMO by the fifteenth day, HMO may execute the contract. TDH reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH or the requesting agency. Provider contracts requested in response to public information a Public Information request must be produced within 48 hours of the 1999 Renewal Contract Tarrant Service Area 64 August 9, 1999 65 request. Requested contracts and all related records must be provided free of free-of-charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDH. TDH retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health care services under this contract. TDH may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systemssystem, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts:: 1999 Renewal Contract Tarrant Service Area 65 August 9, 1999 66 7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program. HMO must provide copies of the TDH/HMO Contract to the provider [Provider] upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider [Provider] is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDH/HMO contract could result in liability for money damages, and or and/or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO. 7.2.8.3 [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇ ▇ecipient edicaid recipient for a covered service. 7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH of the change in writing. If TDH does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which are required by TDH or by changes in state or federal law are effective immediately. 7.2.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of free-of-charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a 1999 Renewal Contract Tarrant Service Area 66 August 9, 1999 67 Medicaid recipient to TDH for referral to THHSC. 7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's [Provider's] free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider [Provider] contracts.

Provider Contracts. 7.2.1 All HMO must enter into written contracts with all providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract)contracts) and maintain copies of the contracts at HMO's administrative office. Provider contracts include all contracts between intermediary entities and the direct provider of health services. HMO must make all contracts available to TDH upon requestTDH, at the time and location requested by TDH. All standard formats of provider contracts must be submitted to TDH for approval no later than 60 120 days after the effective date of this contract, unless previously filed with TDH. HMO must submit 1 paper copy and 1 electronic copy in a form specified by TDH. Any change prior to the standard format must 55 Implementation Date. Standard formats of provider contracts that are executed Dallas Service Area Contract 62 55 later than the 120 days prior to the Implementation Date must be submitted to TDH for approval no later than 30 within 5 working days prior to after the implementation date of execution of the new standard formatprovider contract. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.4. 7.2.1.1 . HMO must notify TDH has 15 working not less than 90 days prior to review the materials and recommend terminating any suggestions or required changes. If TDH has not responded to HMO by the fifteenth day, HMO may execute the subcontract affecting a major performance function of this contract. All major Subcontractor terminations and/or substitutions require TDH reserves the right to request HMO to modify any contract that has been deemed approvedapproval. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH or the requesting agency. Provider contracts requested in response to public information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDH. TDH retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health services under this contract. TDH may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systems, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 7.2.7.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program. HMO must provide copies of the TDH/HMO Contract to the provider upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDH/HMO contract could result in liability for money damages, and or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 7.2.7.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provideroperations,[Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO. 7.2.8.3 7.2.7.3 [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇ ▇ecipient recipient for a covered service. 7.2.8.4 7.2.7.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH of the change in writing. If TDH does not provide written approval within 30 45 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which are required by TDH or by changes in state or federal law are effective immediately. 7.2.8.5 7.2.7.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a recipient to TDH for referral to THHSC. 7.2.8.6 . Dallas Service Area Contract 57 7.2.7.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider contracts.

Provider Contracts. 7.2.1 All providers must have a written contract, either with an intermediary entity or an HMO, to participate in the Medicaid program (provider contract). HMO must make all contracts available to TDH HHSC upon request, at the time and location requested by TDHHHSC. All standard formats of provider contracts must be submitted to TDH HHSC for approval no later than 60 days after the effective date of this contract, unless previously filed with TDHHHSC. HMO must submit 1 one paper copy and 1 one electronic copy in a form specified by TDHHHSC. Any change to the standard format must 55 Dallas Service Area Contract 62 be submitted to TDH HHSC for approval no later than 30 days prior to the implementation of the new standard format. All provider contracts are subject to the terms and conditions of this contract and must contain the provisions of Article V5, Statutory and Regulatory Compliance, and the provisions contained in Article 3.2.4. 7.2.1.1 TDH HHSC has 15 working days to review the materials and recommend any suggestions or required changes. If TDH HHSC has not responded to HMO by the fifteenth day, HMO may execute the contract. TDH HHSC reserves the right to request HMO to modify any contract that has been deemed approved. 7.2.2 Primary Care Provider (PCP) contracts and specialty care contracts must contain provisions relating to the requirements of the provider types found in this contract. For example, PCP contracts must contain the requirements of Article 7.8 of this contract relating to Primary Care Providers. 7.2.3 Provider contracts that are requested by any agency with authority to investigate and prosecute fraud and abuse must be produced at the time and the place required by TDH HHSC or the requesting agency. Provider contracts requested in response to public information a Public Information request must be produced within 48 hours of the request. Requested contracts and all related records must be provided free of free-of-charge to the requesting agency. 7.2.4 The form and substance of all provider contracts are subject to approval by TDH. TDH retains the authority to reject or require changes to any contract that do not comply with the requirements or duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL PERFORMANCE. 7.2.5 TDH reserves the right and retains the authority to make reasonable inquiry and conduct investigations into patterns of provider and Member complaints against HMO or any intermediary entity with whom HMO contracts to deliver health services under this contract. TDH may impose appropriate sanctions and contract remedies to ensure HMO compliance with the provisions of this contract. 7.2.6 HMO must not restrict a provider's ability to provide opinions or counsel to a Member with respect to benefits, treatment options, and provider's change in network status. 7.2.7 To the extent feasible within HMO's existing claims processing systems, HMO should have a single or central address to which providers must submit claims. If a central processing center is not possible within HMO's existing claims processing 56 Dallas Service Area Contract 63 systems, HMO must provide each network provider a complete list of all entities to whom the providers must submit claims for processing and/or adjudication. The list must include the name of the entity, the address to which claims must be sent, explanation for determination of the correct claims payer based on services rendered, and a phone number the provider may call to make claims inquiries. HMO must notify providers in writing of any changes in the claims filing list at least 30 days prior to the effective date of change. If HMO is unable to provide 30 days notice, providers must be given a 30-day extension on their claims filing deadline to ensure claims are routed to correct processing center. 7.2.8 HMO, all IPAs, and other intermediary entities must include contract language which substantially complies with the following standard contract provisions in each Medicaid provider contract. This language must be included in each contract with an actual provider of services, whether through a direct contract or through intermediary provider contracts: 7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care under the TDH STAR program. HMO must provide copies of the TDH/HMO Contract to the provider upon request. [Provider] understands that services provided under this contract are funded by State and federal funds under the Medicaid program. Provider is subject to all state and federal laws, rules and regulations that apply to all persons or entities receiving state and federal funds. [Provider] understands that any violation by a provider of a State or federal law relating to the delivery of services by the provider under this HMO/Provider contract, or any violation of the TDH/HMO contract could result in liability for money damages, and or civil or criminal penalties and sanctions under state and/or federal law. 7.2.8.2 [Provider] understands and agrees that HMO has the sole responsibility for payment of covered services rendered by the provider under HMO/Provider contract. In the event of HMO insolvency or cessation of operations, [Provider's] sole recourse is against HMO through the bankruptcy, conservatorship, or receivership estate of HMO. 7.2.8.3 [Provider] understands and agrees TDH is not liable or responsible for payment for any Medicaid covered services provided to mandatory Members under HMO/Provider contract. Federal and State laws provide severe penalties for any provider who attempts to collect any payment from or bill ▇ ▇ecipient for a covered service. 7.2.8.4 [Provider] agrees that any modification, addition, or deletion of the provisions of this contract will become effective no earlier than 30 days after HMO notifies TDH of the change in writing. If TDH does not provide written approval within 30 days from receipt of notification from HMO, changes can be considered 57 Dallas Service Area Contract 64 provisionally approved, and will become effective. Modifications, additions or deletions which are required by TDH or by changes in state or federal law are effective immediately. 7.2.8.5 This contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. [Provider] must cooperate and assist TDH and any state or federal agency that is charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse. [Provider] must provide originals and/or copies of any and all information, allow access to premises and provide records to TDH or its authorized agent(s), THHSC, HCFA, the U.S. Department of Health and Human Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud Control Unit, upon request, and free of charge. [Provider] must report any suspected fraud or abuse including any suspected fraud and abuse committed by HMO or a recipient to TDH for referral to THHSC. 7.2.8.6 [Provider] is required to submit proxy claims forms to HMO for services provided to all STAR Members that are capitated by HMO in accordance with the encounter data submissions requirements established by HMO and TDH. 7.2.8.7 HMO is prohibited from imposing restrictions upon the provider's free communication with Members about a Member's medical conditions, treatment options, HMO referral policies, and other HMO policies, including financial incentives or arrangements and all STAR managed care plans with whom Provider contracts.