PACIFICARE OF OREGON
1996 MEDICAL GROUP SERVICES AGREEMENT
THE CORVALLIS CLINIC, P.C.
TABLE OF CONTENTS
SECTION PAGE
PREAMBLE ............................................................. 1
1. DEFINITIONS .......................................................... 1
2. RELATIONSHIP OF PARTIES .............................................. 7
2.1 - Liability for Obligations ...................................... 7
2.2 - Independent Contractor ......................................... 7
2.3 - Medical Group Indemnification of OMAP and the
State of Oregon ................................................ 8
2.4 - Physician-Patient Relationship ................................. 8
3. DUTIES OF MEDICAL GROUP .............................................. 8
3.1 - Arrange or Provide Covered Services ............................ 8
3.2 - Medical Group Physicians........................................ 8
3.3 - Standards ...................................................... 9
3.4 - Insurance ...................................................... 10
3.5 - Non-Billing of Members ......................................... 10
3.6 - Continuing Care Obligation Following Termination ............... 11
3.7 - Provider Policies and Procedures Manual ........................ 12
3.8 - Credentialing, Recredentialing and Peer Review.................. 12
3.9 - Quality Management and Improvement Program...................... 14
3.10 - Utilization Management Program................................. 15
3.11 - Conformance Requests and Corrective Action..................... 16
3.12 - Catastrophic Case Management................................... 16
3.13 - Claims Processing.............................................. 16
3.14 - Non-Discrimination............................................. 17
3.15 - Reciprocity Agreements......................................... 17
3.16 - Other Contractual Commitments.................................. 18
3.17 - Dissemination of Information................................... 18
3.18 - Medical Group Subcontracts..................................... 18
3.19 - Medical Group Medical Director................................. 19
3.20 - Participate in PacifiCare Risk-Sharing Programs................ 19
3.21 - PacifiCare Point-Of-Service Plan............................... 19
3.22 - Exceptional Needs Care Coordination............................ 19
3.23 - OMAP Requirements ............................................. 19
4. DUTIES OF PACIFICARE..................,............................... 21
4.1 - Administration ................................................. 21
4.2 - Benefit Information ............................................ 21
4.3 - Assist Medical Group............................................ 21
4.4 - Provision of Data............................................... 21
4.5 - Eligibility Lists............................................... 21
4.6 - Credentialing, Quality Improvement and Utilization
Management Programs............................................. 21
4.7 - Medical Director................................................ 22
4.8 - Services Rendered to Ineligible Persons ........................ 22
4.9 - Medical Group Subcontracts...................................... 22
4.10 - Limitation Upon Termination of Hospital........................ 22
4.11 - Assignment of Members.......................................... 23
4.12 - Insurance ..................................................... 23
4.13 - Services Provided By Publicly Funded Agencies ................. 23
TABLE OF CONTENTS (CONTINUED)
5. COMPENSATION.......................................................... 23
5.1 - Capitation Payments............................................. 23
5.2 - Additional Payments ............................................ 23
5.3 - Collection of Copayments........................................ 24
5.4 - Capitation Adjustments.......................................... 24
5.5 - Changes in Accepted Treatment .................................. 25
5.6 - Special Conditions for Emergency Services....................... 25
5.7 - OMAP Hold Harmless Provision ................................... 25
5.8 - Coordination of Benefits ....................................... 26
5.9 - Collection of Charges from Third Parties........................ 26
6. TERM AND RENEWAL OF AGREEMENT ....................................... 27
6.1 - Term............................................................ 27
6.2 - Negotiation..................................................... 27
7. TERMINATION
7.1 - Termination of Agreement without Cause ......................... 27
7.2 - Termination by Medical Group for Cause ......................... 27
7.3 - Termination by PacifiCare for Cause ............................ 28
7.4 - Termination of HCFA Agreement of Participation in Secure
Horizons ....................................................... 28
7.5 - Termination of Medicaid Agreement or Participation in
PacifiCare Medicaid Plan ....................................... 29
7.6 - Notification of OMAP of Amendment or Termination ............... 29
7.7 - Repayment Upon Termination...................................... 29
7.8 - Termination Not An Exclusive Remedy............................. 29
8. RECORDS, CONFIDENTIALITY, DATE COLLECTION AND RIGHT TO INSPECT
RECORDS............................................................... 29
8.1 - Maintenance of Records.......................................... 29
8.2 - Right To Inspect ............................................... 30
8.3 - Confidentiality of Records ..................................... 31
8.4 - Encounter Data ................................................. 31
8.5 - Financial Statements ........................................... 31
8.6 - Transfer of Copying of Records upon Termination ................ 32
9. GRIEVANCE AND APPEALS PROCEDURE AND DISPUTE RESOLUTION ............... 32
9.1 - Member Grievances and Appeals .................................. 32
9.2 - Member Claims Against Medical Group or Medical Group
Physicians ..................................................... 32
9.3 - Payment Disputes Involving Medical Group and Referral
Providers ...................................................... 32
9.4 - Denied Services................................................. 33
9.5 - Review Committee................................................ 34
9.6 - Quality Improvement Committee .................................. 34
9.7 - Arbitration..................................................... 35
10. NOTICE ............................................................... 35
11. CONFIDENTIALITY ...................................................... 36
11.1 - Information Confidential and Proprietary to PacifiCare......... 36
11.2 - Information Confidential and Proprietary to Medical Group...... 36
11.3 - Confidentiality of this Agreement.............................. 37
12. MISCELLANEOUS PROVISIONS ............................................. 37
12.1 - Protection of Member........................................... 37
12.2 - Transfer of Members............................................ 37
12.3 - Governing Law ................................................. 37
12.4 - Amendments or Modifications ................................... 38
12.5 - Assignment .................................................... 39
12.6 - Solicitation of PacifiCare Members of Employer Groups.......... 39
12.7 - Solicitation of Medical Group Personnel........................ 40
TABLE OF CONTENTS (CONTINUED)
12.8 - Incorporation of Provider Manual and Exhibits.................. 40
12.9 - Entire Agreement .............................................. 40
12.10 - Other Agreements.............................................. 40
12.11 - Provisions Separable.......................................... 40
12.12 - Waiver of Breach.............................................. 40
12.13 - No Third Party Beneficiary.................................... 41
12.14 - Binding on Successors......................................... 41
12.15 - Interpretation................................................ 41
12.16 - Attorneys' Fees and Costs..................................... 41
12.17 - Headings...................................................... 41
Signature Page........................................................ 41
Schedule of Attachments............................................... 42
Exhibit A - Covered Services.......................................... 43
Exhibit B - Benefits Matrix........................................... 64
Exhibit C - Capitation Payments....................................... 67
Exhibit D - Individual Stop-Loss Program ............................. 70
Exhibit E - Hospital Control Program ................................. 73
Exhibit F - Prescription Services Program ............................ 78
Exhibit G - PacifiCare Point-of-Service Plans......................... 80
Exhibit H - Delegation of Credentialing, Recredentialing
and Peer Review........................................... 86
Exhibit I - Delegation of Quality Improvement ........................ 95
Exhibit J - Delegation of Utilization Management and Review........... 99
Exhibit K - Delegation of Claims Payment..............................102
Exhibit L - Medical Group Service Area................................103
Exhibit M - Access Guidelines.........................................104
PACIFICARE OF OREGON, INC.
MEDICAL GROUP SERVICES AGREEMENT
This MEDICAL GROUP SERVICES AGREEMENT ("Agreement") is entered into as
of the Effective Date set forth on the signature page of this Agreement by
and between PACIFICARE OF OREGON, INC., an Oregon corporation ("PacifiCare")
and THE CORVALLIS CLINIC ("Medical Group"), with reference to the following
facts:
RECITALS
A. PacifiCare is a licensed health care service contractor in the State
of Oregon that operates various prepaid health service plans, including
commercial, Medicare and Medicaid plans, that arranges for the delivery of
comprehensive health care services through a health care delivery system to
persons eligible to receive benefits under, and enrolled as Members in, the
PacifiCare Health Plan as defined herein.
B. PacifiCare desires to establish a network of qualified health care
providers, including Medical Group and its Medical Group Physicians, for the
purpose of arranging or providing health care services to Members of
the PacifiCare Health Plan.
C. Medical Group is duly organized, qualified and/or licensed in the
State in which it is located to arrange or provide health care
services through physicians and other health professionals and technicians
employed or under contract with Medical Group, all of whom are appropriately
licensed to practice their professions in the State.
D. Medical Group desires to participate in PacifiCare's prepaid
health service delivery system by providing Medical Services and arranging for
the provision of Hospital Services to Members of the PacifiCare Health Plan in
coordination with PacifiCare, its Members and Participating Hospitals.
E. PacifiCare and Medical Group deem it in their best interests to
enter into this renewable Agreement whereby Medical Group agrees to arrange or
provide Medical Services and Hospital Services to Members.
NOW THEREFORE, in consideration of the promises and mutual covenants
contained herein, the parties agree to the terms and conditions
stated in this Agreement.
1. DEFINITIONS
Whenever used in this Agreement, the following terms shall have the
definitions contained in this Article 1:
1.1 AGREEMENT - is this PacifiCare Medical Group Services Agreement and
any exhibits, attachments and/or amendments hereto.
1.2 ANCILLARY SERVICES - are Covered Services, other than Medical
Services or Hospital Services, such as laboratory, x-ray, physical therapy,
health education, medical social services, home health care, mental health and
acute alcohol and drug abuse services, which Participating Providers shall
provide to Members upon Referral by a Participating Medical Group and the prior
approval of PacifiCare.
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1.3 CAPITATION PAYMENTS - are fixed monthly payments made to Medical
Group by PacifiCare on a prepaid basis for the Capitated Services to be provided
to Members under this Agreement.
1.4 CAPITATED SERVICES - are Covered Services for which Medical Group
receives a Capitation Payment from PacifiCare and assumes full financial
responsibility within the limits of this Agreement, as identified in the
Benefits Matrix applicable to each PacifiCare Health Plan as set forth in
Exhibits B1 through B3.
1.5 CATASTROPHIC CASE - is any single medical condition, including
complications arising from such medical condition, where the total cost of
Covered Services, regardless of payment source, is expected to exceed the stop-
loss limit per condition per calendar year of Covered Services.
1.6 CERTIFIED FINANCIAL STATEMENTS - means an income statement, a
balance sheet and a statement of cash flow of Medical Group, prepared in
accordance with generally accepted accounting principles and certified by the
chief financial officer, president or other authorized representative of Medical
Group to present fairly, in all material respects, the financial position of
Medical Group at the date of the balance sheet and for the period covered by the
income statement and the statement of cash flow.
1.7 COMMERCIAL MEMBER - is an individual who is enrolled as a Member in
a PacifiCare Commercial Plan pursuant to a Subscriber Agreement. Unless
otherwise specified, references in this Agreement to Members shall include
Commercial Members.
1.8 CONFORMANCE REQUEST - is a written request made by PacifiCare to
Medical Group to correct the performance of a Medical Group Physician to conform
to the provisions of this Agreement where such performance does not comply with
PacifiCare Quality Improvement or NCQA standards or applicable state and federal
law.
1.9 COPAYMENTS - are amounts pursuant to a PacifiCare Health Plan which
may be charged to Member by a Participating Provider at the time of the
provision of Covered Services which are in addition to the Capitation Payments
made to Medical Group by PacifiCare.
1.10 COVERED SERVICES - are the Medical Services, Hospital Services,
Ancillary Services and Emergency Services which Members are entitled to receive,
when Medically Necessary, under a specific PacifiCare Health Plan. Covered
Services under each applicable PacifiCare Health Plan are summarized in Exhibits
A1 through A3.
1.11 ELIGIBILITY LIST - is a list of all Members for which Medical Group
is responsible for arranging or providing Covered Services.
1.12 EMERGENCY SERVICES - are Medically Necessary inpatient or
outpatient Covered Services provided inside or outside the Service Area to a
Member as the result of an unforeseen injury, illness or medical condition
manifesting itself by acute symptoms of sufficient severity such that the
absence of immediate medical attention could reasonably be expected to result
in: (a) placing the Member's health in serious jeopardy, (b) serious impairment
of bodily functions or serious dysfunction to any bodily organ or part, or (c)
death of the Member.
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1.13 HCFA - is the Health Care Financing Administration, an
administrative agency of the United States Government responsible for
administering the Medicare program.
1.14 HCFA AGREEMENT - is the Medicare-risk contract entered into by and
between PacifiCare and HCFA, under which PacifiCare is obligated to provide or
arrange for comprehensive health care services on a risk-sharing basis to each
Medicare beneficiary who is enrolled as a Member of the Secure Horizons Health
Plan.
1.15 HHS - is the United States Department of Health and Human Services.
1.16 HOSPITAL SERVICES - are the Medically Necessary inpatient and
outpatient health care services which Participating Hospitals shall provide to
Members and which Medical Group shall arrange, coordinate and authorize for
Members pursuant to the PacifiCare Health Plan in which the Member is enrolled.
Hospital Services under each PacifiCare Health Plan are summarized in Section I
of Exhibits A1 through A3.
1.17 MEDICAID - is a federal and state funded health care program
established by Title XIX of the Social Security Act, as amended, which is
administered in Oregon by OMAP.
1.18 MEDICAID AGREEMENT - is the Provider Services Agreement entered into
by and between PacifiCare and OMAP, under which PacifiCare is obligated to
provide or arrange for comprehensive health care services on a risk-sharing
basis to OMAP Members.
1.19 MEDICAL GROUP - is the Medical Group or independent practice
association identified in the first paragraph of this Agreement and its Medical
Group Physicians.
1.20 MEDICAL GROUP MEMBER - is a Member who has selected or been assigned
to Medical Group or a Medical Group Physician as such Member's Primary Care
Physician.
1.21 MEDICAL GROUP PHYSICIAN - is a person licensed to practice medicine
or osteopathy in the State who either is employed by Medical Group, is partner
or shareholder of Medical Group or has entered into a written contract with
Medical Group to provide Medical Services to Members pursuant to this Agreement.
1.22 MEDICAL GROUP SERVICE AREA - is the geographical area within a
twenty (20) mile radius of Medical Group, as described in Exhibit L.
1.23 MEDICAL GROUP SUBCONTRACTS - are the written contracts entered into
between Medical Group and Medical Group Physicians who are independent
contractors for the performance of Medical Services.
1.24 MEDICAL SERVICES - are the Medically Necessary health care services
which Medical Group shall provide to Members pursuant to the PacifiCare Health
Plan in which the Member is enrolled. Medical Services under each PacifiCare
Health Plan are summarized in Section II of Exhibits A1 through A3. Medical
Services must be prescribed, directed or authorized by Medical Group, unless
such services are Emergency Services. For Secure Horizons only these also
include Urgently Needed Services.
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1.25 MEDICALLY NECESSARY SERVICES - are Covered Services which are
determined by PacifiCare or a Medical Group Physician, in accordance with
accepted standards of medical and surgical practice in the Medical Group Service
Area and the general medical community and the professional standards
recommended by PacifiCare's Quality Improvement Committee, to be required for
the diagnosis and/or treatment of a Member's injury, illness or medical
condition.
1.26 MEDICARE - is the Hospital Insurance Plan (Part A) and the
supplementary Medical Insurance Plan (Part B) provided under Title XVIII of the
Social Security Act, as amended (codified in Title 42 of the United States Code)
and the regulations promulgated thereunder by the Secretary of HHS and HCFA
(codified in Title 42 of the Code of Federal Regulations).
1.27 MEMBER - is an individual who is enrolled in a PacifiCare Health
Plan, who meets all the eligibility requirements for membership in such plan and
for whom all applicable health plan premiums are received by PacifiCare. For the
purpose of this Agreement, Member shall include all eligible family members of
the Subscriber.
1.28 MONTHLY HCFA PAYMENT - is the revenue received by PacifiCare each
month from HCFA, as determined by HCFA, for the Covered Services to be provided
to each Member of the Secure Horizons Health Plan.
1.29 MONTHLY OMAP PAYMENT - is the revenue received by PacifiCare each
month from OMAP, as determined by OMAP, for the Covered Services to be provided
to each Member of the PacifiCare Medicaid Plan.
1.30 NCOA - is the National Committee for Quality Assurance, a managed
care accreditation organization.
1.31 NON-CAPITATED SERVICES - are the Covered Services for which
PacifiCare has assumed full financial responsibility under this Agreement, as
identified in the Benefits Matrix applicable to each PacifiCare Health Plan as
set forth in Exhibits B1 through B3.
1.32 NON-PARTICIPATING PROVIDERS - are licensed physicians, physician
groups, surgeons, osteopaths, paramedical personnel, hospitals and other
licensed health care professionals and health care facilities who provide
services to Members covered under a PacifiCare Health Plan, but who or which do
not have written agreements with PacifiCare or Medical Group to provide such
services.
1.33 OMAP - is the Oregon Department of Human Resources, Office of
Medical Assistance Program, the State administrative agency responsible for
administering the Medicaid program in the State of Oregon.
1.34 OMAP MEMBER - is an individual who is eligible for Medicaid
benefits, as approved by OMAP, and who is enrolled in the PacifiCare Medicaid
Plan pursuant to the Medicaid Agreement. Unless otherwise specified, references
in this Agreement to Member shall include OMAP Members.
1.35 PACIFICARE COMMERCIAL PLANS - are the prepaid health care service
plans sold by PacifiCare to individuals (excluding individuals eligible for the
PacifiCare Medicaid Plan or Secure Horizons) and to employer groups,
associations with employer group participation, unions and other organizations
covering the provision of Covered Services to their employees and dependents,
which services are summarized in Exhibit A1. References to the PacifiCare
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Commercial Plan include the PacifiCare Point-of-Service Plan. Unless otherwise
specified, references in the Agreement to the PacifiCare Health Plan shall
include the PacifiCare Commercial Plans.
1.36 PACIFICARE MEDICAID PLAN - is the prepaid health care service plan
operated by PacifiCare covering the provision of Covered Services to OMAP
Members, which services are summarized in Exhibit A3. Unless otherwise
specified, references in the Agreement to the PacifiCare Health Plan shall
include the PacifiCare Medicaid Plan.
1.37 PACIFICARE HEALTH PLAN - is any one of the various prepaid health
care service plans operated by PacifiCare, including but not limited to, the
PacifiCare Commercial Plans, the PacifiCare Medicaid Plan and Secure Horizons.
1.38 PACIFICARE POINT-OF-SERVICE PLAN - is a PacifiCare Commercial Plan
(also called the Option Plan) approved by the Oregon Department of Consumer and
Business ("D.C.B.S."). Option Members receive financial incentives to obtain In-
Network Services in the form of reduced Copayments and deductibles. Unless
otherwise specified, references in the Agreement to the PacifiCare Commercial
Health Plan shall include the PacifiCare Point-of-Service Plan.
1.39 PACIFICARE SERVICE AREA - is the geographic area in which, as of the
Effective Date of this Agreement, PacifiCare is licensed, authorized or approved
to provide or arrange for Covered Services by (a) the D.C.B.S. for the
PacifiCare Commercial Plans, (b) HCFA for the Secure Horizons Health Plan, and
(c) OMAP for the PacifiCare Medicaid Plan.
1.40 PARTICIPATING FACILITY - is any licensed general acute care
hospital, skilled nursing facility, extended care facility, home health agency,
alcoholism and drug abuse center or any other health care facility which has
entered into a written agreement to provide Covered Services to Members pursuant
to the PacifiCare Health Plan.
1.41 PARTICIPATING MEDICAL GROUP - includes Medical Group and is any
group or association duly organized and qualified by and under the laws of the
State as a professional medical corporation or partnership which employs or
contracts with licensed doctors of medicine or osteopathy, and which has entered
into a written agreement with PacifiCare to provide or arrange Covered Services
to Members who have selected or been assigned to that Participating Medical
Group as their primary provider of care.
1.42 PARTICIPATING PHYSICIAN - is any person licensed to practice
medicine or osteopathy by the State Medical Board or the Board of Osteopathic
Examiners to provide Medical Services within the scope of his or her practice,
and who has entered into a written agreement with PacifiCare or a Participating
Medical Group for the provision of Medical Services to Members.
1.43 PARTICIPATING PROVIDER - is a Participating Physician, Participating
Medical Group, Participating Facility or any other licensed health practitioner
or facility, such as a mental health professional or Ancillary Services
provider, who or which has entered into a written agreement for the provision of
Covered Services to Members.
1.44 PREVAILING RATES - are the usual, reasonable and customary rates for
a particular health service in the Service Area. Usual, reasonable and customary
rates are the amounts that a provider currently uniformly charges patients for
specific services, provided such charges are reasonable in
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relation to the charges of similar providers in the Service Area for the same
services and accommodations.
1.45 PRIMARY CARE PHYSICIAN - is a Participating Physician who is an
internist, general practitioner, family practitioner, pediatrician or women's
health care provider who has agreed to accept the responsibility for providing
primary care services within the scope of his or her license to Members who have
selected or been assigned to that Primary Care Physician, for maintaining the
continuity of patient care, and for initiating and coordinating Referrals for
hospital admissions, outpatient surgeries and specialist care.
1.46 QUALITY IMPROVEMENT COMMITTEES - are committees separately
established and operated by PacifiCare and Medical Group to oversee and ensure
the quality of Covered Services provided to Members as required by PacifiCare,
the D.C.B.S., HCFA, OMAP or any other governmental agency with regulatory or
enforcement jurisdiction over PacifiCare, Medical Group or this Agreement.
1.47 REFERRAL - is a written document approved by a Primary Care
Physician directing a Member to another Participating Provider for the purpose
of obtaining Covered Services that cannot be directly provided by the Primary
Care Physician.
1.48 REFERRAL PROVIDER - is a provider of Medical Services, Hospital
Services or Ancillary Services, other than a Medical Group Physician, with whom
Medical Group has entered into a written agreement to provide Covered Services
to Members upon Referral from a Primary Care Physician.
1.49 SECURE HORIZONS HEALTH PLAN - is the PacifiCare Health Plan covering
the provision of Covered Services to Medicare beneficiaries, which services are
described in Exhibit A2. Unless otherwise specified, references in this
Agreement to the PacifiCare Health Plan shall include the Secure Horizons Health
Plan.
1.50 SECURE HORIZONS MEMBER - is an individual who is eligible for
Medicare benefits, as approved by HCFA, and who is enrolled as a Member in the
Secure Horizons Health Plan pursuant to the HCFA Agreement. Unless otherwise
specified, references in the Agreement to Members shall include Secure Horizons
Members.
1.51 SPECIALIST PHYSICIAN - is a Participating Physician, other than a
Medical Group Physician, who is board-certified or board-eligible in a specialty
of medical care defined and recognized by the American Medical Association, who
is responsible for providing Covered Services to Members upon Referral from a
Primary Care Physician and the prior authorization of Participating Medical
Group.
1.52 SUBSCRIBER AGREEMENT - is the written agreement entered into between
PacifiCare and a Subscriber or Subscriber Group for the provision of Covered
Services to eligible Members enrolled in one of the PacifiCare Health Plans.
1.53 SUBSCRIBER OR SUBSCRIBER GROUP - is an individual (except for
Medicare or Medicaid beneficiary) or the employer, employer group, organization
or company which has entered into a Subscriber Agreement with PacifiCare.
1.54 SUPPLEMENTAL BENEFITS - are Non-Capitated Services under a
Subscriber Agreement, such as prescription services and vision benefits, which
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are offered by PacifiCare in addition to the basic benefits under the applicable
PacifiCare Health Plan and which may require an additional premium from the
Subscriber Group as consideration for the additional benefits.
1.55 URGENTLY NEEDED SERVICES - are Medically Necessary Covered Services
that are required without delay in order to prevent serious deterioration of a
Member's health as the result of an unforeseen illness or injury while the
Member is temporarily absent from the Service Area.
1.56 UTILIZATION MANAGEMENT COMMITTEE - is the committee established by
Medical Group to develop and implement procedures for the efficient use of
resources, consistent with state and federal law and NCQA standards, for the
provision of Covered Services. The Utilization Management Committee shall
perform prospective, current and retrospective review and management of Covered
Services. The Utilization Management Committee shall consist of at least three
(3) Medical Group Physicians.
2. RELATIONSHIP OF PARTIES
2.1 LIABILITY FOR OBLIGATIONS - Notwithstanding any other provision of
this Agreement, nothing contained herein shall cause either PacifiCare or
Medical Group to be liable or responsible for any debt, liability or obligation
of the other party or any third party, unless such liability or responsibility
is expressly assumed by the party sought to be charged therewith. Each party
shall be solely responsible for, and shall indemnify and hold the other party
harmless against, any obligation for the payment of wages, salaries or other
compensation (including all state, federal and local taxes and mandatory
employee benefits), insurance and voluntary employment-related or other
contractual or fringe benefits as may be due or payable by the party to or on
behalf of such party's employees, agents and representatives.
2.2 INDEPENDENT CONTRACTOR
2.2.1 RELATIONSHIP BETWEEN PACIFICARE AND MEDICAL GROUP - The
relationship between PacifiCare and Medical Group is an independent contractor
relationship. Neither Medical Group nor its Medical Group Physicians, partners,
employees and agents are the employees or agents of PacifiCare and neither
PacifiCare nor any employee or agent of PacifiCare is a member, partner,
employee or agent of Medical Group. Medical Group is responsible for Medical
Services and Hospital Services arranged by the Medical Group and provided to
Members. None of the provisions of this Agreement shall be construed to create a
relationship of agency, representation, joint venture, ownership, control or
employment between the parties other than that of independent parties
contracting for the purpose of effectuating this Agreement.
2.2.2 RELATIONSHIP BETWEEN PACIFICARE OR MEDICAL GROUP AND THE STATE
OF OREGON AND OMAP - The relationship between PacifiCare or Medical Group, as a
subcontractor of PacifiCare as a result of this Agreement and participation in
the PacifiCare Medicaid Plan, and the State of Oregon and OMAP are independent
contractor relationships. Neither PacifiCare nor Medical Group nor any of their
agents, officers or employees are agents, officers or employees of the State of
Oregon or OMAP. None of the provisions of this Agreement shall be construed to
create a relationship of partnership, joint venture or employment between
PacifiCare or Medical Group, as a subcontractor of PacifiCare, and the State of
Oregon or OMAP.
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2.3 MEDICAL GROUP INDEMNIFICATION OF OMAP AND THE STATE OF OREGON -
Neither the State of Oregon, OMAP nor their employees or agents nor the OMAP
Members shall be responsible or liable for any acts or omissions of Medical
Group. Medical Group shall defend, indemnify and hold harmless the State of
Oregon and OMAP and its officers, agents and employees, from and against all
actions, suits or claims of any nature whatsoever resulting from or arising out
of the activities or omissions of Medical Group and its Medical Group
Physicians, agents and employees under this Agreement; provided, however,
Medical Group shall not be required to defend or indemnify the State of Oregon
or OMAP or their officers, agents or employees from or against any act or
omission based solely on the alleged negligence of the State of Oregon or OMAP.
2.4 PHYSICIAN-PATIENT RELATIONSHIP - PacifiCare and Medical Group
acknowledge and agree that each Medical Group Physician shall be responsible for
maintaining the professional physician-patient relationship with each Member.
Medical Group Physicians shall have the sole responsibility for the medical care
and treatment of Members under Medical Group Physician's care. Nothing contained
in this Agreement is intended to interfere with the professional relationship
between any Member and Medical Group Physician.
3. DUTIES OF MEDICAL GROUP
3.1 ARRANGE OR PROVIDE COVERED SERVICES. Medical Group shall provide or
arrange all Medically Necessary Covered Services in the Medical Group Service
Area to Members identified on Medical Group's Eligibility List, in coordination
with PacifiCare and other Participating Providers and under all the terms and
conditions set forth in this Agreement and the applicable PacifiCare Health
Plans. Covered Services under the applicable PacifiCare Health Plans are
summarized in Exhibits A1 through A3, attached hereto. Medical Group shall be
financially responsible for: (a) all Capitated Services listed as Medical
Group's responsibility in the Benefits Matrix for the PacifiCare Commercial
Plans, attached hereto as Exhibit B1; (b) all Capitated Services listed as
Medical Group's responsibility in the Benefits Matrix for the Secure Horizons
Health Plan, attached hereto as Exhibit B2; and (c) all Capitated Services
listed as Medical Group's responsibility in the Benefits Matrix for the
PacifiCare Medicaid Plan, attached hereto as Exhibit B3.
3.1.1 CLARIFICATION OF BENEFITS - Medical Group may request that any
disputed clarification or explanation issued by PacifiCare concerning what are
Covered Services, Capitated Services, or Non-Capitated Services be submitted for
review to PacifiCare, except that questions pertaining to the Medical Necessity
of a Covered Service shall be submitted to the PacifiCare Quality Improvement
Committee.
3.1.2 INFORMATION TO MEMBERS - Upon request by PacifiCare, Medical
Group shall assist PacifiCare in educating Members regarding the Covered
Services available under the specific PacifiCare Health Plan in which the Member
is enrolled.
3.2 MEDICAL GROUP PHYSICIANS
3.2.1 RESPONSIBILITIES - Medical Group shall arrange for Covered
Services to be provided to Members by the Medical Group Physicians. Each Medical
Group Physician who is a Primary Care Physician shall be responsible for
providing all Medically Necessary Medical Services, overseeing the continuity of
care, and directing, authorizing and coordinating Referrals for the provision of
Hospital Services and other Ancillary Services for each
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Medical Group Member who has selected or been assigned to that Primary Care
Physician. Medical Group shall also include appropriate Specialist Physicians
and other Referral Providers who shall be responsible for providing Covered
Services to Members upon Referral from Primary Care Physicians.
3.2.2 ACCESSIBILITY AND AVAILABILITY - Medical Group shall require
and demonstrate the continuous availability and accessibility of adequate
numbers of Medical Group Physicians to provide or arrange for Covered Services
to Medical Group Members on a twenty-four (24) hour basis, seven (7) days a
week, including the provision or arrangement of Emergency Services. Medical
Group shall comply with the access standards established by PacifiCare in
accordance with applicable federal and state law and regulations and NCQA
standards, as set forth in the Provider Manual and in Exhibit N of this
Agreement.
3.2.3 MEDICAL GROUP PHYSICIAN INFORMATION - Medical Group shall
provide to PacifiCare at the time of the execution of this Agreement: (a) a
complete list of the names, addresses, State license numbers, specialties,
normal hours of operation (including any provisions for Emergency Services on a
twenty-four (24) hour basis), maximum capacity and maximum waiting periods of
each Medical Group Physician; (b) a list of the Specialist Physicians, hospitals
and other Referral Providers regularly utilized by Medical Group as part of its
Referral system; and (c) any additional provider information required by the
D.C.B.S., HCFA or OMAP. Medical Group shall update this information as received
from Medical Group Physicians or at PacifiCare's request.
3.2.4 CAPACITY LIMITATION NOTICE - Medical Group shall provide at
least thirty (30) days prior written notice to PacifiCare of any significant
changes in the capacity of Medical Group or any Medical Group Physician who is a
Primary Care Physician. A significant change is the inability to accept
assignment of additional Members. After the giving of such notice and the
expiration of the notice period, no Medical Group Physician who is the subject
of such notice shall be required to accept coverage for any additional Members
until such time as Medical Group provides written notice that the applicable
provider is available to accept coverage of additional Members. Primary Care
Physicians who are identified on a limitation of capacity notice shall still be
responsible to provide Covered Services to Medical Group Members whom the
Primary Care Physician had agreed to accept before expiration of the thirty (30)
day capacity notice period. If any Medical Group Physician is unable to provide
Covered Services to additional Members, Medical Group shall still be responsible
for arranging Covered Services to all Medical Group Members through its
remaining Medical Group Physicians.
3.3 STANDARDS
3.3.1 LICENSURE AND CREDENTIALING REQUIREMENTS - Medical Group
represents and warrants to PacifiCare that each Medical Group Physician is
currently and shall remain for the duration of this Agreement: (a) the holder of
a currently valid, unrestricted license to practice medicine or osteopathy in
the State; (b) a member in good standing of the medical staff of, and maintains
appropriate privileges at, a Participating Facility where Covered Services shall
be provided to Members; and (c) meets all of the other credentialing standards
established by PacifiCare as set forth in this Agreement and the Provider
Manual. In addition, Medical Group represents and warrants that all nurses and
other ancillary and paramedical personnel who are employed by or contract with
Medical Group to provide or assist Medical Group
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in providing Covered Services to Members are properly licensed, certified or
otherwise authorized and credentialed to practice in the State.
3.3.2 PROFESSIONAL AND QUALITY OF CARE STANDARDS - All Covered
Services shall be provided by Medical Group Physicians in accordance with
accepted medical, hospital and surgical practices and professional standards
prevailing in the Service Area and the general medical community, and in
conformity with the quality of care standards established by the PacifiCare
Quality Improvement Committee in accordance with applicable federal and state
law and NCQA standards. Medical Group shall ensure that all Medical Group
Physicians comply with such professional and quality of care standards.
3.3.3 MEDICARE AND MEDICAID PARTICIPATION STANDARDS - Medical Group
shall require that all Medical Group Physicians satisfy the standards for
participation and all applicable requirements for providers of health care
services under the Medicare program and Medicaid program. In addition, Medical
Group shall require that all facilities and offices utilized by Medical Group
and Medical Group Physicians to provide Covered Services to Members shall comply
with the facility standards established by HCFA and OMAP pursuant to the
Medicare and Medicaid programs, respectively, and Medical Group and Medical
Group Physicians shall cooperate with any inspections of Medical Group
facilities, as conducted by HCFA, OMAP or PacifiCare staff, that are required to
assure compliance with HCFA or OMAP facility standards.
3.4 INSURANCE - Medical Group shall maintain professional liability
insurance and general liability and errors and omissions liability insurance in
the minimum amounts of one million dollars ($1,000,000) per occurrence and three
million dollars ($3,000,000) per physician annual aggregate for coverage of
Medical Group and its agents, employees and Medical Group Physicians. Such
professional liability insurance shall provide coverage of direct and vicarious
liability relating to any damages caused by an error, omission or any negligent
acts. In addition, Medical Group shall obtain and maintain workers' compensation
coverage for all of its employees in accordance with the State Worker's
Compensation Law. Medical Group shall require each Medical Group Physician who
is an independent contractor to maintain professional liability insurance and
general liability insurance coverage in the minimum amounts of one million
dollars ($1,000,000) per occurrence and three million dollars ($3,000,000)
annual aggregate for coverage of Medical Group Physician and his or her agents
and employees. In the event Medical Group or a Medical Group Physician procures
a "claims made" policy as distinguished from an occurrence policy, Medical Group
or Medical Group Physician shall procure and maintain prior to termination of
such insurance "extended reporting coverage" for the maximum term provided in
their professional liability policy. Medical Group shall notify PacifiCare
immediately upon becoming aware of any material changes in any of the above
insurance coverages and shall provide (or required the applicable Medical Group
Physician to provide) a certificate of such insurance coverage to PacifiCare
upon request.
3.5 NON-BILLING OF MEMBERS - Medical Group agrees to accept payment as
provided in Section 5.1 of this Agreement as payment in full for the Covered
Services required under this Agreement. With the exception of Copayments and
charges for non-Covered Services delivered on a fee-for-service basis to
Members, Medical Group agrees that in no event, including but not limited to,
nonpayment by PacifiCare, insolvency of PacifiCare or breach of this Agreement,
shall Medical Group ▇▇▇▇, charge, collect or receive compensation, reimbursement
or payment nor attempt to charge, collect or receive payment from any Member or
persons other than PacifiCare acting on Member's behalf for Covered Services
provided pursuant to this Agreement. Percentage Member
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copayments shall be charged as a percentage of the rate agreed upon in Section
3.15, Reciprocity. Medical Group shall not maintain any action at law or
equity against any Member or any person acting on Member's behalf to collect any
sums owed by PacifiCare to Medical Group. Upon notice of any violation of this
Section 3.5, PacifiCare may terminate this Agreement pursuant to Section 7.2 and
take all other appropriate action consistent with applicable state and federal
law and the terms of this Agreement to eliminate such charges, including but not
limited to, requiring Medical Group to return all sums improperly collected from
Members or their representatives.
Medical Group agrees that the obligations created by this Section 3.5
survive the termination of this Agreement with respect to Covered Services
provided during the term of this Agreement without regard to the cause of such
termination and shall be construed to be for the benefit of Members, and that
this provision supersedes any oral or written contrary agreement now existing or
hereafter entered into between Medical Group and Member or persons acting on
Member's behalf.
Nothing contained in this Section 3.5 shall prohibit Medical Group from
billing and collecting payment from Members for non-Covered Services provided to
Members and for services rendered due to the fraud or misrepresentation of
Members, at Medical Group's Prevailing Rates. Medical Group shall not ▇▇▇▇
Members for services authorized in writing by Medical Group as Covered Services.
In addition, Medical Group shall include in each Medical Group Subcontract
a provision that in the event that Medical Group fails to pay the applicable
Medical Group Physician for Covered Services provided to Members, the Member
shall not be liable to the Medical Group Physician for any sums owed by Medical
Group to the Medical Group Physician.
3.6 CONTINUING CARE OBLIGATION FOLLOWING TERMINATION - Upon termination
of this Agreement, Medical Group shall continue to provide or arrange for
Covered Services to Members under the care of a Medical Group Physician at the
time of termination until the effective date of transfer of such Members to, or
the assumption of such services by, another Participating Provider and written
notice of such transfer or assumption has been provided by PacifiCare to Medical
Group (the "Continuing Care Period"). PacifiCare shall use its best efforts to
provide for the transfer of Members or the assumption of such services as soon
as is reasonably practicable, taking into account the best interests of the
Member and the availability of appropriate alternative Participating Providers.
PacifiCare shall compensate Medical Group for Covered Services provided to
Members during the Continuing Care Period at eighty-five percent (85%) of
Prevailing Rates.
Notwithstanding the above or any other provision of this Agreement to the
contrary, Medical Group agrees that in the event PacifiCare ceases operations
for any reason, including but not limited to insolvency, Medical Group shall
provide Covered Services and shall not ▇▇▇▇, charge, collect or receive any form
of payment from any Member or have any recourse against a Member for Covered
Services provided after PacifiCare ceases operations. This obligation to
continue providing Covered Services following termination of the Agreement shall
be for the period for which premiums have been paid or the Monthly HCFA Payment
and Monthly OMAP Payment have been received, but shall not exceed a period of
thirty (30) days, except for those Members who are hospitalized on an inpatient
basis as provided below.
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In the event PacifiCare ceases operations or Medical Group terminates this
Agreement on the basis of PacifiCare's failure to make timely Capitation
Payments, Medical Group shall continue to arrange for Covered Services to those
Members who are hospitalized on an inpatient basis at the time PacifiCare ceases
operations or Medical Group terminates this Agreement until such Members are
discharged from the hospital.
Medical Group agrees that the obligations set forth in this Section 3.6
shall survive the termination of this Agreement without regard to the cause of
termination of the Agreement, and shall be construed to be for the benefit of
the Members, and shall be subject to revision as necessary to comply with
regulatory requirements. Medical Group agrees to include the obligations set
forth in this Section 3.6 in each Medical Group Subcontract.
3.7 PROVIDER POLICIES AND PROCEDURES MANUAL - Medical Group shall abide
by the standards, policies and procedures established by PacifiCare for the
administration and operation of the PacifiCare Health Plan in compliance with
applicable state and federal law and NCQA standards. PacifiCare's standards,
policies and procedures are set forth in the PacifiCare Provider Policies and
Procedures Manual (the "Provider Manual"). The Delegated Sections is hereby
incorporated in full into this Agreement by this reference. A copy of the
Provider Manual shall be provided to Medical Group upon execution of this
Agreement. Medical Group shall be responsible for distributing copies of the
Provider Manual to each Medical Group Physician.
3.8 CREDENTIALING, RECREDENTIALING AND PEER REVIEW
3.8.1 PARTICIPATE IN CREDENTIALING, RECREDENTIALING AND PEER
REVIEW - Medical Group shall participate in and cooperate with PacifiCare in the
credentialing, recredentialing and ongoing peer review of Medical Group
Physicians in accordance with the standards, policies and procedures established
by PacifiCare from time to time as set forth herein and in the Provider Manual.
Medical Group shall cooperate with PacifiCare to maintain compliance with NCQA
standards and applicable state and federal laws.
3.8.2 DELEGATION TO MEDICAL GROUP - PacifiCare shall delegate to
Medical Group and Medical Group shall perform those credentialing,
recredentialing and peer review activities specified in Exhibit I. PacifiCare
shall have the right at any time to revoke the delegation of any or all of the
credentialing, recredentialing and peer review activities specified in Exhibit
I.
3.8.3 COOPERATE WITH OVERSIGHT AND MONITORING - Medical Group shall
cooperate with PacifiCare in PacifiCare's ongoing monitoring, oversight and
assessment of Medical Group's performance of any delegated credentialing,
recredentialing and peer review activities through monthly, quarterly and/or
annual reports, meetings and on-site audits and assessments of Medical Group.
Without limiting the foregoing, Medical Group shall maintain credentialing,
recredentialing and peer review information and files in a form acceptable to
PacifiCare, permit PacifiCare to review and copy credentialing and
recredentialing and to provide access to peer review files, cooperate with
PacifiCare in all on-site visits and make records available to PacifiCare upon
request and as required by NCQA and applicable state and federal laws. Medical
Group shall provide to PacifiCare copies of all completed credentialing and
recredentialing applications for each Medical Group Physician and copies of such
other credentialing and recredentialing information which PacifiCare may request
for its monitoring and oversight of delegated activities.
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3.8.4 APPROVAL AND TERMINATION OF MEDICAL GROUP PHYSICIANS - Medical
Group acknowledges and agrees that (i) only Medical Group Physicians who meet
PacifiCare's credentialing standards shall be approved by PacifiCare to provide
Medical Services to Members, and (ii) PacifiCare retains the right, in its sole
discretion, to approve or deny any Medical Group Physician to provide Medical
Services to Members and to reduce, suspend or terminate any Medical Group
Physician from providing Medical Services to Members at any time, with due
process.
(a) NOTICE OF NEW MEDICAL GROUP PHYSICIANS - Medical Group shall
provide PacifiCare with written notice of each new Medical Group Physician
thirty (30) days prior to the Medical Group Physician providing Medical Services
to Members. New Medical Group Physicians shall be deemed approved by PacifiCare
unless PacifiCare provides Medical Group with written notice of objection to the
participation of such new Medical Group Physician prior to expiration of the
thirty (30) day notice period. Any new Medical Group Physician must be
credentialed in accordance with this Section 3.8 prior to providing Covered
Services to Members.
(b) TERMINATION OF MEDICAL GROUP PHYSICIANS. Medical Group shall
take appropriate action to limit, suspend or terminate any Medical Group
Physician from providing Medical Services to Members under this Agreement and
the applicable Medical Group Subcontract under the following circumstances: (i)
the Medical Group Physician ceases to meet the licensure requirement,
credentialing or other standards set forth in this Agreement and the Provider
Manual; (ii) upon Medical Group's or PacifiCare's reasonable determination that
there are serious deficiencies in the quality of care or professional competence
or conduct of the Medical Group Physician which affects or could adversely
affect health, safety or well-being of Members; or (iii) upon the Medical Group
Physician's material breach of a Medical Group Subcontract or inability to
perform under such Subcontract. Medical Group shall immediately and concurrently
provide PacifiCare with written notice of Medical Group's actions hereunder.
Upon termination of any Medical Group Subcontract with a Primary Care Physician,
Medical Group shall notify Members who have selected or been assigned to such
Primary Care Physician of the termination, and shall arrange Covered Services
for such Members through alternative Medical Group Physicians or other
Participating Providers following the termination.
(c) IMMEDIATE TERMINATION OF MEDICAL GROUP PHYSICIAN AT
PACIFICARE'S REQUEST - Medical Group shall immediately terminate any Medical
Group Physician's participation in the delivery of Covered Services to Members
under this Agreement and the applicable Medical Group Subcontract upon receipt
of written notice from PacifiCare demanding such termination. If Medical Group
fails to take the action required by this subsection (d), PacifiCare reserves
the right to take immediate action to prohibit such Medical Group Physician from
continuing to provide Medical Services to Members under this Agreement.
3.8.5 APPROVAL OF MEDICAL GROUP FACILITIES - Medical Group
acknowledges and agrees that: (i) the PacifiCare standards, policies and
procedures for credentialing and recredentialing include standards for review
and approval of the facilities utilized by Medical Group and Medical Group
Physicians to provide Covered Services to Members; and (ii) PacifiCare retains
the responsibility for credentialing and recredentialing of Medical Group
Facilities and the right, in its sole discretion, to approve or deny any Medical
Group facility.
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3.9 QUALITY MANAGEMENT AND IMPROVEMENT PROGRAM
3.9.1 PARTICIPATE IN QUALITY IMPROVEMENT PROGRAM - Medical Group
shall participate in and cooperate with PacifiCare in the operation of the
Quality Management and Improvement Program established by PacifiCare to monitor
the quality of Covered Services provided to Members by Medical Group and other
Participating Providers, as amended or modified from time to time (the "QI
Program"). The QI Program is set forth in the Provider Manual and is hereby
incorporated into this Agreement by this reference. The QI Program shall be
administered in accordance with any and all requirements established by the
D.C.B.S., HCFA and OMAP and the NCQA standards. Medical Group shall cooperate
with PacifiCare to maintain compliance with NCQA standards and applicable state
and federal laws. Medical Group shall cooperate with and abide by all decisions
of the PacifiCare Quality Improvement Committee relating to the quality of care
provided by Medical Group and Medical Group Physicians.
3.9.2 QUALITY IMPROVEMENT COMMITTEE - Medical Group shall maintain a
Quality Improvement Committee that shall perform quality assurance reviews as
required by the PacifiCare Quality Improvement Committee, the D.C.B.S., HCFA,
OMAP or any other governmental agency with regulatory or enforcement
jurisdiction over this Agreement. Medical Group's Quality Improvement Committee
shall meet as frequently as necessary but at least monthly and shall keep
minutes of the committee meetings, copies of which shall be made available for
review by PacifiCare's Quality Improvement Committee from time to time upon
request. The confidentiality of all such minutes shall be protected to the
fullest extent consistent with applicable law. Medical Group agrees that, when
appropriate and upon reasonable notice, PacifiCare's Medical Director or a
member of the PacifiCare medical services staff may participate in Medical Group
Quality Improvement Committee meetings during the discussion of matters relating
to care provided to PacifiCare Members. In addition, Medical Group shall, at the
written request of PacifiCare, make available one Medical Group Physician to
attend and participate in PacifiCare Quality Improvement Committee meetings
related to care provided to Medical Group Members.
3.9.3 DELEGATION TO MEDICAL GROUP - PacifiCare shall delegate to
Medical Group and Medical Group shall perform those quality management and
improvement activities specified in Exhibit J. PacifiCare shall have the right
at any time to revoke the delegation of any or all of the quality management and
improvement activities specified in Exhibit J. In such event, Medical Group
shall continue to be bound by the other provisions of this Section 3.9 regarding
quality management and improvement and shall assist and cooperate with
PacifiCare in quality management and improvement activities.
3.9.4 COOPERATE WITH OVERSIGHT AND MONITORING ACTIVITIES - Medical
Group shall cooperate with PacifiCare in PacifiCare's ongoing monitoring,
oversight and assessment of Medical Group's performance of delegated quality
management and improvement activities through monthly, quarterly and/or annual
reports. Medical Group shall maintain quality improvement and management
information in a form acceptable to PacifiCare, permit PacifiCare to review and
copy quality management and improvement files, cooperate with PacifiCare in any
and all on-site visits and make records available to PacifiCare upon request and
as required by NCQA and applicable state and federal law.
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3.10 UTILIZATION MANAGEMENT PROGRAM
3.10.1 PARTICIPATE IN UTILIZATION MANAGEMENT PROGRAM - Medical
Group agrees to participate and cooperate with PacifiCare in the operation of
the utilization management and review and case management program established by
PacifiCare for the purposes of pre-authorization and concurrent and
retrospective review of the medical necessity, cost effectiveness,
appropriateness, and level of care and utilization of Covered Services provided
to Members by Medical Group, as amended or modified from time to time by
PacifiCare (the "UM Program"). The UM Program is set forth in the Provider
Manual and is hereby incorporated into this Agreement by this reference. The UM
Program shall be administered in accordance with any and all requirements
established by the D.C.B.S., HCFA and OMAP and with the NCQA utilization
management standards. Medical Group shall cooperate with PacifiCare to maintain
compliance with such NCQA standards and applicable state and federal law.
3.10.2 UTILIZATION MANAGEMENT COMMITTEE - Medical Group shall
establish and maintain a Utilization Management Committee consisting of at least
three (3) Medical Group Physicians. The Utilization Management committee shall
meet as frequently as necessary but at least bi-weekly and shall keep minutes of
the committee meetings, copies of which shall be made available for review by
PacifiCare from time to time upon request. The confidentiality of all such
minutes shall be protected to the fullest extent consistent with applicable law.
Medical Group agrees that, when appropriate and upon reasonable notice,
PacifiCare's Medical Director or a member of the PacifiCare medical services
staff may participate in Medical Group Utilization Management Committee meetings
during the discussion of matters relating to medical care provided to PacifiCare
Members.
3.10.3 DELEGATION OF ACTIVITIES TO MEDICAL GROUP - PacifiCare
shall delegate to Medical Group, and Medical Group agrees to perform, those
utilization management and review activities specified in Exhibit K. PacifiCare
shall have the right to revoke the delegation of any or all of the utilization
management activities specified in Exhibit K in the event of Medical Group's
material failure to comply with the terms of Section 3.10 and the subsections
thereto. In such event, Medical Group shall continue to be bound by the other
provisions of this Section 3.10 regarding utilization management and shall
assist and cooperate with PacifiCare in utilization management activities.
3.10.4 COOPERATE WITH OVERSIGHT AND MONITORING ACTIVITIES -
Medical Group shall cooperate with PacifiCare in PacifiCare's ongoing
monitoring, oversight and assessment of Medical Group's performance of delegated
utilization management and review activities through monthly, quarterly and/or
annual reports, meetings and on-site audits and assessments of Medical Group.
Medical Group shall maintain utilization management information in a form
acceptable to PacifiCare, permit PacifiCare to review and copy utilization
management files, cooperate with PacifiCare in any and all on-site visits and
make records available to PacifiCare upon request and as required by NCQA and
applicable state and federal law.
3.10.5 MEDICAL CARE CRITERIA - Medical Group shall consider the
criteria for medical care that are established or approved by PacifiCare's
Quality Improvement Committee and/or Medical Director as a reference in
determining appropriate lengths of stay for hospitalized Members or appropriate
utilization patterns for Referrals.
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3.10.6 HOSPITAL ADMISSIONS - Whenever a Medical Group Physician
determines that a Member requires Hospital Services that are not Emergency
Services, the Medical Group Physician shall arrange for such Hospital Services
through the Medical Group's Utilization Management Committee and its utilization
review program. Medical Group Physicians shall not serve as admitting physicians
for any Members without such prior approval, except in the event Emergency
Services are required. If a Medical Group Physician admits a Member to a
Hospital for Emergency Services, Medical Group shall notify PacifiCare of such
admission within twenty-four (24) hours or as soon as possible, but in no event
later than the next business day after treatment or admission. Admissions for
Emergency Services or Urgently Needed Services shall be made to Participating
Hospitals, if possible.
3.10.7 REFERRALS - Medical Group shall refer Members for Medically
Necessary specialty care only to Specialist Physicians who are Participating
Providers, and only upon the prior approval of the Utilization Management
Committee. Medical Group shall comply with all Referral procedures developed by
PacifiCare as set forth in the Provider Manual prior to Referring a Member to a
Specialist Physician or other Referral Provider.
3.11 CONFORMANCE REQUESTS AND CORRECTIVE ACTION - Medical Group shall
investigate and, when warranted, take appropriate corrective action to address
and resolve quality of care and other problems involving Medical Group
Physicians that are brought to Medical Group's attention through its internal
procedures, by PacifiCare in writing or through audits conducted by HCFA, OMAP
or the D.C.B.S. Medical Group shall develop a written corrective action plan
whenever PacifiCare's Quality Improvement Committee issues a Conformance Request
finding that inappropriate or substandard Covered Services have been provided or
Covered Services that should have been provided have not been provided by
Medical Group or a Medical Group Physician. Upon Medical Group's request,
PacifiCare shall assist Medical Group in the formulation of such corrective
action plans and remedial procedures. Medical Group's corrective action plan
must address procedures for curing any deficiencies reasonably identified by
PacifiCare and must provide for completion of the corrective action plan within
the time frames reasonably established by PacifiCare, as set forth in the
Provider Manual or the Conformance Request. PacifiCare shall issue Conformance
Requests within its discretion and shall have no obligation to issue a
Conformance Request prior to providing notice of termination.
3.12 CATASTROPHIC CASE MANAGEMENT - Medical Group and PacifiCare
recognize the need to manage Catastrophic Cases effectively. Medical Group shall
report known Catastrophic Cases to PacifiCare immediately. Medical Group agrees
that PacifiCare's Medical Director or his or her designee may be involved in the
coordination of Catastrophic Cases. Medical Group shall allow the PacifiCare
Medical Director and PacifiCare health services personnel to perform concurrent
review of Catastrophic Cases. Detailed procedures for Catastrophic Case
management shall be mutually determined by the parties based upon Medical
Group's determination of the Member's transferability. Medical Group shall fully
assist PacifiCare upon request by providing information necessary to the
transfer of Members into regional centers for care of Catastrophic Cases.
3.13 CLAIMS PROCESSING - Medical Group shall be responsible for the
timely payment of claims for Capitated Services to Medical Group Physicians and
Referral Providers who provide Covered Services to Members pursuant to Medical
Group Subcontracts and to Non-Participating Providers who provide Covered
Services to Members. Medical Group shall pay claims under the terms
- 16 -
set forth in Subsections 3.13.1 through 3.13.2 below, and as described in the
Delegated Section of the Provider Manual, incorporated herein.
3.13.1 PAYMENTS TO PROVIDERS - For purposes of this Agreement,
timely payment shall mean payment by the earlier of (i) thirty (30) days after
Medical Group's receipt of a clean claim, or (ii) such other period as is
specified by applicable state or federal law or regulation (3) the time
specified in the applicable Medical Group Subcontract. For purposes of this
Section 3.13.1 and Section 3.13.2, a clean claim is one in which Medical Group
has received the complete claim and all information necessary to determine
liability for the claim. Medical Group shall provide, at PacifiCare's request,
claims reports in a form to be mutually agreed upon by the parties.
3.13.2 MEMBER CLAIMS - Medical Group shall pay clean claims for
emergency services or other covered services for which a Member has been billed
by the earlier of (i) thirty (30) days after receipt of a claim or, (ii) such
other period as is specified by applicable state or federal law or regulation.
If the claim is contested by Medical Group, Medical Group shall notify the
Member that the claim is contested within the time period specified in this
Section 3.13.2 and shall provide PacifiCare with a copy of the notice. The
notice shall identify the portion of the claim that is contested and the
specific reasons for contesting the claim.
3.13.3 PACIFICARE ASSUMPTION OF CLAIMS PAYMENT - Upon reasonable
notice to Medical Group, Medical Group shall permit PacifiCare to conduct on-
site audits to determine Medical Group's compliance with this Section 3.13. In
the event Medical Group materially fails to timely adjudicate claims (either pay
or deny) and fails to cure such failure within thirty (30) days of the receipt
of written notice from PacifiCare, in addition to exercising any other remedies
it may have under this Agreement, PacifiCare may elect to assume Medical
Group's processing and payment obligations and charge Medical Group a reasonable
administrative fee for such services based on a negotiated rate or amount. In
such event, PacifiCare shall deduct the claims paid from Medical Group's
Capitation Payment.
3.14 NON-DISCRIMINATION - Medical Group and the Medical Group Physicians
shall not unlawfully discriminate against any Member or any employee or
applicant for employment because of race, religion, color, national origin,
ancestry, physical handicap, medical condition, marital status, age (over 40),
sex, or sexual orientation. Medical Group and the Medical Group Physicians shall
comply with Title VI of the Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973 Title IX of the Education Amendments of 1972, Section
654 of the Omnibus Budget Reconciliation Act of 1981, the Americans with
Disabilities Act of 1990 and any other applicable federal or state anti-
discrimination laws and the regulations, guidelines and standards promulgated or
adopted thereunder. In addition, Medical Group and the Medical Group Physicians
shall not discriminate against any Members on the basis of income level or the
fact that the Member is a Member of a prepaid health care service plan or a
beneficiary of the Medicare or Medicaid program. Medical Group and the Medical
Group Physicians shall not refuse or fail to provide Covered Services in their
usual and customary manner to any Member, nor attempt to disenroll any Member,
because of a disability or any condition that is a direct result of the
disability or on the basis of any of the other discriminatory criteria set forth
in this Section 3.14. Medical Group shall include the requirements of this
section in each Medical Group Subcontract.
3.15 RECIPROCITY AGREEMENTS - Medical Group shall accept non-Emergency or
specialty Referrals from other Participating Providers and PacifiCare shall
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use good faith efforts to require such other Participating Providers to accept
non-Emergency or specialty Referrals from Medical Group. Payment for the
foregoing Referrals shall be no greater than eighty percent (80%) of Medical
Group's Prevailing Rates for Commercial Members or, for Secure Horizons
Members and OMAP Members, at the Medicare-allowable rates, as long as all
claims for authorized Medical Services are paid within thirty (30) days of the
date of initial billing. Medical Group shall provide Medical Services,
including Emergency Services and Urgently Needed Services, to Members enrolled
in the health benefit plans of PacifiCare affiliates or subsidiaries located in
other states at the payment rates set forth in this Section 3.15.
3.16 OTHER CONTRACTUAL COMMITMENTS - Medical Group represents and assures
PacifiCare that contractual commitments to other health care service
contractors, health maintenance organizations, competitive medical plans and
other managed care entities shall not restrict or impair Medical Group from
performing its duties under this Agreement.
3.17 DISSEMINATION OF INFORMATION - Medical Group agrees that PacifiCare
may use Medical Group's name, address and telephone number as well as the names,
addresses, telephone numbers and specialties of the Medical Group Physicians in
PacifiCare's informational materials distributed to Members, including the
PacifiCare Participating Provider Directory. Medical Group shall obtain the
prior written consent of PacifiCare prior to using PacifiCare's name in any of
Medical Group's promotional, marketing or advertising materials or for any other
reason.
3.18 MEDICAL GROUP SUBCONTRACTS - Medical Group shall enter into Medical
Group Subcontracts with all Medical Group Physicians who are independent
contractors and all Specialist Physicians and other Referral Providers regularly
utilized as part of Medical Group's Referral system. Medical Group shall utilize
written agreements which are consistent with the terms of this Agreement, in
compliance with all applicable state and federal laws and regulations and all
requirements in the HCFA Agreement and OMAP Agreement which are applicable to
subcontractors of PacifiCare, and which have been approved by PacifiCare.
Notwithstanding the existence of the Medical Group Subcontracts, Medical Group
shall remain responsible for satisfying the obligations set forth in this
Agreement.
Medical Group shall provide PacifiCare with a copy of each standard form
Medical Group Subcontract used in arranging services for Members. Within thirty
(30) days of execution of a new Medical Group Subcontract or amendment to an
existing subcontract, Medical Group shall provide to PacifiCare a copy of the
signature page and any amended provisions, including the term dates. Financial
terms shall be provided if necessary for PacifiCare to properly adjudicate
claims or at Medical Group's discretion. Upon request, Medical Group shall make
all executed Medical Group Subcontracts available for review to the D.C.B.S.,
HCFA or OMAP.
In addition to any and all other provisions required to be included in
Medical Group Subcontracts by this Agreement, all Medical Group Subcontracts
shall require the Medical Group Physician or other subcontracting provider to
make all applicable books and records available at all reasonable times for
inspection, examination or copying by PacifiCare, HCFA or OMAP, and to retain
such books and records for a term of at least five (5) years from the close
of the fiscal year in which the Medical Group Subcontract is in effect.
3.18.1 SPECIAL RATE AGREEMENT - Medical Group shall submit written
special rate agreements for any services payable under the Hospital
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Control Program to PacifiCare for purposes of notification and claims
adjudication. Special rate agreements include special provider rates for a
specific Member, as well as rates that apply to all Members.
3.19 MEDICAL GROUP MEDICAL DIRECTOR - Medical Group shall designate a
Medical Group Physician to act as Medical Director for the PacifiCare Health
Plan program within the Medical Group. The Medical Group Medical Director shall
be responsible for providing medical management leadership within the Medical
Group. The duties of Medical group's Medical Director shall include, but are not
limited to: (i) overseeing the operation of the Medical Group Utilization
Management Committee; (ii) overseeing orientation and ongoing education of
Medical Group Physicians regarding the PacifiCare Health Plan and its
philosophy, goals, benefit provisions, policies and procedures on an ongoing
basis; (iii) overseeing operation of the Medical Group Quality Improvement
Committee; (iv) monitoring the performance of the Medical Group Physicians and
staff under the PacifiCare Health Plan for effective management of medical care
and maintenance of satisfactory Member relations; and (v) managing disputes that
may arise between Medical Group Physicians and Members regarding issues of
coverage and care. Medical Group's Medical Director's role may be divided
between more than one Medical Group Physician. Other duties may be assigned to
the Medical Group Medical Director only by mutual agreement between Medical
Group and PacifiCare.
3.20 PARTICIPATE IN PACIFICARE RISK-SHARING PROGRAMS - Medical Group
shall participate in and assume the rights and responsibilities of the following
PacifiCare risk-sharing programs, if applicable:
3.20.1 INDIVIDUAL STOP-LOSS PROGRAM - Medical Group agrees not to
participate in the ISL program with PacifiCare.
3.20.2 HOSPITAL CONTROL PROGRAM - As an incentive for the provision
of Covered Services to Members in a cost-efficient manner, Medical Group shall
participate in the Hospital Control Program as provided in (i) Exhibit E1 for
the Commercial Health Plan, and (ii) Exhibit E2 for the Secure Horizons Health
Plan.
3.20.3 LOW ENROLLMENT GUARANTEE PROGRAM - Medical Group shall
participate in the Low Enrollment Guarantee Program as provided in (i) Exhibit
F1 for the Commercial Health Plan, and (ii) Exhibit F2 for the Secure Horizons
Health Plan.
3.20.4 PRESCRIPTION SERVICES PROGRAM - Medical Group shall
participate in the Prescription Services Program as provided in (i) Exhibit G1
for the Commercial Health Plan, and (ii) Exhibit G2 for the PacifiCare Medicaid
Plan.
3.21 PACIFICARE POINT-OF-SERVICE PLAN - Medical Group shall provide
Covered Services to Members of the PacifiCare Point-of-Service Plan under the
terms and conditions of this Agreement and as further specified in Exhibit H.
3.22 EXCEPTIONAL NEEDS CARE COORDINATION - Medical Group shall ensure the
provision of Exceptional Needs Care Coordination ("ENCC") to OMAP Members who
are aged, blind and disabled in accordance with the requirements set forth in
Oregon Administrative Rules (OAR) ▇▇▇-▇▇▇-▇▇▇.
3.23 OMAP REQUIREMENTS - Pursuant to the terms of the OMAP Agreement,
OMAP requires that the following provisions be included in this Agreement:
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(a) If the sums payable to Medical Group under this Agreement
exceed one hundred thousand dollars ($100,000), Medical Group shall comply with
the applicable standards, orders or requirements issued under Section 306 of the
Clean Air Act (42 U.S.C. Section 1857(h)), Section 508 of the Clean Water Act
(33 U.S.C Section 1386), Executive Order 11738 and Environmental Protection
Agency ("EPA") regulations (40 CFR Part 15), which prohibit the use of
facilities included on the EPA List of Violating Facilities. Any violations
shall be reported to OMAP, HHS and the EPA Assistant Administrator for
Enforcement (EN-329).
(b) Medical Group shall comply with any applicable mandatory
standards and policies relating to energy efficiency which are contained in the
State energy conservation plan issued in compliance with Energy Policy and
Conservation Act (Title III, Part C, Public Law 94-165).
(c) If the sums payable to Medical Group exceed ten thousand
dollars ($10,000), Medical Group shall comply with Executive Order 11246,
entitled "Equal Employment Opportunity," as amended by Executive Order 11375,
and as supplemented in Department of Labor regulations (41 CFR Part 60).
(d) Medical Group shall also comply with the requirements of the
federal Patient Self Determination Act (codified in 42 CFR Part 489, Subpart I)
and Oregon Revised Statute 127, as amended, pertaining to advance directives.
(e) Medical Group and any laboratories used by Medical Group shall
comply with the Clinical Laboratory Improvement Amendments (CLIA 1988) which
require the following: (a) all laboratory testing sites providing services under
this Agreement shall have either a CLIA certificate of waiver or a certificate
of registration along with a CLIA identification number. Those laboratories with
certificates of waiver shall provide only the eight (8) types of tests permitted
under the terms of their waiver. Laboratories with certificates of registration
may perform a full range of laboratory tests.
(f) Medical Group certifies, to the best of Medical Group's
knowledge and belief, that:
i. No federally appropriated funds have been paid or will
be paid, by or on behalf of Medical Group, to any person for influencing or
attempting to influence an officer or employee of any agency, a member of
Congress, an officer or employee of Congress, or an employee of a member of
Congress in connection with the awarding of any federal contract, the making of
any federal grant, the making of any federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any federal contract, grant, loan or cooperative agreement.
ii. If any funds other than federal appropriated
funds have been paid or will be paid to any person for influencing or attempting
to influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress in
connection with this federal contract, grant, loan, or cooperative agreement,
Medical Group agrees to complete and submit Standard Form-LLL "Disclosure Form
to Report Lobbying" in accordance with its instructions.
iii. Medical Group shall require that the language of this
certification be included in the Medical Group Subcontracts or any other
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subcontracts and that all Medical Group Physicians or other subcontractors shall
certify and disclose accordingly.
iv. Medical Group is solely responsible for all liability
arising from a failure by Medical Group to comply with the terms of this
certification. Additionally, Medical Group promises to indemnify OMAP for any
damages suffered by OMAP as a result of Medical Group's failure to comply with
the terms of this certification.
v. This certification is a material representation of fact
upon which reliance was placed when this Agreement was made or entered into.
Submission of this certification is a prerequisite for making or entering into
this Agreement imposed by Section 1352, ▇▇▇▇▇ ▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇▇ Code.
4. DUTIES OF PACIFICARE
4.1 ADMINISTRATION - PacifiCare shall perform all administrative,
accounting, enrollment, eligibility verification and other functions necessary
to the administration and operation of the various PacifiCare Health Plans and
this Agreement. PacifiCare shall provide, at its sole expense, all personnel,
facilities and equipment (including computer hardware and software) required to
enable PacifiCare to perform all such duties and functions in an accurate and
reasonably prompt manner.
4.2 BENEFIT INFORMATION - PacifiCare shall apprise all Members
concerning the type, scope and duration of benefits and Covered Services to
which Members are entitled under the applicable PacifiCare Health Plan.
PacifiCare shall maintain sufficient personnel and facilities to enable
PacifiCare to respond in a reasonably prompt manner to all inquiries by Members
and Medical Group concerning benefits and coverage.
4.3 ASSIST MEDICAL GROUP - PacifiCare shall assist and cooperate with
Medical Group in the development and implementation of procedures necessary to
carry out the provisions of this Agreement.
4.4 PROVISION OF DATA - PacifiCare shall provide Medical Group with
management information, statistical and other data reasonably necessary to carry
out the terms and conditions of this Agreement and for the operation of the
PacifiCare Health Plans. Such data includes, but is not limited to, a written
report, furnished to Medical Group within sixty (60) days after the end of each
quarter, reflecting the utilization of Medical Services and Hospital Services by
Medical Group Members.
4.5 ELIGIBILITY LISTS - PacifiCare shall maintain, update and distribute
to Medical Group, no later than the tenth (10th) day of each month, an
Eligibility List identifying for each month all Members who have selected or
been assigned to Medical Group and for whom Medical Group shall receive a
monthly Capitation Payment. Eligibility Lists shall be provided to Medical Group
in a mutually agreeable print and/or electronic data transmission format. Such
Eligibility List shall be accurate to the best of PacifiCare's ability based
upon information made available to PacifiCare by Subscriber Groups, HCFA and
OMAP as of a time not more than fifteen (15) days prior to the day the
Eligibility List is forwarded to Medical Group.
4.6 CREDENTIALING, QUALITY IMPROVEMENT AND UTILIZATION MANAGEMENT
PROGRAMS - PacifiCare shall establish and administer a credentialing,
recredentialing and peer review program, quality management and improvement
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program and utilization management program in compliance with applicable state
and federal law and NCQA standards. PacifiCare shall perform ongoing monitoring
and oversight to assess Medical Group's performance of any and all
credentialing, quality improvement and utilization management activities
delegated to Medical Group under this Agreement, including but not limited to,
monthly, quarterly and/or annual reports, meetings and on-site audits of Medical
Group to assure compliance with the standards required by PacifiCare's Quality
Improvement Committee, the D.C.B.S., HCFA, OMAP and the NCQA.
4.7 MEDICAL DIRECTOR - PacifiCare shall retain a physician licensed to
practice medicine in the State of Oregon to serve as its Medical Director.
PacifiCare's Medical Director, in consultation with the PacifiCare Quality
Improvement Committee, shall be responsible for: (i) all final medical and
mental health decisions relating to coverage or payment made pursuant to this
Agreement; (ii) all final recommendations regarding the Medical Necessity or
appropriateness of Covered Services or the site at which such services are
provided; and (iii) supervising the standards of professional medical care,
quality and utilization for Covered Services provided or arranged under the
PacifiCare Health Plan.
4.8 SERVICES RENDERED TO INELIGIBLE PERSONS OR NONASSIGNED MEMBERS -
PacifiCare shall pay Medical Group for Covered Services provided to an
ineligible person or to Members who have designated a Participating Provider
other than Medical Group as the Member's Primary Care Physician if such
ineligible person or such non-assigned Member was listed as a Medical Group
Member on the most current Eligibility List provided to Medical Group or was
confirmed verbally by PacifiCare as being an eligible Member or a Medical Group
Member. Medical Group shall submit proof to PacifiCare of having billed the
ineligible person or the person's legal guardian at least twice not less than
thirty (30) days apart. Within thirty (30) days following submission of proof of
billing, PacifiCare shall pay Medical Group eighty percent (80%) of the
remaining uncollected balance of charges at the Prevailing Rates. If subsequent
to payment by PacifiCare, Medical Group receives payment from any source,
Medical Group shall reimburse PacifiCare for any amount by which the total
payments received exceed one hundred percent (100%) of Medical Group's
Prevailing Rates.
4.9 MEDICAL GROUP SUBCONTRACTS - When PacifiCare makes payments directly
to health care providers for Covered Services rendered to Medical Group Members
pursuant to special rate agreements provided to PacifiCare pursuant to Section
3.18.1, it shall make them in accordance with such contract rates. PacifiCare
shall not charge Medical Group more than Medical Group's share of the Medical
Group contract rate on account of Covered Services provided by health care
providers under such contracts with Medical Group.
4.10 LIMITATION UPON TERMINATION OF HOSPITAL - PacifiCare may not
terminate without cause any Participating Hospital or other health facility
with which PacifiCare maintains a written agreement to provide Hospital
Services to Members and at which Medical Group Physicians serve as admitting
physicians for Members without the prior written consent of Medical Group.
For purposes of this Section 4.10, termination for cause shall include: (i)
termination for lack of financial resources as evidenced by financial records
of Participating Facility or repeated failures to pay valid outstanding
debts, (ii) failure to provide Hospital Services according to the standards
required by PacifiCare's Quality Improvement Committee, (iii) failure to
provide Hospital Services to Members in accordance with a written agreement
with PacifiCare, (iv) failure to maintain licensure, certification, insurance
or
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quality standards as required by a written agreement with PacifiCare; or (v)
breach of a material term, covenant or condition and subsequent failure to cure
in accordance with a written agreement with PacifiCare.
4.11 ASSIGNMENT OF MEMBERS - During the term of this Agreement,
PacifiCare shall include Medical Group's name in all materials provided to
Members, potential Members or purchasers of group coverage that list
Participating Providers in the Service Area. Until this Agreement is
terminated, Members shall be permitted to select Medical Group as their Primary
Care Physician and such selections shall be honored by PacifiCare, subject to
Section 12.2; provided, however, that PacifiCare shall not be required to permit
new Members to select Medical Group if Medical Group has failed to comply with a
Conformance Request based on capacity, poor access, poor administrative
operations or quality of care concerns within a reasonable period of time after
receipt of such Conformance Request. PacifiCare shall notify Medical Group
before suspending or limiting selection of Medical Group or any Medical Group
Physician by new Members.
4.12 INSURANCE - At all times during the term of this Agreement,
PacifiCare shall maintain professional liability insurance and general liability
insurance in the minimum amount of ten million dollars ($10,000,000) per
occurrence for coverage of PacifiCare and its officers, agents and employees.
Such insurance coverage shall include coverage for participants in PacifiCare's
quality improvement and peer review committees for claims arising out of their
service on such committees. Upon request, PacifiCare shall provide to Medical
Group a certificate evidencing such coverage.
4.13 SERVICE PROVIDED BY PUBLICLY FUNDED AGENCIES - PacifiCare shall
enter into written agreements with publicly funded agencies to provide the
following Medical Services to OMAP Members: (i) immunizations, and (ii) the
diagnosis and treatment of sexually transmitted diseases and other communicable
diseases. Medical Group shall not be responsible for the authorization or
Referral of OMAP Members to receive the services described in this Section 4.13.
5. COMPENSATION
5.1 CAPITATION PAYMENTS - PacifiCare shall pay Capitation Payments to
Medical Group for (a) the PacifiCare Commercial Plan, excluding the PacifiCare
Point-of-Service Plan, at the rates and according to the procedures set forth in
Exhibit C1; (b) the Secure Horizons Health Plan at the rates and according to
the procedures set forth in Exhibit C2; and (c) the PacifiCare Medicaid Plan at
the rates and according to the procedures set forth in Exhibit C3. Compensation
for the PacifiCare Point-of-Service Plan Members shall be at the rates and
according to the procedures set forth in Exhibit H. Capitation Payments shall be
due and payable by PacifiCare to Medical Group by the tenth (10th) day of each
month for the current month's Covered Services based on the current Eligibility
List.
5.2 ADDITIONAL PAYMENTS UNDER PACIFICARE PROGRAMS - PacifiCare and
Medical Group shall make additional payments to each other, if any are due, in
accordance with the terms of the applicable PacifiCare programs set forth in
Section 3.20 of this Agreement and the sub-sections therein. To the extent that
each party owes an amount to the other party under any such risk programs,
Medical Group agrees that PacifiCare shall combine the payment of all applicable
risk programs such that one aggregate payment is payable to or receivable from
Medical Group. In addition, amounts owed to PacifiCare may be offset against
future Capitation Payments. A fully detailed accounting of the
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results of each of the risk programs shall accompany the aggregate payment or
notice of amount due.
5.3 COLLECTION OF COPAYMENTS - To the extent provided under the
PacifiCare Commercial Plan or Secure Horizons Health Plan, Medical Group may
collect any applicable Copayment directly from a Commercial Member or Secure
Horizons Member, respectively, at or following the time Covered Services are
rendered. Medical Group shall not collect Copayments from OMAP Members under any
circumstances.
5.4 CAPITATION ADJUSTMENTS
5.4.1 ADJUSTMENTS TO CAPITATION BASED UPON ELIGIBILITY - Subject
to Section 5.4.4, PacifiCare shall be entitled to reduce retroactively
Capitation Payments made with respect to any Member if the Member is determined
to have been ineligible for the month for which the Capitation Payments were
made.
5.4.2 ADJUSTMENTS TO CAPITATION BASED UPON RETROACTIVE HCFA OR
OMAP ADJUSTMENTS - PacifiCare shall be entitled to reduce retroactively
Capitation Payments made with respect to any Secure Horizons Member any time
HCFA reduces retroactively the Monthly HCFA Payment made to PacifiCare on behalf
of those Secure Horizons Members. PacifiCare shall be entitled to reduce
retroactively Capitation Payments made with respect to any OMAP Member any time
OMAP reduces retroactively the Monthly OMAP Payment made to PacifiCare on behalf
of those OMAP Members.
5.4.3 ADJUSTMENTS TO CAPITATION BASED UPON COMPUTER SYSTEM ERRORS
OR FOR OTHER REASONS - PacifiCare shall not be entitled to reduce retroactively
Capitation Payments for any reason other than as stated in Sections 5.4.1 and
5.4.2, except that PacifiCare shall be entitled to reduce retroactively
Capitation Payments made on account of computer system errors or other errors in
the calculation of the Capitation Payments to the extent and only to the extent
the reduction exceeds five percent (5%) of the Capitation Payments made during
the month the error occurred.
5.4.4 TIME LIMIT ON ADJUSTMENTS - No Capitation Payment shall be
reduced at a time more than six (6) months after the end of the month during
which the Capitation Payment was made, and no Capitation Payment shall be
reduced at a time more than three (3) months after the end of the calendar year
during which the Capitation Payment was made. This time limit shall not apply
to adjustments as described in Section 5.4.2.
5.4.5 UNDERPAYMENTS - PacifiCare shall pay Medical Group the
amount of any Capitation Payment underpayment, or any other underpayment, as
soon as it is discovered. If PacifiCare receives health plan premiums for a
Member before such Member designates or is assigned to a Primary Care Physician,
and Medical Group or a Medical Group Physician is thereafter designated or
assigned as the Member's Primary Care Physician, PacifiCare shall pay Medical
Group a Capitation Payment on account of such Member effective as of the date on
which health plan premiums were first paid on behalf of such Member.
5.4.6 INTEREST - PacifiCare shall pay Medical Group interest at
the ninety (90) day Treasury ▇▇▇▇ rate on any underpayment of an amount due
under this Agreement from the time the payment was due, provided that if the
payment is late on account of a computer system error or other error or on
account of a late eligibility determination, interest shall accrue from a time
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sixty (60) days after the due date. Medical Group shall pay PacifiCare interest
at the ninety (90) day Treasury ▇▇▇▇ on any adjustment under Sections 5.4.1
through 5.4.3 from a time sixty (60) days after the Capitation Payment was made.
5.4.7 PAYMENT TERMS - If any adjustment under Sections 5.4.1
through 5.4.3 exceeds twenty percent (20%) of Medical Group's Capitation
Payments for the month during which PacifiCare makes a written claim for
adjustment, Medical Group shall be entitled to have the amount of the adjustment
deducted from its Capitation Payments in three (3) equal amounts over a three
(3) month period.
5.4.8 DOCUMENTATION - PacifiCare shall furnish Medical Group
written documentation in support of Capitation Payments made under this
Agreement and any retroactive adjustments to Capitation Payments made under
Sections 5.4.1 through 5.4.3. Such documentation shall be in a form that will
allow Medical Group easily to reconcile it with standard reports otherwise
furnished by PacifiCare under this Agreement. Medical Group or its
representatives shall be entitled, at Medical Group's expense, to conduct
periodic audits of PacifiCare's calculation of Capitation Payments in order to
verify the accuracy of the calculations. In addition, upon Medical Group's
request, PacifiCare shall provide Medical Group with an annual accounting
accurately summarizing all of the financial transactions between the parties for
the contract year.
5.5 CHANGES IN ACCEPTED TREATMENT - In the event that one or more
recognized changes in commonly accepted standards of treatment followed by the
preponderance of the medical profession result in the aggregate in an increase
in the cost of Medical Services, Medical Group and PacifiCare shall equally
share such increase in cost during the term of this Agreement and any Continuing
Care Period thereafter. PacifiCare's Medical Director, in consultation with
Medical Group and the Quality Improvement Committee, shall initially determine
whether a recognized change in commonly accepted standards of treatment followed
by the preponderance of the medical profession has occurred and shall determine
treatment protocols to be followed by Medical Group. Medical Group may request
review of such determinations by PacifiCare pursuant to Section 9.5 or
arbitration pursuant to Section 9.7.
5.6 SPECIAL CONDITIONS FOR EMERGENCY SERVICES - If Medical Group directs
a Member to use the Emergency Services of a hospital and PacifiCare determines
that such direction was inappropriate, PacifiCare may issue a written
Conformance Request to Medical Group. The Conformance Request shall serve as
notice that all subsequent inappropriate referrals may have a penalty applied.
If Medical Group thereafter makes an inappropriate referral for Emergency
Services of a hospital, PacifiCare may deduct the professional component of the
PacifiCare payment from Medical Group's Capitation Payment as a penalty for
improper referral. Medical Group may request review of any determination by
PacifiCare pursuant to this section by the PacifiCare Quality Improvement
Committee.
5.7 OMAP HOLD HARMLESS PROVISION - When providing Covered Services to
OMAP Members, Medical Group agrees to hold harmless (a) the State of Oregon and
OMAP and (b) OMAP Members in the event PacifiCare fails or is unable to pay for
Covered Services provided or arranged by Medical Group pursuant to this
Agreement. Medical Group shall include the requirements set forth in this
Section 5.7 in each Medical Group Subcontract.
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5.8 COORDINATION OF BENEFITS - PacifiCare shall cooperate with and
support, as mutually agreed upon by the parties, Medical Group's coordination of
benefits rights consistent with the requirements of Sections 5.8.1 and 5.8.2
below.
5.8.1 PACIFICARE IS PRIMARY - If a Member possesses health benefits
coverage through another policy which is secondary to PacifiCare under
applicable coordination of benefits rules, including the Medicare secondary
payor program, Medical Group shall accept payment from PacifiCare for Covered
Services as provided herein as full payment for such Covered Services, except
for applicable Copayments. Member shall have no obligation for any Surcharge,
regardless of whether secondary insurance is available.
5.8.2 PACIFICARE IS SECONDARY - If a Member possesses health
benefits coverage through another policy which is primary to PacifiCare under
applicable coordination of benefits rules, including the Medicare secondary
payor program, or if Member is entitled to payment under a workers' compensation
policy, Medical Group may pursue payment from the primary payor or workers'
compensation carrier consistent with applicable state and federal law and
regulations and Medical Group's contract, if any, with the primary payor. In
such event, PacifiCare shall have no responsibility to Medical Group other than
payment of Capitation Payments.
5.9 COLLECTION OF CHARGES FROM THIRD PARTIES; SUBROGATION - PacifiCare
shall cooperate with and support, as mutually agreed upon by the parties,
Medical Group's right to collect from third parties or to pursue subrogation as
described in this Section. If Medical Group is entitled to payment from another
third party (excluding a workers' compensation carrier or primary insurance
carrier under applicable coordination of benefits rules), PacifiCare hereby
assigns to Medical Group for collection, any claims or demands against such
third parties for amounts due for Covered Services provided by Medical Group
pursuant to this Agreement, subject to the following conditions:
(a) To the extent liens are utilized, Medical Group shall utilize
lien forms approved in advance by PacifiCare. PacifiCare shall not unreasonably
withhold such approval.
(b) Medical Group shall provide a copy to PacifiCare upon
requesting a lien from a Member and shall provide notice to PacifiCare upon
initiation of a subrogation claim relating to Covered Services provided to a
Member. Medical Group shall notify PacifiCare each time it pursues and each time
it obtains a signed lien from a Member.
(c) Medical Group shall not commence any legal or equitable action
against a third party to collect charges as described in this section without
obtaining the prior written consent of PacifiCare. It is agreed that reasonable
collection or demand letters shall not constitute the commencement of legal or
equitable action. Under no circumstances shall Medical Group commence any legal
or equitable action against a Member to obtain payment for Covered Services.
(d) Medical Group shall defend, indemnify and hold PacifiCare
harmless for all actions by Medical Group pursuant to this section.
(e) PacifiCare may rescind such assignment in total or on a
claim-by-claim basis by providing written notice of rescission to Medical Group.
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6. TERM AND RENEWAL OF AGREEMENT
6.1 TERM - The initial term of this Agreement shall be twelve (12)
months commencing on January 1, 1996 (the "Commencement Date"), unless
terminated earlier as provided in Section 7 of this Agreement. The term of this
Agreement shall automatically renew for an additional twelve (12) month term on
each successive anniversary of the Commencement Date, unless terminated earlier
as provided in Section 7.
6.2 NEGOTIATION - Until renewal of the initial term and any subsequent
term, the rates of compensation specified in this Agreement shall apply unless
otherwise mutually agreed upon by the parties in writing. If adjustments to any
terms under negotiation cannot be agreed upon by the parties by the renewal
date, the existing terms shall remain in effect until replaced by a renewed
Agreement.
7. TERMINATION
7.1 TERMINATION OF AGREEMENT WITHOUT CAUSE - Either party may terminate
this Agreement without cause by providing termination notice to the other party
at least one hundred and twenty (120) days prior to the annual anniversary of
the commencement date of this Agreement.
7.2 TERMINATION BY MEDICAL GROUP FOR CAUSE - Medical Group shall have
the right to terminate this Agreement upon written notice to PacifiCare in the
following circumstances:
(a) REVOCATION OF LICENSE - Immediately upon revocation,
suspension, expiration or nonrenewal of PacifiCare's license as a health care
service contractor or any other license, certificate or legal authority required
to be maintained by PacifiCare in the State of Oregon in order to perform its
obligations under this Agreement.
(b) NON-PAYMENT - PacifiCare's failure to make Capitation or
any other payments due to Medical Group hereunder within thirty (30) days of
such payment's due date and subsequent failure to cure such non-payment
within thirty (30) days after receipt of written notice by PacifiCare of such
non-payment.
(c) BREACH OF MATERIAL TERM AND FAILURE TO CURE - PacifiCare's
breach of any material term, covenant or condition of this Agreement and
subsequent failure to cure such breach, if curable, within thirty (30) days
after receipt of written notice by PacifiCare from Medical Group of such breach.
The notice of termination shall contain specific reference to the breaches which
constitute cause for termination. If PacifiCare is unable to cure its breach
within the thirty (30) day curing period, the Agreement shall terminate thirty
(30) days after the expiration of the curing period. The remedy of such breach
within the thirty (30) day notice period shall continue this Agreement for the
remaining term, subject to any of the rights of termination contained in this or
any other provision of this Agreement.
(d) INSOLVENCY - Voluntary or involuntary institution of any
rehabilitation, receivership, liquidation, bankruptcy or insolvency action or
proceeding by or against PacifiCare shall immediately and automatically
terminate this Agreement as of the date on which such action or proceeding is
instituted, unless within thirty (30) days of such date, Medical Group gives
PacifiCare or its duly authorized receiver or representative notice of Medical
Group's waiver of this provision.
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7.3 TERMINATION BY PACIFICARE FOR CAUSE - PacifiCare shall have the
right to terminate this Agreement or the participation of any Medical Group
Physician immediately upon written notice to Medical Group in the following
circumstances:
(a) LOSS OF LICENSE - Immediately upon revocation, suspension or
termination of any license, certificate or other legal authority required to be
maintained by Medical Group or the applicable Medical Group Physician in the
State in order to perform the services required under this Agreement or failure
to obtain or renew such license, certificate or authority.
(b) DEFICIENCIES IN QUALITY OF CARE - Medical Group's, or any
Medical Group Physician's, failure to provide or arrange Covered Services to
Members in accordance with the quality of care standards set forth in this
Agreement as reasonably determined by the PacifiCare Quality Improvement
Committee, and subsequent failure to correct such deficiencies within thirty
(30) days after receipt of written notice by PacifiCare of such deficiencies.
The notice of termination shall contain specific reference to the quality of
care deficiencies that support the Quality Improvement Committee's finding and
that constitute cause for termination. PacifiCare reserves the right to
immediately withdraw from Medical Group, or any Medical Group Physician, any or
all the Members assigned to Medical Group or the applicable Medical Group
Physician if Covered Services are not being provided according to the standards
required by this Agreement and/or the health, safety or welfare of Members is
endangered by the continued provision of Covered Services by Medical Group or
the applicable Medical Group Physician, as reasonably determined by PacifiCare's
Quality Improvement Committee.
(c) BREACH OF MATERIAL TERM AND FAILURE TO CURE - Medical Group's,
or any Medical Group Physician's, breach of any material term, covenant or
condition of this Agreement and subsequent failure to cure such breach, if
curable, within thirty (30) days after receipt of notice by PacifiCare from
Medical Group of such breach.
(d) FINANCIAL FAILURE - PacifiCare's reasonable determination of
Medical Group's anticipated inability to provide or arrange for Medical Services
as described herein due to the likelihood of Medical Group's lack of financial
resources, other than due to PacifiCare's non-payment of amounts due to Medical
Group hereunder, as evidenced by Medical Group financial records or Medical
Group's repeated failure to pay valid outstanding debts. If Medical Group has
furnished Certified Financial Statements to PacifiCare, PacifiCare's
determination that Medical Group lacks adequate financial capacity shall be
based upon an analysis of such financial statements. Failure of Medical Group to
provide reasonable evidence and assurances of financial stability and capacity
to perform under this Agreement within fifteen (15) days after receipt of notice
of the determination from PacifiCare shall result in termination of this
Agreement at the end of the fifteen (15) day period.
7.4 TERMINATION OF HCFA AGREEMENT OR PARTICIPATION IN SECURE HORIZONS
HEALTH PLAN - The obligations of PacifiCare and Medical Group with respect to
the Secure Horizons Health Plan shall immediately terminate upon the termination
or nonrenewal of the HCFA Agreement. Such termination of obligations shall be
accomplished by delivery of written notice to Medical Group of the date upon
which termination shall become effective. Termination or nonrenewal of the HCFA
Agreement shall not otherwise affect the obligations of either party under this
Agreement. In addition, either PacifiCare or Medical Group may terminate Medical
Group's participation in the Secure Horizons Health Plan only and the portions
of this Agreement related to the
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Secure Horizons Health Plan only, without affecting the remainder of the
Agreement, by providing sixty (60) days prior written notice of such
termination. In the event of such termination, the Continuing Care Period set
forth in Section 3.6 shall apply for Secure Horizons Members only.
7.5 TERMINATION OF MEDICAID AGREEMENT OR PARTICIPATION IN PACIFICARE
MEDICAID PLAN - The obligations of PacifiCare and Medical Group with respect
to the PacifiCare Medicaid Plan shall immediately terminate upon the
termination or nonrenewal of the Medicaid Agreement with OMAP. Such termination
of obligations shall be accomplished by delivery of written notice to Medical
Group of the date upon which termination shall become effective. Termination or
nonrenewal of the Medicaid Agreement with OMAP shall not otherwise affect the
obligations of either party under this Agreement. In addition, either
PacifiCare or Medical Group may terminate Medical Group's participation in the
PacifiCare Medicaid Plan only and the portions of this Agreement related to
the PacifiCare Medicaid Plan only, without affecting the remainder of the
Agreement, by providing sixty (60) days' prior written notice of termination
to the other party. In the event of such termination, the Continuing Care
Period set forth in Section 3.6 shall apply for OMAP Members only.
7.6 NOTIFICATION OF OMAP OF AMENDMENT OR TERMINATION - PacifiCare shall
notify OMAP in the event of an amendment or termination of this Agreement.
Notice shall be given by letter deposited in the U.S. Postal Service as first
class postage prepaid registered mail addressed to the following:
Oregon Department of Human Resources,
Human Resources Building
Office of Medical Assistance Programs
▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇
▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
7.7 REPAYMENT UPON TERMINATION - Within one hundred eighty (180) days
after the termination of this Agreement and any Continuing Care Period as
provided in Section 3.6, an accounting shall be made by PacifiCare of monies due
and owing either party and payment shall be forthcoming to settle such balance
within thirty (30) days of such accounting. Either party may request an
independent audit of PacifiCare's accounting by a mutually acceptable
independent certified public accountant and such audit shall be paid for by the
requesting party. The parties agree to abide by the findings of such independent
audit. Appropriate payment by the appropriate party, if any, shall be made
within thirty (30) days of such independent audit.
7.8 TERMINATION NOT AN EXCLUSIVE REMEDY - Any termination by either
party pursuant to this Section 7 shall not be an exclusive remedy, and such
terminating party may seek whatever action in law or equity as may be necessary
to enforce its rights under this Agreement.
8. RECORDS, CONFIDENTIALITY. RIGHT TO INSPECT, ENCOUNTER DATA
8.1 MAINTENANCE OF RECORDS - PacifiCare, Medical Group and the Medical
Group Physicians shall maintain such records and information as reasonably
necessary for the proper administration and operation of the PacifiCare Health
Plans in accordance with state and federal law, as further specified in Sections
8.1.1 through 8.1.3 below. The obligations created by this Section 8.1 shall
survive termination of this Agreement without regard to the cause of
termination.
- 29 -
8.1.1 MEMBER MEDICAL RECORDS - Medical Group and the Medical Group
Physicians shall maintain Member medical records and related treatment
information in such form and containing such information as necessary to comply
with applicable state and federal law, including but not limited to, medical
histories, medical charts, records and reports from Specialist Physicians and
other Referral Providers, hospital discharge summaries, records of Emergency
Services and any other information necessary to disclose the quality,
appropriateness and timeliness of Covered Services provided to Members under
this Agreement. Medical Group shall make available to PacifiCare, upon
reasonable notice, such pertinent sections of Member medical records for the
purposes of conducting quality assurance and utilization review or for handling
and resolving Member grievances and appeals.
8.1.2 FINANCIAL RECORDS - Medical Group shall also maintain books of
account and records documenting all financial transactions and all direct and
indirect costs expended in the delivery of Covered Services to Members under
this Agreement, in such form and containing such information as required by
applicable state and federal law. Medical Group shall keep and maintain all
accounting books and financial records on a current basis in accordance with
general accepted accounting principles and standards for book and record
keeping.
8.1.3 RETENTION OF RECORDS - Medical Group and the Medical Group
Physicians shall retain all Member medical records, accounting books and
financial records for a period of at least three (3) years after final payment
is made under this Agreement and all pending matters are closed. In the event
that OMAP, HCFA, HHS or other authorized governmental regulatory agency
commences an audit, investigation, litigation or other action involving the
records of PacifiCare, Medical Group or the Medical Group Physicians before the
end of the three (3) year period, the records shall be retained until all issues
arising out of the audit, investigation, litigation or other action are resolved
or until the end of the three (3) year period.
8.1.4 COPYING CHARGES - Copies of records required by OMPRO will be
billed to PacifiCare at the OMPRO copy reimbursement rate of five cents
(5 cents) per page. Copies of records required for utilization management or
quality improvement review shall be at Medical Group's expense.
8.2 RIGHT TO INSPECT - Medical Group and the Medical Group Physicians
shall provide access at reasonable times upon demand to PacifiCare, the
D.C.B.S., HCFA, HHS, OMAP, the Comptroller General of the United States or any
authorized governmental agency, to inspect, evaluate or audit the facilities,
books and records of Medical Group and the Medical Group Physicians directly
relating to the performance of this Agreement and the Covered Services provided
to Members, including but not limited to, all phases of professional and
ancillary medical care provided to Members, Member medical records (subject to
the confidentiality restrictions set forth in Section 8.3 below), financial
records pertaining to the cost of operations and income received by Medical
Group for Covered Services rendered to Members and any other records or
information necessary to disclose the cost, performance, compliance, quality,
appropriateness and timeliness of Covered Services provided to Members under
this Agreement and the capacity of Medical Group to bear the risk of potential
financial losses. Such inspections or audits shall be conducted in accordance
with applicable federal and state law. Only Member medical records for the
period during which the Member is enrolled in a PacifiCare Health Plan shall be
subject to the inspection rights provided in this Section 8.2.
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The right of HCFA, HHS, the Comptroller General of the United States, OMAP
or the D.C.B.S. to inspect, evaluate and audit the facilities, books and records
of Medical Group shall extend through at least three (3) years after final
payment or settlement is made under this Agreement or any Medical Group
Subcontract and all pending matters are closed. If an audit, litigation or
other action involving the records is commenced by OMAP prior to the end of the
three (3) year period, the records shall be retained until all issues arising
out of the action are resolved or until the end of the three (3) year period,
whichever is later. Medical Group shall comply with any requirements or
directives issued by PacifiCare or governmental authorities as a result of any
such inspection, evaluation or audit. The obligations created by this Section
8.2 shall survive termination of the Agreement without regard to the cause of
termination of this Agreement.
8.3 CONFIDENTIALITY OF RECORDS - PacifiCare and Medical Group and the
Medical Group Physicians shall maintain the confidentiality of all Member
medical records and related treatment information in accordance with applicable
state and federal laws. To the extent required by law, PacifiCare and Medical
Group shall obtain a specific written authorization from Member prior to
releasing Member's medical records.
Subject to the requirement of 42 Code of Federal Regulations Part 431,
Subpart F, Medical Group and the Medical Group Physicians shall not use, release
or disclose any information concerning a Secure Horizons Member or OMAP Member
for any purpose not directly connected with the administration of PacifiCare's,
HCFA's or OMAP's responsibilities under this Agreement or under Title XIX of the
Social Security Act, except upon the written consent of the Secure Horizons
Member or OMAP Member or his or her attorney or legally responsible parent or
guardian. Medical Group and the Medical Group Physicians shall establish and
maintain procedures and safeguards to ensure that their officers, agents,
employees or subcontractors with access to Secure Horizons Member or OMAP Member
records understand and comply with this confidentiality provision.
8.4 ENCOUNTER DATA - Medical Group shall maintain and provide to
PacifiCare, on or about the fifteenth (15th) day of each month, the utilization
and other statistical data and reports pertaining to all Covered Services
provided to Members by Medical Group Physicians during the preceding month as
may be required by PacifiCare, HCFA, HHS or OMAP (the "Encounter Data"). Such
Encounter Data shall include, but is not limited to, a list of all Covered
Services provided to Members by Medical Group Physicians, data and reports
related to patient encounters by Medical Group Physicians, Referral activity,
laboratory and radiology utilization, utilization of Ancillary Services,
Emergency Services, maternity care and such other data or reports as are
specified by PacifiCare in the Provider Manual or required by HCFA, HHS or OMAP.
The frequency, format and medium of transmission of Encounter Data is described
in the Provider Manual. Medical Group shall be responsible for the costs of
submission of Encounter Data. No changes in the format or method of submission
of Encounter Data that result in increased cost to Medical Group, including
increased cost attributable to additional time of Medical Group staff, shall be
made without the consent of Medical Group.
8.5 FINANCIAL STATEMENTS - Medical Group shall provide to PacifiCare,
within forty-five (45) days after the close of each calendar quarter, copies of
its Certified Financial Statements. Medical Group shall also provide to
PacifiCare, within forty-five (45) days after the close of each fiscal year,
copies of its audited annual Certified Financial Statements. In addition,
Medical Group shall make its Certified Financial Statements available for
- 31 -
review, as required, by the D.C.B.S., HCFA, OMAP or any other governmental
agency with regulatory or enforcement jurisdiction over PacifiCare, Medical
Group or this Agreement.
8.6 TRANSFER OR COPYING OF RECORDS UPON TERMINATION - Upon termination
of this Agreement and the expiration of any Continuing Care Period as provided
in Section 3.6 herein, Medical Group shall copy the medical records of all
Members who have selected or been assigned to Medical Group and transfer or
forward such records to PacifiCare or the Participating Provider designated by
PacifiCare who shall be assuming the Member's care following termination, within
a reasonable time not to exceed thirty (30) days after request. The cost of
copying and transferring such Member medical records shall be shared equally by
Medical Group and PacifiCare.
9. GRIEVANCE AND APPEALS PROCEDURE AND DISPUTE RESOLUTION
9.1 MEMBER GRIEVANCES AND APPEALS - PacifiCare shall be responsible for
resolving Member claims for benefits under the applicable PacifiCare Health
Plans and all other claims against PacifiCare. PacifiCare shall resolve such
claims utilizing the grievance and appeals procedure set forth in the applicable
PacifiCare Health Plan. PacifiCare shall notify Medical Group of any grievance
involving a Medical Group Member.
Medical Group shall assist and cooperate with PacifiCare in the handling
of such Member grievances and appeals, consistent with the terms of the
PacifiCare grievance and appeals procedure. Medical Group will provide staffing
and systems for handling informal grievances brought before Medical Group
directly. In the event a written grievance is presented to Medical Group or an
oral grievance is presented and not resolved within fifteen (15) days, Medical
Group will send such grievance to PacifiCare within two (2) days for handling
pursuant to the applicable PacifiCare Health Plan grievance procedure.
9.2 MEMBER CLAIMS AGAINST MEDICAL GROUP OR MEDICAL GROUP PHYSICIANS -
Member claims against Medical Group or a Medical Group Physician for
professional negligence or malpractice are not governed by this Agreement.
Member and Medical Group may seek any appropriate legal action to resolve such
claims deemed necessary. Upon the agreement of the Member and Medical Group,
PacifiCare shall make available the applicable PacifiCare Health Plan grievance
procedure for resolution of such claims. The PacifiCare grievance and appeals
procedure shall not be binding, except upon prior agreement by the parties to
the dispute. All other claims or disputes between a Member and Medical Group
relating to Covered Services provided under this Agreement and claims for
benefits under the PacifiCare Health Plan in which the Member is enrolled shall
be resolved pursuant to the PacifiCare grievance and appeals procedure as
provided in Section 9.1.
9.3 PAYMENT DISPUTES INVOLVING MEDICAL GROUP AND REFERRAL PROVIDERS -
Should a dispute arise between Medical Group and a Referral Provider concerning
a claim for payment for Medical Services rendered to Members, Medical Group or
the Referral Provider may submit a written complaint to PacifiCare. PacifiCare
shall notify Medical Group of any complaint submitted by a Referral Provider,
and Medical Group shall have at least twenty (20) days from receipt of notice to
respond and present information. A determination shall be made by the PacifiCare
Claims Manager based on a review of the facts by appropriate personnel,
including PacifiCare's Medical Director. All such determinations shall be made
in accordance with the terms and conditions of any Medical Group Subcontract
between Medical Group and the Referral Provider.
- 32 -
If the Medical Group Subcontract provides for arbitration of disputes, Medical
Group or the Referral Provider may elect at any time to require resolution of
any dispute pursuant to such Medical Group Subcontract, in which event
PacifiCare shall have no further involvement in the matter.
In the event the PacifiCare Claims Manager determines that Medical Group
owes any amount to Referral Provider, Medical Group shall: (i) make such payment
within thirty (30) days of PacifiCare's determination; (ii) appeal the decision
to the Quality Improvement Committee; or (iii) require that the matter be
submitted to arbitration in accordance with any applicable arbitration provision
in the applicable Medical Group Subcontract. If, following an unappealed
decision adverse to Medical Group by the PacifiCare Claims Manager or by the
Quality Improvement Committee described in Section 9.6, Medical Group fails to
pay the amount due within thirty (30) days, PacifiCare may deduct the amount
owed from Medical Group's next monthly Capitation Payment and pay the Referral
Provider, unless the matter has been submitted to arbitration for resolution. If
the decision of the PacifiCare Claims Manager or the Quality Improvement
Committee described in Section 9.6 is adverse to the Referral Provider, notice
of the decision shall be given to Medical Group and the Referral Provider. The
Referral Provider shall not, under any circumstances, ▇▇▇▇ the Member for
Covered Services. In the event this Agreement has been terminated prior to
completion of the procedures set forth in this Section 9.3, and PacifiCare makes
payment to a Referral Provider in accordance with this Section 9.3, PacifiCare
may seek reimbursement from Medical Group through arbitration as described in
Section 9.7.
9.4 DENIED SERVICES - The procedures set forth in this Section 9.4 shall
apply whenever (i) a Member appeals a denial by Medical Group of the provision
of Medical Services or payment for Medical Services provided to Member on the
basis of a determination that such Medical Services are not Medically Necessary
or are experimental, or (ii) Medical Group appeals a denial by PacifiCare of
Medical Services provided to Members or payment for such services as not
Medically Necessary or as experimental.
9.4.1 INITIAL COMPLAINT - Upon receipt of notice of such an appeal,
PacifiCare shall promptly notify Medical Group and provide Medical Group with
copies of all information submitted by the Member. Within fourteen (14) days
after receipt of notice, Medical Group shall submit written or oral information
concerning the matter to PacifiCare's Medical Director or his or her qualified
designee. PacifiCare's Medical Director or designee shall consider all
information provided by Medical Group.
9.4.2 INITIAL DETERMINATION - PacifiCare's Medical Director or
designee shall make an initial determination, in accordance with the terms of
this Agreement, regarding whether the Medical Services in dispute are to be
provided to Member and whether payment for such Medical Services should be the
responsibility of: (i) Medical Group from Capitation Payments; (ii) PacifiCare,
with shared risk with Medical Group under the Hospital Control Program described
in Exhibit E1 through E3; or (iii) PacifiCare without shared risk with Medical
Group.
9.4.3 REVIEW OF INITIAL DETERMINATION - Medical Group may appeal the
decision of PacifiCare's Medical Director or designee to PacifiCare's Quality
Improvement Committee. Medical Group shall be given at least ten (10) days
notice of the date of the Quality Improvement Committee meeting at which the
matter will be considered. A representative of Medical Group may attend the
portion of the Quality Improvement Committee meeting addressing the matter, and
may present a statement to the committee. The decision of the
- 33 -
Quality Improvement Committee shall be final and binding on PacifiCare and
Medical Group.
9.4.4 OPPORTUNITY TO RESPOND - If at any time following submission
of an initial complaint, the Member submits additional information concerning
the matter, PacifiCare shall promptly notify Medical Group and provide Medical
Group copies of all such information. Medical Group shall be given a reasonable
opportunity to respond to any such additional information before any action is
taken thereon by PacifiCare.
9.5 REVIEW COMMITTEE
9.5.1 COMPOSITION - The PacifiCare Review Committee shall be
composed of two representatives of PacifiCare and two representatives chosen by
majority vote of PacifiCare's Participating Medical Groups. Two alternate
representatives shall be elected by majority vote by such Participating Medical
Groups to serve in the event either of the regular members is affiliated with a
Medical Group involved or interested in a matter to be considered by the Review
Committee or is otherwise unable to participate in review of a matter by the
Review Committee. One of the regular representatives and one alternate selected
by the Participating Medical Groups shall be physicians involved in some or all
of the tasks described in Section 3.11. One of the regular representatives and
one alternate so selected shall be administrators of such groups.
9.5.2 MATTERS SUBJECT TO REVIEW - The Review Committee may consider
the following matters upon request of either PacifiCare or Medical Group: (i)
transfers of Members to or from Medical Group; (ii) a Conformance Request based
on any matters other than clinical patient care concerns; (iii) issues submitted
regarding clarification of benefits; (iv) disputes submitted regarding changes
in practice standards; or (v) other matters with the consent of Medical Group
and PacifiCare.
9.5.3 PROCEDURE - The party seeking review shall provide written
notice to the other party and to each member of the Review Committee of the
matter to be reviewed. If a member of the Review Committee is affiliated with
Medical Group or is unable to participate, the similarly situated alternate
member shall serve. Within fourteen (14) days after the date of the notice, the
Review Committee shall meet in person or by conference call to review the
matter, except that a meeting involving review of a Member transfer shall be
held within seven (7) days after the date of the notice. Representatives of
Medical Group and PacifiCare may present information to the committee at such
meeting.
9.5.4 DECISION - At the conclusion of the meeting described in
9.5.3, the Review Committee shall decide the matter by majority vote and shall
promptly notify Medical Group and PacifiCare of the result. The decision of the
Review Committee shall be binding on both parties unless either party submits
the matter to arbitration pursuant to Section 9.7.
9.6 QUALITY IMPROVEMENT COMMITTEE - Either PacifiCare or Medical Group
may request that the PacifiCare Quality Improvement Committee review and make a
final decision regarding the following: (i) disputes referred to it pursuant to
Section 9.3, subject to the right of Medical Group or a Referral Provider to
require that such dispute be decided pursuant to any applicable arbitration
provision included in the applicable Medical Group Subcontract; (ii) questions
or disputes pertaining to the Medical Necessity of Covered Services; (iii) any
Conformance Request involving clinical patient care matters; or (iv) questions
- 34 -
or disputes relating to clarification of benefits. The party requesting review
shall do so by written notice to the Quality Improvement Committee and the other
party. Both parties shall be notified at least ten (10) days in advance of the
date and time of the meeting at which the Quality Improvement Committee will
consider the matter and shall have the opportunity to present information to the
Quality Improvement Committee at the meeting. The decision of the Quality
Improvement Committee shall be binding on both parties unless either party
submits the matter to arbitration pursuant to Section 9.7.
9.7 ARBITRATION - Any controversy, dispute or claim between PacifiCare
and Medical Group arising out of the interpretation, performance or breach of
this Agreement that has not been resolved pursuant to the dispute resolution
procedures otherwise provided for in this Agreement shall be resolved by binding
arbitration at the request of either party, in accordance with the rules of the
American Arbitration Association. Such arbitration shall occur in Portland,
Oregon, unless the parties mutually agree to have such proceeding in some other
locale. The arbitrators shall apply Oregon substantive law and federal
substantive law where state law is preempted. Civil discovery for use in such
arbitration may be conducted in accordance with the provisions of Oregon law,
and the arbitrator selected shall have the power to enforce the rights,
remedies, duties, liabilities, and obligations of discovery by the imposition of
the same terms, conditions and penalties as can be imposed in like circumstances
in a civil action by a court of competent jurisdiction in the State of Oregon.
The arbitrators shall have the power to grant all legal and equitable remedies
and award compensatory damages provided by Oregon law, except that punitive
damages shall not be awarded. The arbitrators shall prepare in writing and
provide to the parties an award including factual findings and the legal reasons
on which the decision is based. The arbitrators shall not have the power to
commit errors of law or legal reasoning, and the award may be vacated or
corrected pursuant to the term of Oregon law for any such error.
Notwithstanding the above, in the event either PacifiCare or Medical Group
wishes to obtain injunctive relief or a temporary restraining order, such party
may initiate an action for such relief in a court of law and the decision of
the court of law with respect to the injunctive relief or temporary restraining
order shall be subject to appeal only through the courts of law. The courts of
law shall not have the authority to review or grant any request or demand for
damages or declaratory relief.
10. NOTICE
Any notice required or permitted to be given by this Agreement shall be in
writing and may be delivered in person or sent by regular, registered or
certified mail or U.S. Postal Service Express mail, with postage prepaid, return
receipt requested, or by facsimile transmission, to either PacifiCare or Medical
Group at the addresses listed below, or at such other addresses as either
PacifiCare or Medical Group may hereafter designate to the other:
To PacifiCare: PacifiCare of Oregon
▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇
▇▇▇▇▇ ▇▇▇
▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
To Medical Group: The Corvallis Clinic, P.C.
▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇
▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
- 35 -
Any notice sent by registered or certified mail, return receipt requested, shall
be deemed given on the date of delivery shown on the receipt card, or, if no
delivery date is shown, the postmark date. If sent by regular mail, the notice
shall be deemed given forty-eight (48) hours after the notice is addressed and
mailed with postage prepaid. Notices delivered by U.S. Express mail or overnight
courier that guarantees next day delivery shall be deemed given twenty-four (24)
hours after delivery of the notice to the United States Postal Service or
courier. If any notice is transmitted by facsimile transmission or similar
means, the notice shall be deemed served or delivered upon telephone
confirmation of receipt of the transmission, provided a copy is also delivered
via delivery or mail.
11. CONFIDENTIALITY
11.1 INFORMATION CONFIDENTIAL AND PROPRIETARY TO PACIFICARE - Medical
Group agrees to maintain confidential all information designated in this Section
11.1 which is proprietary to PacifiCare and which is confidential and contains
trade secrets of PacifiCare. The information which Medical Group shall maintain
confidential (the "Confidential PacifiCare Information") consists of: (a)
Eligibility Lists and any other information containing the names, addresses and
telephone numbers of Members which has been compiled by PacifiCare; (b) lists or
documents compiled by PacifiCare which include the names, addresses and
telephone numbers of employers, employer groups and employees responsible for
health benefits and the officers and directors of such employer groups; (c)
PacifiCare's Member, employer, administrative service and provider policies and
procedures manuals and all forms related thereto; (d) PacifiCare Subscriber
Agreements and the information contained therein; (e) the financial arrangements
between PacifiCare and any PacifiCare Participating Provider; and (f) any other
information compiled or created by PacifiCare which is proprietary to PacifiCare
and which PacifiCare identifies as proprietary to Medical Group in writing.
Medical Group shall not disclose or use the Confidential PacifiCare
Information for its own benefit or gain either during the term of this Agreement
or after the Effective Date of Termination; provided, however, that Medical
Group may use the Confidential PacifiCare Information to the extent necessary to
perform its obligations under this Agreement or upon express prior written
permission of PacifiCare. Upon the Effective Date of Termination, Medical Group
shall provide and return to PacifiCare all Confidential Information in its
possession in a manner to be specified by PacifiCare. Medical Group shall
cooperate with PacifiCare in maintaining the confidentiality of such
Confidential PacifiCare Information at all times.
11.2 INFORMATION CONFIDENTIAL AND PROPRIETARY TO MEDICAL GROUP - Medical
Group shall provide PacifiCare with a written description of all information
proprietary to Medical Group which is confidential and contains trade secrets of
Medical Group (the "Confidential Medical Group Information"). PacifiCare shall
maintain Confidential Medical Group Information confidential. PacifiCare shall
not disclose or use any Confidential Medical Group Information for its own
benefit either during the term of this Agreement or after the Effective Date of
Termination, except as required by a court or governmental agency of competent
jurisdiction. Upon the Effective Date of Termination, PacifiCare shall provide
and return to Medical Group all Confidential Medical Group information in its
possession in a manner to be specified by Medical Group. PacifiCare shall
cooperate with Medical Group in maintaining the confidentiality of the
Confidential Medical Group Information at all times.
- 36 -
11.3 CONFIDENTIALITY OF THIS AGREEMENT - To the extent reasonably
possible, PacifiCare and Medical Group each agrees to maintain this Agreement as
a confidential document and to maintain the confidentiality of all terms
contained herein. PacifiCare and Medical Group each further agrees not disclose
the Agreement or any of its terms to a third party without the prior approval of
the other party, except where disclosure is required by law. Either party may
disclose this Agreement to professional advisors of such party. Medical Group
may disclose this Agreement to the Medical Group Physicians, provided such
Medical Group Physicians agree to maintain the confidentiality of this
Agreement.
12. MISCELLANEOUS PROVISIONS
12.1 PROTECTION OF MEMBERS - Medical Group shall not impose any
limitations on the acceptance of Members for care or treatment that it does not
impose on its other patients. Medical Group shall not seek, request or demand,
directly or indirectly, to have any Member's membership in the PacifiCare Health
Plan terminated or any Member transferred to another Participating Provider or
alternative health insurance plan because of such Member's need for, or
utilization of, Medically Necessary Covered Services. Medical Group shall not
refuse or fail to provide Medically Necessary Covered Services to any Member. If
any Medical Group Physician refuses or fails to provide Medically Necessary
Covered Services to any Member for any reason whatsoever, it shall remain the
responsibility of Medical Group to assure that such Member receives Medically
Necessary Covered Services from another Medical Group Physician, consistent with
the terms of this Agreement.
12.2 TRANSFER OF MEMBERS - Member generated transfers between
Participating Medical Groups and other Participating Providers shall be approved
by PacifiCare's Member Service Department at any time during the calendar year.
PacifiCare's Health Care Management Department may deny a Member transfer when
the transfer could potentially adversely affect or interrupt the Member's
required medical treatment plan. Transfer of a Member may be denied in the
following clinical situations, without limitation: (a) Member is hospitalized in
an acute or sub-acute facility; (b) Member is a transplant candidate; (c) Member
is a high-risk obstetrical patient; (d) Member is a third trimester obstetrical
patient; and (e) Member is receiving medical care, for an unstable, acute or
chronic medical condition.
PacifiCare's Health Care Management Department shall review all Member
transfer requests where continuity of patient care could be adversely affected
by the transfer. Medical Group may request the transfer or reassignment of a
Member assigned to Medical Group or a Medical Group Physician by PacifiCare to
another Primary Care Physician for cause or if the capacity of Medical Group is
overburdened to the extent that the provision of health care as required by this
Agreement is affected, provided that all provisions of this Agreement are met.
Upon request, PacifiCare shall allow Medical Group to withdraw from the care of
any Member when, in the reasonable professional judgment of a Medical Group
Physician, it is in the best interests of the Member to do so.
12.3 GOVERNING LAW - This Agreement and the rights and obligations of the
parties hereto shall be construed, interpreted and enforced in accordance with,
and governed by, the laws of the State of Oregon and applicable federal law and
the implementing regulations of the governmental agencies responsible for
enforcement of such laws, including but not limited to: the Oregon Health Care
Service Contractors Act, as amended, and the regulations promulgated
thereunder by the D.C.B.S.; the Health Maintenance Organization Act of 1973, as
amended, and the regulations promulgated thereunder by the HHS; Title XVIII
- 37 -
of the Social Security Act ("Medicare"), as amended, and the regulations
promulgated thereunder by HHS and HCFA; and Title XIX of the Social Security Act
("Medicaid"), as amended, and the regulations promulgated thereunder by HHS and
OMAP. Any and all provisions required to be included in this Agreement by any
applicable law or regulations shall bind PacifiCare and Medical Group whether or
not specifically provided herein.
Medical Group shall comply with all Oregon and federal laws and
regulations governing the participating providers of health care service
contractors and the Medicare and Medicaid programs. Medical Group shall also
comply with any and all requirements in the HCFA Agreement and the OMAP
Agreement that are applicable to Medical Group as a subcontractor of PacifiCare
as a result of this Agreement and that are required to be included in
subcontracts entered into by PacifiCare for the performance of services under
the HCFA Agreement and the OMAP Agreement, which applicable provisions shall be
incorporated into this Agreement by this reference. In the event HCFA or OMAP
shall amend the HCFA Agreement or the OMAP Agreement, respectively, requiring
additional provisions to be included in subcontracts, those provisions shall be
incorporated into this Agreement by this reference. Copies of the HCFA Agreement
and the OMAP Agreement shall be provided to Medical Group prior to execution of
this Agreement, and any amendments thereto shall be provided to Medical Group on
the effective date of such amendments or as soon as reasonably possible
thereafter.
12.4 AMENDMENTS OR MODIFICATIONS
12.4.1 AMENDMENTS TO AGREEMENT - PacifiCare may provide notice to
amend this Agreement, including any of the Exhibits attached to this Agreement
and incorporated by reference, by providing thirty (30) days prior written
notice to Medical Group as necessary to comply with an enactment, amendment,
change or interpretation of federal or state law or regulations governing this
Agreement and the parties hereto. Such amendment shall be binding
upon Medical Group except as provided in Section 12.4.4 below. Other
amendments shall be effective only upon the mutual written agreement of the
parties.
12.4.2 AMENDMENTS TO PACIFICARE HEALTH PLANS - PacifiCare may add
new benefit(s) or Covered Service(s) or otherwise amend any particular
PacifiCare Health Plan by providing Medical Group thirty (30) days prior written
notice of such amendment. Such amendment shall be binding upon Medical Group
except as provided in Section 12.4.4 below.
12.4.3 AMENDMENTS TO PROVIDER MANUAL - PacifiCare may provide
notice to amend the Delegated Section of the PacifiCare Provider Policies and
Procedures Manual and any other standards or procedures applicable to Medical
Group or its Medical Group Physicians by providing Medical Group thirty (30) day
prior written notice of such amendments. Such amendment shall be binding upon
Medical Group except as provided in Section 12.4.4 below. Amendments to the
Provider Manual shall be consistent with the terms of this Agreement.
12.4.4 MATERIAL AMENDMENTS - In the event PacifiCare provides
notice of amendment pursuant to Section 12.4.1, 12.4.2 or 12.4.3 above, Medical
Group shall be bound by such amendment unless (i) Medical Group provides
PacifiCare written notice of objection within the thirty (30) day notice period,
and (ii) such change affects a material right, duty or responsibility of Medical
Group, and (iii) such change has a material adverse economic effect upon Medical
Group as reasonably demonstrated by Medical Group to PacifiCare. In such event,
Medical Group and PacifiCare shall seek to agree to an amendment to this
Agreement which satisfactorily addresses the
- 38 -
effect on Medical Group's material duty or responsibility and reimburses the
material adverse economic effect caused to Medical Group. In such event, the
amendment shall not be effective until the parties amend the Agreement through a
written amendment signed by both parties.
12.4.5 REGULATORY APPROVAL - No modification or amendment of this
Agreement shall be effective until such proposed modification or amendment has
been approved or deemed approved by HCFA, HHS, OMAP or the D.C.B.S. if such
approval is required by applicable state or federal law or regulations. If such
regulatory approval is required, the proposed amendment or modification shall be
submitted to the regulating entity for prior approval at least thirty (30) days
before the proposed effective date or such other time period as is specifically
required by applicable state or federal law or regulation.
12.5 ASSIGNMENT - This Agreement and the rights, interests, obligations
or benefits hereunder shall not be assigned or transferred by either party and
shall not be subject to execution, attachment or similar process, nor shall the
duties imposed herein be subcontracted or delegated, without the prior written
approval of the other party. Neither PacifiCare nor Medical Group shall
unreasonably withhold consent to assignment. Notwithstanding the foregoing, but
subject to the terms and conditions set forth in this Section, either party may
assign or transfer this Agreement and its rights, interests, obligations and
benefits hereunder to any entity that has at least majority control of the party
or to any entity of which the party has at least majority control. In the event
the Medical Group assigns or transfers this Agreement to an entity that has at
least majority control of the Medical Group or to an entity of which the Medical
Group has at least majority control, if that entity has existing contracts with
PacifiCare, then the assignment and transfer shall not void or supersede the
contractual duty to service each Service Area, as that term is defined in any
PacifiCare contract, in accordance with the terms of the contract which would
have been applicable to the Service Area but for the assignment. In no event
shall any contract be assigned to any entity which does not assume or which
lacks financial capacity to service the financial obligations of the assigning
party to the other party, and any such assignment shall be void.
12.6 SOLICITATION OF PACIFICARE MEMBERS OR EMPLOYER GROUPS - Medical
Group and the Medical Group Physicians shall not directly or indirectly solicit
the patronage of PacifiCare's current Members or current Subscriber Groups
without PacifiCare's prior written consent. Solicitation shall include any
conduct, during the term of this Agreement and continuing for a period of one
(1) year after the effective date of termination of this Agreement, designed to
persuade Members or Subscriber Groups to discontinue their Subscriber Agreements
with PacifiCare or to encourage Members or Subscriber Groups to participate in a
health maintenance organization or other health care service plan offered by
Medical Group or its Medical Group Physicians. PacifiCare shall not consider the
following to be solicitation by Medical Group or the Medical Group Physicians:
(a) a request initiated and made directly by a Member or
Subscriber Group to Medical Group or a Medical Group Physician to recommend a
health care plan, any recommendations or discussions of any type by Medical
Group or a Medical Group Physician in response to that request, or any
negotiation or agreement between such Member or Subscriber Group and Medical
Group resulting from that request or such recommendations or discussions;
(b) a Member or Subscriber Group informing Medical Group of its
decision to terminate membership with PacifiCare and requesting from Medical
- 39 -
Group or Medical Group Physicians advice on available health care plans,
advice of any type given by Medical Group or its Medical Group Physicians in
response to that request or any negotiation or agreement between such Member
or Subscriber Group and Medical Group resulting from that advice;
(c) solicitation of PacifiCare's current Members or current
Subscriber Groups by a health maintenance organization or other health care
service plan with which Medical Group participates;
(d) a notice to patients from Medical Group that it and its
Medical Group Physicians no longer participate in a PacifiCare Health Plan,
which notice may list or describe those health maintenance organizations or
other health care service plans with which Medical Group participates; or
(e) general advertising or solicitation not directed to specific
Members or Subscriber Groups.
Medical Group shall not use any Member or PacifiCare Subscriber Group
information for its own benefit or to gain advantage over any Member or
PacifiCare Subscriber Group during the term of this Agreement or for a period of
six (6) months after the effective date of termination of this Agreement. The
breach of this section during the term of this Agreement shall be grounds for
termination of this Agreement pursuant to Section 7.2 of this Agreement.
12.7 SOLICITATION OF MEDICAL GROUP PERSONNEL - During the term of this
Agreement and for a period of one (1) year after the effective date of
termination of this Agreement, PacifiCare shall not directly or indirectly
solicit physicians or other health care providers who are partners, shareholders
or employees of or under contract with Medical Group to leave Medical Group or
accept employment other than with Medical Group. General advertising concerning
employment opportunities shall not be considered direct or indirect solicitation
for purposes of this Section 12.7.
12.8 INCORPORATION OF PROVIDER MANUAL AND EXHIBITS - The Delegated
Sections of the Provider Manual and all exhibits attached to this Agreement
are an integral part of this Agreement and are hereby incorporated into this
Agreement by this reference.
12.9 ENTIRE AGREEMENT - This Agreement, including the Delegation Section
of the Provider Manual and the exhibits attached hereto and incorporated herein
by reference, contains all the terms and conditions between Medical Group and
PacifiCare and supersedes all other agreements, oral or otherwise, between
Medical Group and PacifiCare concerning the subject matter of this Agreement.
12.10 OTHER AGREEMENTS - Nothing in this Agreement shall prevent
PacifiCare and Medical Group from contracting with each other for provision of
services not covered by this Agreement.
12.11 PROVISIONS SEPARABLE - The invalidity or non-enforceability of any
term or provision of this Agreement shall in no way affect the validity or
enforceability of any other term or provision of this Agreement.
12.12 WAIVER OF BREACH - The waiver by either party of a breach or
violation of any provision of this Agreement shall not operate as or be
construed to be a waiver of any subsequent breach thereof.
- 40 -
12.13 NO THIRD PARTY BENEFICIARY - Except as otherwise provided in this
Agreement, this Agreement is not intended to, nor shall be deemed, construed or
interpreted to, create any rights or remedies in any third party, including a
Member.
12.14 BINDING ON SUCCESSORS - This Agreement shall be binding upon, and
inure to the benefit of, the parties and their respective executors,
administrators, personal representatives, heirs, successors and permitted
assigns.
12.15 INTERPRETATION - In the event any claim is made by either party
relating to any conflict, omission or ambiguity in this Agreement, no
presumption or burden of proof or persuasion shall be implied by virtue of the
fact that this Agreement was prepared by or at the request of any particular
party or such party's legal counsel.
12.16 ATTORNEYS' FEES AND COSTS -- If any action at law or suit in equity
or arbitration is brought to enforce or interpret the terms of this Agreement or
to collect any monies due hereunder, the prevailing party shall be entitled to
reasonable attorneys' fees and reasonable costs, together with interest thereon
at the highest rate provided by law, in addition to any and all other relief to
which it may otherwise be entitled.
12.17 HEADINGS - The headings of the various sections of this Agreement
are inserted for the purpose of convenience and description only and do not
expressly, or by implication, limit or define or extend the specific terms of
the section so designated.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as
dated below.
PACIFICARE OF OREGON, INC. THE CORVALLIS CLINIC, P.C.
By: /s/ ▇▇▇▇ ▇. ▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
--------------------------- -----------------------------
▇▇▇▇ ▇. ▇▇▇▇▇▇ Name: ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
Contract Administrator ----------------------------
(Please Print)
Date: 6/21/96 Date: 7-8-96
-------------------------- -------------------------
Tax I.D. # ▇▇-▇▇▇▇▇▇▇
-41-
PACIFICARE OF OREGON, INC.
SCHEDULE OF EXHIBITS
MEDICAL GROUP SERVICES AGREEMENT
A Covered Services
A1 PacifiCare Commercial Health Plan
A2 Secure Horizons Health Plan
A3 PacifiCare Medicaid Plan
B Benefits Matrix
B1 PacifiCare Commercial Health Plan
B2 Secure Horizons Health Plan
B3 PacifiCare Medicaid Plan
C Capitation Payments
C1 PacifiCare Commercial Health Plan
C2 Secure Horizons Health Plan
C3 PacifiCare Medicaid Plan
D Individual Stop-Loss Program
D1 PacifiCare Commercial Health Plan
D2 Secure Horizons Health Plan
D3 PacifiCare Medicaid Plan
E Hospital Control Program
E1 PacifiCare Commercial Health Plan
E2 Secure Horizons Health Plan
F Prescription Services Program
F1 PacifiCare Commercial Health Plan
F2 PacifiCare Medicaid Plan
G PacifiCare Point-of-Service Plan
G1 Point of Service Capitated Program
G2 Point of Service Hospital Control Program
H Delegation of Credentialing, Recredentialing and Peer Review
I Delegation of Quality Improvement
J Delegation of Utilization Management and Review
K Delegation of Claims Payment
L Medical Group Service Area
M Access Guidelines
- 42 -
EXHIBIT A1
COVERED SERVICES
PACIFICARE COMMERCIAL HEALTH PLAN
I. HOSPITAL SERVICES
A. COVERED SERVICES - Hospital Services are authorized by Medical Group
and are the financial responsibility of Participating Hospital. A summary of the
Hospital Services which are Covered Services includes the following:
1. INPATIENT HOSPITAL CARE - Commercial Member shall be assigned
semi-private units, unless medical necessity dictates private accommodations.
Where the Commercial Member requests private accommodations, not required for
medical purposes, the incremental difference in fee-for-services rates shall be
the responsibility of the Commercial Member. A summary of inpatient care
includes:
(a) Medical/surgical care, intensive care, cardiac care and
other special care units;
(b) Nursing services, meals, drugs, medications, blood
transfusions;
(c) Medical and surgical supplies and appliances;
(d) Inpatient rehabilitation services, such as: physical,
occupational and speech therapy.
2. SKILLED NURSING FACILITY CARE - Commercial Members shall be
assigned semi-private units, unless medical necessity dictates private
accommodations. Where the Commercial Member requests private accommodations,
not required for medical purposes, the incremental difference in the fee-for-
services rates shall be the responsibility of the Member. Skilled nursing
facilities must be Medicare licensed and approved.
3. HOSPITAL-BASED PHYSICIAN SERVICES - Professional component of
hospital-based physician service for either an inpatient hospital-based
service or an outpatient service, including outpatient surgery, provided
either in a hospital outpatient department or an ambulatory surgical center,
except for the charges of an anesthesiologist.
4. TRANSPORTATION EXPENSES - Approved ambulance services
provided within the Medical Group Service Area for Members. Where transfer of
Commercial Member from one facility to another is authorized by Medical Group or
PacifiCare, the cost of such transfer shall be a Hospital Service. The method
of transfer shall be determined by Medical Group, but Medical Group shall
coordinate all Member transfers to or from Participating Hospital with Hospital
personnel. Also included are paramedic services provided as Emergency
Services or Urgently Needed Services in the Medical Group Service Area.
5. EMERGENCY SERVICES IN THE SERVICE AREA - Emergency services
include emergency room charges and associated emergency room physician and
ancillary charges, inpatient medical and other services provided by an
appropriate source, that may NOT be delayed until facilities or physicians of
the Participating Hospital or Medical Group can be used without possible
serious effects to the health of the Commercial Member. Such services
must appear to be needed immediately to prevent the death of the Commercial
Member or serious impairment of his or her health, and are considered
Emergency Services as long as the transfer of the Member to the Hospital or
Medical
- 43 -
Group is precluded because of the risk to the Member's health or the distance
and nature of illness involved would make such transfer unreasonable.
6. HOME HEALTH AND HOSPICE CARE (INCLUDING HOME IV THERAPY) - As
defined by Medicare as a minimum; however, additional home health care may be
provided as a covered benefit in lieu of hospitalization, as mutually agreed
to by Medical Group and Hospital.
7. OUTPATIENT SURGERY - Facility charges, supply charges and the
professional component of hospital-based physician services (E.G., laboratory
or radiology services), normally included in the charge for inpatient
procedures, for outpatient surgery provided at the hospital or an ambulatory
surgical center, except for the charges of an anesthesiologist.
8. OTHER HOSPITAL SERVICES:
(a) Devices surgically implanted (including lenses implanted
during cataract surgery) during a hospital confinement or during outpatient
surgery performed at the Hospital outpatient surgery department or an
ambulatory surgical center.
(b) Appealed Services - Hospital Services denied by Medical
Group and PacifiCare that are found on appeal or arbitration through the Member
grievance resolution process to be Hospital Services that Member was entitled
to have furnished under the PacifiCare Health Plan.
(c) Chemotherapy drugs.
B. EXCLUDED SERVICES - Hospital Services excludes the following:
1. Durable Medical Equipment (except as provided in A(1)(c) and
A(8)(a) above);
2. Medical Services in the Service Area as defined in Section II of
this Exhibit A1.
3. Outpatient prescription drugs
4. Vision materials (lenses and frames or contact lenses), except
lenses surgically implanted during cataract surgery during outpatient surgery
at a Hospital outpatient department or an ambulatory surgical center.
5. Emergent out-of-area hospital services.
6. Denied services.
7. Behavioral health services.
II. MEDICAL SERVICES
A. COVERED SERVICES - Medical Services provided in the Medical Group
Service Area are the financial responsibility of Medical Group. A summary of the
Medical Services include the following:
1. PHYSICIAN SERVICES - Commercial Members shall be entitled to
Medically Necessary inpatient and outpatient physician services included in
PacifiCare Health Plan. A summary of some physician services include the
following:
- 44 -
(a) In-area inpatient and outpatient physician services
(including anesthesiology services)
(b) Outside Referrals to consultants, including
consultations performed by physicians in the emergency room
2. OUTPATIENT SERVICES - Such services include, among others:
(a) Professional component of outpatient services,
including outpatient surgery, except for the professional component of
hospital-based physician services for outpatient services, including surgery not
normally included in the charge for inpatient procedures, for such services
provided at a hospital outpatient department or an ambulatory surgical center,
including charges for an anesthesiologist.
(b) Short term, Medically Necessary rehabilitation
(speech, physical and occupational) therapy.
(c) Health education and social services.
(d) Immunizations.
(e) Periodic health evaluations.
(f) Hearing screening, including audiogram.
(g) Allergy testing and treatment, including allergy serum.
3. DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES AND MEDICAL
SUPPLIES
(a) Durable Medical Equipment (DME). On an outpatient basis,
when determined to be Medically Necessary.
(b) Prosthetic devices, except devices surgically implanted
during a Hospital confinement, or during outpatient surgery performed at a
hospital outpatient department or an ambulatory surgical center.
(c) Medical Supplies - Supplies used in connection with
treatment or to aid in the recovery of a medical condition.
4. OTHER SERVICES - Medical Services denied by Medical Group and
PacifiCare that are found on appeal or arbitration through the Member grievance
resolution process to be Medical Services that Member was entitled to have
furnished under the PacifiCare Health Plan.
B. EXCLUDED SERVICES - Medical Services exclude the following:
1. Professional component of hospital-based physician services
normally included in the Hospital's charge for inpatient procedures (except for
anesthesiology), for inpatient procedures and outpatient services, including
surgery, performed at Hospital or an ambulatory surgical center.
2. All other services included as a Hospital Service in Section I
of this Exhibit A1.
3. Outpatient prescription drugs.
4. Vision materials (lenses and frames or contact lenses), except
vision material following cataract surgery.
5. Chemotherapy drugs.
6. Emergent out-of-area professional services.
- 45 -
7. Refractions (provided through PacifiCare's Vision Care Plan).
8. Denied services.
9. Behavioral health services.
- 46 -
EXHIBIT A2
COVERED SERVICES
SECURE HORIZONS HEALTH PLAN
I. HOSPITAL SERVICES
Hospital Services are the financial responsibility of Hospital. A summary
of the services includes the following:
1. INPATIENT HOSPITAL CARE - Inpatient hospital care. Member shall be
assigned semi-private units, unless medical necessity dictates private
accommodations. Where the Member requests private accommodations, not required
for medical purposes, the incremental difference in fee-for-services in rates
shall be the responsibility of the Member. A summary of inpatient care includes:
(a) Medical/Surgical Care, Intensive Care, Cardiac Care and other
special care units;
(b) Nursing Services, meals, drugs, medications, blood transfusions;
(c) Medical and Surgical supplies and appliances;
(d) Rehabilitation services, such as: physical, occupational and
speech therapy;
2. SKILLED NURSING - Skilled nursing facility care. Patients shall be
assigned semi-private units, unless medical necessity dictates private
accommodations. Where the Member requests private accommodations, not required
for medical purposes, the incremental difference in the fee-for-services rates
shall be the responsibility of the Member. Skilled nursing facilities must be
Medicare licensed and approved.
3. HOSPITAL-BASED PHYSICIAN SERVICES - Professional component of
hospital-based physician service for either an inpatient hospital-based service
or an outpatient service, including outpatient surgery, provided either in a
hospital outpatient department or an ambulatory surgical center, except for the
charges of an anesthesiologist.
4. TRANSPORTATION EXPENSES - Approved Ambulance services for Members.
Where transfer of Member from one facility to another is authorized by Medical
Group or PacifiCare, the cost of such transfer shall be a Hospital Service. The
method of transfer shall be determined by Medical Group, but Medical Group shall
coordinate all Member transfers to or from Hospital with Hospital personnel.
Also included are paramedic services provided as Emergency Services or Urgently
Needed Services.
5. EMERGENCY SERVICES IN THE SERVICE AREA - Emergency services include
emergency room charges and associated emergency room physician and ancillary
charges, inpatient medical and other services provided by an appropriate source,
that may not be delayed until facilities or physicians of the Hospital or
Medical Group (or alternatives authorized by Medical Group) can be used without
possible serious effects to the health of the Member. Such services must appear
to be needed immediately to prevent the death of the Member or serious
impairment of his health, and are considered emergency services as long as the
transfer of the Member to the Hospital or Medical Group is precluded because of
the risk to the Member's health or the distance and nature of illness involved
would make such transfer unreasonable.
- 47 -
6. HOME HEALTH AND HOSPICE CARE (INCLUDING HOME IV THERAPY) -
As defined by Medicare as a minimum; however, additional Home Health Care may be
provided as a covered benefit in lieu of hospitalization, as mutually agreed to
by Medical Group and Hospital.
7. OUTPATIENT SURGERY - Facility charges, supply charges and the
professional component of hospital based physician services (e.g., laboratory or
radiology services), normally included in the charge for inpatient procedures,
for outpatient surgery provided at the hospital or an ambulatory surgical
center, except for the charges of an anesthesiologist.
8. OTHER HOSPITAL SERVICES:
(a) Devices surgically implanted (including lenses implanted during
cataract surgery) during a hospital confinement, during outpatient surgery at a
Hospital Outpatient department or an ambulatory surgical center.
(b) Appealed Services - Hospital services denied by Participating
Medical Group and PacifiCare that are found on appeal or arbitration through the
Member grievance resolution process to be Hospital Services that Member was
entitled to have furnished through the PacifiCare Health Care Delivery system.
(c) Chemotherapy drugs.
9. HOSPITAL SERVICES EXCLUDE THE FOLLOWING:
(a) Durable Medical Equipment (except as provided in Section 8
above);
(b) Medical Services in the Service Area as defined by Exhibit L;
(c) Outpatient prescription drugs
(d) Vision materials (lenses and frames or contact lenses), except
lenses surgically implanted during cataract surgery during outpatient
surgery at a Hospital outpatient department or an ambulatory surgical center.
(e) Emergent out-of-area hospital services.
(f) Denied services
II. MEDICAL SERVICES
Medical Services provided in the service area are the financial responsibility
of the Medical Group. A summary of the services include the following:
1. PHYSICIAN SERVICES - Members shall be entitled to Medically Necessary
Medicare covered inpatient and outpatient physician services included in
PacifiCare's Secure Horizons, Medical and Hospital Plan. A summary of physician
services include the following:
(a) In-area inpatient and outpatient physician care including
anesthesiologist;
(b) Outside referrals to consultants including ER consultations
2. OUTPATIENT SERVICE - Such services include, among others:
(a) Professional component of outpatient services, including
outpatient surgery, except for the professional component of hospital based
physician services for outpatient services, including surgery not normally
included in the charge for inpatient procedures, for such services provided at
- 48 -
a hospital outpatient department or an ambulatory surgical center, including
charges for an anesthesiologist.
(b) Short term, Medically Necessary rehabilitation (speech, physical
and occupational) therapy
(c) Health Education and Social Services
(d) Immunizations
(e) Periodic health evaluations
(f) Hearing Screening, including Audiogram
(g) Allergy testing and treatment, including allergy serum
3. DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES AND MEDICAL SUPPLIES
(a) Durable Medical Equipment (DME). Medical Group agrees to provide
such devices and aids on an outpatient basis, determined Medically Necessary.
(b) Prosthetic devices except devices surgically implanted during a
Hospital confinement, or during outpatient surgery performed at a hospital
outpatient department or an ambulatory surgical center.
(c) Medical Supplies - Supplies used in connection with treatment or
to aid in the recovery of a medical condition.
4. OTHER SERVICES - Medical Services denied by participating Primary Care
Physician (Medical Group) and PacifiCare that are found on appeal or
arbitration through the Member grievance resolution process to be Medical
Services that subscriber was entitled to have furnished through the PacifiCare
Secure Horizons health care delivery system.
5. MEDICAL SERVICES EXCLUDE THE FOLLOWING:
(a) Professional component of Hospital Based Physician services
normally included in the Hospital's charge for inpatient procedures (except for
anesthesiology), for inpatient procedures and outpatient services, including
surgery, performed at Hospital or an ambulatory surgical center
(b) All other services included as a Hospital Service in Exhibit A;
(c) Outpatient prescription drugs;
(d) Vision materials (lenses and frames or contact lenses),
except vision material following cataract surgery;
(e) Chemotherapy drugs;
(f) Emergent out-of-area professional services;
(g) Refractions (provided through PacifiCare's Vision Care Plan);
(h) Denied services;
(i) Outpatient mental health visits in excess of twenty (20) visits
per Member per year.
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EXHIBIT A3
COVERED SERVICES
PACIFICARE MEDICAID PLAN
MEDICAL AND HOSPITAL BENEFITS FOR OMAP MEMBERS:
OMAP Members are entitled to the Medical and Hospital Services and other
benefits set forth in this Exhibit A3.
A. SERVICE AREA: Linn and ▇▇▇▇▇▇ Counties. In order to be eligible to
receive benefits under the PacifiCare Medicaid Plan, OMAP Members and enrolled
dependents must reside in the Service Area.
B. PROVIDER SYSTEM
(1) PRIMARY CARE PHYSICIAN
To receive Covered Services under this Agreement, each OMAP Member must
select or be assigned to a Primary Care Physician.
Referral by the Primary Care Physician is required for obstetrical-
gynecological and routine women's examinations. The only exception to the PCP
referral requirement is for therapeutic abortion ("TAB"). In the case of TAB,
the OMAP Member may self refer to a Participating Provider.
All Referral care must be preauthorized unless care is received due to a
medical emergency. All Referrals to Non-Participating Providers must be
preauthorized in writing in advance of treatment.
(2) NON-PARTICIPATING PROVIDER CARE
Referral to a Non-Participating Provider requires prior authorization
by OMAP Member's Primary Care Physician. PacifiCare will work with the Primary
Care Physician to assure use of Participating Providers whenever possible.
(3) HOSPITALIZATION
Should OMAP Member's Primary Care Physician or other Participating
Provider determine that an OMAP Member needs to be hospitalized, arrangements
will be made for the OMAP Member to be admitted in a Participating Hospital.
PacifiCare's Medical Director will review elective admissions or non-elective
Emergency hospitalization and will work with the Primary Care Physician to
assure that his or her treatment plan avoids unnecessary time in the hospital.
(4) CASE MANAGEMENT
PacifiCare has entered into case management agreements with certain medical
centers and specialized treatment programs to handle severe health problems that
necessitate services such as transplantation, neonatal care, open heart surgery,
neuromuscular treatment and spinal cord injury care.
(5) ALTERNATIVE SERVICES
PacifiCare shall have the right to pay benefits for alternative services
not otherwise covered by the PacifiCare Medicaid Plan if the following three
conditions are met:
- 50 -
/ / alternative services are medically appropriate;
/ / major continuing claims expense is anticipated; and
/ / the Primary Care Physician and the PacifiCare's Medical Director
approve the use of alternative services.
Payment of benefits for alternative services shall be at PacifiCare's sole
discretion based on PacifiCare's evaluation of the individual case. The fact
that PacifiCare has paid benefits for alternative services for an OMAP Member
shall not obligate PacifiCare to pay such benefits for any other OMAP Member,
nor shall it obligate the payment of benefits for continued or additional
alternative services for the same OMAP Member. All amounts PacifiCare pays for
alternative services under this provision shall be considered Covered Services
for all purposes of this Agreement.
(6) EMERGENCY SERVICES
PacifiCare covers Emergency Services when provided or arranged by the
Primary Care Physician. In a MEDICAL EMERGENCY ONLY, as used hereinafter and
defined as "Emergency Services" in Section 1 of this Agreement, PacifiCare will
cover Emergency Services provided by the nearest appropriate facility even
though it may not be a Participating Facility. The procedures an OMAP Member
must follow in an Emergency situation are fully explained in the OMAP Member
Handbook.
C. DESCRIPTION OF COVERED SERVICES OR BENEFITS
All capitated services, supplies and equipment under this Agreement must be
rendered by a Participating Provider in order to be covered, except in the case
of Emergency Services or preauthorized Referral to a Non-Participating Provider.
However, certain services must also be authorized by PacifiCare even when such
care is provided or approved by a Primary Care Physician. The following
benefit description discusses the Covered Services, benefit maximums, benefit
limitations, exclusions from coverage, and conditions of service that apply to
the coverage provided under the PacifiCare Medicaid Plan.
If proper authorization is not obtained prior to receiving Medical
Services from other Participating Providers or Non-Participating Providers,
PacifiCare will deny those claims and the OMAP Member may be responsible for
charges incurred.
D. MEDICAL SERVICES (PHYSICIAN SERVICES)
Medical Services providing by a Participating Physician are covered as
explained in the following paragraphs:
(1) PREVENTIVE HEALTH CARE
PacifiCare covers the following Preventive Health Care benefits provided
through the OMAP Member's Primary Care Physician:
Periodic Health Exams: PacifiCare covers periodic health exams and EPSDT
(Early Prevention Screening, Detection and Treatment) according to the
following schedule:
- 51 -
Infancy: Routine newborn care in the nursery plus six EPSDT schedule
screenings to a Primary Care Physician's office during the first year of life.
Children
Age 1: (Two office calls during the year). (EPSDT at 15 and 18
months of age.)
Children:
Age 2-6: One exam every year.
(EPSDT at 2, 3, 4, 5 and 6 years of age.)
Age 7-20: One exam every two years.
(EPSDT at 8, 10, 12, 14, 16, 18 and 20 years of age.)
Adults:
Age 21-34: One exam every four years.
Age 35 and above: One exam every two years.
NOTE: Adult periodic health exams are calculated according to age from the
previous date of service.
Eye and hearing screenings to determine the need for vision or hearing
correction are covered for children through age twenty (20) according to the
EPSDT schedule. Both eye and hearing must be provided by the child's Primary
Care Physician.
(2) EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDI).
PacifiCare will provide health screening on a regularly scheduled basis for any
enrollee under twenty-one (21) years of age -- screening, diagnosis and
treatment will be carried out as provided in OMAP's guide for Medical-Surgical
Services. Records will be kept in the patient's record.
EPSDT screening will consist of at least:
1. Health and Developmental History,
2. Unclothed physical exam,
3. Developmental assessment,
4. Immunizations appropriate for age and health history,
5. Assessment of nutritional status,
6. Vision testing,
7. Hearing testing,
8. Laboratory procedures appropriate for age and population groups,
9. For children 18 months of age and over, referral to a dentist for
diagnosis and treatment.
Routine women's exams, including Pap smears, are covered once every
calendar year. Routine mammographic breast screening will be covered
according to the schedule endorsed by the American College of Obstetricians
and Gynecologists. Routine mammograms obtained more frequently than the schedule
will not be covered.
(3) IMMUNIZATIONS: PacifiCare covers immunizations, such as polio,
measles, rubella, whooping cough, hemophilus B (HIB), diphtheria, tetanus, and
mumps for both adults and children. Immunizations for the sole purpose of
travel are not covered.
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(4) FAMILY PLANNING AND INFERTILITY: Including Family Planning
counseling, information on birth control, insertion of IUD, vasectomy
and tubal ligation, are provided by Participating Physicians. Contraceptive
devices and contraceptive drugs are not covered.
All Medical Services for diagnosis and treatment of involuntary
infertility are not covered. X-ray, laboratory, and medications provided in
conjunction with infertility studies are not covered.
OMAP Members are not restricted to PacifiCare for family planning
services. PacifiCare is not responsible for family planning services unless
provided or referred by PacifiCare.
Admission to the hospital or outpatient surgical center for family
planning services must be preauthorized by the admitting Participating
Physician if provided by PacifiCare.
(5) NUTRITIONAL COUNSELING: Is covered, as Medically Necessary.
(6) DIABETES SELF-MANAGEMENT EDUCATION PROGRAMS: These programs are
covered when conducted by a Participating Provider in an outpatient setting.
(7) PRIMARY CARE PHYSICIAN HOME AND OFFICE VISITS
PacifiCare covers home and office visits provided by an OMAP Member's
Primary Care Physician for treatment of illness and injury.
(8) REFERRAL PHYSICIAN OFFICE VISITS
PacifiCare also covers Referrals by Primary Care Physicians to other
professional providers. Referrals to Non-Participating Providers who render
specialty care must be preauthorized in writing by PacifiCare before such care
is received.
(9) THERAPEUTIC INJECTIONS
Therapeutic injections, such as allergy shots, are covered when given
in a Participating Provider's office, except when comparable results can be
obtained safely with home self-care, or through oral use of a prescription drug.
RAST (Radioallergosorbent) testing must be ordered by a Participating
allergist in order to be eligible for benefits.
Vitamin and mineral injections are not covered unless Medically Necessary
for treatment of a specific medical condition.
Hepatitis B immunizations are covered only for newborns, well-child
visits, and high risk individuals who meet PacifiCare criteria and must be prior
authorized.
(10) HOSPITAL VISITS
Physician visits are paid during a period of covered hospital confinement
when rendered by the Primary Care Physician who hospitalizes the OMAP Member.
PacifiCare will pay for one physician visit per day of hospital confinement
unless further visits are Medically Necessary to manage a critical situation.
PacifiCare will cover a Medically Necessary inpatient consultation
- 53 -
ordered by the attending physician, however, ongoing care must be rendered by
the attending physician.
(11) SURGERY
PacifiCare covers total surgical care when such surgery is approved by an
OMAP Member's Primary Care Physician and authorized by PacifiCare. PacifiCare
then pays for the preauthorized services of surgeons, and the additional
Medically Necessary services of assistant surgeons, anesthesiologists or
registered anesthetists.
(12) COSMETIC SURGERY
Surgery that improves appearance without restoring an impaired body
function is not covered. All "reconstructive" procedures which are partially
cosmetic in nature must be pre-authorized. Preauthorization will be denied if
the procedure is found NOT to be Medically Necessary in the judgment of
PacifiCare's Medical Director subject to OMAP Member's right of appeal under
Oregon Administrative Rules.
In all cases surgical breast augmentation and nasal rhinoplasty are not
covered services.
In certain specific cases medically necessary breast reduction is covered.
PacifiCare will use OMPRO'S criteria.
Post-mastectomy reconstructive procedures with or without prostheses,
including use of tissue expanders, etc., are not covered. Revisions of
reconstructions are not covered.
Congenital cosmetic deformities may be pre-authorized for surgical repair
on a case by case basis. Hormonally related conditions may be reviewed for
coverage as an enrollee's development warrants. In all cases, the decision
regarding coverage of congenital cosmetic conditions shall be made by
PacifiCare's Medical Director subject to OMAP Member's right of appeal under
Oregon Administrative Rule.
Any form of acne surgery, including cryotherapy, dermabrasion, and excision
of acne scarring will be covered only when such surgery is preauthorized by
PacifiCare and when performed directly by a Participating Physician.
Temporomandibular joint (TMJ) medical or dental management including
surgery is not covered.
(13) MATERNITY CARE
All Medically Necessary care for pregnancy, newborn delivery and related
conditions are covered, the same as any other condition that requires medical
and surgical care.
As in all cases of routine care, BENEFITS ARE PAYABLE ONLY WITHIN THE
SERVICE AREA and only when provided by Participating Providers. Delivery at
term can be anticipated and is not considered a medical emergency for purposes
of this Agreement. An OMAP Member may lose benefits for delivery of a child if
the OMAP Member travels out of the Service Area and delivers while away, unless
PacifiCare can be satisfied that the choice to travel was compelling and the
delivery unexpectedly early. A Participating Physician should be
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consulted to ascertain the risk of an out-of-area delivery before traveling late
in pregnancy.
E. HOSPITAL INPATIENT SERVICES
(1) ACUTE CARE
When a Participating Provider obtains preauthorization and admits Members
to a hospital for acute care, Contractor will cover:
_ semi-private room and board;
_ isolation, coronary or other special acute care units, when
Medically Necessary; and
_ Hospital Services and supplies necessary for treatment and
furnished by Participating Hospital, such as operating and recovery rooms, blood
and blood components, traction equipment and special diets.
Coverage for take home prescription drugs following a period of
hospitalization and dispensed by the hospital will be limited to a three-day
supply.
Referrals to a Non-Participating Hospital must be preauthorized by
PacifiCare unless a medical emergency necessitates such admission.
A preauthorized hospitalization in a Non-Participating Facility will be
covered.
In a medical emergency, benefits paid to a Non-Participating Facility will
continue until the OMAP Member can be safely transported to one of PacifiCare's
Participating Facilities for continued hospitalization. OMAP Members refusing
transport to a Participating Facility when it is safe for them to transfer will
forfeit continued benefits for that hospitalization and all concurrent
Non-Participating Provider care.
(2) LICENSED NURSING FACILITY PROVIDING SKILLED CARE:
As an alternative to hospitalization, the PacifiCare can authorize up to
sixty (60) days per calendar year in a licensed nursing facility that provides
skilled care. In order to be covered, the care must be Medically Necessary and
preauthorized by the Primary Care Physician.
PacifiCare does not provide benefits for routine nursing care, self-help or
training, personal hygiene or custodial care. Nor does PacifiCare provide
benefits for care in a licensed nursing facility providing skilled care in cases
of senile deterioration, mental deficiency or retardation, and psychotic or
psychoneurotic conditions.
F. REHABILITATION
Physical, occupational and speech therapy will be covered to restore or
improve lost function caused by illness, injury, or developmental delay when; 1)
prescribed by a Participating Provider and 2) preauthorized; and 3) delivered
by a Participating Provider.
Children referred for speech therapy by a participating professional
provider may have an initial evaluation by a speech therapist who contracts
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with PacifiCare. The results of the evaluation will be reviewed by the OMAP
Member's Primary Care Physician who has authority to determine whether speech
therapy is Medically Necessary.
The standard PacifiCare shall use to authorize all rehabilitation therapies
shall be the Medical Necessity for such services.
In all cases, specialized cognitive rehabilitation programs are not
covered.
G. AMBULATORY SERVICES
(1) OUTPATIENT SURGERY
When prior authorized, PacifiCare covers operating rooms and recovery
rooms, surgical supplies and other services ordinarily provided by a hospital or
surgical center that subcontracts with PacifiCare to perform "Outpatient
surgery" (surgery that does not require an overnight stay in a hospital).
Certain surgical procedures are covered only when performed as outpatient
surgery. Eligible surgery performed in a Participating Provider's office is
covered.
(2) X-RAY AND LAB
PacifiCare covers diagnostic x-rays and laboratory tests related to
treatment of a covered illness or injury.
(3) THERAPEUTIC X-RAY
PacifiCare covers radium, radioisotopic and x-ray therapy.
(4) IMAGING AND INVASIVE DIAGNOSTIC PROCEDURES
Imaging services, such as MRI and CT scans, and diagnostic procedures that
require entry into the body cavity, such as angiograms and endoscopy, are
covered when prior authorized.
H. EMERGENCY CARE
(1) EMERGENCIES WITHIN THE SERVICE AREA
In an emergency, OMAP Members should always call their Primary Care
Physician first. The Primary Care Physician will advise the most medically
prudent course of action (E.G., whether to come to the office or to the
emergency room of a Participating Hospital.
PacifiCare recognizes that certain medical emergencies may prevent OMAP
Members from initially seeking care from their Primary Care Physician. In such
an instance, OMAP Members should seek care from the nearest appropriate facility
and then call the Primary Care Physician within twenty-four (24) hours of the
incident, or as soon thereafter as possible.
(2) EMERGENCIES OUTSIDE THE SERVICE AREA
When OMAP Members have medical emergencies outside of the Service Area,
medical care may be obtained from the closest appropriate facility, such as a
clinic or physician's office, urgent care center, or hospital emergency room.
- 56 -
The OMAP Member must then notify his or her Primary Care Physician within
twenty-four (24) hours after the occurrence, or as soon thereafter as possible.
If OMAP Members are hospitalized due to a medical emergency outside the
Service Area, the Primary Care Physician and the Medical Director will monitor
their condition and will determine when the OMAP Member can be transferred to a
Participating Facility. PacifiCare does NOT provide benefits for care beyond
the date the Primary Care Physician and PacifiCare's Medical Director
determine an OMAP Member can be safely transferred.
If an OMAP Member is outside the Service Area and has an urgent need for
medical care, PacifiCare shall provide the same benefits that apply to a
medical emergency. The following ARE NOT considered to be eligible for out-
of-area urgent care coverage:
- routine adult physical examinations, women's examinations,
wellbaby and child care, immunizations or eye examinations;
- diagnostic work-ups for chronic conditions; and
- elective surgery and/or hospitalization unless prior authorized
by PacifiCare as services not available from Participating Providers.
(3) AMBULANCE TRANSPORTATION
Emergency ground or air ambulance transportation is covered. Transportation
required by PacifiCare to return an OMAP Member into the Service Area to obtain
continuing care is covered when required by PacifiCare to continue care after a
Medical Emergency.
I. OTHER SERVICES
(1) HOME HEALTH CARE
Medically Necessary home health care is covered when prior authorized by
PacifiCare. Such visits must be provided by an approved home health agency.
A treatment plan from the home health agency also must be reviewed by
PacifiCare before benefits will be approved. At a minimum the home health
agency must:
- provide skilled nursing and other therapeutic services in the
place of residence of its patients;
- provide for the supervision of services by a physician, a
registered nurse or a licensed practical nurse;
- maintain clinical records of all patients;
- receive prior authorization in writing from PacifiCare to
provide home health services in each case.
Services for home health care are subject to all contract limitations.
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(2) DURABLE MEDICAL EQUIPMENT AND SUPPLIES
PacifiCare provides durable medical equipment and supplies according to
OMAP program rules and regulations as specified in the OMAP provider guide,
Durable Medical Equipment and Supplies. Medical supplies used, and casts
applied, in a Participating Provider's office are covered along with surgical
implants, including such items as pacemakers and artificial joints.
(3) PODIATRY SERVICES
Services of podiatrists are covered when the OMAP Member is Referred by his
or her Primary Care Physician for diagnosis and treatment of A SPECIFIC CURRENT
PROBLEM.
J. LIMITATIONS
Certain benefits for Covered Services are limited, as shown in the
following paragraphs:
(1) PRESCRIPTION DRUGS
The following medications and accessories are covered only when prescribed
by a Participating Physician and obtained at pharmacies contracting with
PacifiCare. The Participating pharmacies will be formulary compliant in
dispensing policies.
(a) THE FOLLOWING ARE COVERED:
- Drugs for which a prescription is required by law.
- The following non-legend drugs and items, regardless of
strength or dosage form, whether singly or in combination, on prescription ONLY:
- Gastro-Intestinal:
Aluminum Hydroxide
Milk of Magnesia
Tums
- Topical Products:
Hydrocortisone 0.5%, 1%
Neosporin ointment
▇▇▇
Lotrimin A/F
- Vitamins/Minerals:
Ferrous Sulfate
- Expectorants and Cough Syrups:
Robitussin DM, CF, Plain
- Antiemetic:
Mcclizine
- Analgesics:
Acetaminophen
Aspirin
Ibuprofen
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- Antihistamines:
Chlorpheniramine
- Decongestants:
Pseudoephedrine
- Others:
Niacin
Pedialyte
Sodium Chloride for inhalation
- Insulin. Disposable insulin needles/syringes.
- Dextroamphetamine (e.g. Dexedrine) Methamphetamine
(e.g. Desoxyn)
- Tretinoin, all dosage forms (e.g. Retin-A), for individuals
through the age of 25 years. For individuals over the age of 25 years a
preauthorization by a Participating Provider is required.
- Compounded medication of which at least one ingredient is a
prescription legend drug.
- Any other drug which under the applicable state law may only
be dispensed upon the written prescription of a physician or other lawful
prescriber.
(b) THE FOLLOWING ARE NOT COVERED:
(1) Drugs and medications when used for cosmetic purposes.
(2) Non-legend drugs other than those specified in
subparagraph (a), above.
(3) Anorectics (any drug used for the purpose of weight
loss), except for those listed above.
(4) Drugs related to non-covered transplants.
(5) Infertility medications.
(6) Psychotherapeutic Drugs related to the treatment of
mental illness or chemical dependency. (Tranquilizers, Anti-Depressants,
Lithium Products, Sedatives, Methadone, Hypnotics, Etc.)
(7) Dental prescriptions.
(8) Contraceptives, oral or other, whether medication or
device, regardless of intended use.
(9) DESI drugs.
(10) Immunization agents, biological sera, blood or blood
plasma.
(11) Immunosuppressants, primarily indicated for organ
transplantation unless PacifiCare has specifically agreed to cover the
transplant
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(12) Lewnorgestrel (Norplant)
(13) Minoxidil (Rogaine) for the treatment of alopecia.
(14) Nicorette (or any other drug containing nicotine or
other smoking deterrent medications)
(15) Yohimbine (Yocon)
(16) Charges for the administration or injection of any drug
(including Methadone treatment programs).
(17) Prescriptions which an OMAP Member is entitled to receive
without charge from any Worker's Compensation Laws.
(18) Drugs labeled "Caution-limited by federal law to
investigational use," or experimental drugs, even though a charge is made to the
individual.
(19) Medication which is to be taken by or administered to
an individual, in whole or in part, while he or she is a patient in a licensed
hospital, rest home, sanitarium, extended care facility, convalescent
hospital, nursing home or similar institution which operates on its premises, or
allows to be operated on its premises, a facility for dispensing
pharmaceuticals.
(20) Any prescription refilled in excess of the number
specified by the Participating Physician, or any refill dispensed after one year
from the Participating Physician's original order.
(c) DISPENSING LIMITATIONS FOR DRUGS
- The amount normally prescribed by Participating Physician,
but not to exceed a thirty (30) day supply.
(2) TRANSPLANTS
PacifiCare will provide transplant benefits for Medically Necessary
transplantation procedures for kidney and cornea.
TERMS AND CONDITIONS. Covered Services and benefits are provided only
in accordance with the following terms and conditions:
- PacifiCare determines that the procedure represents the safest
and most effective method of treatment.
- PacifiCare provides a written referral for care to transplant or
hemodialysis facility selected by PacifiCare from a list of facilities it has
approved.
- If, after referral, either PacifiCare or the medical staff of
the referral facility determines that the OMAP Member does not satisfy its
respective criteria for the services involved, PacifiCare's obligation is
limited to paying for Covered Services provided prior to such determination.
- Neither PacifiCare nor Participating Physicians undertake to
provide a donor or a donor organ or to assure the availability of a donor or
of a donor organ or the availability or capacity of referral transplant
facilities approved by PacifiCare.
- 60 -
- If the organ recipient is covered under this contract,
PacifiCare will pay for donor costs, whether or not the donor is covered under
this contract. "Donor costs" refer to charges associated with removing the
tissue from the donor's body and preserving or transporting it to the site where
the transplantation is performed as well as any other charges pertaining to
locating and procuring the organ. If the donor is covered under the
PacifiCare Medicaid Plan and the recipient is not, PacifiCare will not pay any
benefits toward donor costs. Complications and unforeseen effects of the
donation will be covered like any other illness.
- Living expenses are not covered for any person, including the
OMAP Member.
- Transportation is not covered for any person, including the
OMAP Member.
(3) MEDICAL BENEFIT EXCLUSIONS
PacifiCare will not cover the following:
(a) Services or supplies rendered by a Non-Participating
Provider when such care has not been preauthorized by PacifiCare, except in
cases involving a medical emergency.
(b) Services or supplies rendered by Participating Providers,
other than the OMAP Member's Primary Care Physician, if not referred by the
Primary Care Physician and preauthorized through PacifiCare.
(c) Services or supplies received by OMAP Members before coverage
under the PacifiCare Medicaid Plan begins, or after coverage under the
PacifiCare Medicaid Plan ends. For hospitalization, an occasion of service
begins upon admission.
(d) Services or supplies which are, in PacifiCare's judgment,
experimental or investigational for the diagnosis of the OMAP Member being
treated. Also excluded are services and supplies which support or are
performed in connection with the experimental or investigational treatment. For
purposes of this exclusion, experimental or investigational services include,
but are not limited to, any services or supplies which, at the time the services
are rendered and for the purpose and in the manner they are being used:
- have not yet received full FDA approval for other than
experimental, investigational, clinical testing; or
- are performed under a written research protocol by the provider;
or
- any that are not recognized by medical practitioners as
conforming to accepted medical practice in the state of Oregon.
(e) Self-help, training, or instructional programs, including, but
not limited to, how to use durable medical equipment or how to care for a person
in the family.
(f) Services or supplies provided for treatment of addiction to
tobacco, tobacco products or nicotine substitutes, including hypnosis,
- 61 -
biofeedback, forms of relaxation training or counseling used to modify tobacco
use.
(g) Services otherwise available:
- services or supplies for which payment could be obtained in
whole or in part if an OMAP Member had applied for payment under any city,
county, state or federal law (except for Medicaid coverage);
- care for military service-connected disabilities for
which the OMAP Member is legally entitled to services and for which facilities
are reasonably available to the enrollee.
- services or supplies for which no charge is made, or for
which no charge is normally made in the absence of coverage.
(h) Services for alcoholism, drug abuse and addiction are not
provided.
(i) Mental health services including any treatment for insanity,
mental illness or disorder, or drug abuse induced mental condition are not
provided. This exclusion includes related somatic medical services and
prescription drugs.
(j) Pain clinics or specialty pain programs.
(k) Vocational counseling.
(l) Services or materials in an institution for the mentally
retarded except while a bed patient in an acute care hospital for conditions
other than mental retardation.
(m) Massage or massage therapy.
(n) Any infertility treatment or reversal of sterilization
procedures.
(o) Services or supplies related to transsexualism, sex
transformations, or paraphilias (sexual deviations), also mental,
psychological, or physical evaluations for any of these disorders.
(p) Biofeedback for any condition.
(q) Private duty nursing (except when medically necessary
as prescribed by a participating professional provider); personal comfort items
such as television, telephone and guest meals while in a hospital if charged
separately from the cost of the room.
(r) Diet or rest cure hospitalization, custodial care, personal
hygiene and other forms of supervised self-care.
(s) Services performed for cosmetic purposes including certain
reconstructive procedures unless performed for correction of functional
disorders, disease or as a result of an injury (subject to criteria
established by Contractor). Breast augmentation, and nasal rhinoplasty are not
covered procedures.
(t) Services and supplies provided for obesity or weight reduction.
Specifically excluded are; gastric stapling procedures, weight
- 62 -
loss programs, counseling, hypnosis, biofeedback, neurolinguistic programming,
guided imagery and other forms of relaxation training as well as subliminal
suggestion used to modify eating behavior.
(u) All dental or orthodontic services and supplies (except for
fractured jaw) with the further exclusion of all hospitalization and related
charges when hospitalization is necessary to perform dental services, except as
provided under a separate dental PCO arrangement.
(v) Orthognathic surgery including maxillary or mandibular
osteotomies, dental care, and TMJ medical, dental, or surgical management.
Exception: the provision of prosthetics to repair head and facial structures
damaged by trauma, disease, surgery or congenital deformity that cannot be
managed with living tissue.
(w) Routine eye exams, (except for EPSDT screenings,) for OMAP
Members age twenty (20) or older, to determine need for vision correction. In
addition, benefits will not be provided for the following:
- the fitting, provision or replacement of eyeglasses, or
contact lenses;
- any charges for orthoptics, vitamin therapy, low vision
therapy or eye exercises or fundus photography; and
- routine contact lens checks.
(x) Surgical procedures which alter the refractive character of
the eye, including, but not limited to, radial keratotomy, myopic
keratomileusis and other surgical procedures of the refractive keratoplasty
type, the purpose of which is to cure or reduce -myopia or astigmatism.
Additionally, reversals or revisions of surgical procedures which after the
refractive character of the eye are excluded.
(y) Routine physical examinations primarily for coverage, licensing,
employment; and non-preventive purposes or other medical examinations or tests
not connected with the care and treatment of an actual illness or injury
(unless provided for under the prevention benefits of this contract). School
physicals occurring more often than the scheduled preventive benefits are also
excluded.
(z) Immunizations for the primary purpose of travel.
(aa) Appliances or equipment primarily for comfort, convenience,
cosmetics, environmental control or education, such as air conditioners,
humidifiers, air filters, whirlpools, heat lamps or tanning lights.
(ab) Any charges for medical records necessary to determine benefits.
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EXHIBIT B1
BENEFITS MATRIX
DIVISION OF FINANCIAL RESPONSIBILITY
PACIFICARE COMMERCIAL HEALTH PLAN
(To be included by PacifiCare)
- 64 -
EXHIBIT B2
BENEFITS MATRIX
DIVISION OF FINANCIAL RESPONSIBILITY
SECURE HORIZONS HEALTH PLAN
(To be included by PacifiCare)
- 65 -
EXHIBIT B3
BENEFITS MATRIX
DIVISION OF FINANCIAL RESPONSIBILITY
PACIFICARE MEDICAID PLAN
(To be included by PacifiCare)
- 66 -
EXHIBIT C1
CAPITATION PAYMENTS
PACIFICARE COMMERCIAL HEALTH PLAN
MONTHLY CAPITATION PAYMENTS
PacifiCare shall pay to Medical Group, as full payment for all Covered
Medical Services provided to each Commercial Member who has selected or been
assigned to Medical Group as his or her Primary Care Physician, a monthly
Capitation Payment equal to the following:
$42.00 pmpm based on January 1996 demographics and plan design. The
capitation rate will fluctuate with age, sex and copy adjustments.
The Capitation Payment covers the Medical Services listed in Section II of
Exhibit A1.
MATERNITY PAYMENTS
For term pregnancies within nine (9) months after initial PacifiCare
membership, PacifiCare shall make a one-time lump sum payment to Medical Group
of $850. Medical Group shall be responsible to notify PacifiCare. Payment
will be made following delivery.
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EXHIBIT C2
CAPITATION PAYMENTS
SECURE HORIZONS HEALTH PLAN
MONTHLY CAPITATION PAYMENTS
PacifiCare shall pay to Medical Group, as full payment for all Covered
Services provided to each Secure Horizons Member who has selected or been
assigned to Medical Group as his or her Primary Care Physician, a monthly
Capitation Payment equal to the following:
39.32 % of the total Secure Horizons Revenue
The Capitation Payment covers the Medical Services listed in Section II of
Exhibit A2.
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EXHIBIT C3
CAPITATION PAYMENTS
PACIFICARE MEDICAID PLAN
I. MONTHLY CAPITATION PAYMENTS
PacifiCare shall pay to Medical Group, as full payment for all Covered
Services provided to each OMAP Member who has selected or been assigned to
Medical Group as his or her Primary Care Physician, a monthly Capitation Payment
equal to the following:
OHP PLM Adults PLM Child
LESS THAN
100% 100-133% 100-133% AB/AD w/ AB/AD w/o OAA w/ OAA w/o CSD
FPL FPL FPL GA Medicare Medicare Medicare Medicare Children
-------------------------------------------------------------------------------------------------------
$74.22 $514.24 $94.06 $194.24 $76.70 $355.12 $61.99 $240.76 $80.14
The Capitation Payment covers the Medical Services listed in Section II of
Exhibit A3.
II. MATERNITY WITHHOLD
PacifiCare shall reconcile the Maternity Withhold distribution on an annual
basis, aggregating all experience and distributions received for the
OHP contract year, October 1 through September 30. The reconcilliation
and distribution shall be done within sixty (60) days following the receipt of
any distribution, and documentation from the State of Oregon. PacifiCare will
follow the State methodology in distributing any monies received by
PacifiCare.
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EXHIBIT D1
INDIVIDUAL STOP-LOSS PROGRAM
PACIFICARE COMMERCIAL HEALTH PLAN
Medical Group does not participate in Individual Stop-Loss Program.
- 70 -
EXHIBIT D2
INDIVIDUAL STOP-LOSS PROGRAM
SECURE HORIZONS HEALTH PLAN
Medical Group does not participate in Individual Stop-Loss Program.
- 71 -
EXHIBIT D3
INDIVIDUAL STOP-LOSS PROGRAM
PACIFICARE MEDICAID PLAN
Medical Group does not participate in Individual Stop-Loss Program.
- 72 -
EXHIBIT E1
HOSPITAL CONTROL PROGRAM
PACIFICARE COMMERCIAL HEALTH PLAN
1. INTRODUCTION
The Hospital Control Program (HCP) is designed to provide a financial incentive
for the control of inpatient, in-area emergency services and selected other
outpatient services. When actual incurred costs compared to a predetermined
budget are favorable, the savings will be shared with Medical Group. Conversely,
when actual incurred costs exceed the budget, the Medical Group also shares the
additional costs. Limitations are included at both the individual Member level
(through the payment of a reinsurance premium for specific Stop-Loss) and at the
aggregate level (through a percentage limitation on overall shared savings or
losses) to mitigate extraordinary performance fluctuations.
2. BUDGET TERM
For the period January 1, 1996, through December 31, 1996. If adjustments to
the hospital control budget under negotiation cannot be agreed to by the parties
by the renewal date, this Agreement may be terminated pursuant to Section 7.1.
Retroactive changes shall be allowed, if mutually agreed upon in writing by
the parties.
HOSPITAL BUDGET: $32.00 pmpm
3. ACTUAL COSTS
Actual costs are defined for purposes of this program as charges for those
services included in the Hospital Control Program incurred during the contract
period that are:
a. Paid, at net, by PacifiCare
b. Received and unpaid as of the run date of the HCP settlement
calculation at gross amount billed.
LESS
c. Prior years' claims and recoveries associated with authorized
services will be carried forward each year on the basis that
claims will not exceed recoveries by more than the lesser of
point five percent (.5%) pmpm of the total hospital control
budget or four thousand dollars ($4,000).
d. An estimated amount to account for discounts and Copayments expected
to be received on the unpaid claims included as actual costs.
4. CALCULATIONS OF SAVINGS AND LOSSES
If actual costs are less than the earned budget, then Medical Group will be paid
according to the attached schedule.
An interim calculation of the HCP results will be made by PacifiCare for each
quarter based on estimated incurred costs. The calculations will be computed
- 73 -
on a contract year-to-date basis. The results will be reported to the Medical
Group within sixty (60) days of the end of each quarter. If there are deficits
in the HCP, the Medical Group will be required to make a payment to PacifiCare
in the amount the calculation indicates.
Medical Group shall submit all requests to reconcile the quarterly risk
settlement no later than sixty (60) days after receipt of each quarterly risk
settlement report. PacifiCare shall respond to reconciliation requests
within sixty (60) days of receipt of request. No later than August 31 after
the end of the prior year can the Medical Group submit request for claims
readjudication under risk settlement for the prior year.
Final payment will be made within one hundred and fifty (150) days of the end of
the contract period.
5. SPECIAL CONDITIONS FOR EMERGENCY SERVICES
If the Medical Group directs a Member to use the emergency services of a
hospital, and PacifiCare determines that direction was inappropriate, PacifiCare
may issue a written Conformance Request to Medical Group. The Conformance
Request will serve as notice that all subsequent inappropriate referrals may
have a penalty applied. If Medical Group thereafter makes an inappropriate
referral for emergency services of a hospital, PacifiCare may deduct the
professional component of the PacifiCare payment from Medical Group's capitation
as a penalty for improper referral. Medical Group may request review of any
determination by PacifiCare pursuant to this Paragraph by the Quality Assurance
Committee.
6. UNAUTHORIZED ADMISSIONS
Calculations shall not include unauthorized admissions whereby a patient is
admitted by a nonparticipating or nonreferring physician in a nonemergency
status or out-of-area hospitalization.
- 74 -
EXHIBIT E1 (Continued)
HOSPITAL CONTROL PROGRAM - SCHEDULE
ase Medical Premium $85.81 $85.81 $85.81 $85.81 $85.81 $85.81 $85.81 $85.81 $85.81
hysician Cap [1] $42.00 $42.00 $42.00 $42.00 $42.00 $42.00 $42.00 $42.00 $42.00
ospital Budget [2] $32.00 $32.00 $32.00 $32.00 $32.00 $32.00 $32.00 $32.00 $32.00
ctual Costs $24.00 $25.00 $26.00 $27.00 $28.00 $29.00 $30.00 $31.00 $32.00
avings $ 8.00 $ 7.00 $ 6.00 $ 5.00 $ 4.00 $ 3.00 $ 2.00 $ 1.00 $ 0.00
acifiCare $ 2.00 $ 2.00 $ 2.00 $ 1.00 $ 1.00 $ 0.00 ($.72) ($.72) ($.72)
orvallis Clinic [3] $ 6.00 $ 5.00 $ 4.00 $ 4.00 $ 3.00 $ 3.00 $ 2.72 $ 1.72 $0.72
otal to Delivery Sys. $72.00 $72.00 $72.00 $73.00 $73.00 $74.00 $74.72 $74.72 $74.72
ut of Area Costs $ 1.65 $ 1.65 $ 1.65 $ 1.65 $ 1.65 $ 1.65 $ 1.65 $ 1.65 $ 1.65
otal Health Care Costs $73.65 $73.65 $73.65 $74.65 $74.65 $75.65 $76.37 $56.37 $76.37
acifiCare MLR 85.8% 85.8% 85.8% 87.0% 87.0% 88.2% 89.0% 89.0% 89.0%
otal to HealthQuest $48.00 $47.00 $46.00 $46.00 $45.00 $45.00 $44.72 $43.72 $42.72
Assumptions:
[1] $42 pmpm is based on January 1996 age/sex and copy adjustments and will
fluctuate accordingly.
[2] Fixed pmpm. The Clinic will not purchase reinsurance from PacifiCare.
[3] Hospital Costs beyond $32 pmpm are at PacifiCare's risk.
Corv Platfm3/96 - 75 - 6/14/96
EXHIBIT E2
HOSPITAL CONTROL PROGRAM
SECURE HORIZONS HEALTH PLAN
1. INTRODUCTION
The Hospital Control Program (HCP) is designed to provide a financial incentive
for the control of inpatient, in-area emergency services and selected other
outpatient services. When actual incurred costs compared to a predetermined
budget are favorable, the savings will be shared with Medical Group. Conversely,
when actual incurred costs exceed the budget, the Medical Group also shares the
additional costs. Limitations are included at both the individual Member level
(through the payment of a reinsurance premium for specific Stop-Loss) and at the
aggregate level (through a percentage limitation on overall shared savings or
losses) to mitigate extraordinary performance fluctuations.
2. BUDGET TERM
For the period January 1, 1996, through December 31, 1996. If adjustments
to the hospital control budget under negotiation cannot be agreed to by the
parties by the renewal date, this Agreement may be terminated pursuant to
Section 7.1. Retroactive changes shall be allowed if mutually agreed upon in
writing by the parties.
HOSPITAL BUDGET: 41.84% of total premium
3. ACTUAL COSTS
Actual costs are defined for purposes of this program as charges for those
services included in the Hospital Control Program incurred during the
contract period that are:
a. Paid, at net, by PacifiCare
b. Received and unpaid as of the run date of the HCP settlement
calculation at gross amount billed.
LESS
c. Prior years' claims and recoveries associated with authorized services
will be carried forward each year on the basis that claims will not
exceed recoveries by more than the lesser of point five percent (.5%)
pmpm of the total hospital control budget or four thousand dollars
($4,000).
d. An estimated amount to account for discounts and Copayments expected to
be received on the unpaid claims included as actual costs.
4. CALCULATION OF SAVINGS AND LOSSES
If actual costs are less than the earned budget, then Medical Group will be paid
fifty percent (50%) of the amount saved.
If actual costs are greater than the earned budget, then Medical Group will be
liable for fifty percent (50%) of the deficit.
An interim calculation of the HCP results will be made by PacifiCare for each
quarter based on estimated incurred costs. The calculations will be computed on
a contract year-to-date basis. The results will be reported to the Medical
- 76 -
Group within sixty (60) days of the end of each quarter. If there are deficits
in the HCP, the Medical Group will be required to make a payment to PacifiCare
in the amount the calculation indicates.
Medical Group shall submit all requests to reconcile the quarterly risk
settlement no later than sixty (60) days after receipt of each quarterly risk
settlement report. PacifiCare shall respond to reconciliation requests within
sixty (60) days of receipt of request. No later than August 31 after the end
of the prior year can the Medical Group submit request for claims
readjudication under risk settlement for the prior year.
Final payment will be made within one hundred and fifty (150) days of the end of
the contract period.
5. SPECIAL CONDITIONS FOR EMERGENCY SERVICES
If the Medical Group directs a Member to use the emergency services of a
hospital, and PacifiCare determines that direction was inappropriate,
PacifiCare may issue a written Conformance Request to Medical Group. The
Conformance Request will serve as notice that all subsequent inappropriate
referrals may have a penalty applied. If Medical Group thereafter makes an
inappropriate referral for emergency services of a hospital, PacifiCare may
deduct the professional component of the PacifiCare payment from Medical Group's
capitation as a penalty for improper referral. Medical Group may request review
of any determination by PacifiCare pursuant to this Paragraph by the Quality
Assurance Committee.
6. UNAUTHORIZRD ADMISSIONS
Calculations shall not include unauthorized admissions whereby a patient is
admitted by a nonparticipating or nonreferring physician in a nonemergency
status or out-of-area hospitalization.
- 77 -
EXHIBIT F1
PRESCRIPTION SERVICES PROGRAM
PACIFICARE COMMERCIAL HEALTH PLAN
The purpose of the Pharmacy Control Program is to provide an incentive to the
Medical Group to ▇▇▇▇▇▇ efficient utilization of prescription services. If
pharmacy costs for a calendar year are below the Medical Group's budget, the
Medical Group has the opportunity to share in the savings. In the event that
the pharmacy costs exceed the Medical Group's budget, the Medical Group will
share in the deficit.
PHARMACY CONTROL PROGRAM BUDGET
The Pharmacy Control Program budget shall equal eighty-two percent (82%) of the
outpatient prescription drug benefit supplemental premium per member assigned to
the group per month.
ACTUAL COSTS
The Actual Costs will be the actual expenses paid by PacifiCare for pharmacy
services of those members assigned to the Medical Group for the applicable
month.
BUDGET SURPLUS
In the event that Actual Costs are less than the Pharmacy Control Program
Budget, the amount will be referred to as a Budget Surplus. If Actual Costs are
up to $1 less than the Budget, PacifiCare shall pay the Medical Group 100% of
the savings, up to $1 pmpm. In the event that Actual Costs are more than $1
below the Budget, PacifiCare shall pay the Medical Group $1 pmpm (for the first
dollar under budget) and 50% of the Budget Surplus beyond the first dollar.
BUDGET DEFICIT
In the event that Actual Costs exceed the Budget during the calendar year, the
amount of this excess will be referred to as a Budget Deficit. If Actual Costs
are up to $1 over the Budget, Medical Group shall pay PacifiCare 100% of the
amount of the deficit, up to $1 pmpm. In the event that Actual Costs are more
than $1 over the Budget, the Medical Group shall pay PacifiCare $1 pmpm (for the
first dollar over budget) and 50% of the Budget Deficit beyond the first dollar.
UTILIZATION REPORTS
PacifiCare shall provide quarterly utilization reports to Medical Groups. Total
pharmacy expenditures for the Pharmacy Control Program will be calculated and
reported on an annual basis only.
PHARMACY CONTROL PROGRAM CALCULATIONS
The annual Pharmacy Control Program calculations shall be completed within one
hundred twenty (120) days of year end. If Medical Group is entitled to a payout,
PacifiCare shall make payment within one hundred twenty days of year end. If
PacifiCare is entitled to a payout by the Medical Group, the Medical Group
agrees to make payment to PacifiCare within sixty (60) days of receipt of the
Pharmacy Control Program Calculations. If Medical Group fails to make payment to
PacifiCare within sixty days, PacifiCare reserves the right to withhold owed
amount from future capitation payments.
- 78 -
EXHIBIT F2
PRESCRIPTION SERVICES PROGRAM
PACIFICARE MEDICAID PLAN
The purpose of the Pharmacy Control Program is to provide an incentive to the
Medical Group to ▇▇▇▇▇▇ efficient utilization of prescription services. If
pharmacy costs for a calendar year are below the Medical Group's budget, the
Medical Group has the opportunity to share in the savings.
PHARMACY CONTROL PROGRAM BUDGET
The Pharmacy Control Program budget shall equal:
OHP PLM Adults PLM Child
LESS THAN100% 100-133% 100-133% AB/AD w/ AB/AD w/o OOA w/ OAA w/o CSD
FPL FPL FPL GA Medicare Medicare Medicare Medicare Children
-------------------------------------------------------------------------------------------------------------
Rx Line
Budget $10.97 $15.25 $6.05 $16.23 $76.19 $160.12 $78.97 $76.97 $11.14
ACTUAL COSTS
The Actual Costs will be the actual expenses paid by PacifiCare for pharmacy
services of those members assigned to the Medical Group for the applicable
month.
BUDGET SURPLUS AND DEFICIT
If Actual Costs are less than the Total Budget, PacifiCare shall pay the Medical
Group 50% of the savings.
Medical Group is not responsible for deficits in the Pharmacy Control Budget.
UTILIZATION REPORTS
PacifiCare shall provide quarterly utilization reports to Medical Groups. Total
pharmacy expenditures for the Pharmacy Control Program will be calculated and
reported on an annual basis only.
PHARMACY CONTROL PROGRAM CALCULATIONS
The annual Pharmacy Control Program calculations shall be completed within one
hundred twenty (120) days of year end. If Medical Group is entitled to a
payout, PacifiCare shall make payment within one hundred twenty days of year
end. If PacifiCare is entitled to a payout by the Medical Group, the Medical
Group agrees to make payment to PacifiCare within sixty (60) days of receipt of
the Pharmacy Control Program Calculations. If Medical Group fails to make
payment to PacifiCare within sixty days, PacifiCare reserves the right to
withhold owed amount from future capitation payments.
- 79 -
EXHIBIT G1
CAPITATED PAYMENTS
PACIFICARE POINT-OF-SERVICE PLAN
1. DEFINITIONS - The following definitions shall apply to the PacifiCare
Point-of-Service Plan:
1.1 COMMERCIAL PLAN - is the PacifiCare Commercial Health Plan which does
not provide coverage for Out-Of-Network Services.
1.2 IN-NETWORK SERVICES - are Covered Services which are (a) provided or
arranged by Medical Group pursuant to the PacifiCare Commercial Plan, (b)
received from a Non-Participating Provider following the direction, written
referral or prior authorization from a Participating Medical Group or a Medical
Group Physician, or (c) Emergency Services.
1.3 OPTION MEMBERS - are Members who are enrolled in the PacifiCare
Point-of-Service Plan and assigned to Medical Group.
1.4 OUT-OF-NETWORK SERVICES - Are Covered Services, excluding Emergency
Services, which are sought and received by Option Members without the direction,
advice, written referral or prior authorization from their Participating
Medical Group or a Medical Group Physician. Out-of-Network Services are covered
under the PacifiCare Point-of-Service Plan at a lower benefit level.
1.5 POINT-OF-SERVICE (POS) PLAN (OR "OPTION PLAN") - is the PacifiCare
Commercial Plan under which Members are entitled to coverage for both
In-Network and Out-of-Network Services. An Option Member selects a Primary Care
Physician at the time of enrollment and receives a higher level of benefits for
In-Network Services directed and authorized by the Member's Primary Care
Physician and a lower level of coverage for Out-of-Network Services.
2. TERMS OF PACIFICARE COMMERCIAL PLAN - Except as otherwise indicated in
this Exhibit H, all terms and conditions applicable to the PacifiCare
Commercial Plan apply to the Point-of-Service Plan.
3. COVERED SERVICES - Medical Group agrees to provide, arrange and direct
Covered Services for Option Members under the same terms and conditions as the
Commercial Plan and in the same manner as for Commercial Members, without
regard to the option of Out-of-Network Services.
4. ELIGIBILITY LIST - PacifiCare agrees to provide Medical Group with an
Eligibility List for the Option Members separate from the Eligibility List
furnished by PacifiCare for Commercial Members enrolled in the Commercial Plan.
Each Option Member will also receive a separate Member identification card
distinct from the Member identification care provided to Commercial Members.
Services provided to Members who convert from the Commercial Plan to the
Point-of-Service Plan, but which are not yet reflected on the Eligibility List,
may be billed to PacifiCare as if they are covered, if accompanied by a signed
Eligibility Guarantee form.
5. ADMINISTRATIVE PROCEDURES FOR POINT-OF-SERVICE PLAN - Medical Group shall
cooperate in arranging access to Out-of-Network Services in accordance with any
and all policies and procedures established by PacifiCare specifically for the
Point-of-Service Plan, as set forth separately in the Provider Manual, including
but not limited to, procedures for the submission of claims, authorizations,
subrogation and third party liability.
- 80 -
6. COMPENSATION
A. FEE FOR SERVICE
1. COMPENSATION - Medical Group's compensation under the PacifiCare
Point-of-Service Plan and indemnity look alike portion includes the following
RBRVS factors:
E & M OTHER
$47.16 $53.60
Medical Group agrees to cooperate in arranging access to Non-Participating
Providers at Medical Group's contracted rates where PacifiCare finds that
arrangement advantageous.
2. THIRD PARTY LIABILITY - Medical Group further agrees to provide
PacifiCare with any Member patient information required to subrogate the claim
where the possibility of dual coverage or liability may exist.
3. OPTION PLAN UTILIZATION CONTROL PROGRAM
3.1 INTRODUCTION - The Option Plan Utilization Control
Program is designed to promote the financial incentive for control of
Out-of-Network Services. When actual incurred costs compared to a pre-determined
budget are favorable, the savings will be shared with Medical Group. If actual
costs are less than the earned budget, then Medical Group shall be paid fifty
percent (50%) of the amount saved up to ten percent (10%) of the total budget.
There is no down-side risk sharing program.
3.2 BUDGET AND BUDGET TERM - The budget listed below is in
effect from January 1, 1996 through December 31, 1996:
$93.67
Note: If membership in Option plan for Medical Group exceeds 250 members,
PacifiCare and Medical Group will renegotiate Budget and Term.
3.3 ACTUAL COSTS - Actual costs are defined for purposes of
the Point-of-Service Utilization Control Program as those services included in
the Utilization Management Budget (UMB) incurred that are:
(a) Paid, at net, by PacifiCare;
(b) Received and unpaid as of the run date of the UMB
settlement calculation at gross amount billed; and
(c) Medical Group authorized services from the immediate
prior calendar year which, due to their authorization by Medical Group more than
ninety (90) days after the end of the calendar year, will be carried forward
into the next year's cost calculations.
LESS
(d) Member costs in excess of the amount stated in
Section 8.2 above;
(e) Prior years' claims and recoveries associated with
authorized services will be carried forward each year on the basis that claims
will not exceed recoveries by more than the lesser of point five percent (.05%)
pmpm of the total hospital control budget or four thousand dollars ($4,000); and
- 81 -
(f) An estimated amount to account for discounts and
Copayments expected to be received on the unpaid claims included as actual
costs.
3.4 CALCULATION - An interim calculation of the UMB results
will be made by PacifiCare for each quarter based on estimated incurred costs.
The calculations will be computed on a contract year-to-year basis. The results
will be reported to Medical Group within sixty (60) days of the end of each
quarter.
3.5 MONTHLY REPORTING - PacifiCare will distribute a report
monthly, on or before the fifteenth (15th) day of each month, that lists the
payments made during the previous month for services included in the UMB.
3.6 THIRD PARTY LIABILITY - Prior years' actual claims and
recoveries associated with hospital or Emergency Services expenses that are
considered third-party liability, workers' compensation, etc. will be carried
forward each year. Third-party liability claims and recoveries will be included
in the aggregate of all claims and recoveries, whereas the aggregate claims
cannot exceed recoveries by more than the lesser of point five percent (.05%)
of pmpm of the total Hospital Control Budget or four thousand dollars ($4,000).
B. CAPITATED POINT OF SERVICE
Medical Group agrees that the financial arrangement under Section B of this
Exhibit H will replace the financial arrangement under Section I of this Exhibit
H following thirty (30) days notice of this decision to Medical Group by
PacifiCare.
Capitation payment for PacifiCare Point of Service plan subscribers will be
determined in the same manner as for Commercial plan subscribers, as described
in Exhibit C1, except for the following:
MONTHLY CAPITATION PAYMENTS
PacifiCare shall pay to Medical Group, as full payment for all Covered
Services provided to each Point of Service Member who has selected or been
assigned to Medical Group as his or her Primary Care Physician, a monthly
Capitation Payment equal to the following:
65% of the Percent of Premium specified in Exhibit C1, less 65% of the ISL
Premium rate specified for the ISL program as noted in Exhibit D1.
The actual amount of the Capitation Payment payable to Medical Group will
vary according to the mix of Medical Group Members under age, sex and Copayment
plan categories. The Capitation Payment covers the Hospital Services
listed in Section I of Exhibit A1 and the Medical Services listed in Section II
of Exhibit A1. Prior to distribution of the Capitation Payment, PacifiCare
shall deduct the premium for the Individual-Stop Loss program as specified in
Exhibit D1. The Capitation Payment also includes payment of the Hospital
Control Utilization Budget.
- 82 -
MATERNITY PAYMENTS
For term pregnancies within nine (9) months after initial PacifiCare
membership, PacifiCare shall make a one-time lump sum payment to Medical Group
of $850. Medical Group shall be responsible to notify PacifiCare. Payment will
be made following delivery.
- 83 -
EXHIBIT G2
HOSPITAL CONTROL PROGRAM
PACIFICARE POINT OF SERVICE PLAN
1. INTRODUCTION
The PacifiCare Point of Service Control Program is designed to provide a
financial incentive for the control of In-Network Hospital Services and
Out-of-Network Services.
PacifiCare Point of Service Subscriber member months and related In-Network
Hospital Service expenses shall not be included in calculating the Commercial
Utilization Control Program described in Exhibit E1.
2. BUDGET
Point of Service Budget shall be equal to the Commercial HUCP budget as
described in Exhibit E1 plus the thirty-five percent (35%) withhold from the
Point of Service Capitation, as described in Exhibit H1, less sixty-five
percent (65%) of the reinsurance premium specified in Exhibit E1.
3. ACTUAL COSTS applied against the Point of Service Budget will consist of:
a. In-Network Hospital Services costs incurred during the period of
calculation for which PacifiCare has received a claim and paid net of discounts;
In-Network Hospital Services incurred prior to the period of calculation and
paid during the current period; and for quarterly interim calculations,
In-Network Hospital Services incurred during the period for which PacifiCare has
received a claim but has not paid, less an average aggregate discount factor
(for year end calculations, only paid claims will be included); LESS Subscriber
claim costs in excess of the In-Network Hospital Services reinsurance deductible
specified above;
b. Claims paid charges for Out-of-Network Services incurred during the
current period; and paid claim charges for Out-of-Network Services incurred but
not included in prior period Point of Service Control Program calculations; LESS
c. Third party liability and coordination of benefit recoveries for
In-Network and Out-of-Network Services that are received during the period of
calculation.
4. SAVINGS DISTRIBUTION - In the event that total charges are less than the
earned Point of Service Budget, Medical Group shall be entitled to participate
in a capitation restoration program, whereby Medical Group shall receive the
difference between actual capitation paid for PacifiCare Point of Service
Subscribers for the period and the amount Medical Group would have received had
Medical Groups capitation payments been based on one hundred percent (100%) of
the rates as defined in Exhibit C. Distribution to Medical Group under this
capitation restoration program shall be limited to the savings available
pursuant to the Point of Service Control Program calculation. Additionally,
Medical Group shall receive fifty percent (50%) of any remaining savings, if
any, after the Medical Group capitation restoration distribution.
Medical Group is not at financial risk in the event that total charges
exceed the earned Point of Service Budget.
- 84 -
5. PERIODIC CALCULATIONS - the PacifiCare Point of Service Control Program
shall be administered on a Medical Group specific basis. For Medical Groups with
multiple facilities, the program shall be calculated for each facility, however
savings and payment distributions shall be based on Medical Groups consolidated
results.
Cumulative calculations of the PacifiCare Point of Service Control Program
results will be based on calendar quarters in conjunction with Commercial Plan
Hospital Control Program calculations, which are within sixty (60) days of the
end of each calendar quarter except for the first and forth quarters for which
no calculation or payment will be made in anticipation of the year end
settlement. Interim distribution payments will be limited to sixty percent
(60%) of calculated savings to account for incurred but not received claims.
Year end calculations and payments of the PacifiCare Point of Service Control
Program shall be made within one hundred eighty (180) days of the end of each
calendar year.
- 85 -
EXHIBIT H
CREDENTIALING DELEGATION TABLE
NOT DELEGATED TO MEDICAL GROUPS
THE FOLLOWING TABLE DOES NOT APPLY
- 86 -
-----------------------------------------------------------------------------------------------------------------------------
CR CR STANDARDS, NARRATIVE POTENTIALLY PCO COMMENTS
STANDARDS DELEGATED TO
APPROVED
PROVIDERS
-----------------------------------------------------------------------------------------------------------------------------
PROGRAM DESCRIPTION
-----------------------------------------------------------------------------------------------------------------------------
1.0 The managed care organization has X Delegated organization
written policies and procedures for the must include PCO's
credentialing process that include the P&Ps as an addendum to
original credentialing, recredentialing, their P&Ps
reclassification and/or reappointment of PCO must review the
physicians and other licensed delegated
independent practitioners who fall under organizations P&Ps to
its scope of authority and action. verify that PCO's
-Are there criteria that are applied to P&P's are included in
each applicant? an addendum, and then
-Are exceptions to criteria clearly review their
defined? credentialed
-Is there a stated time frame for /recredentialed files
recredentialing? to verify that they
-Is the recredentialing process clearly are complying with
described? PCO and NCQA
-Is there a stated process for reviewing, standards.
and revising P&Ps?
-----------------------------------------------------------------------------------------------------------------------------
GOVERNANCE APPROVAL
-----------------------------------------------------------------------------------------------------------------------------
2.0 The governing body, or the group or X Governance cannot be
individual to whom the governing body delegated. PCO's
has formally delegated the credentialing governing body must
function, reviews and approves the approve all PCO's
credentialing policies and procedures. credentialing
/recredentialing
policies and
procedures.
-----------------------------------------------------------------------------------------------------------------------------
COMMITTEE APPROVAL
-----------------------------------------------------------------------------------------------------------------------------
3.0 The managed care organization designates X PCO cannot delegate
a credentialing committee or other peer final approval of
review body that makes recommendations delegated credentialed
regarding credentialing decisions. or recredentialed
-Credentialing Policies and Procedures candidates. PCO
must reflect committee composition and Credentialing
meeting frequency. Committee will need to
-Committee minutes must reflect that the review and approve
-------------------------------------------------------------------------------------------------------------------
- 87 -
-----------------------------------------------------------------------------------------------------------------------------
committee thoughtfully considers the lists from delegated
credentials of each applicant. credentialing entities
and give final
approval.
The delegated
organization must
notify PCO of any
newly credentialed or
recredentialed
providers, at least
monthly.
-----------------------------------------------------------------------------------------------------------------------------
SCOPE OP AUTHORITY
-----------------------------------------------------------------------------------------------------------------------------
4.0 The managed care organization identifies X
those practitioners who fall under its
scope of authority and action.
4.1 Included, at a minimum, are all
physicians and other licensed
independent practitioners listed in the
managed care organizations literature
for members.
-----------------------------------------------------------------------------------------------------------------------------
CREDENTIALING PROCESS
-----------------------------------------------------------------------------------------------------------------------------
5.0 The initial credentialing process is X Primary verification
ongoing and up-to-date. At a minimum, can be delegated. The
the delegated organization obtains and process must meet NCQA
reviews verification of the following standards and
from primary sources. document, at a
5.1 A current valid license to practice; minimum,
5.2 Clinical privileges in good standing identification of the
at the hospital designated by the source, date verified,
practitioner as the primary admitting and reviewers
facility, as applicable; initials.
5.3 A valid DEA or CDS certification, as
applicable;
5.4 Graduation from medical school and
completion of a residency, or board
certification, as applicable;
5.5 Work history;
5.6 Current, adequate malpractice
insurance according to the managed care
organization's policy; and
5.7 Professional liability claims
history.
-----------------------------------------------------------------------------------------------------------------------------
- 88 -
-----------------------------------------------------------------------------------------------------------------------------
6.0 The applicant completes an application X The application form
for membership. should include all of
6.1 The application includes a statement these points outlined
by the applicant regarding; in the standard. If a
6.1.1 reasons for any inability to copy of an application
perform the essential functions of the from an organization
positions, with or without external to PCO is
accommodation; used, the copy must
6.1.2 lack of present illegal drug use include an original
#; attestation and
6.1.3 history of loss of license and/or physician signature to
felony convictions; correctness and
6.1.4 history of loss or limitation of completeness of the
privileges or disciplinary activity. application.
6.2 There is an attestation to
correctness /completeness of the
application.
-----------------------------------------------------------------------------------------------------------------------------
7.0 There is evidence that the delegated X PCO must review the
organization requests information on the delegates policy and
practitioner from recognized monitoring procedures on
organizations. obtaining information
7.1 The managed care organization has from appropriate
requested information from the National agencies. There must
Practitioner Data Bank. be evidence that the
7.2 The managed care organization has delegate's policy on
requested information from the State obtaining information
Board of Medical Examiners or Department has been followed.
of Professional Regulations (if
available).
7.3 The managed care organization has
reviewed for pervious sanction activity
by Medicare and Medicaid.
-----------------------------------------------------------------------------------------------------------------------------
SITE VISIT
-----------------------------------------------------------------------------------------------------------------------------
8.0 There is an initial visit to each X PCO must conduct site
potential primary care practitioner's visits on all PCPs and
office and to the offices of PCO high-volume
obstetricians/gynecologists and other delegates specialists.
high-volume specialists. this to the The site visit must
8.1 The visit results in documentation OMA/ARC occur within a one-
of a structured review of the site and Program year period prior to
of medical recordkeeping practices to the credentials
ensure conformance with the managed care committee's review and
organization's standards. recommendation.
-----------------------------------------------------------------------------------------------------------------------------
- 89 -
-----------------------------------------------------------------------------------------------------------------------------
Completed site visit
forms must be
maintained in PCO's
credentialing file.
There should be notes
in PCO's credentialing
file that describes
the results of the
visits.
PCO would not delegate
this to Medical Groups
or credentialing
agencies.
-----------------------------------------------------------------------------------------------------------------------------
OTHER PROVIDERS
-----------------------------------------------------------------------------------------------------------------------------
9.0 The managed care organization has X Prior to contracting,
written policies and procedures for the the managed care
initial quality assessment of health organization should
delivery organizations with which it verify that the
intends to contract. The managed care delivery organization
organization should confirm that the has met all state and
health delivery organization has been federal licensing and
reviewed and approved by a recognized regulatory
accrediting body, and is in good requirements.
standing with state and federal PCO should confirm
regulatory bodies. If the health that the health care
delivery organization has not been delivery organization
approved by a recognized accrediting has been approved by a
body, the managed care organization must recognized accrediting
develop and implement standards of body.
participation. Health delivery Verification from
organization include, but are not primary sources for
limited to: either licensure or
accreditation is not
CR9.1 Hospitals required.
CR9.2 Home Health Agencies
CR9.3 Nursing Homes
CR9.4 Free Standing Surgical Centers
-----------------------------------------------------------------------------------------------------------------------------
RECREDENTIALING PROCESS
-----------------------------------------------------------------------------------------------------------------------------
10.0 There is a process for the periodic X X Reverification of
verification of credentials primary verification
(recredentialing, reappointment, or credentials can be
recertification) that is ongoing and up- delegated. PCO must
-----------------------------------------------------------------------------------------------------------------------------
- 90 -
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to-date. verify that the
10.1 At a minimum, the recredentialing, delegates policies and
recertification or reappointment process procedures include
includes verification from primary PCO's P&Ps and an
sources of: attachment, and then
10.2.1 a valid state license to evaluate the extent to
practice; which the delegate
10.2.2 clinical privileges in good adheres to its
standing at the hospital designed by the policies and
practitioner as the primary admitting procedures in
facility; recredentialing
10.2.3 a valid DEA or CDS certificate, providers.
as applicable; PCO demonstrates
10.2.4 Board certification, as oversight of delegated
applicable; activities, and
10.2.5 current, adequate malpractice conducts for Provider
insurance according to the managed care Groups that are not
organization's policy; delegated.
10.2.6 professional liability claims
history.
10.3 The recredentialing process
includes a current statement by the
applicant regarding
10.3.1 physical and mental health
status;
10.3.2 lack of immurement due to
chemical dependency abuse.
-----------------------------------------------------------------------------------------------------------------------------
11.0 There is evidence that the managed care X The delegate must
organization requests information from PCO does document primary
recognized monitoring organizations. oversight/ verification
11.1 The managed care organization has continuous including, at a
requested information from the National monitoring minimum,
Practitioner Data Bank. identification of the
11.2 The managed care organization has source, date verified,
requested information from the State and reviewers
Board of Medical Examiners or Department initials.
of Professional Regulations (if
available).
11.3 The managed care organization has
reviewed for previous sanction activity
by Medicare and Medicaid.
-----------------------------------------------------------------------------------------------------------------------------
12.0 The recredentialing, recertification or X PCO's and it's
performance appraisal process also delegates must have
-----------------------------------------------------------------------------------------------------------------------------
- 91 -
-----------------------------------------------------------------------------------------------------------------------------
includes review of data from member recertification
complaints, results of quality reviews, policies and
utilization management, and member procedures
satisfaction surveys. Both PCO and it's
12.1 member complaints; delegates
12.2 results of quality reviews; recertification
12.3 utilization management; processes must
12.4 member satisfaction surveys incorporate
information from
various QI processes,
such as member
complaints, results of
QI studies, UM, and
member satisfaction
surveys.
Practitioners must be
recredentialed every
two years.
-----------------------------------------------------------------------------------------------------------------------------
13.0 The recredentialing process includes an X PCO must conduct site
on-site visit to provider offices. PCO visits on all PCPs
13.1 The visit results in documenting of delegates and high-volume
a structured review of the site and of to the specialties.
medical recordkeeping practices to OM/ARC The site visit must be
ensure conformance with the managed care Program completed prior to
organization's standards. recredentialing.
13.2 The following offices should be There must be explicit
visited: standards for
13.2.1 all primary care providers criteria.
13.2.2 all obstetricians/gynecologists; Completed site visit
13.2.3 high-volume specialists forms must be
maintained in the
credentialing file.
There should be notes
in the credentialing
file that describes
the results of the
visits.
PCO would directly
work with the OMA ARC
program, but not to
provider groups or
other entities
-----------------------------------------------------------------------------------------------------------------------------
- 92 -
-----------------------------------------------------------------------------------------------------------------------------
DELEGATION
-----------------------------------------------------------------------------------------------------------------------------
14.0 The managed care and delegated X PCO must have P&Ps to
organization has policies and procedures suspend or terminate
for the reducing, suspending, or providers when serious
terminating practitioner privileges. quality deficiencies
14.1 There is a mechanism for, and are identified.
evidence of implementation of procedures PCO must have an
for, reporting to appropriate appeal process for
authorities serious quality deficiencies practitioners whose
which could result in suspension or privileges have been
termination of a practitioner's reduced, suspended, or
participation. terminated.
14.2 There is an appeal process in There must be evidence
instances where the managed care that PCO identifies
organization reduces, suspends, or serious quality
terminates a practitioner's deficiencies, and
participation for reasons relating to takes appropriate
quality of care, competence, or action.
professional conduct. The managed care PCO must have a
organization makes known to the mechanism
practitioner the procedure by which to for
appeal an adverse determination. notifying any
practitioner and
their organization
that privileges have
been reduced,
suspended, or
terminated by the
appeal process.
-----------------------------------------------------------------------------------------------------------------------------
15.0 If the managed care or delegated X Delegate's contract
organization delegates any credentialing provisions must
(and recredentialing, recertification, include PCO's
or reappointment) activates to credentialing and
contractors, there is evidence of recredentialing P&Ps
oversight of the contracted activity. PCO must monitor it's
15.1 There is written description of: delegates
15.1.1 the delegated activities; credentialing and
15.1.2 the delegate's accountability for recredentialing
these activities. processes at least
15.2 The managed care organization annually.
retains the right to approve new Delegate must have
providers and sites, and to terminate or process for notifying
suspend individual providers. PCO of provider
15.3 The managed care organization additions, deletions,
-----------------------------------------------------------------------------------------------------------------------------
- 93 -
-----------------------------------------------------------------------------------------------------------------------------
monitors the effectiveness of the or other
delegate's credentialing and status
reappointment or recertification changes.
processes at least annually. PCO must reserve the
right to
approve/disapprove
individual
practitioners and
sites.
PCO delegates must
coordinate PCO's QI
program and the
delegate's
recertification
process.
PCO staff must review
delegates
credentialing
committee minutes,
credentialing files,
verification
documentation and
incorporated
recredentialing
processes.
-----------------------------------------------------------------------------------------------------------------------------
- 94 -
EXHIBIT I
DELEGATION OF QUALITY IMPROVEMENT
FOLLOWING THREE PAGES
- 95 -
-----------------------------------------------------------------------------------------------------------------------------
QI QI STANDARDS, NARRATIVE DELEGATED TO PCO
STANDARDS PROVIDER GROUP
-----------------------------------------------------------------------------------------------------------------------------
1.0 PROGRAM STRUCTURE X
-----------------------------------------------------------------------------------------------------------------------------
2.0 ACCOUNTABILITY TO THE GOVERNING BODY X
-----------------------------------------------------------------------------------------------------------------------------
3.0 COORDINATION WITH OTHER MANAGEMENT ACTIVITY X
-----------------------------------------------------------------------------------------------------------------------------
3.1 QI information is used in recredentialing, recontracting, and/or annual
performance evaluations:
Provider Groups X
PCO-contracted ancillary providers X
Provider Group contracted ancillary providers X
Provider Group contracted specialists X
-----------------------------------------------------------------------------------------------------------------------------
3.2 QI activities are coordinated with other performance monitoring activities, X
including UM, RM, and resolution and monitoring of member complaints and
grievances.
-----------------------------------------------------------------------------------------------------------------------------
3.3 There is a linkage between QI and other management functions of the managed care X
organization. Examples of such linkages include network changes, benefits
redesign, medical management systems, practice feedback to physicians, and
patient education.
-----------------------------------------------------------------------------------------------------------------------------
4.0 PROVIDER CONTRACTS:
PCO-contracted Provider Groups X
PCO-contracted ancillary providers X
PCO-contracted hospitals and HDOs X
Provider Group contracted specialists X
Provider Group contracted ancillary providers X
-----------------------------------------------------------------------------------------------------------------------------
5.0 SCOPE AND CONTENT X
-----------------------------------------------------------------------------------------------------------------------------
6.0 IMPORTANT ASPECTS OF CARE AND SERVICE X
-----------------------------------------------------------------------------------------------------------------------------
6.1 The monitoring and evaluation of important aspects of care and service includes X
high-volume services and high-risk services, and the care of acute and chronic
conditions.
-----------------------------------------------------------------------------------------------------------------------------
6.2 The managed care organization is accountable for adopting and using practice X
guidelines or explicit criteria that are based on reasonable scientific evidence
and reviewed by managed care organization providers.
-----------------------------------------------------------------------------------------------------------------------------
6.3 The managed care organization evaluates the continuity and coordination of care X
members receive.
-----------------------------------------------------------------------------------------------------------------------------
6.4 The managed care organization has mechanisms to detect underutilization as well X
as overutilization.
-----------------------------------------------------------------------------------------------------------------------------
7.0 ACCESS TO CARE AND SERVICE:
Access standards X
-----------------------------------------------------------------------------------------------------------------------------
- 96 -
-----------------------------------------------------------------------------------------------------------------------------
Performance on these standards is assessed against these standards: X
-----------------------------------------------------------------------------------------------------------------------------
8.0 HEALTH MANAGEMENT SYSTEMS X
-----------------------------------------------------------------------------------------------------------------------------
9.0 MEASUREMENT AND IMPROVEMENT
-----------------------------------------------------------------------------------------------------------------------------
9.1 Quality indicators that are objective, measurable, and based on current X
knowledge and clinical experience are used to monitor and evaluate each
important aspect of are and service identified.
-----------------------------------------------------------------------------------------------------------------------------
9.1.1 The managed care organization has performance goals and/or a benchmarking X
process for each indicator.
-----------------------------------------------------------------------------------------------------------------------------
9.2 Appropriate methods and frequency of data collection are used for each indicator X
-----------------------------------------------------------------------------------------------------------------------------
9.2.1 QI activities include the collection of necessary data
-----------------------------------------------------------------------------------------------------------------------------
9.3 Data collected through monitoring and evaluation activities are analyzed
- Collection and Submission X
- Oversight and Evaluation of Data Quality X
-----------------------------------------------------------------------------------------------------------------------------
9.3.1 Appropriate clinicians are used to evaluate data on clinical performance of X
practitioners
-----------------------------------------------------------------------------------------------------------------------------
9.3.2 Multidisciplinary teams are used, where indicated, to analyze and address X
systems issues.
-----------------------------------------------------------------------------------------------------------------------------
10.0 ACTION AND FOLLOW-UP:
The managed care organization takes actions to improve quality and assess the
effectiveness of these actions through systematic follow-up. X
-----------------------------------------------------------------------------------------------------------------------------
10.1 There is evidence that results of evaluations are used to improve clinical care X
and service.
-----------------------------------------------------------------------------------------------------------------------------
10.2 There is a systematic method of tracking areas identified for improvement to X
assure that appropriate action is taken.
-----------------------------------------------------------------------------------------------------------------------------
10.3 The managed care organization assures follow-up on identified issues to ensure X
that actions for improvement have been effective.
-----------------------------------------------------------------------------------------------------------------------------
11.0 EFFECTIVENESS OF THE QI PROGRAM X
-----------------------------------------------------------------------------------------------------------------------------
11.1 There is an annual written report on quality, including a report of completed QI
activities, trending of clinical and service indicators and other performance
data, and demonstrated improvements in quality. X
-----------------------------------------------------------------------------------------------------------------------------
11.2 There is evidence that QI activities have contributed to improvement in the care X
and services provided members.
-----------------------------------------------------------------------------------------------------------------------------
12.0 DELEGATION OF QI ACTIVITY: X
If the managed care organization delegates any QI activities to contractors,
there is evidence of oversight of the contracted activity.
(I suggest we use the NCQA Tool Matrix (page 45 of the tool book; attached) to
document and delegation to groups, especially if there are any exceptions to PCO
general standards.
-----------------------------------------------------------------------------------------------------------------------------
- 97 -
EXHIBIT I
DELEGATION OF QUALITY IMPROVEMENT (Continued)
PACIFICARE OF OREGON MEDICAL RECORDS
DELEGATION TABLE BY NCQA STANDARD
----------------------------------------------------------------------------------------------------
MEDICAL RECORDS MEDICAL RECORDS POTENTENTIALLY PCO COMMENTS
STANDARDS STANDARDS, NARRATIVE DELEGATED
TO APPROVED
PROVIDERS
----------------------------------------------------------------------------------------------------
1.0 Medical Records are X Oversight
maintained Responsibility
in a ; mechanics of
manner that is this oversight
current, detailed, is delegated
organized, and to the OMA/ARC
permits effective Program
patient care and
quality review
----------------------------------------------------------------------------------------------------
1.1 All records reflect X Oversight
all aspects of care delegated to
the OMA/ARC
Program
----------------------------------------------------------------------------------------------------
1.2 Records available to X Oversight
health practitioners delegated to
at each encounter the OMA/ARC
Program
----------------------------------------------------------------------------------------------------
2.0 Managed care set X Coalition
standards for Coalition of of HMO's
medical records; HMO's wrote provides
systematically and agreed to oversight
reviews records for standards; to the
conformance and mechanics of OMA/ARC
institutes this oversight Program
corrective action is delegated
when standards are to the OMA/ARC
not met Program
----------------------------------------------------------------------------------------------------
3.0 Documentation of X X
items demonstrates Oversight
medical records are delegated to
in conformity the OMA/ARC
Program
----------------------------------------------------------------------------------------------------
Medical Records: Flow Sheet/Each Provider
1. Maintenance of clinical medical records.
2. Review of office space medical records for conformance with standards.
3. Documentation that medical records are in conformity with good medical
practice.
- 98 -
EXHIBIT J
DELEGATION OF UTILIZATION MANAGEMENT
Next Two Pages
- 99 -
------------------------------------------------------------------------------------------------------------------------------------
UM UM STANDARDS, NARRATIVE DELEGATED PCO UNCERTAIN COMMENTS
STANDARDS TO IF
PROVIDERS DELEGATED
------------------------------------------------------------------------------------------------------------------------------------
1.0 Managed care organization has documented X
Utilization Management (UM) program description
that describes both delegated and non-delegated
activities.
------------------------------------------------------------------------------------------------------------------------------------
2.0 Where procedures are used for pre-authorization X X See above.
and concurrent review, qualified medical
professional supervise and review decisions.
------------------------------------------------------------------------------------------------------------------------------------
3.0 There is a set of written UM review decision X The Plan gives direction to
protocols that are based on reasonable medical the groups that they use
evidence. MILLIMAN & ▇▇▇▇▇▇▇▇▇ as
their Protocol.
------------------------------------------------------------------------------------------------------------------------------------
4.0 Efforts are made to obtain all necessary X X Timelines are mandated by
information, including printed clinical PCO with oversight.
information and consultation with treating
physician as appropriate.
------------------------------------------------------------------------------------------------------------------------------------
5.0 Decisions are made in a timely manner depending on X X PCO mandates appeals
the urgency of the situation. language.
------------------------------------------------------------------------------------------------------------------------------------
6.0 Reasons for denial include a document available to X X See 1.0.
member. Notification of a denial includes appeal
process.
------------------------------------------------------------------------------------------------------------------------------------
7.0 Managed Care Organization has policies and X The technology assessment
procedures in place to evaluate the appropriate process and Committee are
use of new medical technology or new applications not delegated and are held
of established technologies including medical at PacifiCare. The groups
procedures, drugs and devices. access PacifiCare's
decisions around new
technologies for coverage
determinations.
------------------------------------------------------------------------------------------------------------------------------------
8.0 There are mechanisms to evaluate effects of the X Currently PCO is beginning
program using member satisfaction data, provider to look at a broader
satisfaction and other appropriate means. spectrum review of the UM
issues. The groups do
address our UM issues
within their own systems
through data and/or
experiential information in
terms of over utilization
issues. None of the groups
------------------------------------------------------------------------------------------------------------------------------------
- 100 -
------------------------------------------------------------------------------------------------------------------------------------
UM UM STANDARDS, NARRATIVE DELEGATED PCO UNCERTAIN COMMENTS
STANDARDS TO IF
PROVIDERS DELEGATED
------------------------------------------------------------------------------------------------------------------------------------
are accessing member
satisfaction or provider
satisfaction in their
issues, neither is
PacifiCare. That will be
something that we need to
look at.
------------------------------------------------------------------------------------------------------------------------------------
9.0 Managed care delegates any UM activities to X Applies to all above.
contractors if there is oversight of contracted
activity.
------------------------------------------------------------------------------------------------------------------------------------
- 101 -
EXHIBIT K
DELEGATION OF CLAIMS PAYMENT
(In Development)
- 102 -
EXHIBIT L
MEDICAL GROUP SERVICE AREA
SERVICE AREA DEFINITION
SERVICE AREA
Service area is the geographic area within Linn and ▇▇▇▇▇▇ Counties.
Said radius commences with the address of Medical Group and extends for twenty
(20) miles over the shortest route using public streets and highways.
Medical Group's Service Area shall be established for Medical Group
main office, its operated satellite offices, and subcontracted primary care
provider locations.
- 103 -
EXHIBIT M
ACCESS GUIDELINES
PACIFICARE OF OREGON
ACCESS GUIDELINES(1)
-------------------------------------------------------------------------------------
TIMEFRAME FOR APPOINTMENT
ACCESS INDICATOR
-------------------------------------------------------------------------------------
Emergency Immediate
-------------------------------------------------------------------------------------
Urgent Within 24 hours
-------------------------------------------------------------------------------------
Nonurgent (Symptomatic) 7 Calendar Days
-------------------------------------------------------------------------------------
Routine Health Assessment 30 Calendar Days
(Asymptomatic)
EXAMPLES OF ROUTINE VISITS:
PAP, IMMUNIZATIONS, WELL BABY
CHECK, BLOOD PRESSURE CHECK,
PO2 LEVELS, DIABETIC CHECK
-------------------------------------------------------------------------------------
History and Physical 42 Calendar Days
Examination
New Member Appointments
-------------------------------------------------------------------------------------
Specialty Urgent Referral Within 24 Hours
-------------------------------------------------------------------------------------
Specialty Nonurgent Referrals:
- Specialty asymptomatic 30 Calendar Days
routine health referral,
e.g., ophthalmology
- Specialty asymptomatic 21 Calendar Days
nonroutine health referral
(From time patient is
notified a referral will be
requested, until seen by
referral specialist)
- Specialty nonurgent 14 Calendar Days
symptomatic referral (From
time referral is authorized
by Patient Care Committee of
Provider, until member is
seen by Referral Specialist)
-------------------------------------------------------------------------------------
(1) Access to care may vary based on the severity of the members presenting
symptoms. These access parameters are not intended to substitute for sound
clinical judgment based on an individual's needs.
- 104 -
PACIFICARE OF OREGON/WASHINGTON
MEDICAL GROUP SERVICES AGREEMENT
1996 AMENDMENT
ALL CHANGES EFFECTIVE 1/1/96
The Medical Group Services Agreement ("Agreement") by and between PacifiCare,
Inc., and CORVALLIS CLINIC, entered into on January 1, 1996, is hereby amended
in the following particulars:
Section 5.5 is amended, Section 12.18 is added to the Agreement, and Exhibit
"F1" of the Agreement is amended as attached.
IN WITNESS WHEREOF, the parties agree to the foregoing amendments to
the Agreement as dated below.
PACIFICARE OF OREGON CORVALLIS CLINIC
By: /s/ ▇▇▇▇ ▇. ▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
------------------------------ ------------------------------
▇▇▇▇ ▇. ▇▇▇▇▇▇
Contract Administrator Name: ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
--------------------------------
(please print)
Title: CEO
-------------------------------
Tax ID#:
Date: 8/2/96 Date: 8-6-96
------------------------------- --------------------------------
- 1 -
5.5 CHANGES IN ACCEPTED TREATMENT - In the event that one or more
recognized changes in commonly accepted standards of treatment followed by the
preponderance of the medical profession result in the aggregate in an increase
in the cost of Covered Services, Medical Group and PacifiCare shall equally
share such increase in cost during the term of this Agreement and
any Continuing Care Period thereafter.
A significant increase in the cost of Covered Services shall be
considered to exist within the meaning of this Section if the cost of treatment
in accordance with appropriate treatment protocols increases by more than one-
half of one percent (.5%) of Medical Group's Capitation Payments in a calendar
year.
PacifiCare's Medical Director, in consultation with Medical Group and the
Quality Improvement Committee, shall initially determine whether a
recognized change in commonly accepted standards of treatment followed by the
preponderance of the medical profession has occurred and shall
determine treatment protocols to be followed by Medical Group. Medical
Group may request review of such determinations by PacifiCare pursuant to
Section 9.5 or arbitration pursuant to Section 9.7.
********
12.18 ADDITIONAL PROVISIONS APPLICABLE TO MEDICAL SERVICES CONTRACT - To
the extent this Agreement is deemed a Medical Services Contract as defined by
Oregon law, the following provisions shall apply in addition to all other
provisions of this Agreement:
12.18.01 NOTICE AND HEARING RIGHTS. If this Agreement is
terminated or not renewed based upon issues relating to the quality of patient
care rendered by Medical Group, Medical Group shall be entitled to the notice
and hearing rights afforded under PacifiCare's policies and procedures
regarding termination of provider groups for reasons relating to quality of
care.
12.18.02 ANNUAL ACCOUNTING. Upon Medical Group's request,
following the end of each calendar year during the term of this Agreement,
PacifiCare shall furnish Medical Group with an annual accounting accurately
summarizing the financial transactions between Medical Group and PacifiCare for
such calendar year.
12.18.03 WITHDRAWAL FROM CARE OF PATIENT. Medical Group may
withdraw from the care of a patient, when, in the professional judgment of
Medical Group, it is in the best interest of the patient to do so.
12.18.04 MEDICAL DIRECTOR. A doctor of medicine or osteopathy
licensed under ORS Chapter 677 shall be retained by PacifiCare as the
PacifiCare Medical Director and shall be responsible for all final medical and
mental health decisions relating to coverage or payment made by PacifiCare
pursuant to this Agreement.
- 2 -
EXHIBIT F1
PRESCRIPTION SERVICES PROGRAM
PACIFICARE COMMERCIAL HEALTH PLAN
The purpose of the Pharmacy Control Program is to provide an incentive to the
Medical Group to ▇▇▇▇▇▇ efficient utilization of prescription services. If
pharmacy costs for a calendar year are below the Medical Group's budget, the
Medical Group has the opportunity to share in the savings.
PHARMACY CONTROL PROGRAM BUDGET
The Pharmacy Control Program budget shall equal nine dollars thirty cents
($9.30) per member assigned to the group per month.
ACTUAL COSTS
The Actual Costs will be the actual expenses paid by PacifiCare for pharmacy
services of those members assigned to the Medical Group for the applicable
month.
BUDGET SURPLUS
In the event that Actual Costs are less than the Pharmacy Control Program
Budget, the amount will be referred to as a Budget Surplus. If Actual Costs are
less than the Budget, PacifiCare shall pay the Medical Group seventy-five
percent (75%) of the savings. Medical Group is not responsible for Actual
Costs in excess of earned budget.
UTILIZATION REPORTS
PacifiCare shall provide quarterly utilization reports to Medical Groups.
Total pharmacy expenditures for the Pharmacy Control Program will be
calculated and reported on an annual basis only.
PHARMACY CONTROL PROGRAM CALCULATIONS
The annual Pharmacy Control Program calculations shall be completed within one
hundred twenty (120) days of year end. If Medical Group is entitled to a
payout, PacifiCare shall make payment within one hundred twenty days of year
end.
- 3 -
PACIFICARE OF OREGON/WASHINGTON
MEDICAL GROUP SERVICES AGREEMENT
1996 AMENDMENT
ALL CHANGES EFFECTIVE 1/1/96
The Medical Group Services Agreement ("Agreement") by and between PacifiCare,
Inc., and CORVALLIS CLINIC, entered into on January 1, 1996, is hereby amended
in the following particulars:
Exhibit E1 - Hospital Control Program - PacifiCare Commercial Health Plan - of
the Agreement, is amended by adding the highlighted paragraph as follows:
4. CALCULATION OF SAVINGS AND LOSSES
If actual costs are less than the earned budget, then Medical Group will be paid
according to the attached schedule.
Interim settlements on the Hospital Control Program shall be made on a quarterly
basis commencing with the second quarter. Payment shall equal 75% of the amount
due to Medical Group. Payment is due within 60 days after the end of the
reporting period.
Medical Group shall submit all requests to reconcile the quarterly
risk settlement no later than sixty (60) days after receipt of each quarterly
risk settlement report. PacifiCare shall respond to reconciliation requests
within sixty (60) days of receipt of request. No later than August 31 after the
end of the prior year can the Medical Group submit request for claims
readjudication under risk settlement for the prior year.
Final payment will be made within one hundred and fifty (150) days of the end of
the contract period.
IN WITNESS WHEREOF, the parties agree to the foregoing amendments to
the Agreement as dated below.
PACIFICARE OF OREGON CORVALLIS CLINIC
By: /s/ ▇▇▇▇ ▇. ▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
----------------------------- -----------------------------
▇▇▇▇ ▇. ▇▇▇▇▇▇
Contract Administrator Name: ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
------------------------------
(please print)
Title: Chief Executive Officer
-----------------------------
Tax ID#:▇▇-▇▇▇▇▇▇▇
Date: 9/5/96 Date: September 16, 1996
------------------------------ ------------------------------