UNIVERSAL HEALTH CARE INSURANCE COMPANY
PROVIDER SERVICES AGREEMENT
This Provider Service Agreement (“Agreement”) is made and entered into as of this ______day of ______, 20___, (“Effective Date”), by and between,______(“Provider”) and Universal Health Care Insurance Company, Inc., a subsidiary of Universal Health Care Group, Inc., a Delaware corporation, referred to herein as (“Health Plan”).
RECITALS
WHEREAS, Health Plan offers a Medicare Advantage Private Fee-For-Service (“PFFS”) plan and a Medicare Advantage Preferred Provider Organization (“PPO”); and
WHEREAS, Health Plan desires to contract with various health care service providers in order to assure Health Plan members that certain health care service providers have agreed in advance to provide health care services to Health Plan members in accordance with the Health Plan’s terms and conditions; and
WHEREAS, Health Plan has been granted a Medicare Advantage contract with the Federal Centers for Medicare and Medicaid Services (“CMS”) in order to enroll, and arrange for health care services for Medicare Members; and
WHEREAS, Providerprovides health care services that are covered under the Health Plan and desires to contract with Health Plan to provide and/or arrange for all Medically Necessary Covered Services to certain Health Plan Members in the specialty of ______; and
AGREEMENT
NOW, THEREFORE, in consideration of the above recitals and the mutual promises and covenants contained herein, the parties hereby agree as follows:
SECTION 1: DEFINITIONS
Clean Claim: means a UB-04 or HCFA 1500, as applicable, or any successor form, which has been fully and accurately completed.
CMS: The Centers for Medicare and Medicaid Services.
Co-payment: means any amount, other than a deductible or co-insurance, required to be paid by a Member for a Covered Service in accordance with the Schedule of Benefits applicable to the particular benefit plan in which such Member is enrolled
Covered Service: means all medical, hospital, and other services covered under the applicable health services benefit plan in which a Member has enrolled and other services covered under the Health Plan’s Schedule of Benefits.
Emergency Medical Condition: An emergency medical condition is: (1) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: 1. Serious jeopardy to the health of a patient including a pregnant woman or a fetus. 2. Serious impairment to bodily functions. 3. Serious dysfunction of any bodily organ or part. (2) With respect to a pregnant woman: 1.That there is adequate time to affect safe transfer to another hospital prior to delivery. 2. That a transfer may pose a threat to the health and safety of the patient or fetus. 3. That there is evidence of the onset and persistence or uterine contraction or rupture of the membranes which results in medical screening, examination and evaluation by a physician, or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an Emergency Medical Condition exists, and the care, treatment, or surgery for a Covered Service by a physician which is necessary to relieve or eliminate the Emergency medical condition, within the service capability of a hospital. This includes Covered Services that are (1) furnished by a physician qualified to furnish Emergency services and (2) needed to evaluate or stabilize an Emergency medical condition. This provision also includes the ability for immediate transfer to another PCP or Health Plan if the Enrollee’s health or safety is in jeopardy.
Emergency Services and Care: medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists, and if it does, the care, treatment, or surgery for a covered service by a physician which is necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital.
HIPAA: Health Insurance Portability and Accountability Act
Medicare Contract: the contract between the Health Plan and the Centers for Medicare and Medicaid Services (CMS), or its successor, in which the Health Plan agrees to provide or arrange for the provision of health care services to persons eligible for Medicare under Title XVIII of the Social Security Act.
Member: any individual or eligible dependent of such individual, who has been enrolled in a health services benefit plan offered by or administered by the Health Plan.
Participating Physician: duly licensed doctor of medicine, dentistry, psychiatry, osteopathic medicine, doctor of chiropractic or podiatric medicine, having an unrestricted license to practice medicine in the jurisdiction in which such individual’s services are to be provided.
Participating Provider: includes Participating Physicians, Hospitals and other professionals and other facilities with which the Health Plan has a contract to provide Covered Services.
Preferred Provider Organization: (PPO) a benefit plan providing differing levels of coverage for “in-
network” (participating) and “out-of-network” (non-participating) services. “Medicare PPO” refers to a PPO plan provided under a contract with the Centers for Medicare and Medicaid Services (CMS).
Schedule of Benefits: the schedule of Covered Services corresponding to the health services benefit plan under which a particular Member has enrolled. The Schedule of Benefits also lists certain items or services, which are excluded or limited. Any service obtained by Members that is excluded or which has exceeded the limitation for that service is not a Covered Service and will be the financial responsibility of the Member.
Subcontractor: a person or entity that is contracted by a Provider to provide Covered Services to Members pursuant to this Agreement.
SECTION 2: NEW PRODUCTS/PAYMENT MECHANISM.
During the term of this Agreement, Health Plan may, from time to time, develop new products and/or payment mechanisms. Provider shall be provided with thirty (30) days written notice prior to the implementation of such new products or payment mechanisms. If Provider does not object to the implementation of such new product or payment mechanism within such thirty (30) day notice period, Provider shall be deemed to have accepted the new product or payment mechanism. In the event Provider objects to any such new product or payment mechanism, the parties shall confer in good faith to reach agreement. If such agreement cannot be reached, Health Plan may implement such new product and or payment mechanism; Provider shall have the right to terminate this Agreement pursuant to Section 7.
SECTION 3: MEDICAL SERVICES. Provider agrees to provide or arrange for Medically Necessary Covered Services for Members in accordance with Attachment A and without regard to race, color, religion, national origin, or handicap of any Member. Provider agrees further to render said Medically Necessary Covered Services to Health Plan Members in the same manner and in accordance with the same standards of the profession.
SECTION 4: PROVIDER FEES. Health Plan shall pay Provider in accordance with payment arrangements outlined in Attachment B-1 and B-2. Provider shall collect any co-payment and/or co-insurance amount applicable to the services provided. Payment from Health Plan plus the payments owed by Members pursuant to their contract shall be accepted by Provider as payment in full for all Medically Necessary Covered Services. Provider agrees that all payments due as a result of services rendered to Health Plan Members shall be made after all properly documented claims/invoices have been received by the Health Plan.
Health Plan reserves the right to make adjustments to payments previously made herein to reflect corrections based on internal or external audits or other reviews. Provider shall have the right to review Health Plan’s audit results, if any, at a time and place mutually convenient to both parties. This clause shall survive the termination of this Agreement for a period of one (1) year. Provider agrees to promptly notify Health Plan of all duplicate payments regardless of cause. Upon notice Health Plan may offset such overpayments as outlined.
SECTION 5: POLICIES AND PROCEDURES.
Provider agrees to abide by all quality assurance, utilization review, credentialing, licensing, insurance and other policies and procedures established and revised by Health Plan from time-to-time. Provider shall be notified of any revisions to the policies and procedures and they shall become binding upon Provider thirty (30) days following written notification. Any revisions affecting Provider shall not be discriminatory and shall apply to all Providers similarly situated. If Provider objects to any such revision, Provider may give notice of such objection and submit their intent to terminate the Agreement using the provider termination process outlined in Section 7 of this Agreement. Universal may at its discretion accept a providers termination at an earlier time than the ninety (90) day notice time period and remove the provider from the network.
SECTION 6: REGULATORY REQUIREMENTS.
Agency Liability: Provider agrees that neither Centers for Medicare and Medicaid Services (CMS), nor any Health Plan Member will be held liable for any debts of the Health Plan and in accordance with 42 CFR 417.15, that the Member is not liable to the Provider for any services for which the Health Plan is liable. The Health Plan as the Medicare Advantage Contractor is ultimately responsible to CMS for any functions and responsibilities as described in the Medicare Advantage Contractor regulations. This Section shall survive the termination of this Agreement for any reasons, including breach of contract because of insolvency.
Confidentiality of Records: In accordance with 42 CFR 438.224, 422.504(a)(13), and 422.118, the Provider shall safeguard the privacy of any health information that identifies a particular Health Plan Member. Health Plan, Provider shall abide by all state and federal laws regarding confidentiality and disclosure of medical records, as well as compliance to enrollee accuracy and other health and enrollee information. Provider further agree to allow Health Plan the right to periodically monitor and access Provider records in order to ensure Provider’s compliance with all state and federal confidentiality laws and Health Plan policies and procedures.
Claim Payment: In accordance with 42 CFR 422.520(b), all claims for payment, whether electronic or non-electronic must be mailed or electronically transferred to the Health Plan within one hundred twenty days (120) of the discharge for inpatient services or the date of service for outpatient services. Within twenty (20) days of receipt of all electronically submitted claims, the Health Plan shall pay the claim or notify the Provider if the claim is denied or contested. For all non-electronically submitted claims, the Health Plan shall pay the claim or notify the Provider within thirty (30) days if the claim is denied or contested. This Agreement calls for the claims/invoices to be submitted on the appropriate HCFA 1500 or UB04 form and that ninety five (95) % of all clean claims will be paid by Health Plan within thirty (30) days. The Health Plan shall abide by all other prompt payment of claims provisions of 42 CFR 422.520(b) including processing of overpayments and underpayments.
HIPAA: Health Plan and Provider shall abide by all federal and state laws regarding confidentiality, accuracy, and disclosure of medical records and other health and enrollee information. Provider shall assure its own compliance and that of any business associates with all the privacy and security provisions of HIPAA regulations and in accordance with 42 CFR, Part 431, Subpart F, as they become effective.
Member Non Liability: In accordance with CFR 422.504(g)(1)(i), 422.504(g)(1)(ii), 422.504(g)(1)(iii) and CFR 422.504 (g)(3), Provider hereby agrees that in no event, including but not limited to non-payment by Health Plan, insolvency or breach of the Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members of Health Plan or persons other than Health Plan acting on their behalf for Medically Necessary Covered Services provided pursuant to this Agreement and that Provider will “Hold Harmless” Members of Health Plan under this provision. This provision shall not prohibit collection of any co-payments, cost sharing, and/or co-insurance in accordance with the terms of the Agreement, unless the member is a Dual Eligible Enrollee, where the Member will not be responsible for any plan cost sharing for Medicare part A and B services. Collection of cost sharing amounts will be deemed as waived by Provider or when the state is responsible for paying those amounts, remuneration will be sought by Provider through the state.
Provider agrees that in event of the Health Plan insolvency or other cessation of operations, benefits to Members will continue through the period for which premium has been paid and benefits to Members confined in an inpatient facility of the date of insolvency or other cessation of operations will continue until their discharge. Provider further agrees not to seek reimbursement from the Health Plan’s Medicare Members for services rendered to them under or in the course of this Agreement. Should the contract with the CMS be terminated or expire, payment for all services performed for eligible Medicare Members prior to termination will be guaranteed by the Health Plan.
Provider further agrees that: (1) this provision shall survive the termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the Member, (2) this provision supersedes any oral or written contrary Agreement now existing or hereafter entered into between Provider and Member or persons acting on their behalf, and (3) this provision shall apply to all employees and Subcontractors of Provider, and Provider shall obtain from such persons specific Agreement to this provision.
Medical Records: Medical records shall be maintained for a period of not less than ten (10) years, including after termination of this Agreement and be retained further if records are under inspection, evaluation or audit until such inspection, evaluation or audit is completed. Upon request, Health Plan or any federal or state regulatory agency, as permitted by law, may obtain copies and have access to any medical, administrative or financial record of Provider related to Medically Necessary Covered Services provided by Provider to any Member. Provider further agrees to release copies of medical records of Members who have been discharged from Provider to Health Plan for retrospective review and special studies.
NPI: Provider must have a National Provider Identifier (NPI) in accordance with the timelines established in 45 C.F.R. Part 162, Subpart D.
Right to Audit: Provider agrees to give the Health Plan, CMS, State Regulators; or their designees the right to audit, monitor, evaluate or inspect any books, contracts, medical records, patient care documentation and other records of the Provider that pertain to: (1) the quality, appropriateness, accuracy, charges, dates and all other commonly accepted information elements for services rendered, and timeliness of service performed under this Agreement; and that care was provided in a manner consistent with professionally recognized standards of health care, all benefits covered by Medicare, in accordance with 42 CFR 422.504(a)(3)(iii), 42 CFR 422.188 (2) reconciliation of benefit liabilities; (3) determination of amounts payable; (4) medical audit or review; (5) utilization review; or (6) other relevant matters as such person(s) conducting the audit, evaluation or inspection deems necessary, in accordance with 42 CFR 422.504(e)(2).
The right to access described above shall extend through ten (10) years from the final date of the applicable contract period or completion of the audit, whichever is later, provided however, that such access may be required for a longer time period if: (1) CMS determines that there is a special need to retain a particular record or group of records for a longer period and CMS provides notice at least thirty (30) days before the normal disposition date; or (2) CMS determines that there has been a termination, dispute, fraud or similar fault, in which case, the retention may be extended to ten (10) years from the date of any resulting final resolution of the matter; or (3) CMS determines that there is a reasonable possibility of fraud, in which case it may perform the inspection, evaluation or audit at any time, in accordance with 42 CFR 422.504(e)(3), 42 CFR 422.504(i)(2)(ii), and 42 CFR 422.504(e)(4).
Negligent Acts and Wrongful Conduct: The Provider will indemnify, defend, and hold harmless Health Plan, Federal Agencies, State Agencies, Regulatory Agencies, and Members, from and against all claims, damages, causes of action, costs of expense, including court cost and reasonable attorney fees to the extent proximately caused by any negligent act or other wrongful conduct arising from this agreement. This will survive the termination of the agreement, including breach due to insolvency, and the Agency may waive this requirement for itself, but not Health Plan Enrollees, for damages in excess of the statutory cap on damages for public entities if the Provider is a public health entity with statutory immunity (all such waivers must be approved in writing by the Agency).