3417 73rd Street, Suite T Lubbock, Texas 79423

806-785-0590 FAX 806-785-5488

Payor List September 2013

ADVANTAGE TEAM CHOICE – Effective January 1, 2005

Karen Sawyer 806-795-5959

140% Current Year Lubbock RBRVS (Medicare) for E&M CPT Codes

165% Current Year Lubbock RBRVS (Medicare) for all other CPT Codes

150% Current Year Lubbock RBRVS (Medicare) for Laboratory Services

Anesthesia $50/unit

AETNA – Effective July 15, 2005

Angie Rogers 830-620-0977

Fees based on Current Lubbock RBRVS

150% for E&M CPT codes (90780-99602)

185% for Surgical CPT codes (10021-69990)

150% for Lab and Pathology CPT codes (80048 – 88400)

150% for Radiology CPT codes (70010 – 79999)

120% for HCPCS J codes (J0120 – J9999); (A0021 – H2037); (K0001 – S9881); (S9986 – V5364)

All other services not otherwise identified – 100% of Aetna Market Fee Schedule

Anesthesia $55 / unit

AETNA MEDICARE ADVANTAGE AMENDMENT – Effective August 1, 2010

Angie Rogers 830-620-0977

Covered Services will be reimbursed at 100% of the current Rest of Texas RBRVS Based Fee Schedule

AMERIGROUP – Effective March 1, 2012

Timothy Salinas 806-748-4880

100% of Current Year Medicare Fee Schedule for Professional Services

50% of Current Year Medicare Fee Schedule for Clinical Lab Services

60% of Current Year Medicare Fee Schedule for Durable Medical Equipment

100% of Current Year Medicare Fee Schedule for Drugs and Biologicals

Medicaid and CHIP: 100% of Current Year Medicaid Fee Schedule

BLUE CROSS BLUE SHIELD – Effective December 15, 2003

Lupe Rocha 806-783-4610

Contract and All fee schedules on the Southwest Medical IPA website: www.swmipa.com

CAPSTAR – Effective March 1, 2012

Maria Aguilar 806-783-9995

Fees based on Current Year RBRVS

175% Surgery Codes (10000 – 69999)

150% Radiology Codes (70000 – 7999)

150% Pathology Codes (80000 – 89999)

130% Medicine / E&M Codes (90000 – 99999)

120% HCPCS Codes

Anesthesia $62 / unit

HUMANA CHOICE CARE – Effective January 21, 2011

Chrissy Perkins 512-851-6002

Primary Care 135% ChoiceCare 005-795 Schedule (except for Drugs & Biologicals and Lab Services)

Specialists 180% ChoiceCare 005-795 Schedule (except for Drugs & Biologicals and Lab Services)

Anesthesia $65.00 per unit

Physician Extenders, Podiatrists 85% ChoiceCare 005-795 Schedule (except for Drugs & Biologicals and Lab Services)

Drugs and Biologicals 100% ChoiceCare 201-544 Schedule

In-Office Lab Services 100% ChoiceCare 005-795 Schedule (all other labs paid at 0%)

Any service/code not listed above 100% ChoiceCare 005-795 Schedule

This agreement also includes participation in ChoiceCare’s Medicare Advantage network. Reimbursement for services provided to Medicare Advantage members is as follows:

Physicians 100% ChoiceCare 005-795 Schedule

Physician Extenders 85% ChoiceCare 005-795 Schedule

ChoiceCare’s 005-795 fee schedule is based on the Medicare Resource Based Relative Value Scale. Choice Care’s 005-795 fee schedule is available on the IPA’s website (www.swmipa.com). The in-office allowed lab list is attached to this messenger and is also available on the IPA’s website. ChoiceCare schedule 201-544 for Drugs and Biologicals is available on the IPA’s website.

CIGNA – (includes Great West) – Effective August 1, 2010

Katrina Ventre 972-863-5468

Fee Schedules and Contract on the IPA’s website (www.swmipa.com)

FIRSTCARE – Effective April 1, 2000

Stephanie Dumas 806-784-4312

Fee Schedules and Contract on the IPA’s website (www.swmipa.com

FIRSTCARE Value Network Plan – Effective July 1, 2013

Fees in accordance with the FirstCare HMO fee schedule

Fee Schedules and Contract on the IPA’s website (www.swmipa.com)

GALAXY – Effective April 15, 2003

Mary Woods

Reimbursement 90% of billed charges

HEALTHSMART – Effective August 15, 2001

Chrystal Scott 214-574-2374

Codes ranging from 99201 – 99400: 135% of Current RBRVS, locality 99

All other codes: 185% of Current RBRVS, locality

Any code not listed in the fee schedule will revert to 20% off Provider’s billed charges

Anesthesia $52 / unit

HealthSmart Network for Workers’ Compensation/Occupational Injuries:

90% of Texas Worker’s Compensation Fee Schedule

HEALTHSPRING (Medicare Advantage Plan)– Effective December 1, 2009

Sarah Clark 806-236-6750

Reimbursement to participating Primary Care Physician shall be 105% of the current year’s Medicare RBRVS Allowable Fee Schedule. Primary Care Physician (“PCP”) means a Participating Provider who is a General Practice, Family Practice, Pediatric, Internal Medicine, or other Physician designated by HealthSpring to provide Primary Care Services to Members pursuant to a Participating Provider agreement with HealthSpring.

Reimbursement to participating Specialist Physician shall be 100% of the current year’s Medicare RBRVS Allowable Fee Schedule.

Laboratory CPT Codes (80000 – 89999) - Labs are to be sent to Quest with the exception of CPT codes included on the in office lab list (Attachment 1). In office labs will be reimbursed at 100% of current Medicare RBRVS. All other labs not sent to Quest will be reimbursed at 80% of current Medicare RBRVS.

Imaging CPT codes (70000 – 79999) – In office imaging will be reimbursed according to contract at 105% of current Medicare to PCPs and 100% of current Medicare to Specialists.

HCPCS Codes – HCPCS codes will be reimbursed according to contract at 105% of current Medicare to PCPs and 100% of current Medicare to Specialists.

MULTIPLAN (includes Beechstreet, PHCS, and Texas True Choice)– Effective November 1, 2011

Contract on the IPA’s website (www.swmipa.com)

Contract Rates Exhibit D pp. 15 – 17

OMNI – Effective September 1, 2002

Jorgann Lane 806-373-5944

135% of 2001 Medicare RBRVS Fee Schedule for CPT Codes (99201 – 99499)

200% of 2001 Medicare RBRVS Fee Schedule for CPT Codes (10040 – 89999)

Anesthesia $50 / unit

PRIME HEALTH SERVICES – Effective January 1, 2012

Lindsay Hardin 615-565-8229

130% of Medicare for all codes with a Medicare Allowed Amount

75% of Billed Charges for unlisted codes