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2.3.3.1 <br />2.3.3.2 <br />2.3.3.3 <br />2.3.3.4 <br />2.3.3.5 <br />2.3.3.6 <br />2.3.3.7 <br />2.3,3.8 <br />Technical component of MRI (Magnetic Resonance Imaging), MRA (Magnetic <br />RcsooonceAnglography) and CT (Computed Tomography) <br />PET (Positron Emission Tomography) Scans <br />Durable medical equipment, medical supplies, orthotics and prosthetics <br />Physical and Occupational Therapy, Speech Therapy and Audiology <br />Acupuncture and Chiropractic Services <br />Technical component of Sleep Study Medicine <br />Vision Exam <br />Those CPT codes identified as Policy Codes by the Campany <br />2.3 .4 The Maximum Allowable for drugs and medications, including but not limited to <br />biologicals, immune globulins, vaccines and immunizations, shall be the Company's <br />medication fee schedule In effect on the date of service. <br />2.4 For services for which no RW has been established by CMS, the Maximum Allowable for <br />Covered Services shall be determined using lngenlx RVUs. <br />2.5 For services for which no RVU has been established by CMS or by lngenlx the Maximum <br />Allowable for Covered Services shall be the Company's participating fee schedule in effect <br />on the date of se,vice. <br />2.6 The Max imum Allowable tor Covered Services rendered by behavioral he.ilth providers shall <br />be the Company's participating fee schetlul e in effect on the da\e of se~lce . <br />2 .7 Forse.rvfces rendered by other ,Jicensed praeuuonera not specifically identified In Sect on 2.3 <br />·above , lhs Maximum Allowabfe for Covered Services shall be the Compa.ny 's fee schedule <br />specific to the praclltioner lype In effect on tho date of service , <br />2.8 Conversion factor(s), fee schedules showing common Covered Services or a11y other <br />reimbursement factor referenced here in VJ1ll be provided to the Mod/cal Group. The <br />Maximum Allowable fO? Covered SeNlces not set forth 011 a lee schedule shall be provided <br />upon request. The Company has no obllgatlon to . provide lees , com1erslon factars or o!he r <br />reknbursemenl rates to Medical Group for Covered Se,vices not typically performed by the <br />Medical Group. <br />Ill. COPAYMENT, COINSURANCE, DEDUCTIBLE <br />3.1 Where-the Subscriber Ag reement J)ro1.1rdes for payment of c opayment, coinsuranc e or <br />d~ductible.s by U,a Patient. payment by Company for Cove111d Services shall be less the <br />appUcable copayment-; co nsura11ce or deductible . <br />IV. NOTICE OF UPDATES <br />4.1 1 he Company shall provide Medlcal Group ninety (90) days prior notice of changes to the <br />Company's reimbursement mBlhodqlogy, RVU conversion factor, C,MS Of lngenh, RVU year, <br />tlie percentage rererenced !n 2.3 .2 ., or Company fee-schedules, excluding changes lo fees <br />lied to CMS fee schedules . <br />V. NON -DISCLOSURE <br />5.1 Medical Group agrees that unless required by law or otherwise allowed by the Agreement, <br />Medloal Group shaU not disclose the reimbu rsement retes establla\'1ed by the Company <br />without pr or written consent of Compa11y. 'Medical Group rurther agrees not lo dlaelose the <br />reimbursement rates to l ndivldl1al health care practi ti oners , other than those health care <br />practitioners on lta Board, If ap1>l!cable, in any fol'l11at. Medical Group acJ<nowledgu that the <br />unauthc rized di~l~sure of lhl_s Information may cauae Irrepa rable damage to the Company , <br />and Medical Group agrees !hat lhe Con,pany may seek relief far breach of this pro.11ls lon . <br />Asurts Medical S1andard MGA Exhibit C A18816B5-4AA Pago2 of2.