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ASURIS NORTWEST HEAL TH
<br />MEDICARE ADVANTAGE PPO REIMBURSEMENT ADDENDUM
<br />This 19 an Acldendum ("Addendu,n "), effective on Docember 31, 9999, to the Partk:lpallng Agreement
<br />("Agreemenr), by end between Asurfs NorOlwest Health rcornpeny~) and KITTITAS COUNTY
<br />HEAL TH DEPT ("Provider"), All references herein to 'Provider' shall mean •Provider," or "Medi cal
<br />Group : as those terms are used and defined n the Agreemant(s).
<br />WHEREAS . Company has a conlract to serve as a Medi care Advantage (MA) plan for the U.S.
<br />Departmenl of Heal th and Human Serv. ees (HHS)., Centers tor Medicare and Med cad Services
<br />(CMS), to adm1t:1ister Medicare benefits within certain counties in the Company serv ice areas;
<br />WHEREAS, Provi der llas an eXJ stlng Agreement to provide medlcal services to Members , as more
<br />particularly set forth in t11e Agreen,enl;
<br />WHEREAS, Provider is entering into this Addendum to provide medical services lo MA PPO
<br />Members :
<br />NOW THEREFORE , in consideration of the foregoing premises and other good and valua,ble
<br />cons lderat lon, receipt anc:I sufficiency of whleh are acknowledged, !he parties hereb y agree as follows :
<br />A. REIMBURSEMENT PROVISIONS
<br />The following re mbursement provisions and ree schedule amounts shall apply lo Provider for
<br />Covered Services ·rendered to MA PPO Me mbers:
<br />1, The fee schedule lo r profess onal providers fs slrU~tured on the most recent edition of the OPT
<br />coding n,anual. Fo, mosl procedures , Company wlll determine Ma,dmum Allowable Fees usir:ig
<br />the Reaource Based Relative Value Scale (RB RVS) pub lishe d by the Center, for M11dlcare &
<br />Medicaid Services (CMS). In ll'ie ab!l(!nce of CMS RBRVS unit value:a for specific procedums ,
<br />Company wlO establish auch unit values for purpose$ of Its Maxlmum Nlowable Fee
<br />delerrnlnation . For cer1afn procedures , the Maximum Aflowable Fee will be lnd iv dually
<br />determined at Company 's discretion . Procedures assigned ''by report" status are paid ar.
<br />determined by Corr111any'11 Medical Olrocton
<br />2. The allowa nce for each CPT proced ure code is the le11er of 1/ie charge or lhe -(ee asslgoe d lo
<br />that proced1.1re code under the fee schedule. Payment for Covered Services. Is b,ased upon this
<br />allowance.
<br />3. For Covered Services provided'by MOs , OOs , OPMs, and ODs, the fee schedule shall be based
<br />upon one hundred and two p_erc en t (102%) of the currenl Medicare fee schedule for the locale
<br />where the sef:Vice la rendered .
<br />4. For Covered Services pro11ided by Advanced Practice Profess onal Nurses and Physician
<br />A"lslants, the fee sched ule shall be based upoo eighty-five pe rcent (85%) of the
<br />MD/00/0PM/OO rate listed above. Payments ror Physician Ass istants and Certified Reg lst.e.red
<br />Nurse Firs t As,s ls tants assisting at surgery shell be reimbursed based on Medicare guidelines .
<br />5. For Covered SelV ces provided by other provider typee (i .e., 1121 MOs, Dos , OPMs , OD s, NP s
<br />ar,d PAs), nctudlng but not flmited to : PT, OT, ST, CRNAs , DCs 1 the fae scnedule shall be based
<br />upon the current Medicare allO\oJable fa" the pro11 lder type ba.sed on the locate where ttte servll::e
<br />is rendered. Company follows Chapter 12 of the Med icare Cl!ilms Processing Manual for the
<br />prov ider type , e)(ample : Ucensed Clinlc.il Social Wo,ker {\.CSW) is paid seventy-five pt?rcent
<br />(75%) ot the Me~lcare phyi,lcian fee schedllle .
<br />6. For Covered Service~ ror Laboratory and Fl ethology services for which Medicare has established
<br />a fee throll.9h ll s Cllnlcal Laboratory Fee Schedule , reimbursement shap be ba.6C d upon nlnely
<br />percent (90%) of lhe current Medicare fee sched ule for the local e where the service Is render.ed.
<br />7. Durable Medical Eq uipment, Proslhe!lcs, 0rthotics, Supplies (DMEPOS) and Drugs will be
<br />rein,bu.md accord ing lo Co mpan y re lmbu~menl policy.
<br />MA PPO Profanlonal Ralmburaamenl Addendum Asurio1 A18816854M Page 1 of 2
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