HomeMy WebLinkAboutAsuris and KCPHD AgreementKittitas County
Review Form
Grants & Contract Agreement
Today's Date
Fund/Department
116 -Public Health
Contract/Grant Information
Agenda Date
Contract /Grant Agency: Asuris
Period Begin Date: 05/15/2018 Period End Date: 15 days after notice of
termination _
Total Grant/Contract Amount: None
Grant/Contract Number:
Contract/Grant Summary:
The agreement between Kittitas County Public Health Department and Asuris Northwest Health is
established to allow the health department to bill insurance for services provided.
Recommendation for Board of Health and Board of Health Review on
Department Head Signature:
Administrator Date:
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Signature of Prosecutor's Office
Signature of Auditor's Office
Signature of Board of Health member
Financial Information
Total Amount $
Percentage County Funds
Date
Date
Date
State Funds $
Matching Funds $
In -Kind $
Explain
Federal Funds $
CFDA#
Grant/Contract Review Page 1
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring — reporting requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed?
New Division Created?
Revenue Code
I Yes ❑ attach budget form
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub -Contract Approved Date:
No ❑ Why not
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes[] No ❑
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
Signature: Date:
Department:
Assignment of I racking Intormation
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer I Date
Grant/Contract Review Page 2
�r� P.O. Box 21267
ANS,
�c�Seattle, WA 98111-3267
ORTHWEST HEALTH
April 25, 2018
KITTITAS COUNTY HEALTH DEPT
507 N NANUM ST
STE 102
ELLENSBURG, WA 98926-2886
Dear KITTITAS COUNTY HEALTH DEPT:
Thank you for your interest in becoming a participating provider with Asuris Northwest Health (Asuris).
Strong provider networks are essential for the delivery of quality health care to our members, and we
appreciate your willingness to join our networks.
Enclosed are the necessary documents required to join our provider network(s). Please review and sign
each agreement using the following steps:
1. Carefully review all documents
2. If you agree with the terms of the agreement, click "Continue" in the green "Accept Terms" box
3. Follow the instructions to electronically sign your agreement
4. A confirmation message will display once the terms of the agreement have been accepted
5. A final copy of the agreement will be electronically returned to you, along with an eSignature
receipt document containing signature information
You'll receive an email from us that will confirm the network(s) you are participating on and your
effective date of participation.
Important notes:
Claims submitted before your effective date of participation will be processed as out -of -
network.
• You must agree to the terms and electronically sign your provider agreement(s) to complete the
contracting process.
• Delays in signing your agreement(s) will impact your network participation date and may require
that you complete the credentialing process again.
Visit our provider website at asuris.com to view the tools and resources available to assist you in the
contracting process. If you have any questions, please contact our Provider Relations team. Contact
information is available in the Contact us section of our website.
Sincerely,
John S. Partin
Vice President
Network Management
Enclosures
Our provider website, asuris.com, offers extensive information and resources to support you.
You can find information about member cards, pre -authorization requirements and much more.
PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT
between
ASURIS NORTHWEST HEALTH
and
KITTITAS COUNTY HEALTH DEPT
EFFECTIVE DATE:
ASURIS NORTHWEST HEALTH, a Washington health care service contractor, and any
successor organizations ("Company"), and KITTITAS COUNTY HEALTH DEPT a Washington
corporation that has entered into contracts with and/or employs providers who are duly licensed to render
health care services in the state (hereinafter referred to as "Medical Group"). This Agreement is a master
agreement that may be amended from time to time pursuant to Section VIII of the Agreement, and
through the addition, alteration or elimination of those Provider Networks in which Medical Group has
agreed to become a Participating Provider.
By virtue of Medical Group's status as a Participating Provider in a given Provider Network, Medical
Group will furnish services to members of those Health Plans offered or administered by the Company (or
another entity with access to the applicable Provider Network pursuant to an agreement with Company as
allowed by Section 5.6) which rely on that Provider Network for the provision of Covered Services.
Medical Group also agrees to provide services to any Member under any Provider Network in which
Medical Group participates pursuant to the terms of this Agreement and any addenda attached hereto.
Nothing in this Agreement gives Medical Group the right to participate in any new Provider Networks or
lines of business developed by Company, unless Medical Group is offered and accepts participation in
the new Provider Network or line of business. This Participating Medical Group Agreement and the
applicable terms and conditions for participation in those Provider Networks, in which Medical Group is a
Participating Provider, are collectively referred to herein as the "Agreement." Participation in each
Provider Network is enforceable under the terms and conditions contained in the relevant Provider
Network addendum and, in the event of a conflict between the language of the Agreement and any
addendum relating to a particular Provider Network, the language of the relevant addendum will prevail.
IN CONSIDERATION of mutual covenants and promises stated herein and other good and
valuable consideration, the undersigned have agreed to be bound by this Agreement as of the Effective
Date.
RECITALS
The Company is a Washington non-profit Company registered with the Washington State Office of the
Insurance Commissioner as a health care service contractor, and as such is subject to laws specifically
applicable to health care service contractors.
The Medical Group is a legal entity comprised of physicians and/or other health care providers all of
whom are licensed and/or certified by the state(s) in which the Medical Group is located.
DEFINITIONS
1.1 BENEFITS means payment by the Company for services and supplies covered under a
group or individual Health Plan.
1.2 CERTIFICATE means the evidence of insurance provided to an insured under a group or
individual Health Plan.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 1 of 20
1.3 COINSURANCE. means the Member's percentage share for any Covered Service
provided at less than 100 percent.
1.4 COPAYMENT means a fixed dollar amount that the Member's Health Plan requires the
Member to pay for a Covered Service.
1.5 COVERED SERVICES are those health services and supplies provided to Members by
Participating Providers which qualify for payment under the terms of a Member's Health
Plan, as described in the applicable Certificate or policy, including any amendments
thereto.
1.6 CREDENTIALING is the collection, verification and review of information by Company to
determine whether a provider is eligible to participate in the Provider Networks. The
Company shall have sole discretion in determining whether to participate with any
applicant.
1.7 DEDUCTIBLE means the dollar amount that the Member must pay each calendar year
before Company begins to make payments.
1.8 HEALTH PLAN means any group or individual, insured or self-funded health care plan
issued and/or administered by Company or by another entity with access to the
applicable Provider Network pursuant to an agreement with Company, including, but not
limited to, The Regence Group, Regence BlueShield or any of its affiliates, and or other
state and federal programs.
1.9 MEDICAL GROUP means a group of physicians and/or other health care providers who
provide services under the same tax identification number.
1.10 MEDICAL GROUP PROVIDER means a member, employee or contractor of the Medical
Group who is duly licensed or legally authorized to render health care services in the
state of Washington and who is obligated, by virtue of his/her membership in, contractual
relationship with or employment by Medical Group, to provide services to Members.
1.11 MEDICAL EMERGENCY is the emergent and acute onset of a symptom or symptoms,
including severe pain, that would lead a prudent lay person acting reasonably to believe
that a health condition exists that requires immediate medical attention, and that failure to
provide medical attention would result in serious impairment to bodily functions or serious
dysfunction of a bodily organ or part, or would place the person's health in serious
jeopardy.
1.12 MEDICAL. NECESSITY Except for services subject to WAC 284-43-7000, "Medically
Necessary" or "Medical Necessity" means health care services or supplies that a
physician or other health care provider, exercising prudent clinical judgment, would
provide to a patient for the purpose of preventing, evaluating, diagnosing or treating
an illness, injury, disease or its symptoms, and that are (a) in accordance with generally
accepted standards of medical practice; (b) clinically appropriate, in terms of type,
frequency, extent, site and duration, and considered effective for the patient's illness,
injury or disease; and (c) not primarily for the convenience of the patient, physician, or
other health care provider, and not more costly than an alternative service or
sequence of services or supply at least as likely to produce equivalent therapeutic or
diagnostic results as to the diagnosis or treatment of that patient's illness, injury or
disease. For these purposes, "generally accepted standards of medical practice" means
standards that are based on credible scientific evidence published in peer-reviewed
medical literature generally recognized by the relevant medical community, Physician
Specialty Society recommendations and the views of physicians and other health care
providers practicing in relevant clinical areas and any other relevant factors. For services
subject to WAC 284-43-7000, "Medical Necessity" or "Medically Necessary" shall have
the meaning set forth in WAC284-43-7020.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 2 of 20
1.13 MEMBER means a person who is eligible and has been accepted by the Company for
coverage and for whom the applicable rate has been paid for Benefits under a Health
Plan.
1.14 PARTICIPATING PROVIDER means any hospital, physician, other health care
professional, or other provider of medical services or supplies who (a) is legally qualified
to provide medical services or supplies under Washington state law; (b) has contracted
with the Company, directly or through intermediaries, to furnish Covered Services to
Members as part of one or more of the Company's Provider Networks; and (c) is eligible
for reimbursement under a Subscriber Agreement.
1.15 PARTICIPATING PROVIDER NETWORK is the collective group of hospitals, facilities,
clinics, physicians and other health care professionals under contract with the Company
to participate in the Company's network of providers identified as the Participating
Provider Network.
1.16 PAYOR means the entities set forth below that offer or administer a health care plan and
contracts with the Company pursuant to Section 5.6 for access to one or more Provider
Networks in which Medical Group participates. Payors are limited to the following entities
and their subcontractors who contract with Payor for access to one or more Provider
Networks: subsidiaries and affiliates of the Company as set forth on Exhibit A, a Blue
Cross and/or Blue Shield Plan, a government program, a trust, and a self-funded health
plan administered by the Company or one of its subsidiaries or affiliates.
1.17 ADMINISTRATIVE MANUAL is a separate reference source developed and issued by
Company for providers that includes additional details, policies, procedures and other
information that a Participating Provider will need to know in order to properly perform its
obligations under this Agreement.
1.18 PROVIDER NETWORK means the Asuris Northwest Health Participating Provider
Network and any other Asuris Northwest Health network of Participating Providers or
lines of business that Provider agrees to participate pursuant to an addendum attached to
this Agreement.
1.19 RECREDENTIALING is a periodic process by which the Company may determine, in its
sole discretion, whether to continue participating with a Medical Group.
1.20 SUBSCRIBER AGREEMENT is a contract between the Company or Payor and an
individual or group in which the Company agrees to provide, indemnify for or administer
health care benefits and which provides a benefit incentive if a subscriber or enrolled
dependent obtains health care services from Participating Providers in the Provider
Network. This includes, but is not limited to, administrative services only (ASO) contracts
the Company or Payor enters into with employers, other out of area Blue Cross/Blue
Shield Plans and Blue Cross and Blue Shield Association services and state and federal
governmental programs. This may also include Subscriber Agreements issued by the
Company's branches and affiliates as set forth on Exhibit A, in accordance with Section
5.6, as well as Subscriber Agreements issued by any successor organization of the
Company.
1.21 NON -COVERED SERVICE is a service or supply that is not a Covered Service for any of
the following reasons: (1) the service or supply is Investigational or not Medically
Necessary; or (2) the service or supply is not an available benefit or a Covered Service
under the Subscriber Agreement for any reason.
1.22 INVESTIGATIONAL: The definition provided in the Subscriber Agreement. To the extent
that the Subscriber Agreement does not provide a definition of Investigational, the
following definition shall apply: a health intervention that the Company or Payor has
classified as Investigational. The Company will review Scientific Evidence from well-
designed clinical studies found in peer-reviewed medical literature, if available, and
information obtained from Medical Group regarding the health intervention to determine if
Asuris MGA Agreement (Rev. 05/2017) Al8816854AA Page 3 of 20
it is Investigational. A health intervention not meeting all of the following criteria, is, in the
Company's judgment, Investigational:
Q The Scientific Evidence must permit conclusions concerning the effect of the
Health Intervention on health outcomes, which include the disease process,
Injury or Illness, length of life, ability to function and quality of life.
The health intervention must improve net health outcome.
• The Scientific Evidence must show that the health intervention is as beneficial as
any established alternatives.
• The improvement must be attainable outside the laboratory or clinical research
setting.
For purposes of this definition, Scientific Evidence means scientific studies published in
or accepted for publication by medical journals that meet nationally recognized
requirements for scientific manuscripts and that submit most of their published articles for
review by experts who are not part of the editorial staff; or findings, studies or research
conducted by or under the auspices of federal government agencies and nationally
recognized federal research institutes. However, Scientific Evidence shall not include
published peer-reviewed literature sponsored to a significant extent by a pharmaceutical
manufacturing company or medical device manufacturer or a single study without other
supportable studies.
II. PROVISION OF MEDICAL SERVICES
2.1 MEDICALLY NECESSARY SERVICES — Medical Group will provide Medically
Necessary Services to Members in accordance with the terms of this Agreement.
Company will only bear financial responsibility for Medically Necessary, Covered
Services furnished to Members by Medical Group. Company will not make retroactive
denials of Covered Services that were pre -certified or concurrently certified as medically
necessary unless the certification was based upon a material misrepresentation by
Medical Group.
2.2 COVERED SERVICES — Company will define the Covered Services for the Health Plans
for which Medical Group has agreed to provide services.
2.3 STANDARDS OF CARE — The Medical Group shall provide services to Members in
accordance with generally accepted professional standards of care and medical and
billing practices in the community. Medical Group agrees to furnish Covered Services to
Members without regard to the Member's enrollment in the Health Plan as a private
purchaser or as a participant in publicly funded programs.
2.4 RELATIONSHIP WITH MEMBERS — Company will not be liable for nor will it exercise
control or direction over the methods or professional judgments relied upon by Medical
Group and Medical Group's Providers, employees or representatives in providing
services pursuant to this Agreement. Medical Group will be solely responsible for
supervising and controlling Medical Group's employees to assure that such services are
provided in a manner that complies with generally accepted standards of care. Medical
Group Provider will be responsible for clinical decisions regarding the medical care and
treatment of Members. Nothing in this Agreement limits Medical Group Provider's right to
communicate freely with Members, including the right to inform Members that Medical
Group Provider believes services are appropriate or necessary, even if Company has
determined the services are not Covered Services.
2.5 NONDISCRIMINATION - Medical Group will provide the Covered Services contemplated
herein without regard to the race, age, sex, religion, creed, color, national origin or
ancestry of any Member. During the term of this Agreement, Medical Group will not
unlawfully discriminate against any employee or applicant for employment because of
race, religion, color, national origin, ancestry, physical handicap, health status, marital
Asuris MGA Agreement (Rev. 05/2017) Al8816854AA Page 4 of 20
status, age or sex. Medical Group will include the non-discrimination compliance
provision of this clause in all subcontracts entered into to fulfill its obligations under this
Agreement.
III. PAYMENT FOR MEDICAL SERVICES
3.1 PROVIDER COMPENSATION — Medical Group will be compensated for Medically
Necessary Covered Services provided to Members in accordance with the
compensation arrangements for the applicable Provider Network and the terms of
Members' Health Plans. The compensation arrangements for each Provider Network in
which Medical Group is a Participating Provider is set forth in exhibits and addenda
attached hereto and incorporated herein. The Medical Group agrees to accept the
compensation set forth in the payment exhibits as payment in full for Covered Services
provided to Members, whether that amount is paid in whole or in part by the Company,
the Member or by any combination of payers. The Company reserves the right to
establish and alter the payment methodology and levels from time to time with ninety (90)
days prior notice. Acceptance of reimbursement based on new payment levels or
methodology constitutes consent.
The Company shall pay claims as soon as practical, but subject to the following minimum
standards — (1) the Company shall pay 95% of the monthly volume of clean claims within
thirty (30) days of receipt by the Company; and (2) the Company shall pay or deny 95%
of the monthly volume of all claims within sixty (60) days of receipt by the Company. For
purposes of this Section 3.1, a "clean claim" means a claim that has no defect or
impropriety, including any lack of any required substantiating documentation, or particular
circumstances requiring special treatment that prevents timely payments from being
made on the claim under applicable Washington law. To the extent required by
Washington law, the Company shall pay simple interest at the rate of one (1 %) percent
per month on payable, clean claims not paid by the Company within sixty-one (61) days
of receipt. Such interest shall be calculated based on the amount to be paid to the
Medical Group for the Covered Services and shall be added to the Medical Group's
reimbursement without further claim submission from the Medical Group. Claims for
services provided to Members pursuant to a contract with, or on behalf of, the federal
government, including but not limited to the Federal Employees Health Benefits Program
(FEHBP), shall not be subject to interest set forth in this Section 3.1.
3.2 COMPENSATION FOR REFERRALS — Medical Group agrees not to accept any
compensation in return for referring any Member to a Medical Group for the furnishing of
any item or service payable by Company. Medical Group also agrees to refer Members
to providers in accordance with applicable state law and the laws and regulations of the
Medicare program.
3.3 MEMBER IDENTIFICATION — Medical Group will be responsible for establishing the
identity of all patients who present themselves as Members in any Health Plans and will
promptly report to Company any apparent abuse of the privileges of such Health Plans.
3.4 BILLING FOR PROVIDER SERVICES — Medical Group agrees to submit claims for
Covered Services electronically or as prescribed by Company or required by law. Claims
should be submitted within thirty (30) days of the date of services and, in any event,
shall be submitted no later than twelve (12) months from the date that Members receive
services. Claims not submitted within twelve (12) months of date of service shall be
disallowed and the Medical Group shall not bill the Member or Company for services
or supplies associated with such claims. The Medical Group shall not bill the
Company for more than the Medical Group's usual and customary fee for the services
rendered, nor shall the Medical Group bill services provided to Members at a rate
higher than the Medical Group bills services provided to persons without health care
coverage. The Medical Group agrees to abide by Company directives, whether
communicated by the Company through its Administrative Manual or other
communications and publications.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 5 of 20
Claims for which the Company is the secondary insurer must be submitted within thirty
(30) days of the primary carrier's payment or denial.
The Medical Group agrees to submit claims using the most appropriate, current and
specific coding when billing for services rendered. The Medical Group agrees that it will
not engage in misleading billing practices or otherwise interfere with timely and accurate
claims adjudication.
Except for infrequent and isolated waivers for charitable purposes, the Medical Group
shall charge to and make reasonable attempts to collect from the Member all coinsurance
amounts owed by the Member, after receiving a claims adjudication determination by the
Company, and may collect all deductibles and copayments at the time of service.
Because of the difficulty of ascertaining damages resulting from breach of this provision,
the parties agree that the Company shall be entitled to deny all or part of claims as
liquidated damages if the Medical Group fails to make a reasonable attempt, using such
steps as normally taken to collect Deductibles, coinsurance or Copayments. In no event
shall the Medical Group charge to a Member for Deductibles, coinsurance or
Copayments exceed the amounts established by the Company. As required by WAC
284-43-320(3) the Company hereby informs the Medical Group that willfully collecting or
attempting to collect an amount knowing that the collection is in violation of this
Agreement constitutes a class C felony under RCW 48.80.030(5). In no event shall the
Medical Group seek additional reimbursement for Covered Services delivered to
Members, except for any copayments, deductibles or coinsurance amounts that the
Member may owe, as determined by the Company.
3.5 MEMBERS TO BE HELD HARMLESS
3.5.1 The Medical Group hereby agrees that in no event, including, but not limited to,
nonpayment by the Company, Company's insolvency or breach of this
Agreement, shall the Medical Group bill, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any recourse
against Member or person, other than the Company, acting on their behalf, for
services provided pursuant to this Agreement. This provision shall not prohibit
collection of Deductibles, Copayments, Co -Insurance, and/or non -Covered
Services, which have not otherwise been paid by a primary or secondary carrier
in accordance with regulatory standards for Coordination of Benefits, from
covered persons in accordance with the terms of the Member's Health Plan.
3.5.2 The Medical Group agrees, in the event of the Company's insolvency, to
continue to provide the services promised in this Agreement to Members for the
duration of the period for which premiums were paid to the Company on the
Members' behalf, or until the Members' discharge from inpatient facilities,
whichever time is greater.
3.5.3 Notwithstanding any other provision of this Agreement, nothing in this Agreement
shall be construed to modify the rights and benefits contained in the Member's
Health Plan.
3.5.4 The Medical Group may not bill Members for Covered Services (except for
Deductibles, Copayments or Co -Insurance) where the Company denies
payments because the Medical Group has failed to comply with the terms of this
Agreement.
3.5.5 The Medical Group further agrees (i) that the above provisions 3.5.1, 3.5.2, 3.5.3,
and 3.5.4 shall survive termination of this Agreement regardless of the cause
giving rise to termination and shall be construed to be for the benefit of the
Company's Members, and (ii) that this provision supersedes any oral or written
contrary agreement between the Medical Group and Members or persons acting
on their behalf.
Asuris MGA Agreement (Rev. 05/2017) Al8816854AA Page 6 of 20
3.5.6 If the Medical Group contracts with other health care providers or facilities who
agree to provide Covered Services to Members with the expectation of receiving
payment directly or indirectly from the Company, such providers or facilities must
agree to abide by the above provisions 3.5.1, 3.5.2, 3.5.3, and 3.5.4 and 3.5.5.
3.6 TH[RD-PARTY PAYMENT — Members may be eligible for coverage from another payer
including, but not limited to, other individual or group health plans, liability insurers,
entities providing workers' compensation or occupational disease coverage, Medicare or
other government programs. The parties will inform each other whenever a Member has
coverage from such other payers. Medical Group will collect payment from third -party
payers, using Medical Group's customary collection procedures, whenever such payers
have primary responsibility to provide or pay for Covered Services in accordance with the
Coordination of Benefits and third -party liability requirements of Members' Health Plans.
If Company is required to pay a portion of Medical Group's charges for Covered Services
not covered by other payers, Company will pay Medical Group only that amount which
when added to the amounts paid or owed by the other payer and any Copayment,
Deductible or Co -Insurance charges for which the Member is responsible, will not exceed
the payment for such services under this Agreement.
3.7 DUPLICATE BILLING — Unless otherwise instructed by Company, Medical Group agrees
to refrain from submitting more than one bill to Company for Covered Services furnished
to Member pursuant to this Agreement. Medical Group will not, under any
circumstances, including a delay in Company's processing of Medical Group's claims, bill
Members for Covered Services while waiting for payment.
3.8 ADJUSTMENTS — Medical Group will refund to the Company all overpayment amounts
Company has paid to Medical Group because of payment error, duplicate insurance,
Workers' Compensation recovery or other third party liability recovery, among other
reasons, up to the amount of the overpayment. Medical Group will refund such
overpayment amounts provided that written notification that a refund is due is received
within twenty-four (24) months of original payment of the claim (thirty (30) months in the
case of claims involving Coordination of Benefits), except if recovery from a third party is
the cause of the delay. In the case of recovery from a third party, the Company may
request that Medical Group refund a payment or part of a payment at any time if: (a) a
third party, including a government entity, is found legally responsible or liable for
satisfaction of the claim as a consequence of liability imposed by law (e.g., tort liability);
and (b) the Company is unable to recover directly from the third party because the third
party has either already paid or will pay the Medical Group for the claim. Notwithstanding
the foregoing, Medical Group may contest a refund request made by the Company.
However, if Medical Group fails to contest the refund request, in writing, within thirty (30)
days of receipt of written notification that a refund is due, Company shall conclude that
Medical Group has accepted the Company's refund request and may deduct from future
payments due to Medical Group the amount equal to the amount of the overpayment,
among other remedies.
Medical Group shall not request from Company any additional payment to satisfy a claim
unless the request is (a) in a writing that specifies why Company owes the additional
payment, and (b) made within twenty-four (24) months after the original date the claim
was paid or denied (thirty (30) months in the case of claims involving Coordination of
Benefits).
None of the aforementioned time limitations apply to requests for refunds or additional
payments involving fraud. All disputes and appeals of billing issues pursuant to Section 9
must be initiated within the aforementioned time limitations.
3.9 NON -COVERED SERVICES
3.9.1 Except as otherwise set forth in this Section 3.9, Medical Group may charge
Member for Non -Covered Services under the Subscriber Agreement without
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 7 of 20
obtaining written Member consent. Neither Company nor Payor shall be liable
for any health care services or supplies which are determined by Company,
Payor or their designee to be a Non -Covered Service; however, the Member may
be liable for Non -Covered Services subject to the terms set forth in Sections
3.9.2 through 3.9.4 herein. In no event will Company or Payor be responsible for
any amount owed by Member to Medical Group for Non -Covered Services in the
event that Medical Group is unable to collect such amount from Member.
3.9.2 Medical Group may bill a Member for services or supplies determined by
Company or its designee to be not Medically Necessary only if Medical Group
has obtained appropriate Member consent in writing. At a minimum, the written
Member consent must include the following information: Member name; specific
service or supply; date of service, if known; a statement informing the Member
that the service or supply may be a Non -Covered Service; and a statement
where the Member agrees to pay for the Non -Covered Service. The written
Member consent must be signed by the Member, Member's guardian or
Member's authorized health care representative and maintained in Medical
Group's records. Medical Group agrees to write off and not charge Company,
Payor or Member any amount owed for not Medically Necessary services or
supplies if Medical Group fails to obtain such written consent.
3.9.3 For services rendered to Members enrolled in Medicaid that are determined by
Company or Payor to be Investigational, Medical Group must obtain the written
Member consent as described in the Healthy Options Administrative Manual
before rendering services in order to charge the Member for the services. If
Medical Group fails to obtain such written Member consent, Medical Group
agrees to write off and not charge Company, Payor or Member for such
Investigational services. For all other Members receiving services that may be
deemed Investigational by Company or Payor, a written Member consent is not
required in order to charge Members for such services. However, Company still
encourages Medical Group to inform Member before services are rendered that
such services may be deemed Non -Covered Services by Company or Payor,
and that if the services are deemed Non -Covered Services the cost of such
services will be the responsibility of the Member.
3.9.4 Services or supplies provided to Members after they have exhausted their annual
or lifetime benefit for such services as provided in the Subscriber Agreement
shall no longer be subject to the terms of this Agreement, except for the claim or
claim line (as applicable) that results in the benefit maximum to be exceeded.
For that claim or claim line (as applicable), Medical Group agrees that any
balance billed to the Member shall be the lesser of billed charges or the allowed
amount under this Agreement less any amount paid by Company or Payor. The
"claim line" language is applicable where services or supplies are paid
individually. The "claim" language is applicable for services paid based on an
episode of care.
3.9.5 Medical Group shall not bill Members for Covered Services (except for
deductibles, copayments or coinsurance) where Company or Payor denies
payment because Medical Group has failed to comply with the terms of this
Agreement.
3.10 INELIGIBLE MEMBERS — Company is not obligated to make payment to Medical Group
for services provided to an individual who is not, at the time such services are received, a
duly eligible Member. The fact that an individual possesses an identification card will not
obligate Company to pay or provide services if on the date(s) that such services were
rendered, the individual is, or is later to have found to have been, ineligible for medical
benefits, except in cases where the Company has provided prior authorization to the
Medical Group for a requested service. Authorization by Company for a requested
service does not guarantee that the Member is eligible or will continue to be eligible for
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 8 of 20
benefits on the date(s) that such services are rendered
3.11 GOVERNMENT PROGRAMS — Medical Group agrees to accept the Medicaid
reimbursement made by the Company, or the Company's reimbursement, as payment in
full for Covered Services rendered to Members enrolled in the State of Washington,
Department of Social and Health Services Medical Assistance Programs (Medicaid).
This provision is intended to cover those Medicaid Members who receive care outside of
their assigned Provider Network. In no event shall the Medical Group seek additional
reimbursement for Covered Services rendered to such Members. All claims for Medicaid
Members must be submitted within three hundred sixty five (365) days from the date of
service. The Medical Group is not obligated to accept all or any Medicaid Members
referred to it, nor is the Medical Group automatically a Participating Provider in the
Company's Medicaid programs by accepting the Medicaid reimbursement. Medical
Group agrees to report to Company any occurrence in which a Medicaid member is billed
for a Covered Service or Non -Covered Service, regardless of Member consent to
assume financial liability.
IV. COMPLIANCE WITH COMPANY'S POLICIES AND PROGRAMS
4.1 PROFESSIONAL REQUIREMENTS — Medical Group and Medical Group Providers will
remain in full compliance with all applicable laws and regulations governing the practice
of medicine and will be duly licensed, in good standing, to practice medicine in Medical
Group's respective jurisdiction (s), including such jurisdictions as may be required by
virtue of Medical Group's participation in a Provider Network. Evidence of such licensure
and of Medical Group's DEA certification will be made available to Company upon
request. The Medical Group agrees that it and its subcontractors and employees shall
comply with all applicable statutes, laws and regulations, including those set forth in WAC
284-43 and those that govern health care service delivery to Members.
Medical Group agrees to notify Company, in writing, within five (5) working days of any
material change in the status of Medical Group which is likely to impair or interfere with
Medical Group's performance under this Agreement including, but not limited to: (i) loss
or suspension of licensure or certification; (ii) placement on probation by professional
licensing or certification agency; (iii) loss or restriction of full active admitting privileges at
any hospital; (iv) the issuance of any formal charges against Medical Group by any
governmental agencies, or any other licensing or accreditation organization which would,
if sustained, materially impair Medical Group's ability to comply with Medical Group's
duties and obligations under this Agreement; and (v) suspension or expulsion from the
Medicare or Medicaid programs.
4.2 ADMINISTRATIVE MANUAL — The Company shall make available to the Medical
Group copies of the Company's Administrative Manual, electronically, which outlines
billing requirements, general benefits information, Medical Management requirements
and other updated information. The Medical Group agrees to comply with the policies
and procedures set forth in the Administrative Manual and that compliance is necessary
to meet the obligations under this Agreement. The Company may revise and update the
Administrative Manual from time to time with ninety (90) days' notice to the Medical
Group. The Medical Group agrees that such revisions become a part of the
Administrative Manual and the Medical Group agrees to comply with any such
revisions. The Medical Group agrees to abide by Company directives, whether
communicated by the Company through its Administrative Manual or other
communications and publications. Notwithstanding the foregoing, the parties
understand that if there are any conflicts with the Administrative Manual and the
Agreement, this Agreement shall prevail.
4.3 UTILIZATION MANAGEMENT AND QUALITY IMPROVEMENT — To the extent that
Medical Group participates in Provider Networks for Health Plans which have
implemented utilization management and/or quality improvement policies and programs,
Medical Group will fully comply with such policies and programs, the details of which are
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 9 of 20
described in the applicable addenda or the Administrative Manual
4.4 MAINTENANCE AND RETENTION OF RECORDS — Medical Group will maintain
medical, financial and administrative records concerning services provided to Members in
accordance with Company's requirements, applicable federal and state laws and
generally accepted business and professional practices. Medical Group will ensure that
a medical record is established and maintained for each Member who receives services
from Medical Group in accordance with Company's standards. This record will be
opened at the time of a Member's first visit and shall include contemporaneous, written
documentation of the Member's condition, the treatment and services provided, the date
on which the services were provided, and the identity of the provider rendering the
services. Alterations or amendments to records must include the date and time of the
alteration or amendment and the signature of the person making the alteration or
amendment. Company may deny claims in those cases where, in the Company's sole
discretion, there is inadequate documentation of the services rendered, in which case the
Medical Group shall not bill the Member. Medical Group will maintain such records for a
period of at least ten (10) years from the date of service or from the date a Member
attains the age of majority, whichever is later. The obligations of Medical Group under
this section will survive the termination of this Agreement, regardless of the cause giving
rise to such termination.
4.5 ACCESS TO BOOKS AND RECORDS
4.5.1 Company, its authorized representatives and government agencies, will have the
right to audit and make or obtain copies of medical, financial and administrative
records, directly related to services rendered to Members for purposes that may
include, but not be limited to: accuracy of claims, coverage for services, medical
necessity, proper utilization, appropriateness of services, Credentialing and
Recredentialing, and quality improvement and appropriateness of billing, upon
reasonable notice, during regular business hours of Company. The Company
also may conduct desk audits of the Medical Group's facility(ies) and Member's
records. Company shall provide Medical Group with at least three (3) business
days advance notice of such audit unless Company determines there is a
significant quality of care issue or risk that documents may be altered, created or
destroyed. In such case, Company may conduct an audit upon twenty-four (24)
hours advance notice. Notice of the audit shall apprise the Medical Group of the
period of time for which records are to be audited. The provider agrees to have
all records for that period available at the time of the audit. Records not
produced at the time of the audit will be deemed non-existent. Audits shall be
conducted in a manner that, to the greatest extent possible, avoids disruption of
the provider's business affairs and minimizes the burden on the Medical Group.
Audits will comply with all laws, statutes and regulations pertaining to the
confidentiality of medical and financial records. Copies of records requested by
the Company or its representative will be furnished to the Company upon request
and without charge to the Company or Members, except for records related to
utilization management review, which shall be°reimbursed at the rates set forth in
the Administrative Manual.
Insofar as Members are required to execute an authorization for the release of
their medical records to Company upon becoming Members, Medical Group
agrees to accept from Company, as a legally sufficient release of Members'
medical records, Members' participation in Health Plans of Company and
Company will not be required to obtain an additional medical release form from
Members in order to inspect, review, or make copies of Members' medical
records. This provision will survive the termination of this Agreement, regardless
of the cause giving rise to such termination.
4.5.2 Company's remedies for the Medical Group's failure to cooperate with an audit or
for insufficient documentation, inappropriate billing, or substandard quality of care
Asuris MGA Agreement (Rev. 0512017) Al8816854AA Page 10 of 20
discovered as a result of an audit shall include, but not be limited to: (i) recovery
of payments made by Company for improperly billed claims through lump sum
payments or deductions from future payments subject to the terms and
conditions set forth in Section 3.8; (ii) pre -payment review of all Medical Group's
claims; (iii) a requirement that Medical Group submit medical records with claims;
and/or (iv) immediate termination of Medical Group's agreements. When
Company denies claims for inappropriate billing; the Medical Group shall not bill
the Member.
4.5.3 The Medical Group shall have the right to audit Company's records related to
adjudication of the Medical Group's claims. The audit may be performed either
by the Medical Group or by the independent auditor selected by the Medical
Group. Such audits shall be conducted during Company's regular business
hours at Company's office and shall be limited to records necessary to perform
the audit. The Medical Group shall give Company at least three (3) business
days advance notice of such audit and shall inform Company of the records to be
audited. Company shall have the records for that time period available for the
auditors at the time of the audit. Such audits shall be conducted in a manner
that, to the greatest extent possible, avoids disruption of Company's business
affairs and minimizes the burden on the Company. Audits will comply with all
laws, statutes and regulations pertaining to the confidentiality of medical and
financial records.
4.5.4 Failure by a party to cooperate with an audit shall be a breach of this Agreement.
The audit rights set forth in this Section 4.5 shall survive termination of this
Agreement.
4.6 CONFIDENTIALITY OF MEDICAL RECORDS — Company and Medical Group will
maintain the confidentiality of information contained in Members' medical records and will
only release such information as permitted or required by applicable state and federal
laws and regulations governing the confidentiality of personal health information.
4.7 DIRECTORY UPDATES — Medical Group agrees to comply with Company policies and
procedures related to furnishing information, including but not limited to information on
which providers are accepting new patients, the provider's location, contact information,
specialty, medical group and any institutional affiliations, necessary to ensure provider
directories are up-to-date, accurate, and complete pursuant to federal and state law,
including 45 C.F.R. 156.230(b).
V. RELATIONSHIP OF THE PARTIES
5.1 INDEPENDENT CONTRACTOR — Medical Group and Company are independent
contractors. This Agreement is not intended to create an employer-employee partnership
or joint venture relationship between Company and Medical Group or their respective
directors, officers, employees or agents.
5.2 USE OF NAME — Each party will have the right to use the name of the other party to
inform existing or potential Members, patients and other providers under contract with
Company that Medical Group is a Participating Provider in one or more of Company's
Provider Networks.
5.3 RELIANCE ON PARTICIPATION APPLICATION — Medical Group acknowledges that in
reviewing and offering Medical Group participation in any of Company's Provider
Networks, Company has relied to a material extent upon the statements and information
supplied by Medical Group in Medical Group's participation application. Medical Group
warrants that such statements and information are true and complete to the best of
Medical Group's knowledge and belief. Medical Group agrees to hold Company
harmless with respect to any claims which may arise from statements and information
supplied by Medical Group.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 11 of 20
5.4 PARTICIPATION OF OTHER PROVIDERS IN PRACTICE — Medical Group understands
and agrees that continued participation in any of Company's Provider Networks requires
that all Medical Group Providers must apply and be accepted for participation in the
Provider Network. The failure of one or more of the health care providers in Medical
Group to be accepted for participation or their refusal to apply for or, upon approval,
accept such participation, may result in termination of this Agreement pursuant to Section
7.3. Accordingly, Medical Group must provide Company with at least thirty (30) days'
advance notice if one or more physicians/health care providers intend to join Medical
Group.
5.5 NON -EXCLUSIVITY — This Agreement will not be construed to be an exclusive
agreement between Company and Medical Group. Nothing in this Agreement or any
related documents will be construed to restrict the participation of any of the parties in
any other health care delivery system or payment plan.
5.6 PROVIDING SERVICES TO MEMBERS OF PAYORS — Medical Group understands and
agrees that the Company may enter into an agreement with Payors that want access to
and use of those Provider Networks in which Medical Group participates. Medical Group
hereby authorizes Payors contracting with Company to offer Medical Group's services to
groups of employees or individuals in accordance with the terms of this Agreement and
the provision of any Subscriber Agreement offered or administered by Payor for the
payment of Covered Services. Medical Group agrees to furnish services to Members of
such Payors when those Members utilize the Company's Provider Networks in
accordance with the same terms and conditions of participation and compensation as
apply when such services are furnished to Members under this Agreement. A list of the
Company's subsidiaries and affiliates is set forth on Exhibit A hereto. Company will
provide Medical Group with advance written notice should the list of affiliates and
subsidiaries in Exhibit A change and if Company enters into an agreement with a Payor
that is not specifically named in Section 1.16 or Exhibit A hereto.
5.7 USE OF NETWORK PROVIDERS — Unless Covered Services are unavailable from
Participating Providers, Medical Group will refer to and accept all coverage from
providers who are participating in Company's Provider Network.
5.8 RATE INFORMATION — Both parties agree that, unless required by law or authorized
by this Agreement, a party shall not disclose the reimbursement rates set forth in this
Agreement without prior written consent of the other party. The parties acknowledge that
the unauthorized disclosure of rate information may cause irreparable damage to the
other party. Notwithstanding the above, Company may disclose to Participating
Providers in Medical Group's service area the information and data required to allow
those Participating Providers to effectively manage the quality, care and cost of Members
Company has attributed to them. Company may also disclose health care claims and cost
data to community organizations, such as Puget Sound Health Alliance (PSHA) that seek
to improve health care quality and affordability by reporting aggregated data to
purchasers of health care services.
5.9 DISCLOSURE OF RATES TO MEMBERS — Notwithstanding any other provision of this
Agreement to the contrary, either party may disclose to Members the reimbursement rate
or allowed amount set forth in this Agreement for a Covered Service and/or the Member's
actual or estimated cost-sharing amount (e.g., copayment, deductible, and/or
coinsurance) for a Covered Service to explain claims payment and to facilitate informed
decisions regarding health care services use and cost.
VI. INSURANCE AND INDEMNIFICATION
6.1 PROFESSIONAL LIABILITY COVERAGE — Medical Group will obtain, at Medical
Group's own cost, and keep in force, adequate policies providing comprehensive general
liability, professional liability and other insurance, as may be necessary to insure Medical
Group, Medical Group's Providers, agents and employees against any claim or claims for
damages arising out of the rendering of or failure to render professional services
Asuris MGA Agreement (Rev. 05/2017) Al8816854AA Page 12 of 20
pursuant to this Agreement. Policy limits of professional malpractice coverage must be
no less than $1 million per occurrence and $3 million aggregate, unless the parties
otherwise agree in writing. Medical Group will maintain policies of general liability and
other insurance in amounts consistent with Medical Group practice standards. Evidence
of the insurance coverage required under this section will be made available to Company
upon request. Medical Group will give Company at least fifteen (15) days advance notice
of cancellation of any modification of such medical malpractice insurance.
6.2 NOTICE OF CLAIMS — Medical Group will notify Company immediately of the filing of
any claims against Medical Group or other person(s) for whose acts or omissions Medical
Group is responsible, filed by any Member with respect to any Member. Company will
promptly notify Medical Group of the initiation of legal action against Company by a
Member concerning or relating to services rendered by Medical Group hereunder.
6.3 INDEMNIFICATION — Within the limits of their respective policies of professional and
general liability insurance, and to the extent not otherwise inconsistent with the laws of
the applicable jurisdiction, each party will indemnify and hold harmless the other, its
appointed boards, officers, employees, agents and subagents, individually and
collectively, from all fines, claims, demands, suits or actions of any kind or nature arising
by reason of the indemnifying party's acts or omissions in the course of its performance
of its obligations under this Agreement. Nothing in this Agreement or in its performance
will be construed to result in any person being the officer, servant, agent or employee of
the other party when such person, absent this Agreement and its performance, would not
in law have had such status.
VII. TERM AND TERMINATION
7.1 TERM — This Agreement will take effect on the effective date set forth above and will
continue in effect unless and until terminated by either party. While termination of the
Agreement will terminate Medical Group's participation in all of Company's Provider
Networks, termination of Medical Group's participation in any one or more of Company's
Provider Networks may, at Company's discretion, result in the termination of Medical
Group's participation in other Provider Networks in which Medical Group participates.
7.2 TERMINATION — The parties agree that they are contracting at will. Either party may
terminate this Agreement or any addendum attached thereto at any time and for any
reason, with or without cause, upon ninety (90) days written notice to the other party. The
terminating party has sole discretion to determine whether a cause exists for
termination and whether that cause justifies termination. When the Company terminates
this Agreement or any addendum thereto, the Company will offer the applicable provider
appeals process for the Medical Group to obtain the Company's reconsideration of
the basis for the Company's decision, but the Company retains sole and ultimate
discretion to decide whether a cause exists and justifies termination. In the event of a
termination, the parties shall have no right to claim and do hereby waive and release any
claim for damages that may result from or arise out of that termination, other than any
claim that the parties may have for services rendered to Members prior to the
effective date of the notice of termination.
7.3 IMMEDIATE TERMINATION — Notwithstanding any other provision of this Agreement,
Company may terminate this Agreement immediately upon notice to Medical Group in the
case of any of the following:
7.3.1 Medical Group Provider's license to practice medicine is put on probation,
suspended or revoked;
7.3.2 Medical Group Provider's right to prescribe controlled substances is put on
probation, suspended or revoked;
7.3.3 Medical Group Provider is arrested or indicted for or convicted of a crime;
Asuris MGA Agreement (Rev. 05/2017) Al8816854AA Page 13 of 20
7.3.4 Medical Group's professional liability insurance, as required by this Agreement, is
cancelled or terminated without replacement coverage having been secured,
7.3.5 Loss or restriction of Medical Group Provider's privileges at any hospital;
7.3.6 Medical Group or Medical Group Provider fails or refuses to provide or arrange
for the provision of Covered Services to Members in a professionally acceptable
manner;
7.3.7 Medical Group or Medical Group Provider is suspended or expelled from
Medicare, Medicaid or other government programs;
7.3.8 Medical Group Provider fails to meet Company's Credentialing criteria at any
time.
7.4 CONSENT NOT REQUIRED — This Agreement may be terminated without the consent of
any Member, Participating Provider or any other third party.
7.5 EFFECT OF TERMINATION — Termination will have no effect upon the rights and
obligations of the parties arising out of any transactions occurring prior to the effective
date of termination. The Medical Group may notify their Members if terminated as a
Participating Provider. The Medical Group may accomplish this notice within fifteen (15)
working days of issuance of a notice of termination to or from the Company and will
provide the Company with a copy of the notification sent to its Members. In addition, the
Company shall make a good faith effort to assure that written notice of a termination
within fifteen (15) working days of receipt or issuance of a notice of termination is
provided to all Members who are seen on a regular basis by the Medical Group. If
Medical Group has one or more practitioners who are primary care providers, the
Company shall make a good faith effort to assure that notice is provided to all Members
of that primary care provider.
Medical Group will cooperate with Company in the orderly transfer of Members' care,
including records, to other Participating Providers in the applicable Provider Network.
The parties will cooperate on promptly resolving any outstanding financial, administrative
or patient care issues upon the termination of this Agreement or Medical Group's
Participating Provider status in any one or more of Company's Provider Networks.
During the term of this Agreement, and following its termination or termination of Medical
Group's Participating Provider status in any one or more of Company's Provider
Networks, Medical Group agrees to refrain from any action that interferes with the
relationship between Company and its existing or prospective Members, or other
providers.
7.6 CONTINUATION OF SERVICES AND PAYMENTS — Upon termination of this
Agreement without cause, Medical Group will continue to render Covered Services as if
still a Participating Provider, to primary care Members until the earliest of the following: 1)
the date services being rendered to the Member by Medical Group are completed or
medically appropriate provisions have been made for another provider to assume
responsibility for providing such services; 2) sixty (60) days following notice to Members
of the termination of Medical Group's status as a Participating Provider; or 3) the end of
the Member's group health plan open enrollment period. The provision of such services
and the reimbursement to Medical Group for these services will be subject to all
applicable terms of this Agreement on the same basis as those services provided during
the term of this Agreement.
7.7 PRIOR ACTS — In the event of termination of this Agreement, for whatever reason, each
party will remain liable for its activities or the activities of its employees or representatives
during the term of the Agreement.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 14 of 20
VIII. AMENDMENTS
8.1 The Agreement; any addenda, attachments, fee schedules or exhibits thereto; any
policies or procedures incorporated into the Agreement by reference; the provider
administrative manual; and medical and reimbursement policies may be amended by
the Company by giving ninety (90) days prior written notice to the Medical Group of
such amendment(s). If the Medical Group objects to the amendment, the Medical Group
may terminate this Agreement by giving the Company written notice no later than thirty
(30) days after receipt of the written notice of the amendment. Said termination will be
effective at the end of the ninety (90) day notice period, unless within sixty-five (65)
days of the date of the notice of amendment, the Company gives the Medical Group
written notice that the Company will not implement the amendment.
In the event state or federal laws are enacted, or state or federal regulations are
promulgated, which Company determines renders this Agreement, or any provision,
illegal or this Agreement is otherwise deemed by a state or federal regulatory agency
to violate such laws or regulations, this Agreement shall be immediately reformed to
comply with such laws or regulations or terminated. Amendments required because of
legislative, regulatory or legal requirements do not require the consent of the Medical
Group and will be effective immediately upon notice to the Medical Group of the effective
date thereof. Company will, as promptly as possible, provide notice to the Medical Group
of such amendments.
IX. DISPUTE RESOLUTION
9.1 MEMBER COMPLAINTS — Medical Group agrees to cooperate fully with the Company in
the investigation and resolution of Member complaints and grievances concerning
Covered Services provided under this Agreement. Upon request, Medical Group will
furnish the Company with a copy of its procedures for handling Member complaints.
9.2 INTERNAL PROVIDER APPEAL PROCESSES — Company shall maintain one or more
internal provider appeal processes to adjudicate disputes that may arise between Medical
Group and the Company. The Company's internal provider appeal processes are set
forth in Exhibit D to this Agreement and incorporated herein by reference. Unless
otherwise indicated herein or in Exhibit D, Medical Group must exhaust the applicable
provider appeals process before initiating any of the post -appeal processes set forth
below.
In the event the Company rejects a Medical Group's request to dispute an issue, or fails
to notify Medical Group that Medical Group's request to dispute an issue has been
accepted, within thirty (30) days from the date the request is made, Medical Group may
bypass the applicable provider appeals process and proceed directly to mandatory non-
binding mediation, which shall be conducted in accordance with RCW chapter 7.07.
Medical Group and Company shall each bear their own costs of mediation and shall split
equally the costs of the third -party mediator.
In addition, if Medical Group submits a dispute to the Provider Billing Dispute Appeal
Process, and the Company fails to timely render a decision based on the time frames
described in Exhibit D, Medical Group may bypass the Provider Billing Dispute Appeal
Process and proceed directly to one or more of the post -appeal processes described
below.
9.3 POST -APPEAL PROCESSES — If, after the exhaustion of the applicable internal provider
appeals process, either party is dissatisfied with the outcome of the internal provider
appeal and wants to further dispute the issue(s), the disputed issue(s) must be submitted
to one or more of the processes as described below. Any prerequisites to initiating one
of the processes described below must be met before the process can be initiated.
Alternative dispute resolution, unless so elected by the Medical Group as provided
herein, is not required to the exclusion of judicial remedies.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 15 of 20
9.3.1 BINDING EXTERNAL REVIEW — For disputes that have exhausted the Provider
Billing Dispute and Medical Necessity/Investigational Procedure Appeal Process,
Medical Group may elect binding external review to resolve the disputed issue(s),
if certain conditions are met. In all cases if a dispute is submitted to external
review, the decision of the external reviewer is binding and the final decision on
the disputed issue. Disputes submitted to external review shall not be submitted
to mediation, arbitration or judicial remedy as provided herein. A description of
the external review process and any prerequisites to initiating the external review
process can be found in Exhibit D. Disputes that do not meet the criteria to be
submitted to binding external review may be submitted to binding external review
only upon mutual written agreement of the parties.
9.3.2 MANDATORY NON-BINDING MEDIATION — For disputes that have not been or
cannot be submitted to external review, the disputed issue(s) must be submitted
to mandatory non-binding mediation prior to seeking binding arbitration or
judicial remedy, except as otherwise provided herein. Mandatory non-binding
mediation must be requested within sixty (60) days following the date of the
Company's decision on Medical Group's last internal provider appeal. Where
Medical Group is allowed to bypass the internal provider appeal process as
provided herein, mandatory non-binding mediation must be requested within sixty
(60) days from the last day the Company has to timely respond to a dispute or a
request for a dispute. Medical Group and the Company shall each bear their
own costs of mediation and shall split equally the costs of the third -party
mediator.
9.3.3 JUDICIAL REMEDY & ARBITRATION — If, after exhausting the Company's
internal provider appeals process and completing mandatory non-binding
mediation, either party is still dissatisfied with the outcome and wants to further
dispute the issue(s), the disputing party shall elect to resolve the disputed
issue(s) through judicial remedy or binding arbitration.
9.3.3.1 JUDICIAL REMEDY — If, after completing any prerequisites to judicial
remedy as provided herein, the disputing party elects to resolve the
dispute through judicial remedy, the parties agree to comply with the
terms set forth in Section 10.7.
9.3.3.2 BINDING ARBITRATION — If, after completing any prerequisites to
binding arbitration as provided herein, the Medical Group elects to
resolve the dispute through final and binding arbitration, arbitration must
be initiated by making a written demand for arbitration on the Company.
The demand for arbitration must identify all issues on which the Medical
Group seeks arbitration, the contractual provisions on which the Medical
Group relies, the amount in dispute, and the relief requested.
The arbitration shall be conducted within one hundred and fifty (150)
miles of Medical Group's principal office address where notices under
the Agreement are sent, unless the parties mutually agree to conduct the
arbitration in a different location. The parties agree that the dispute shall
be submitted to one (1) arbitrator selected by mutual agreement of the
parties. If the parties cannot agree on an arbitrator, they shall obtain a list
of ten (10) possible arbitrators from a neutral source, such as the
American Arbitration Association, and shall strike arbitrators from the list
in turn, beginning with the party who won a coin toss, until only one
arbitrator remains. The remaining arbitrator shall hear the dispute,
unless either party shows such bias as would disqualify a judge from
hearing the proceeding, in which case the arbitrator shall be the next to
last name stricken. The parties shall share equally the fee of the
arbitrator, excluding the filing fee, if any, incurred in commencement of
the proceeding. The parties shall have the right to make substantive
Asuris MGA Agreement (Rev. 05/2017) Al8816854AA Page 16 of 20
motions. The arbitrator shall be bound by applicable federal and state
law and shall render a written decision within thirty (30) days of the
hearing. The arbitrator shall award the prevailing party any applicable
filing fees and arbitrator's fees paid by the prevailing party. The
arbitrator also may award the prevailing party attorneys' fees and costs
associated with the arbitration proceeding. Judgment upon an award
rendered by the arbitrator may be entered in any court having jurisdiction
thereof.
The parties agree that the joinder or consolidation of an arbitration
proceeding under the Agreement with an arbitration of disputes or claims
of any non-party to the Agreement is prohibited, regardless of the nature
of the issues or disputes involved.
9.4 FAILURE TO TIMELY APPEAL — If the disputing party (the party that demands or
initiates the internal provider appeal, external review, mediation, arbitration, or judicial
remedy) fails to demand or initiate an internal provider appeal, external review,
mediation, arbitration or judicial remedy as required by this Agreement and within the
time frames prescribed in Exhibit D and this Agreement, the Company's last
determination on the disputed issue(s) shall be deemed final and binding. In addition, the
disputed issue(s) shall be conclusively deemed to have been waived by the disputing
party and shall not be the subject of any further internal, external, judicial, or other
dispute resolution process. Once the decision is deemed final, nothing in this Agreement
shall prevent the prevailing party from pursuing remedies available to it, including without
limitation a judicial remedy, to collect any amounts owed to it by the other party. Also,
nothing in this Agreement shall prevent a party from asserting defenses, claims, causes
of action or demands in response to an internal appeal, mediation, arbitration or judicial
remedy initiated by the disputing party. This provision shall survive termination of this
Agreement.
9.5 PRECEDENTIAL EFFECT OF DECISIONS — The parties agree that any disputes that
arise under this Agreement shall be considered independently and on their own merits
without regard for any other determination made by a third -party through one of the post -
appeal processes or by Company through the internal provider appeal process or
otherwise. The parties agree that none of the determinations made under this
Agreement through one of the dispute resolution processes described above shall be
used as precedent for other disputes that may arise between Company and Medical
Group or between Company and any third -party. This provision shall survive termination
of this Agreement.
9.6 OTHER APPEALS — In the event a dispute arises that does not meet the requirements to
be reviewed through one of the other dispute resolution processes set forth herein,
Medical Group may contact Medical Group's provider consultant to attempt to resolve the
dispute informally or Medical Group may send a written request as outlined further in the
Company's Administrative Manual. The Administrative Manual provides detailed contact
information. If the dispute cannot be resolved, Medical Group may make a formal
request for a meeting on the disputed issue(s) no later than ninety (90) days from the
date Medical Group first raised the dispute with the Company. The request must be made
in writing and provide details on the disputed issue(s) and the relief requested. The
meeting may be by phone or in person and should be held within forty-five (45) days of
the Company's receipt of the meeting request.
The Company will provide Medical Group with a written determination of its position on
the disputed issue(s) no later than thirty (30) days after the meeting.
X. GENERAL PROVISIONS
10.1 SEVERADI.LITY — If any provision of this Agreement is rendered invalid or unenforceable
by any state or federal statute or regulations or declared null and void by any court of
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 17 of 20
competent jurisdiction, the remaining provisions of this Agreement will remaining in full
force and effect.
10.2 ASSIGNMENT — This Agreement, and any rights or obligations hereunder, shall not be
assigned, delegated or transferred by Medical Group without the prior written consent of
Company. Company may assign this Agreement to any entity that controls, is controlled
by, or is under common control with Company, or which succeeds to its business through
a sale, merger or other corporate transaction.
10.3 BINDING EFFECT — This Agreement will be binding upon and inure to the benefit of the
respective successors and assigns of Company and Medical Group.
10.4 WAIVER OF BREACH — Waiver of breach of any provision of this Agreement will not be
deemed a waive of any other breach of the same or different provision.
10.5 FORCE MAJEURE — Neither party will be deemed to be in violation of this Agreement if it
is prevented from performing its obligations by events beyond its control including,
without limitations, acts of God or of the public enemy, flood or storm, strikes, or statute,
rule or action of the government or agency. The parties will make a good faith effort;
however, to assure that Members have access to Medical Group's services, consistent
with applicable law, despite such events.
10.6 NOTICES AND COMMUNICATION BETWEEN THE PARTIES - The following provisions
will apply to notices and communications between the parties to this Agreement.
10.6.1 Certain Notices Required Under_This Agreement. The following notices must be
sent via overnight delivery with delivery confirmation or certified mail, return
receipt requested:
a. all notices for termination of this Agreement;
b. all requests for mediation; and
C. all requests for arbitration.
10.6.2 All Other Notices and Communications. All other notices and communications
between the parties which are necessary for the proper administration of this
Agreement (including notices required within this Agreement which are not
included in Section 10.6.1 above) may be communicated via regular U.S. mail,
confirmed facsimile, or electronic mail.
In addition, Company may notify Medical Group of policy changes, Administrative
Manual changes, and other general communications through its Provider Web
Site, as long as Company sends notice by U.S. mail, facsimile, or electronic mail
(1) informing Medical Group that Company has published a policy change,
Administrative Manual change, or other general communication on its Web Site,
and (2) directing Medical Group to the location of the policy change,
Administrative Manual change, or other general communication on Company's
Provider Web Site. Notice in this manner shall constitute notice under the
Agreement.
10.6.3 Confidential and Protected Health Information. If a notice or communication
includes information which is confidential or proprietary to either or both parties and/or
which includes Protected Health Information ("PHI") as defined under Health Insurance
Portability and Accountability Act of 1996 (42 U.S.C. 201 et seq.), then the following
restrictions must be observed when communicating such information:
10.6.3.1 U.S. Mail/Certified Mail/Overnight Delivery — No additional
requirements.
10.6.3.2 Facsimile Transmission— The information must be prefaced by a
formal cover sheet noting the confidentiality of such information.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 18 of 20
10.6.3.3 Web Site - Not a permitted method of notice or communication for
confidential information and PHI, unless the Web Site is secured or
the information is appropriately encrypted.
10.6.3.4 Electronic Mail - Not a permitted method of notice or communication
for confidential information and PHI, unless the electronic mail is
secured or the information is appropriately encrypted.
10.6.3 Address for Notices. Notices to Medical Group shall be sent to: (1) the facsimile
or postal address of Medical Group's billing service location or any other revised
postal address or facsimile provided by Medical Group to Company in writing; or
(2) the electronic mail address designated by Medical Group for electronic
notices. Notices to Company shall be sent to the address set forth in this
Agreement or any revised address provided to the Medical Group in writing. The
facsimile, postal address or electronic mail address for notices may be changed
upon prior written notice to the other party.
10.6.4 When Made. For notices described under Section 10.6.1 above, the notice will
be deemed to have been made on the date it was delivered. For notices and
communications described under Section 10.6.2, the notice or communication
will be deemed to have been made when sent or mailed.
10.7 GOVERNING LAWNENUE — The validity of this Agreement and of any of its terms and
provisions, as well as the rights and duties of the parties hereunder, shall be interpreted
and enforced pursuant to and in accordance with the laws of the State of Washington and
other applicable State and Federal laws. In the event any legal proceedings are
instituted between the parties arising out of this Agreement, such legal proceedings shall
be subject to the mandatory mediation requirements set forth in Section 9.3 above and
instituted in the courts of the County of Spokane, State of Washington. Each of the
parties agrees to submit to the jurisdiction of such courts.
10.8 HEADINGS — The headings contained in this Agreement are for reference purposes only
and will not affect the meaning or interpretation of this Agreement.
Asuris MGA Agreement (Rev. 05/2017) A18816854AA Page 19 of 20
10.9 ENTIRE AGREE..MENT/SUPERCESSION — This Agreement, its exhibits, addenda and
any amendments thereto promulgated pursuant to Section VIII of this Agreement and any
documents incorporated by reference constitute the entire agreement between Company
and Medical Group. It supersedes all prior written or oral understanding between the
parties relating to the subject matter of this Agreement.
IN WITNESS WHEREOF, the parties have caused this Agreement to be signed on the date and
year written below.
KITTITAS COUNTY HEALTH DEPT Asuris Northwest Health
Signature Signature
_I., Obis`. `� 1 John Partin
Name Print Name
AAyv% :S'+ra+0 V _ Vice President, Network Management
Title Title
Date Date
Tax Identification Number
Office address to be used in notices:
Participating Provider Asuris Northwest Health
Ki*'t+aS Gg t Kt6lit Oe.ct.ffti, Nei Attention: Provider Network Management
►:I N Nzyn4 Si a;4e- f02, 528 E. Spokane Falls Blvd., Suite 301
X14 zvts b tt 92-'U4 Spokane, WA 99202
Asuris MGA Agreement (Rev. 05/2017) Al8816854AA Page 20 of 20
EXHIBIT A
ASURIS NORTHWEST HEALTH AFFILIATES & SUBSIDIARIES
As of the effective date of this Agreement, listed below are the affiliates of Asuris Northwest Health. This
list also includes each affiliate's subsidiaries that provide services related to health care as referenced in
Section 5.6. Asuris Northwest Health will notify Medical Group if this list changes.
Regence Blue Cross Blue Shield of Oregon, Portland, Oregon*
LifeMap Assurance Company
Regence Blue Shield of Idaho, Lewiston, Idaho**
Regence BlueShield, Seattle, Washington***
Healthcare Management Administrators
BridgeSpan Health Company
* Regence BlueCross BlueShield of Oregon is an affiliate only for providers with practice locations in
Benton County, in the State of Washington.
**Regence BlueShield of Idaho is an affiliate only for providers with practice locations in Pend Oreille,
Spokane and Whitman Counties, in the State of Washington.
***Regence BlueShield is an affiliate only for providers with practice locations in Okanogan, Chelan,
Kittitas, Grant, Benton, Franklin and Whitman Counties, in the State of Washington.
Asuris Medical Standard MGA Exhibit A Affiliates & Subsidiaries Al8816854AA Page 1 of 1
EXHIBIT B
List of Medical Group Providers Covered by this Agreement
(To be completed by the Medical Group)
Mark, 0 I.otr6w) HD
Asuris Medical Standard MGA Exhibit B List of Providers A18816854AA Page 1 of 1
EXHIBIT C
ASURIS NORTHWEST HEALTH
PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT
REIMBURSEMENT METHODOLOGY AND FEE SCHEDULE
THIS EXHIBIT TO THE PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT (the
"Agreement") is effective for dates of service on or after the effective date of the Agreement and replaces
and supersedes any prior payment and/or rate exhibits. Any term not defined herein shall have the
meaning set forth in the Agreement.
DEFINITIONS
1.1 Billed Charges —charges submitted by Medical Group for Covered Services.
1.2 Maximum Allowable — the amount that Company agrees to pay, subject to standard
Company administrative guidelines, reimbursement policies and payment methodologies,
including but not limited to reimbursement for CPT® code modifiers.
1.3 Anesthesia Services — services described by CPT® codes to which the American Society
of Anesthesiologists has assigned a base unit.
1.4 Total Anesthesia Units — ASA base unit for a CPT® code plus time units, which are defined
as total time for a service in 15 -minute increments. Sixty minutes is 4 time units. Per the
Company's reimbursement policy, after one minute, Company rounds units up to the next
15 -minute increment.
1.5 CMS RVUs — the Centers for Medicare and Medicaid Services (CMS) site -of -service based
(facility or non -facility), non-GPCI adjusted Relative Value Units (RVUs), which are updated
annually in the Federal Register. The Company shall provide notice as described in Article
V below of the CMS RVUs in effect for a particular date of service.
1.6 Ingenix RVUs — (formerly known as St. Anthony's RVU's) the site -of -service based (facility
or non -facility), non-GPCI adjusted Relative Value Units in The Essential RBRVS - A
Comprehensive Listing of RBRVS Values for CPT® and HCPCS Codes, published by
Ingenix. The Company shall provide notice as described in Article V below of the Ingenix
RVUs in effect for a particular date of service.
II. FEE SCHEDULE/PAYMENT METHODOLOGY
Applies to Participating and Preferred Plan Provider Networks when applicable by
appropriate network participation.
2.1 Medical Group agrees to accept as payment in full the lesser of Billed Charges or the
Maximum Allowable for Covered Services provided to Members.
2.2 The Maximum Allowable for covered Anesthesia Services shall be calculated by multiplying
the anesthesia conversion factor established by the Company for the date of service, times
the Total Anesthesia Units for the service.
2.3 The Maximum Allowable for Covered Services provided by MDs and DOs shall be calculated
by multiplying the MD/DO conversion factor established by the Company for the date of
service times the CMS RVU, except as noted below. The Maximum Allowable for Covered
Services provided by ARNPs and PAs shall be calculated by multiplying the ARNP/PA
conversion factor established by the Company for the date of service times the CMS RVU,
except as noted below:
2.3.1 For services with professional and technical components, the associated global
Maximum Allowable for Covered Services will equal the sum of these components.
2.3.2 The Maximum Allowable for Covered Services included in Medicare's Clinical
Diagnostic laboratory fee schedule shall be a percentage, as established by the
Company for the date of service, of the most current version of that fee schedule.
2.3.3 The Maximum Allowable for Covered Services for the following shall be the amount
set forth on the Company's fee schedule:
Asuris Medical Standard MGA Exhibit C Al8816854AA Page 1 of 2
IV.
V.
2.3.3.1 Technical component of MRI (Magnetic Resonance Imaging), MRA (Magnetic
Resonance Angiography) and CT (Computed Tomography)
2.3.3.2 PET (Positron Emission Tomography) Scans
2.3.3.3 Durable medical equipment, medical supplies, orthotics and prosthetics
2.3.3.4 Physical and Occupational Therapy, Speech Therapy and Audiology
2.3.3.5 Acupuncture and Chiropractic Services
2.3.3.6 Technical component of Sleep Study Medicine
2.3.3.7 Vision Exam
2.3.3.8 Those CPT codes identified as Policy Codes by the Company
2.3.4 The Maximum Allowable for drugs and medications, including but not limited to
biologicals, immune globulins, vaccines and immunizations, shall be the Company's
medication fee schedule in effect on the date of service.
2.4 For services for which no RVU has been established by CMS, the Maximum Allowable for
Covered Services shall be determined using Ingenix RVUs.
2.5 For services for which no RVU has been established by CMS or by Ingenix the Maximum
Allowable for Covered Services shall be the Company's participating fee schedule in effect
on the date of service.
2.6 The Maximum Allowable for Covered Services rendered by behavioral health providers shall
be the Company's participating fee schedule in effect on the date of service.
2.7 For services rendered by other licensed practitioners not specifically identified in Section 2.3
above, the Maximum Allowable for Covered Services shall be the Company's fee schedule
specific to the practitioner type in effect on the date of service.
2.8 Conversion factor(s), fee schedules showing common Covered Services or any other
reimbursement factor referenced herein will be provided to the Medical Group. The
Maximum Allowable for Covered Services not set forth on a fee schedule shall be provided
upon request. The Company has no obligation to provide fees, conversion factors or other
reimbursement rates to Medical Group for Covered Services not typically performed by the
Medical Group.
COPAYMENT, COINSURANCE, DEDUCTIBLE
3.1 Where the Subscriber Agreement provides for payment of copayment, coinsurance or
deductibles by the Patient, payment by Company for Covered Services shall be less the
applicable copayment, coinsurance or deductible.
NOTICE OF UPDATES
4.1 The Company shall provide Medical Group ninety (90) days prior notice of changes to the
Company's reimbursement methodology, RVU conversion factor, CMS or Ingenix RVU year,
the percentage referenced in 2.3.2., or Company fee schedules, excluding changes to fees
tied to CMS fee schedules.
NON -DISCLOSURE
5.1 Medical Group agrees that unless required by law or otherwise allowed by the Agreement,
Medical Group shall not disclose the reimbursement rates established by the Company
without prior written consent of Company. Medical Group further agrees not to disclose the
reimbursement rates to individual health care practitioners, other than those health care
practitioners on its Board, if applicable, in any format. Medical Group acknowledges that the
unauthorized disclosure of this information may cause irreparable damage to the Company,
and Medical Group agrees that the Company may seek relief for breach of this provision.
Asuris Medical Standard MGA Exhibit C A18816854AA Page 2 of 2
EXHIBIT D
PROVIDER DISPUTE RESOLUTION PROCESSES
Glossary
Adverse Determination: For purpose of the appeal process means any of the following: a denial,
reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,
including any such denial, reduction, termination, or failure to provide or make payment that is based on a
determination of any of the following:
• application of utilization review;
• determination that a treatment is not Medically Necessary; or
• Billing Dispute.
Appeal Record: Includes all information which was relied upon in making the payment determination; or
was submitted, considered, or generated in the course of making the payment determination, whether or
not such document, record, or other information was relied upon in making the payment determination; or
demonstrates compliance with the Company's Claims procedures, administrative processes and
safeguards; or constitutes a statement of policy or guidance with respect to the payment determination.
Billing Dispute: A dispute with a Provider arising from Covered Services provided to Members by such
Provider concerning:
• the Company's application of coding and payment rules and methodologies for fee for service
claims (including bundling and downcoding),
• application of a Current Procedural Terminology (CPT°) modifier, and/or other reassignment of a
code by the Company to patient specific factual situations, including the appropriate payment
when two or more CPT Codes are billed together, or
whether a payment enhancing modifier is appropriate.
Claims: A Provider's request for payment submitted in the usual course of business between the
Provider and the Company.
External Review: Review of a Billing Dispute Appeal or a Medical Necessity Procedure Appeal submitted
to the External Review Organization with which the Company has contracted to provide these review
services by a Provider in compliance with the terms of the Adverse Determination Appeal Process.
External Review Organization ("ERO"): An independent organization employing physicians and other
medically qualified individuals or experts, which acts as the decision maker for External Reviews, through
an independent contractor relationship with the Company.
Provider: Provider means practitioner, clinic, provider, or other health care provider as defined in the
Agreement.
"Our" or "We": References to our or we mean Asuris Northwest Health or the Company.
"You" or "Your": References to you or your mean Medical Group as defined in the Agreement
Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 1 of 9
Provider Appeals
Provider Billing Dispute and
Medical Necessity Procedure Determination Appeal Process
Introduction
A. Applicability
The Company Provider Billing Dispute and Medical Necessity Procedure Determination Appeal
Process (Adverse Determination Appeal Process) will apply when the Provider is at financial risk
for the cost of the claim. The member appeal process will apply when the member is or may be at
financial risk for the cost of the claim. For purposes of Billing Disputes only, the definition of
Provider shall include providers who contract with Company as Participating Providers and non -
contracted providers.
Internal Review Process
A. Time Period for Submission of an Adverse Determination Appeal by Provider
An Adverse Determination Appeal must be submitted in writing within the following timeframes
1. For Washington Providers, within 24 months after payment of the claim or notice that the
claim was denied or 30 months for claims subject to coordination of benefits.
2. If a Provider wishes to appeal a refund request initiated by Company, that Provider can
submit an Adverse Determination Appeal within the same timeframe as other Adverse
Determination Appeals as listed above. Note: The timeframe begins when the written
request for refund is sent to the Provider
Failure to request review within the stated time period (absent a finding which, in our sole
discretion, sets forth acceptable extenuating circumstances) will preclude the right to appeal and
may jeopardize the right to contest the decision in any forum.
B. Process for Submission of an Adverse Determination Appeal
1. A Provider may use the Provider Adverse Determination Appeal form, which can be found on
Company's Provider Web Site: www.asuris.com/provider
2. The appeal form for Provider Billing Disputes and Medical Necessity denials or a written
description of the issue(s) on the appeal must be submitted to Company, as further outlined
on Company's provider web site.
3. The following information must be submitted with the Provider Adverse Determination Appeal
form or the written description of the issue(s) on appeal:
(a) A detailed description of the disputed issue(s);
(b) The basis for disagreement with the decision; and
(c) All evidence and clinical documentation supporting your position.
Asuris Standard MGA Exhibit D Dispute Resolution Process Al8816854AA Page 2 of 9
C. Review Process
1. The individual reviewing the issue(s) on appeal will meet the following criteria:
(a) Is not an individual who made or consulted in the initial determination,
(b) Is not a subordinate of an individual involved in the initial determination.
2. If the initial determination is upheld, you have the option to seek External Review or one of
the other dispute resolution processes set forth in the Agreement. A description of the
External Review option will be supplied, including the time limit for requesting External
Review. The time limit for requesting External Review is ninety (90) calendar days after the
written Internal Review determination.
3. Company will communicate a written decision on an Internal Review of an Adverse
Determination Appeal within thirty (30) calendar days of our receipt of all documentation
reasonably needed to make the determination. A description of the External Review option
will be supplied with the written decision, including the time limit for requesting External
Review.
D. Adverse Determinations Not Eligible for Adverse Determination Appeals
The following will not be considered to be eligible appeals:
1. Except for Billing Disputes, appeals made by non contracting providers. Appeals by non
contracting providers may be eligible for the member appeal process.
2. Appeals of post service claims where the member or Provider sought a pre -service appeal of
the same claim.
3. Appeal of a post service claim where the member has appealed the same claim.
4. The member has filed suit under Section 502 of ERISA or other suit for denial of the health
care services or supplies regarding an Adverse Determination.
E. Qualified Reviewer
For an Internal Review pertaining to an Adverse Determination Appeal (not to include Billing
Disputes), only a medical or dental practitioner holding an active, unrestricted license, who
possesses the appropriate level of training and/or expertise required to evaluate the necessity of
the service under review, and who is other than the one that made the initial Adverse
Determination, may deny the appeal of the Provider who treated the condition. A nurse or other
health care professional employed by Company may review the Adverse Determination Appeal
and may grant but not deny it. If the nurse or other health care professional does not grant the
appeal, then a Qualified Reviewer, designated by Company, other than the one that made the
initial Adverse Determination, shall review and decide the Adverse Determination Appeal in
accordance with our medical and reimbursement guidelines.
Provider External Review Process
If the initial determination is upheld through the Internal Review process, the option to seek External
Review of the determination will be made available.
A. Prerequisites for External Review
1. The Internal Review process must be exhausted before requesting an External Review of the
determination unless both Company and the Provider agree in writing to forego the Internal
Review process and proceed directly to External Review.
2. A Provider who chooses External Review will submit a written notice to Company within
ninety (90) calendar days from the date of the Internal Review Determination.
Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 3 of 9
B. External Review Provisions:
An Adverse Determination Appeal may be submitted for External Review when the amount in
dispute exceeds $500 unless the Provider notifies the Company that the Provider intends to
submit additional Adverse Determination Appeals for External Review on the same or similar
issues during the one-year period following the submission of the original Adverse
Determination Appeal and the cumulative amount in dispute over the one-year period
exceeds $500. The request for External Review is at the option of the Provider, who may
instead choose any other dispute resolution allowed by the Agreement. If chosen, the
External Review shall be binding.
2. The Adverse Determination Appeal must be submitted to Company in writing. The
Administrative Manual and the Appeal Form for Provider Billing Dispute and Medical
Necessity Denial provides detailed contact information.
3. Company will forward Adverse Determination Appeals that meet the prerequisites as listed in
section A above to a designated External Review Organization.
The Provider shall pay a filing fee of $50.00 for each Adverse Determination Appeal.
(a) The Company shall notify the Provider the filing fee is due
(b) Payment must be submitted before the External Review begins; provided, however,
that the Provider shall be entitled to a refund of such payment in the event that the
Provider prevails in the External Review process.
(c) Provider shall submit the filing fee within sixty (60) calendar days of notice from the
Company that filing fee is due or the External Review request will be closed.
5. Upon receipt of a timely filing fee, Company will provide to the External Review Organization
the Appeal Record.
6. The External Review Organization will process the Adverse Determination Appeal and notify
the Provider and Company of its recommendation within thirty (30) calendar days of receipt of
the filing fee. The decision will be binding on Company and the Provider.
7. In the event that the External Review decision requires payment by Company, such payment
shall be initiated within fifteen (15) calendar days after we receive notice of the determination.
External Audit and Investigation Appeal Process
The External Audit and Investigation Appeal Process is intended to give you an opportunity to request
reconsideration of audit findings issued by our External Audit and Investigation Department and to ensure
we have reviewed all information relevant to the audit findings. Please note that contract terminations
resulting from audit findings must follow the Provider Contract Termination Appeal Process.
A. Reconsideration Request
Upon receipt of our audit findings, you have forty-five (45) business days to review and dispute these
findings before the audit becomes final. In order to appeal the findings, you must submit a written request
for a reconsideration of audit findings. You will be given the address for where to send your
reconsideration request with your audit findings.
Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 4 of 9
The request must be received by Company within forty-five (45) business days of your receipt of the
audit findings and must include, at a minimum, the following:
■ A detailed statement of the issue(s) in dispute
■ At the election of the Provider, notification of a request for a meeting with the panel reviewing the
issue(s) in dispute
• Any documents which the Provider contends supports his/her position
(Exception: Please note that all documentation required to justify your billing, including but not
limited to chart notes, must be present in your files at the time of an audit. Additions to file
documentation and/or the production of files that were not made available to us at the time of an
audit will not be considered in connection with an appeal involving adverse audit findings. We will,
however, consider your explanation as to why the documentation was not present at the time of
the audit.)
If we do not receive such a reconsideration request within forty-five (45) business days of your receipt of
the audit findings, the findings will be final.
The request for reconsideration will be reviewed by the manager of our External Audit and Investigation
Department, investigators within that department, and other Company representatives, as determined by
the manager of the department (hereinafter referred to as the "Panel"). At the discretion of the Panel, a
Company Medical Director may be consulted prior to the final decision.
A meeting, prior to the Panel's review of your request for reconsideration, can be arranged either at your
office or a Company office, as mutually convenient. You must request this meeting when submitting your
request for reconsideration.
At the meeting, you may appear in person and may be accompanied by an attorney or other
representative. You and your representative may make an oral statement to the Panel and respond to
questions from the Panel. The purpose of this meeting is to give you an opportunity to present your
position to the Panel in person.
If the Panel needs additional documentation to reach a decision, the additional documentation must be
submitted within twenty (20) calendar days of the date of the Panel's written request for information,
unless your written request for a reasonable extension of time is granted.
■ If the requested documentation is received on time, it will be included in the request for
reconsideration.
• If the documentation is not received on time, the request for reconsideration will continue and a
decision will be made based on the information originally submitted.
You will be sent written notice of the decision within forty-five (45) business days following the meeting
with the Panel or, if no such meeting was requested, within forty-five (45) business days of our receipt
of the audit reconsideration request, not including the time waiting for additional information from you.
During the period of time in which we are waiting for additional information, the appeal decision time
frame is suspended until the information is received or the time to respond to the request has expired.
The decision on an audit reconsideration request is deemed final forty-five (45) business days
after your receipt of the Panel's decision, unless a timely written request for a Medical Director
Review is received.
III. B. Medical Director Review
If you are not satisfied with the decision made following the reconsideration request to the Panel, you may
request a Medical Director Review of the audit findings. The written request for a Medical Director Review
and any supporting information must be received by Company within forty-five (45) business days of
your receipt of the Panel's decision. The address where to send your request will be included in our
response to your request for reconsideration.
The Medical Director Review will be held no more than forty-five (45) business days following receipt of
the request, not including the time in which the Company is waiting for additional information from you.
The review will be conducted by a Medical Director who was not involved in an earlier review of the audit
findings.
Asuris Standard MGA Exhibit D Dispute Resolution Process Al8816854AA Page 5 of 9
If the Medical Director needs additional documentation to reach a decision, the additional documentation
must be submitted within twenty (20) calendar days of the date of the Medical Director's written request
for information, unless your written request for a reasonable extension of time is granted.
■ If the requested documentation is received on time, it will be included in the Medical Director
Review.
• If the documentation is not received on time, the Medical Director Review will continue and a
decision will be made based on the information originally submitted.
During the period of time in which the Company is waiting for additional information, the forty-five (45)
business day clock to complete the Medical Director Review is suspended until the information is received
or the time to respond to the request has expired.
You will be sent written notice of the decision within forty-five (45) business days following the Medical
Director Review.
The Medical Director Review is the final step in the External Audit and Investigation Appeal
Process. Once a decision has been made by the Medical Director, the External Audit and
Investigation Appeal Process has been completed and the decision shall be deemed final. If you
are not satisfied with the Company's decision after completing the External Audit and
Investigation Appeal Process and want to continue to dispute the issue(s), you must initiate the
appropriate process(es) as outlined in your Provider contract.
Provider Contract Termination Appeals
A contracted Provider may initiate an appeal of a contract termination decision made by Company
through the Provider Contract Termination Appeal Process.
IV. A. Level One Appeal
To request a Level One Appeal, you must send a written request to the Company's Credentialing
Department, at the address listed below within thirty (30) business days of receipt of the termination
notification.
Provider Contract Termination Appeal - Level One
Attention: Credentialing Department
P.O. Box 21267, M/S S-555
Seattle, WA 98111-3267
A request for an appeal regarding a contract termination must include, at a minimum:
• A detailed description of the disputed issue(s)
• The basis for your disagreement with the decision
• All evidence and documentation supporting your position
(Exception: Please note that all documentation required to justify your billing, including, but not
limited to, chart notes, to be present in your files at the time of an audit. Additions to file
documentation or the production of files that were not made available to Company at the time of
an audit will not be considered in connection with an appeal involving adverse audit findings. We
will, however, consider your explanation as to why the documentation was not present at the time
of the audit.)
• Your requested outcome
Upon receipt of the Level One Appeal request, we will send you an acknowledgement letter within fifteen
(15) business days.
The Level One Appeal Panel is comprised of at least three (3) individuals that have not been directly
involved in the Credentialing Committee or termination decision and have the appropriate level of
knowledge and training to understand the issues presented. At least one panel member must be a
Participating Provider.
Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 6 of 9
Level One Appeals meetings are held on a bi-monthly basis. Your appeal will be scheduled for review at
the next available Level One Appeal Panel meeting, subject to the time that your appeal request and any
additional information is received and the volume of appeals being reviewed by the panel.
If additional information is requested, it must be submitted within fifteen (15) business days of the date
of the written request for information, unless a written request for a reasonable extension of time is
granted.
■ If the information is not received on time, a decision will be made at the next Level One Appeal
Panel meeting, based on the limited information available.
• If the additional information is received on time, the new information will be taken into
consideration at the next Level One Appeal Panel meeting.
Information not submitted within the time limit will not be considered for the Level One Appeal, unless
otherwise allowed by the Level One Appeal Panel.
You will receive a written determination within ten (10) business days of the Level One Appeal Panel
decision.
The Level One Appeal decision is deemed final on the thirtieth (30th) business day after you
receive it, unless a written request for a Level Two Appeal is received timely.
B. Level Two Appeal — "In -Person Hearing"
If you are not satisfied with the results of the Level One Appeal, you may submit a written request to the
Credentialing Department, at the address listed below, for a Level Two Appeal, "in-person hearing" no
later than thirty (30) business days after your receipt of the Level One Appeal decision.
Provider Contract Termination Appeal - Level Two
Attention: Credentialing Department
P.O. Box 21267, M/S S-555
Seattle, WA 98111-3267
The Level Two Appeal Panel is comprised of at least three (3) individuals that have not been directly
involved in the Level One Appeal, the Credentialing Committee, or the termination decision and have the
appropriate level of knowledge and training to understand the issues presented. At least one panel
member must be a Participating Provider.
The request for a Level Two Appeal must identify in detail the following:
• All issues on which you request re-evaluation
At election of the Provider, notification that more than two (2) hours is needed for the hearing
• Information not previously submitted to the Level One Appeal panel, if any
(Exception: We expect all documentation required to justify your billing, including, but not limited
to, chart notes, to be present in your files at the time of an audit. Additions to file documentation
or the production of files that were not made available to Company at the time of an audit will not
be considered in connection with an appeal involving adverse audit findings. We will, however,
consider your explanation as to why the documentation was not present at the time of the audit.)
• Your requested outcome
The hearing is generally completed within two (2) hours and will be scheduled for two (2) hours, unless
you notify us when requesting your Level Two Appeal that additional time is needed. We will make our
best efforts to accommodate reasonable requests for additional time, as long as we are notified when you
request the Level Two Appeal.
Upon receipt of the Level Two Appeal request, we will send you an acknowledgement letter within fifteen
(15) business days.
Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 7 of 9
Level Two Appeals meetings are scheduled upon request. We will make our best efforts to provide
proposed times and dates within sixty (60) business days of the Company's receipt of your Level Two
Appeal request. Once you have been provided the proposed times and dates you will have five (5)
business days to notify us of your preferred time and date for the Level Two Appeal hearing. If you fail to
notify us of your preferred time and date for the Level Two Appeal hearing within five (5) business days of
receiving the proposed times and dates, the hearing will be set on one of the proposed times and dates.
Prior to the Level Two Appeal hearing, you will receive a "Notice of Hearing." The "Notice of Hearing"
will indicate the following:
Date of the hearing
• Time of the hearing
Location of the hearing
Names of the members of the Level Two Appeal panel
Reasons for the adverse action
• Names of witnesses who will testify on Company's behalf at the hearing
Your rights at the hearing
At the hearing, you have the following rights:
• To have representation by an attorney or other person of your choice
To have a court reporter make a record of the proceedings at an additional cost to you. Costs
associated with the court reporter must be paid by you prior to receiving a copy of the transcript
a To call witnesses and to examine/cross-examine witnesses
• To present relevant evidence (as determined by the panel)
To submit a written statement at the close of the hearing
Approximately thirty (30) calendar days before the scheduled date of the hearing, a Level Two Appeal
binder will be sent to you or your representative. The binder will include, among other things, the
documentation reviewed by the Credentialing Committee initially and at the Level One Appeal, as well as
any documentation submitted by you. If you wish to submit additional information to further supplement
the Level Two Appeal binder, this information, as well as a list of witnesses that you plan to call, examine,
and cross examine at the hearing, must be received no later than fourteen (14) calendar days prior to
the hearing date. Unless otherwise allowed by the Level Two Appeal panel, documentation and witnesses
not submitted at least fourteen (14) calendar days prior to the hearing date will not be considered by the
Level Two Appeal panel and should not be brought to the hearing for the panel's consideration. The only
exception is that you may submit a written statement at the close of the hearing.
If the Level Two Appeal binder is later supplemented with new or revised information prior to the hearing,
you will receive copies of the new or revised material as soon as practicable before the scheduled date of
the hearing. After the Level Two Appeal binder has been finalized, it will be forwarded to the Level Two
Appeal panel for review prior to the hearing. Neither you nor Company may supplement the binder within
thirteen (13) calendar days prior to the hearing, unless a written request for an exception is approved by
the Chair of the Level Two Appeal panel.
You will receive written notification of the Level Two Appeal decision within fifteen (15) business days of
the hearing. If the Level Two Appeal panel cannot reach a decision within fifteen (15) business days, or
if additional information is needed to reach a decision, you will be informed of any additional information
needed and a new date by which the decision will be made.
Decisions of the Level Two Appeal panel related to contract terminations are deemed final. Once a
decision has been made by the Level Two Appeal panel, you have completed the Provider
Contract Termination Appeals process. If you are not satisfied with our decision after completing
the Provider Contract Termination Appeal process and want to continue to dispute the issue(s),
you must initiate the appropriate process(es) as outlined in your Provider contract.
Asuris Standard MGA Exhibit D Dispute Resolution Process Al8816854AA Page 8 of 9
C. Additional Information Regarding the Provider Contract Termination Appeals Process
a. Provider Status During a Contract Termination Appeal
You will continue as a Participating Provider, however you will be temporarily removed from all
provider directories and any pending action by Company is put in abeyance until the appeal is
resolved and a final decision is made. If, however, the basis for the termination decision relates to
the health, safety or welfare of our members, or if the we have exercised our right to immediately
terminate the Provider contract for reasons allowed by the Provider contract, your participation
status will be terminated for the duration of the appeal process and reinstated only if you prevail
during the Provider Contract Termination Appeal process.
b. The Data Bank Reportable Actions
Company is required by law to report certain adverse actions or decisions against you to the
National Practitioner Data Bank (Data Bank). If our termination decision stands, either by virtue
of you choosing not to appeal or if the decision is upheld by the appeals panel, we may be
obligated to report this termination to the Data Bank, as applicable. You may not "self -term" to
avoid being reported to the Data Bank. Additional information on these reporting requirements is
available on the Data Bank website, at www.npdb.hrsa.gov.
Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 9 of 9
ASURIS NORTHWEST HEALTH
PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT
PREFERRED PLAN PROVIDER NETWORK ADDENDUM
EFFECTIVE DATE:
This Addendum to the Participating Provider Medical Group Agreement, herein referred to as the
"Medical Group Agreement", amends the Medical Group Agreement between Asuris Northwest
Health (the "Company") and KITTITAS COUNTY HEALTH DEPT ("Medical Group"), to recognize
additional provisions which apply to the Preferred Plan Provider Network, and to provide for the
recognition of health care services, and for payment of benefits for health care services, provided
to Preferred Members. Except as specifically amended herein, all terms and conditions of the
Medical Group Agreement remain in effect.
I. DEFINITIONS
A. "Preferred Member" is any subscriber or enrolled dependent entitled to benefits under a
Preferred Plan offered or administered by the Company or Payor, or any subscriber or
enrolled dependent entitled to benefits under a Subscriber Agreement offered or
administered by the Company or Payor that provides incentives for Members to seek
services from Preferred Plan Providers and Participating Providers in the Company's
Participating Provider Network.
B. "Preferred Plan" is any Subscriber Agreement that provides a benefit incentive for
subscribers or enrolled dependents to seek health care services from Preferred Plan
Providers.
C. "Preferred Plan Provider" is a Participating Provider in the Company's Preferred Plan
Provider Network.
D. "Preferred Plan Provider Network" is the collective group of hospitals, facilities, clinics,
physicians and other health care professionals under contract with the Company through
a Preferred Plan Provider Network Addendum.
II. PROVISIONS
A. Medical Group agrees to be a Preferred Plan Provider, participate in the Preferred Plan
Provider Network and provide health care services to Preferred Members.
B. The Company shall actively market Preferred Plans that provide incentives for Preferred
Members to seek services from Preferred Plan Providers with the Company's Preferred
Plan Provider Network.
C. The Company shall also actively market a Subscriber Agreement that provides incentives
for Members to seek services from Preferred Plan Providers and Participating Providers
in the Company's Participating Provider Network. If Medical Group provides services for
Members who are covered under such a Subscriber Agreement, the rates and terms
associated with the Preferred Plan Provider Network, as well as the cost sharing amounts
and terms in the Subscriber Agreement associated with the Preferred Plan Provider
Network, shall be used to determine the reimbursement amount for Medical Group.
Asuris Medical Standard MGA Preferred Plan Addendum A18816854AA Page 1 of 2
D. Medical Group agrees to maintain Participating Provider status in the Company's
Participating Provider Network.
E. Medical Group agrees to comply with the terms and conditions for Preferred Plan
Providers set forth in the Administrative Manual, which can be found on the Company's
website at http://www.asuris.com/provider/library/manual/index.htmi.
F. If a Medical Group Provider has admitting privileges, the Medical Group Provider shall
maintain admitting privileges in at least one hospital within the Preferred Plan Provider
Network.
G. Medical Group shall admit or arrange for hospital admissions and referral services of
Preferred Members only to Preferred Plan Providers, unless the Preferred Member is
covered under a Subscriber Agreement that provides incentives for Preferred Members
to seek services from Preferred Plan Providers and Participating Providers in the
Company's Participating Provider Network and the Preferred Member is being admitted
or referred to a Participating Provider in the Company's Participating Provider Network;
the Preferred Member's condition makes it impossible; the service is not available
through the Preferred Plan Provider Network; or the Preferred Member chooses care
outside the Preferred Plan Provider Network. Medical Group should advise the Preferred
Member whenever health care services are to be obtained outside of the Preferred Plan
Provider Network that the Preferred Member may be subject to additional out-of-pocket
expense. Any questions regarding network participation and benefit levels should be
directed to the Company.
H. Medical Group agrees to accept the Preferred payment set forth on the payment exhibit
as payment in full for covered services rendered to Preferred Members.
This Addendum shall continue in effect, unless terminated according to the process set forth
in the Medical Group Agreement. Either party may terminate this Addendum without
terminating the remainder of the Medical Group Agreement. However, in the event either
party terminates the Medical Group Agreement, this Addendum terminates as well.
The terms of this Addendum shall become a part of, and shall be specifically incorporated into, the
terms of the Medical Group Agreement. In the event of any conflict or inconsistency between the
terms of this Addendum and the terms of the Medical Group Agreement, the terms of this Addendum
shall prevail.
Asuris Northwest Health KITTITAS COUNTY HEALTH DEPT
Signature
John Partin
Name
Vice President. Network Management
Title
Date
Signature
_9pbin }fiee,A
Print Name
Admivii5frcfe
Title
Date
Asuris Medical Standard MGA Preferred Plan Addendum A18816854AA Page 2 of 2
Asuris Northwest Health
Medicare Provider Compliance Addendum
This is a Medicare Provider Compliance Addendum (the "Compliance Addendum") to the Participating
Agreements and any and all amendments, addenda, attachments or exhibits thereto (collectively, the
"Agreements" and each individually, the "Agreement"), between Asuris Northwest Health ("Asuris") and (the
"Provider" or "FDR" as those terms are defined below), effective this First day of October, 2016.
WHEREAS, Asuris has contracts to administer Medicare Advantage Plans and/or Medicare Part D plans
(collectively "Medicare") for the Centers for Medicare & Medicaid Services ("CMS") of the U.S. Department of
Health and Human Services ("HHS") to administer Medicare benefits within certain counties;
WHEREAS, the first tier, downstream or related entity ("FDR") has entered into an Agreement to provide
healthcare and or administrative services related to Asuris's Medicare business; and
WHEREAS, CMS requires Asuris to incorporate additional Medicare Compliance contract language into its
agreements with first tier, downstream, and related entities.
NOW, THEREFORE, in consideration, and with full understanding that these provisions may be outlined in
the main Agreement or addendum, the parties agree and will abide by the Compliance Addendum, as follows:
1. Com liance with Medicare Laws Re ulations and CMS Guidance: FDR agrees to comply with all
applicable Medicare laws, regulations, and CMS guidance. 42 C.F.R §§ 422.504(i)(4)(v) and
423.505(i)(4)(iv).
2. Medicare Standards of Conduct and Policies and Procedures: FDR agrees to make available
Standards of Conduct and policies and procedures to all of its employees who provide administrative
services or health care services for Asuris's Medicare business pursuant to this Agreement at the
time of hire and annually thereafter. FDR may either provide (a) Asuris's Standards of Conduct and
policies and procedures to FDR's employees, or (b) FDR's own comparable Standards of Conduct
and policies and procedures to FDR's employees. Medicare Managed Care Manual ("MMC Manual"),
Chapter 21, §§ 50.1.3 and 50.3.1; and Medicare Prescription Drug Benefit Manual ("PDB Manual"),
Chapter 9, §§ 50.1.3 and 50.3.1.
3. Conflict of interest: FDR agrees to comply with Asuris's Conflict of Interest Policy or its own Conflict
of Interest Policy that complies with CMS requirements. FDR will require its governing body, officers,
and senior leadership (as applicable) to sign a conflict of interest at the time of hire and annually
thereafter certifying that they are free from any conflict of interest related to Medicare. 42 C.F.R. §§
422.503(b)(4)(vi)(A) and 423.504(b)(4)(vi)(A).
Fraud, Waste, and Abuse ("FWA") and General Compliance Training: FDR agrees that all of its
employees who provide administrative services or health care services for Asuris's Medicare
business pursuant to the Agreement participate in Medicare Parts C and D FWA training and
Medicare Parts C and D General Compliance training within ninety (90) days of hire and annually
thereafter. Required FWA and General Compliance training is developed and provided by CMS and
is available through the CMS Medicare Learning Network (MLN) at
http://www.cros.gov/MLNProducts. FDRs who have met the FWA certification requirements through
enrollment into the Medicare program or accreditation as a Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) are deemed to have met the training and educational
requirements for fraud, waste, and abuse only. FDR must maintain documentation sufficient to
demonstrate to Asuris that FDR fulfilled the FWA and General Compliance training requirement.
MMC Manual, Chapter 21, § 50.3.2; PDB Manual, Chapter 9, § 50.3.2; 42 C.F.R. §§
422.503(b)(4)(vi)(A) & (C) and 422.504(b)(4)(vi)(A) & (F).
Reporting Cam liance and FWA Concerns: FDR agrees to report compliance or FWA concerns to
CMS or Asuris. Reporting should occur within five (5) days of discovery; if there is an immediate
impact to beneficiary access to care and/or a financial strain, please report immediately but at least
within twenty-four (24) hours. Asuris has a no -tolerance policy for retaliation or retribution against any
employee or FDR for good -faith reporting of FWA. 42 C.F.R. §§ 422.503(b)(4)(vi)(D) and
423.504(b)(4)(vi)(D).
Asuris MA Compliance Addendum 10/2016 Al8816854AA Page 1 of 3
6. Enforcement of Disciplinary Standards: FDR agrees to establish and publish its own disciplinary
standards, which include its expectation that employees report compliance issues and unethical or
illegal behavior. FDR's disciplinary standards must state that any violation of these standards will
result in appropriate disciplinary action, up to and including termination of employment. FDR's
violation of this provision may result in Asuris's termination of the Agreement. 42 C.F.R. §§
422.503(b)(4)(vi)(E) and 423.504(b)(4)(vi)(E).
OIG Exclusion 1 GSA Debarment: Pursuant to Federal law, FDR certifies that neither it nor any of its
employees or governing body members are on: (a) the List of Excluded Individuals and Entities
("LEIE") from the HHS Office of Inspector General ("OIG"); and (b) the General Services
Administration ("GSA") Debarment List. If an employee or governing body member is on either list,
FDR will immediately remove that person from any work related directly or indirectly to any Federal
healthcare program. FDR agrees to check both lists prior to hire and on a monthly basis to ensure
that none of its employees have become excluded from participation in Federal programs. The term
"employees" includes temporary employees, volunteers, and consultants. If applicable, FDR will
establish a process to identify and prevent payment for claims at point-of-sale for any drugs or
services prescribed, dispensed or delivered by excluded providers. 42 C.F.R. §§ 422.503(b)(4)(vi)(F),
422.752(a)(8), 423.504(b)(4)(vi)(F), 423.752(a)(6); and 42 C.F.R. § 1001.1901.
8. Record Retention and Audit Rights: FDR agrees to retain any books, contracts, records, and
documents related to Asuris's contract with CMS for a period of ten (10) years from the final date of
the contract period or the completion of any audit, whichever is later. FDR agrees to comply with any
document requests by Asuris pursuant to an audit or to monitor FDR's compliance with the terms of
this Agreement or Compliance Addendum. FDR will provide these documents to Asuris without
charge. 42 C.F.R. §§ 422.504(d), 422.504(e), 422.504(i)(4)(iii), 423.504(d)(2), 423.505(i)(4)(iii).
HHS Audit Rights: FDR agrees to allow HHS, the Comptroller General, or their designees to audit
and inspect any books, contracts, computer or other electronic systems, including medical records
and documentation, related to Asuris's contract with CMS. This right to audit and inspect any
pertinent information for any particular contract period will exist through ten (10) years, from the final
date of the contract period or from the date of completion of any audit, whichever is later. 42 C.F.R §§
422.504(i)(2) and 423.505(i)(2). FDR's failure to comply with this section could result in referral to law
enforcement and/or implementation of corrective action. 42 C.F.R. Subpart O.
10. Enrollee Protections: FDR agrees that it will not hold any of Asuris's Medicare enrollees liable for the
payment of any fees that are the legal obligation of Asuris. Asuris agrees to indemnify its Medicare
enrollees for the payment of any fees that are the legal obligation of Asuris for services furnished by
providers who do not contract, or who have not entered into an agreement with Asuris, to provide
services to Asuris's members. For Asuris's Medicare enrollees that are hospitalized as of the
termination date of Asuris's agreement with CMS, FDR will continue to provide covered services
through such enrollee's date of discharge. 42 C.F.R §§ 422.504(g), 422.504(i)(3)(i), and 423.505(8).
11. Credentialinn : Asuris will either (a) review the credentials of medical professionals affiliated with FDR;
or (b) review and approve a credentialing process, which Asuris may audit on an ongoing basis. 42
C.F.R § 422.504(i)(4)(iv).
12. Accountability Provisions: Asuris agrees that it may only delegate functions to FDRs in a manner
consistent with 42 C.F.R §§ 422.504(i)(3)(ii), 422.504(1)(4), 423.505(i)(3)(ii), and 423.505(1)(4).
13. Monitoring and Termination: Asuris will monitor FDR's performance under the Agreement on an
ongoing basis. Asuris has the option to terminate the Agreement with FDR if CMS or Asuris
determines that FDR has (a) not performed satisfactorily under the terms of the Agreement or
Compliance Addendum, (b) failed to maintain compliance, or (c) engaged in FWA. 42 C.F.R §§
422.504(i)(4)(ii), 423.505(i)(4)(ii), and 423.505(i)(4)(iii).
14. Flow -Down Provision: FDR shall incorporate the terms of this Compliance Addendum into any and all
subcontracts entered into delegating any of FDR's obligations to Asuris under the Agreement or
Compliance Addendum. 42 C.F.R §§ 422.504 (1)(3),422.504 (i)(4)(v) 423.505 (i)(3)(iii), and
423.505(i)(4).
15. Confidentiality and Accuracy of Records: FDR shall comply with the applicable confidentiality and
enrollee accuracy requirements, including: (a) all applicable Federal and State laws regarding
Asuris MA Compliance Addendum 10/2016 A18816854AA Page 2 of 3
confidentiality and disclosure of medical records, including disclosures pursuant to court orders and
subpoenas; and (b) timely access by enrollees to their records and information. 42 C.F.R. §§ 422.118
and 422.504(a)(13).
16. Dual-eli ig bles: If FDR is a health care provider, FDR agrees that all enrollees eligible for both
Medicare and Medicaid will not be held liable for Medicare Part A and B cost sharing when the State
is responsible for paying such amounts. As a provider, FDR will be informed of Medicare and
Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid, and may not impose
cost-sharing that exceeds the amount that would be permitted for an individual under Medicaid if the
individual were not enrolled in such a plan. Provider will (a) accept Asuris's payment as payment in
full, or (b) bill the appropriate State source. 42 C.F.R. §§ 422.504(g)(1)(iii) and 422.504(i)(3)(i).
17. ASLIFIS'S contractual obligations: FDR's services and activities pursuant to the Agreement are
consistent and comply with Asuris's contractual obligations. 42 C.F.R. § 422.504(i)(3)(iii).
18. Prompt -payment: If FDR is a health care provider, Asuris's contract or written agreement with FDR
will include a prompt payment provision. 42 C.F.R. §§ 422.504(c), 422.520, 422.520(b),
423.505(i)(3)(v), and 423.520.
19, Delegatmn: If Asuris delegates to another organization the selection of providers, contractors, or
subcontractors, Asuris retains the right to approve, suspend, or terminate any such arrangement. 42
C.F.R. § 422.504(i)(5).
20. Amendments required by law: If Medicare laws, regulations, or CMS guidance require a change to
any provision of this Compliance Addendum, this Compliance Addendum will be deemed amended to
conform with the law, regulation, or guidance on the date said requirements become effective. Asuris
will make reasonable business efforts to notify FDR of those changes, but in no event does any lack
of notice change the applicability of federal law.
21. Location of Services: FDR agrees that it shall not perform functions offshore, or delegate functions to
offshore entities or persons, without obtaining advanced approval in writing from Asuris and
demonstrating compliance with CMS guidelines and Asuris policies, terms, and conditions.
22. Ikon -Discrimination: FDR agrees to provide covered services to members without regard to race,
ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation,
genetic information or source of payments. MMC Manual, Chapter 4, § 10.5.
Any term not defined herein shall have the meaning set forth in the Agreement. The terms of this Compliance
Addendum shall become a part of, and shall be specifically incorporated into, the terms of the Agreement. In
the event of any conflict or inconsistency between the terms of the Compliance Addendum and the terms of
the Agreement or any Medicare Advantage Addendum(s), the terms of the most current Compliance
Addendum shall apply.
IN WITNESS WHEREOF, the parties hereto enter into this Compliance Addendum effective on the Effective
Date set forth above.
Asuris Northwest Health
Sincerely,
John Partin
VP, Network Management
Asuris MA Compliance Addendum 1012016 A18816854AA Page 3 of 3
ASURIS NORTHWEST HEALTH
2013 MEDICARE ADVANTAGE AMENDMENT
EFFECTIVE DATE: December 31, 9999
This 2013 Medicare Advantage Amendment (the "Amendment") amends the following agreements
(collectively, the "Agreements" and each individually, the "Agreement") and any and all amendments,
addenda, attachments or exhibits to those Agreements, between Asuris Northwest Health ("Company")
and Provider, as that term is defined below:
1. Participating Provider Agreement
2. Participating Provider Medical Group Agreement
3. Participating Facility Agreement
4. Participating Hospital Agreement
5. Participating Organizational Provider (Home Medical Equipment) Agreement
6. Participating Organizational Provider (Laboratory) Agreement
RECITALS
A. The Provider and Company are parties to one or more of the Agreements.
B. The Company desires to amend the Agreements to address changes in Provider compensation
payable under the Medicare Advantage program to account for (i) the federal sequestration
announced for 2013, and (ii) other future unplanned, unforeseen, or unusual events.
C. Therefore, in consideration of those premises and other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, the parties agree to the terms and
conditions set forth in this Amendment.
AGREEMENT
1. Definitions. For purposes of this Amendment, the following terms will have the following stated
meanings. Any term not defined in this Amendment will have the meaning given to the term in
the Agreement.
"Advance Monthly CMS Payments" means the advance monthly payments that are made by
CMS to Company, in Company's capacity as a Medicare Advantage organization, in return for
providing Covered Services to MA Members during those months.
"Advance Payment Adjustment" means the amount of any reduction in the Advance Monthly
CMS Payments that are made by CMS to Company, expressed as a percentage reduction from
the amount of the Advance Monthly CMS Payments that Company would have otherwise
received in the absence of the reduction, and that is caused by or that results from any
unplanned, unforeseen, or unusual budgetary event that was not contemplated by Company, or
that was not contemplated by Provider, or that was not contemplated by both Company and
Provider, when Company and Provider agreed upon the Medicare Advantage Compensation that
is otherwise applicable or payable to Provider under the Agreement. Unplanned, unforeseen, or
unusual events include without limitation any state or federal budgetary sequestrations, any
changes in state or federal law or policy, any mid -year budget adjustments, or any unanticipated
taxes or fees that cause a reduction in the Advance Monthly CMS Payments otherwise due to, or
expected to be received by, Company.
Asuris Medical Standard 2013 Medicare Advantage Sequestration Amendment A18816854AA Pagel
"Medicare Advantage Compensation" means the compensation payable under the Agreement,
by Company to Provider in return for providing Covered Services to MA Members.
"Provider" means "Medical Group", "Hospital", "Facility", or "Provider" as those terms are used
and defined in the relevant Agreement where they are used.
2. The Medicare Advantage Compensation paid to Provider for Covered Services received by MA
Members during a particular month will be reduced by the same percentage as, or by such lower
percentage as Company may determine in Company's sole discretion, any Advance Payment
Adjustment imposed upon or levied against the Advance Monthly CMS Payments that are paid to
Company during that month. For example, if a federal budgetary sequestration reduces the
Advance Monthly CMS Payments paid to Company by 2% during the months of April and May of
a particular year, then the Medicare Advantage Compensation payable under the Agreement to
Provider for any Covered Services received by MA Members during April and May of that year
will also be reduced by 2%, or by such other lower percentage that Company may determine in
Company's sole discretion.
3. Other Provisions. The provisions of the Agreement that are not amended or deleted by this
Amendment remain unchanged and in full force and effect.
Asuris Medical Standard 2013 Medicare Advantage Sequestration Amendment Al8816854AA Page 2
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C4-23-07
Baltimore, Maryland 21244-1850
CENTERS FOR MEDICARE &MEDICAID SERVICES
CENTER FOR MEDICARE
Date: June 17, 2015
To: All Medicare Advantage Organizations and Prescription Drug Plan Sponsors
From: Gerard Mulcahy, Director
Medicare Parts C and D Oversight and Enforcement Group
Subject: Update - Reducing the Burden of the Compliance Program Training
Requirements
On May 23, 2014 the Centers for Medicare & Medicaid Services (CMS) published CMS -4159-F,
Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and
the Medicare Prescription Drug Benefit Programs. This memo provides guidance for how your
organization can satisfy the requirements related to "Reducing the Burden of the Compliance Program
Training Requirements" for sponsors and first-tier, downstream and related entities (FDRs) that was
detailed in that final rule. See also (§§ 422.503(b)(4)(vi)(C)(3) and 423.504(b)(4)(vi)(C)(4)).
Sponsors must provide general compliance and fraud, waste and abuse (FWA) training for all
employees of their organization and entities they partner/contract with to provide benefits or services.
Starting January 1, 2016, to comply with training requirements sponsors must accept from FDRs
certificates of completion of CMS' training located on the Medicare Learning Network (MLN).
CMS developed web -based compliance training to ensure the requirement is met and to reduce the
largely duplicative training required of FDRs by the multiple organizations with whom they contract. The
compliance and FWA training topics include:
• Relevant laws and regulations related to Medicare Parts C and D FWA.
• An overview of compliance expectations, how to ask compliance questions, request
compliance clarification, hotline reporting.
• Types of non-compliance and FWA that can occur in the settings in which sponsor and FDR
employees work.
• Processes for Sponsors and FDR employees to report suspected Medicare program non-
compliance and FWA to the sponsor.
■ Case examples and resources.
CMS recognizes that many organizations use sophisticated training mechanisms and invest substantial
resources to deliver and track their employee's compliance with CMS requirements. In the final rule,
CMS stated that we would consider and determine if the CMS training modules could be available in a
format for downloading into organizations' existing training systems. To further minimize the
administrative burden on Sponsors and FDRs, CMS is broadening the availability of the CMS
compliance program training.
Asuris Medicare Compliance CMS Memo 2015 A18816854AA Page 1 of 2
Sponsors will have two (2) options for ensuring its FDRs (including the FDR's employees) have satisfied
the general compliance and FWA training requirement that must be completed 90 days after initial
hire/contracting and annually thereafter as described in the regulations and sub- regulatory guidelines.
(1) FDRs and its employees can complete the general compliance and/or FWA training modules
located on the CMS Medicare Learning Network (MLN). Once the individual completes the
training, the system will generate a certificate of completion. The MLN certificate of completion
must be accepted by all Sponsors.
(2) FDRs may download, view or print the content of the CMS standardized training modules from
the CMS website to incorporate into their organization's existing compliance training
materials/systems. The CMS training content cannot be modified to ensure the integrity and
completeness of the training. However, an organization can add to the CMS training to cover
topics specific to their organization. Training materials are available at the following path:
http:/Iwww.cros. gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/ProviderCompliance.html
CMS will accept either the MLN system generated certificates of completion, or, an attestation confirming
that the organization has completed the appropriate compliance and FWA training. Attestations must
include language specifying the entity complies with CMS compliance and FWA training requirements,
and, if choosing to implement option (2) the training provided includes CMS content without modification.
Further, sponsors and FDRs must maintain certificates or documentation of training completion and will
furnish upon request a certificate of training such as certificates of completion, training logs, system
generated reports, spreadsheets etc. FDRs providing training logs, reports, etc. must include at least
employee names, dates of employment, dates of completion, passing scores (if captured) to clearly
document training completion.
Sponsors are required to validate that all of the general compliance and FWA training requirements are
completed by their FDRs. In addition, Sponsors are accountable for maintaining records for a period of 10
years of the time and must require their FDRs to maintain training records of the FDRs' employees.
While use of the web -based training via the CMS MLN website is optional for Sponsors employees, a
benefit of using the web -based training and education modules is the ability to receive continuing
education credits for course completion.
Additional compliance information is available at:
https:/Iw,,vN. cros. gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-
Audits/ComplianceProgramPolicyandGuidance.html
More guidance regarding training and education requirements can be found in the Compliance Program
Guidelines located in the Internet Only Manual (IOM) Pub. 100-16, Medicare Managed Care Manual
Chapter 21, and IOM Pub.100-18, Medicare Prescription Drug Benefit Manual Chapter 9. Additional
guidance on the specifications and new location of the web -based compliance training modules is
forthcoming.
For compliance -training related questions please contact: Parts—C_and—D_CP_Guidelines@cros.hhs.gov
For FWA training—related questions, please contact: FWATraining@cros.hhs.gov
Asuris Medicare Compliance CMS Memo 2015 A18816854AA Page 2 of 2
This checklist will help ensure you are compliant with the Medicare requirements for first tier, downstream, and related
entities (FDRs). You must maintain documentation sufficient to demonstrate to us or Medicare that these elements are met.
Before hiring a new employee or
governing body member
❑ Check both the Office of Inspector General (OIG)
and General Services Administration (GSA) federal
exclusion lists to ensure that no employees are
excluded from participation in federal programs.
The term "employees" includes temporary
employees, volunteers and consultants. If
applicable, establish a process to identify and
prevent payment for claims at point-of-sale for any
drugs or services prescribed, dispensed or
delivered by excluded providers.
GSA exclusion list: sam.gov
• OIG exclusion list: oig.hhs.gov/exclusions
Within 90 days of hire
❑ Provide Standards of Conduct and policies
and procedures to all employees who provide
administrative services or health care services
for Asuris Medicare business.
❑ Require governing body, officers and senior
leadership (as applicable) to sign a conflict of
interest disclosure.
❑ Provide Medicare parts C and D fraud, waste and
abuse (FWA) training to all employees who provide
administrative services or health care services for
Asuris' Medicare business. Note: FDRs who
have met the FWA certification requirements
through enrollment into Parts A or B of the
Medicare program or through accreditation as a
supplier of DMEPOS are deemed to have met the
FWA training and education requirements.
❑ Provide Medicare parts C and D General
Compliance training to all employees who provide
administrative services or health care services for
Asuris Medicare business.
November 2015
Monthly for all employees and
governing body members
❑ Check both the OIG and GSA federal
exclusion lists to ensure that no employees
have become excluded from participation in
federal programs.
• GSA exclusion list: sam.gov
OIG exclusion list: oig.hhs.gov/exclusions
Annually for all employees and governing
body members
❑ Provide Standards of Conduct and policies and
procedures to all employees who provide
administrative services or health care services for
Asuris Medicare business.
❑ Require governing body, officers and senior
leadership (as applicable) to sign a conflict of interest
disclosure.
❑ Provide Medicare parts C and D fraud, waste and
abuse training and Medicare parts C and D General
Compliance to all employees who provide
administrative services or health care services for
Asuris Medicare business.
Report all compliance concerns
For concerns regarding ethics, compliance or fraud,
contact us through one of these confidential
options:
• Fraud, waste and abuse: 1 (800) 323-1693
Anonymous reporting line: 1 (888) 384-3577
Medicare compliance, privacy, HIPAA
compliance or ethics: 1 (877) 878-2273
Visit our FDR resource page at regence.com/
fdr-resources.
Asvfus,. �
NC)+3THW€. S f HEALTH
ASURIS NORTWEST HEALTH
MEDICARE ADVANTAGE PPO REIMBURSEMENT ADDENDUM
This is an Addendum ("Addendum"), effective on December 31, 9999, to the Participating Agreement
("Agreement"), by and between Asuris Northwest Health ("Company") and KITTITAS COUNTY
HEALTH DEPT ("Provider"). All references herein to "Provider" shall mean "Provider," or "Medical
Group," as those terms are used and defined in the Agreement(s).
WHEREAS, Company has a contract to serve as a Medicare Advantage (MA) plan for the U.S.
Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services
(CMS), to administer Medicare benefits within certain counties in the Company service areas;
WHEREAS, Provider has an existing Agreement to provide medical services to Members, as more
particularly set forth in the Agreement;
WHEREAS, Provider is entering into this Addendum to provide medical services to MA PPO
Members;
NOW THEREFORE, in consideration of the foregoing premises and other good and valuable
consideration, receipt and sufficiency of which are acknowledged, the parties hereby agree as follows:
A. REIMBURSEMENT PROVISIONS
The following reimbursement provisions and fee schedule amounts shall apply to Provider for
Covered Services rendered to MA PPO Members:
The fee schedule for professional providers is structured on the most recent edition of the CPT
coding manual. For most procedures, Company will determine Maximum Allowable Fees using
the Resource Based Relative Value Scale (RBRVS) published by the Centers for Medicare &
Medicaid Services (CMS). In the absence of CMS RBRVS unit values for specific procedures,
Company will establish such unit values for purposes of its Maximum Allowable Fee
determination. For certain procedures, the Maximum Allowable Fee will be individually
determined at Company's discretion. Procedures assigned "by report" status are paid as
determined by Company's Medical Director.
2. The allowance for each CPT procedure code is the lesser of the charge or the fee assigned to
that procedure code under the fee schedule. Payment for Covered Services is based upon this
allowance.
3. For Covered Services provided by MDs, DOs, DPMs, and ODs, the fee schedule shall be based
upon one hundred and two percent (102%) of the current Medicare fee schedule for the locale
where the service is rendered.
4. For Covered Services provided by Advanced Practice Professional Nurses and Physician
Assistants, the fee schedule shall be based upon eighty-five percent (85%) of the
MD/DO/DPM/OD rate listed above. Payments for Physician Assistants and Certified Registered
Nurse First Assistants assisting at surgery shall be reimbursed based on Medicare guidelines.
5. For Covered Services provided by other provider types (i.e., not MDs, DOs, DPMs, ODs, NPs
and PAs), including but not limited to: PT, OT, ST, CRNAs, DCs, the fee schedule shall be based
upon the current Medicare allowable for the provider type based on the locale where the service
is rendered. Company follows Chapter 12 of the Medicare Claims Processing Manual for the
provider type, example: Licensed Clinical Social Worker (LCSW) is paid seventy-five percent
(75%) of the Medicare physician fee schedule.
6. For Covered Services for Laboratory and Pathology services for which Medicare has established
a fee through its Clinical Laboratory Fee Schedule, reimbursement shall be based upon ninety
percent (90%) of the current Medicare fee schedule for the locale where the service is rendered.
7. Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) and Drugs will be
reimbursed according to Company reimbursement policy.
MA PPO Professional Reimbursement Addendum Asuris1 A18816854AA Page 1 of 2
B. MISCELLANEOUS PROVISIONS
1. Company will not make any additional payment for facility or professional services based upon a
rural health care designation under the Medicare program, including any designation such as a
Critical Access Hospital (CAH), Physician Scarcity Area (PSA) or any other designation, unless
the resulting payment is agreed to by Company in advance and in writing.
2. Provider agrees to look solely to Company for compensation for Covered Services provided to
Members. Provider agrees to collect directly from Member any outpatient co -payment which may
be established from time to time by Company for each office call and for each home visit. The co-
payment shall be a credit against the amount due from Company for Covered Services rendered
to a Member, without regard to whether the Provider has actually collected any co -payment.
3. For purposes of prompt payment of claims under this MA Addendum only, claims for Covered
Services provided to MA Members under this Addendum shall not be subject to any late fees,
interest, or other penalties as established by the Agreement or by state law. See 42 CFR §
422.520(b).
4. Consistent with all other MA Member Agreements offered by Company, Company will follow
CMS's standards in determining Medical Necessity, including, without limitation, Medicare's
national coverage decisions (NCDs) and applicable local medical review policies (LMRPs).
5. This Addendum shall continue, unless terminated according to the process set forth in the
Agreement. Either party may terminate this Addendum without terminating the remainder of the
Agreement. However, in the event either party terminates the Agreement, this Addendum terminates
as well.
Any term not defined herein shall have the meaning set forth in the Agreement. The terms of this
Addendum shall become a part of, and shall be specifically incorporated into, the terms of the
Agreement. In the event of any conflict or inconsistency between the terms of this Addendum and the
terms of the Agreement, the terms of this Addendum shall apply. This Addendum supersedes and
replaces in its entirety any prior MA Addenda between the parties.
MA PPO Professional Reimbursement Addendum Asurisl Al8816854AA Page 2 of 2