HomeMy WebLinkAboutFirst Choice Agreement (2)First Choice Health",
First Choice Health Network
Preferred Provider/Group Agreement
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This Agreement is entered into between First Choice Health Network, Inc., a Washington corporation , ("FCHN , Inc.") and First
Choice He alt h Network of Oregon , lnc.1 an Oreg on corporati on , ("FCHN, Oreg on ") on one hand , and
Kittitas Cquhly Public Health Dep artment {hereinafter ''Provi der~) on the oth er hand . The effecti ve date of this Agre em ent is
lhe-zf'1:lay or f'(llf:J ~ o I f( {"Effective Date"), FC HN , Inc, and FCH N, Ore gon is collectively referred to herein a·s "FCHN".
In consideration of the mutual promises and covenants set forth herein, FCHN and Provider agree as follows:
1. DEFINITIONS
1.1 Agreement means this Preferred Provider Agreement for health services between FCHN and the
Provider/Provider Group and any Amendments , Schedules and Exhibits hereto.
1.2 Benefit Plan means a program offered by or administered by a Payor for the payment of Covered Services
provided to an eligible Participant. Benefit Plans may be insured or self-insured, and shall not indude discount
medical plan programs defined as including, but not limited to, programs that do not include an element of
insurance risk and/or prepaid medical services.
1.3 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.
1.4 Coinsurance means a cost-sharing obligation that requires the Participants to pay a percentage of the cost of
specified Covered Services.
1.5 Co-payment means the amount that a Participant is responsible to pay under a Benefit Plan at the time of
serv ice.
1.6 Covered Services means those specified Medically Necessary health care benefits and services which a
Participant is eligible to receive under the Participant's Benefit Plan. Covered Services is further defined as
services for which a Provider is entitled to receive payment from a Payor pursuant to the terms of this Agreement
and for which benefits under the Participant's Benefit Plan have not been exhausted.
1.7 Deductible means the amount a Participant must pay for Covered Services each calendar or contract year before
a Payor commences payment for Covered Services as defined under the applicable Benefit Plan.
1.8 Emergency Medical Condition means the emergent and acute onset of a symptom or symptoms, including
severe pain, that would lead a prudent layperson , acting reasonably to believe that a health condition exists that
requires immediate medical attention, if 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 Participant's health in serious
jeopardy.
1.9 Medical Director means the officer of FCHN, the Payor, or other party who is in charge of the applicable Medical
Management Program for the Participant.
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1.10 Medical Management Program means a program consisting of but not limited to authorization; concurrent
medical review; primary case management; and a quality assurance program, with the objective to assure that
health care services provided to Participants are Medically Necessary and delivered in an appropriate setting.
1.11 Medical Necessity or Medically Necessary means a medical service or medical supply, as determined by the
Medical Management Program, which meets all of the following criteria:
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1. It is required for the treatment or diagnosis of a covered medical condition;
2. It is the most appropriate supply or level of service that is essential for the diagnosis or treatment of the
Participant's covered medical condition;
3. It is known to be effective in improving health outcomes for the Participant's covered medical condition in
accordance with sufficient scientific evidence and professionally recognized standards;
4. It is not furnished primarily for the convenience of the Participant or the provider of services; and
5. It represents the most economically efficient use of medical services and supplies that may be provided
safely and effectively to the Participant.
Medical Necessity alone does not determine coverage.
Participant means any person who is eligible to receive Covered Services under the terms and conditions of a
specific Benefit Plan.
Participating Provider or Provider means a physician or other provider licensed to provide health care services
under applicable federal and/or state laws who has entered into a written agreement with FCHN to provide
Covered Services to Participants pursuant to the terms of the applicable Benefit Plan and this Agreement.
Payor means employers, insurance companies, associations, trusts, third-party administrators (TPA) and any
other legal entity which (i) has an obligation to administer and pay for Covered Services provided to a Participant
under a Benefit Plan, and (ii) has entered into or is subject to a written agreement with FCHN.
Primary Care Provider ("PCP") means a Participating Provider who is an allopathic or osteopathic physician or
other licensed healthcare provider, practicing in the field of general practice, family practice, general internal
medicine or general pediatrics, who meets FCHN's credentialing standards, and under the terms of this
Agreement, agrees to provide Covered Services to Participants within the scope of his/her license.
Provider Group means a clinic or group (i) comprised of health care professionals all of whom are licensed
and/or certified under applicable federal and/or state laws and who bill as one entity, and (ii) which has contracted
with FCHN to provide Covered Services to Participants.
Provider Policies and Procedures means those policies and procedures established by FCHN which set forth
FCHN's and Payors' policies and procedures including, but not limited to, billing and claims payment, provider
credentialing, participant grievances, utilization review, and quality management.
Specialist Provider means a Participating Provider who is an allopathic or osteopathic physician or other
licensed healthcare provider who (i) practices in a particular specialty, (ii) is either Board certified or obtains Board
certification within five (5) years after completing residency training, (iii) meets FCHN's credentialing standards,
and (iv) under the terms of this Agreement, agrees to provide Covered Services to Participants within the scope of
his or her license.
Urgent Services means Covered Services provided when a Participant not residing in FCHN's Service Area is
temporarily absent from his or her area of residence and (i) such services are Medically Necessary and
immediately required as a result of unforeseen illness, injury, or condition, and (ii) ii was not reasonable given the
circumstances for the Participant to obtain the services through a provider network in the Participant's area of
residence.
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1.20 Utilization Review means the prospective, concurrent , or retrospective assessment of the necessity and
appropriateness of the allocation of health care resources and services of a provider or facility given or proposed
to be given to a Participant.
2. RESPONSIBILITIES OF PROVIDER
2.1 Provide or Arrange for Covered Services
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For each Participant , Provider shall provide , or arrange for the provision of Covered Services on a timely basis ,
without regard to health status or medical condition , and in accordance with generally accepted medical practice
guidelines and standards pursuant to the terms of this Agreement, and in accordance with applicable FCHN
Provider Policies and Procedures . Except in the case of an Emergency Medical Condition , Provider agrees to
verify each Participant's eligibility prior to providing Covered Services . In the case of an Emergency Medical
Condition, Provider will notify FCHN or the appropriate Payor of the provision of Medically Necessary services to
treat a Participant's Emergency Medical Condition during the first business day immediately following the
provision of such serv ices .
Provider agrees to furnish Covered Services to each Participant on the same basis as such services are made
ava ilable to individuals who are not Participants, and without regard to the Participant's enrollment in FCHN as a
private purchaser or as a participant in publicly financed programs of health care services . In providing services
under this Agreement , Provider shall exercise the degree of care, skill , and knowledge expected of a reasonably
prudent health care provider and in a manner consistent with currently approved methods and practices in
Provider's medical specialty. Provider shall exercise his or her own professional medical judgment , free of any
direction or control by FCHN, and shall remain solely responsible for the quality of services rendered.
Accessibility and Hours of Service
Provider shall arrange for the provision of Covered Services to Participants during normal business hours at the
usual places of business of Provider. Provider shall ensure that Prov ider arranges for and maintains call
schedules that provide appropriate call coverage to Participants in the event Participants are unable to contact
their Participating Providers .
Primary Care Providers (PCP's)
For Participants enrolled in Benefit Plans requiring a referral , PCP's are intended to be the patient's first source of
care . PCPs are requ ired to comply with any applicable Medical Management and Quality Improvement programs
as outlined in Section 2.9. Some Participant Benefit Plans may require the PCP to facilitate Medically Necessary
Specialist Provider referrals via an approved process. In those instances, Provider agrees to provide referrals in
accordance with the approved process . If the type of specialist needed for a specific condition is not represented
in the Participant's Benefit Plan's panel of Participating Providers , the PCP will facilitate a referral to a medically
appropriate non-participating specialist.
Specialist Providers
Specialist Providers shall adhere to the degree of responsibility requested by the referring FCHN PCP. For
Participants enrolled in Benefit Plans requiring referrals by a PCP, the Specialist Provider shall also communicate
to the referring PCP regarding the Participant's evaluation and treatment plan . Specialist Providers are required to
comply with any applicable Medical Management , Utilization Review , and Quality Improvement programs as
described in Section 2.9. The Primary Care Provider , in conjunction with the Specialist Provider, shall decide
whether follow-up care shall be provided by the Primary Care Provider or through continued specialty referral .
Benefit Plan
Provider hereby authorizes Payors contracting with FCHN to offer Provider's services to groups of employees or
individuals in accordance with the provisions of any Benefit Plans offered by such Payors . Nothing in this
Agreement shall have the effect of mod ifying benefits , terms or conditions contained in a Benefit Plan. In the
event of any conflict between this Agreement and a Benefit Plan, the benefits , terms and conditions of the Benefit
Plan shall govern with respect to Covered Services provided to Participants in the Benefit Plan. Provider's
services are not offered in connection with motor vehicle insurance , personal injury protection , workers
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compensation, or any other program for the payment of healthcare services that is excluded from the definition of
a benefit plan under applicable law.
2.6 Licensing Requirements
At all times during the term of this Agreement, Provider , or if Provider is a Provider Group , all of the licensed
healthcare providers comprising the Provider Group, shall possess and maintain in good standing all necessary
licenses, certifications, registrations, permits, or other approvals required by State and/or Federal law to provide or
arrange for the provision of Covered Services to Participants. Provider shall submit evidence of such licenses,
certifications, registrations, permits, or other approvals to FCHN upon request.
Provider shall immediately notify FCHN, in writing , if any of the following events occur with respect to Provider , or
in the case of a Provider Group, with respect to any licensed healthcare provider that is a member of the Group :
a. Provider's license or certification to practice his or her profession in any state is terminated, revoked,
suspended, restricted or expires, or Provider or is disciplined by the action of any state professional
agency having jurisdiction or authority over a Provider;
b. Provider changes his or her scope of practice or does not obtain or maintain the Board certification
required by this Agreement;
c. Provider's medical staff or other clinical privileges at any hospital, surgery center, or other facility are
denied, terminated , suspended, restricted, revoked, or not renewed, or Provider ceases to be a fully
qualified member of such a medical staff;
d. Provider suffers from physical or mental impairments which would significantly impair Provider 's ability
to carry out the responsibilities under this Agreement or may pose a risk of harm to patients;
e. Provider is or becomes excluded, terminated, or otherwise ineligible to bill one or more government
healthcare programs; or
f. Provider is convicted of a crime related to healthcare .
2.7 Demographic Changes
Provider shall notify FCHN in advance of any demographic updates including, but not limited to, change of
business address, billing address, practice locations, tax identification number, phone numbers, roster of
Participating Providers , NPI numbers, or other information reasonably needed for claims processing. Failure to
provide advance notice of such changes may result in delayed, inaccurate, or non-payment of claims .
2.8 Insurance
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Provider shall provide and maintain, at its sole cost and expense at all times during the term of this Agreement,
policies of general comprehensive liability and professional liability insurance, or a program of self-insurance
compliant with applicable state law, all with minimum limits acceptable to FCHN. Such policies shall insure
against any claim or claims for damage arising by reason of personal injury or death occasioned directly or
indirectly in connection with the acts or omissions of Provider and Provider's agents or employees related to
services rendered pursuant to this Agreement. Provider agrees to maintain the above described insurance after
the expiration or termination of this Agreement for the periods contained in the applicable statutes of limitation.
Provider shall notify FCHN immediately but no more than two (2) business days from notification of any revocation,
reduction in coverage , or termination of any such policy. Upon request, Provider shall provide FCHN with evidence of
compliance wth this insurance requirement in the form of a certificate of insurance or evidence of sen-insurance in an
amount and form acceptable to FCHN .
The provisions of this Section shall survive expiration or termination of this Agreement.
Medical Management, Utilization Review and Quality Improvement
Provider agrees to comply with and participate in FCHN 's or Payors' Medical Management Program, Utilization
Review, and quality improvement programs and requirements, credentialing, grievance, appeal and adverse
benefit determination procedures, whichever is applicable, which may include but are not limited to, pre-
authorization, notification, concurrent review , retrospective review, case management, disease management
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programs , pharmacy and specialty pharmacy programs, pharmacy benefit substitution process, referral
management, quality assurance and improvement programs and Medical Necessity oversight.
Provider further agrees to share Participant information as specifically related to the Medical Management
Program and utilization management functions described above. Provider is required to allow access to
Participant records , provide for copying and release of records, and to speak to the FCHN or Payor Medical
Director or designee upon request, as allowed by applicable law and regulation, in a timely manner to facilitate the
Medical Management Program and utilization review . Non-compliance with the Medical Management Program
may result in non-payment of Provider by Payor.
Subcontracts
If Provider subcontracts with any other provider to provide Covered Services to Participants hereunder, Provider
understands and agrees that the subcontract and the subcontracting provider must comply with all terms of this
Agreement and applicable state law and regulation .
Non-Covered Services/Exclusions
Provider shall provide notice to Participant of Participant's personal financial obligations for non-covered services,
which includes services that are not Medically Necessary. Provider may bill a Participant for non-covered
services only if Provider has , prior to the provision of non-covered services, obtained a written acknowledgment
and acceptance of financial responsibility for such services from the Participant after full disclosure to Participant
of (i) Provider's intent to bill Participant for non-covered services, and (ii) the non-liability of FCHN or Payors for
such non-covered services.
FCHN Provider Policies and Procedures
Providers shall comply with all Provider Policies and Procedures which are electronically accessible to Provider,
as updated with sixty (60) days advance notice to Provider, or if applicable, the notice described in Section 3.2
below, including, but not limited to, billing and claims payment, provider credentialing, Participant grievances,
appeal and adverse benefit determination procedures, Utilization Review, quality management, data reporting
requirements, pharmacy benefit substitution processes , confidentiality requirements and any applicable federal or
state requirements. Subject to any continuation of care provisions of this Agreement, Provider may terminate this
Agreement in accordance with Section 8.2.1 if Provider does not agree with such updates. In the event that any
provision in the Provider Policies and Procedures or any amendment thereto is inconsistent with the terms of this
Agreement, the terms of this Agreement shall control.
Claims Payment
Provider shall look only to Payors for payment of claims. FCHN is not a guarantor of, or in any way responsible to
Provider for, any claim payments.
Acceptance of Payment
Provider shall seek and accept payment from Payors for Covered Services as outlined in Schedule B to this
Agreement in accordance with the FCHN Provider Policies and Procedures and the applicable Benefit Plan.
Provider shall have the right to bill, charge , or collect a deposit directly from the Participant for any applicable
Deductible, Co-payment, or Coinsurance, or , consistent with Section 2.11, for any service that is not a Covered
Service. In no event may Provider bill or collect from Participants any difference between Provider's charges and
the amount of the FCHN fee schedule for Covered Services set forth in Schedule B.
Compliance
Provider agrees to comply with all of the terms of this Agreement, all applicable federal and state laws and
regulations, all applicable rules and standards of accrediting agencies having jurisdiction over and designated by
FCHN, and as applicable, the ethical standards of the American Medical Association, all of the above as they may
be adopted, amended, revised, or renumbered.
Provider Group
Where Provider is a Provider Group, Provider agrees to ensure that the licensed physicians and other healthcare
providers comprising the Provider Group are informed of, and agree to comply with and be bound by, the terms of
this Agreement.
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3. RESPONSIBILITIES OF FCHN
3.1 Payment for Covered Services
FCHN shall require all Payors contracting with ii to pay Provider for Covered Services rendered to Participants in
accordance with Section 4, Claims Submission and Payment, of this Agreement and the applicable Benefit Plan.
3.2 Provider Relations
FCHN shall provide Provider with certain administrative support including, but not limited to Provider orientation
and ongoing education. FCHN agrees to furnish Provider electronic access to the FCHN Provider Policies and
Procedures setting forth its policies on billing and claims payment, provider credentialing, Participant grievances,
appeal and adverse benefit determination procedures, data reporting requirements, pharmacy benefit substitution
processes, confidentiality requirements, Utilization Review, quality management, and any applicable federal and
state requirements.. FCHN shall notify Provider at least sixty (60) days prior to the effective date of changes to
policies or procedures that affect Provider compensation or health care service delivery unless changes to federal
or state law or regulations make such advance notice impossible, in which case notice shall be provided as soon
as possible. Provider may terminate this Agreement pursuant to Section 8.2.1 and subject to continuation of care
provisions in Section 8.3 without penalty if Provider does not agree with such changes. FCHN shall review and
give consideration to any Provider comments received prior to the effective date of any change.
3.3 Provider Directories and Promotion
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FCHN agrees to include Provider in appropriate provider directories or website listings. In the event this
Agreement is terminated, or the directory listing is incorrect or incomplete, FCHN shall update the listing and
correct such errors when a new directory is published.
Provider shall not advertise or otherwise market Provider's status as a Participating Provider without FCHN's prior
written approval of the form and content of such advertising or marketing, including the use by Provider of any
names, logos, trademarks, service marks, copyrighted material, domain names, symbols, or other intellectual
property of FCHN or a Payor. The foregoing shall not prevent Provider from using FCHN's name, during the term
of this Agreement, to list Provider's participation with FCHN on Provider's website or in printed informational
materials in a manner consistent with listings of other payors, networks, or managed care plans with which
Provider participates. Provider shall discontinue any such usage of FCHN's name and any advertising or
marketing related to FCHN and Payors immediately upon termination of this Agreement.
Liability Insurance
FCHN, at its sole cost and expense, shall procure and maintain such policies of general liability and professional
liability insurance as it shall deem necessary to insure ii against any claim arising from the performance or non-
performance of its duties under this Agreement. To the extent possible, FCHN shall provide Provider with not
less than fifteen (15) days advance written notice of any cancellation, expiration, reduction or other material
change in the amount or scope of such insurance. FCHN shall provide evidence of compliance with this
insurance requirement upon request by Provider.
Eligibility
FCHN shall require all Payors contracting with ii to provide timely information on a Participant's eligibility for
Covered Services, including any limitations or conditions on services or benefits, upon request by Provider.
FCHN shall require that during ordinary business hours, FCHN Payors shall assure reasonable access, through
standard means of communication, or with respect to Payors doing in business in Oregon, using electronic
transactions as required by applicable law, for the confirmation that services are Covered Services and a
Participant is eligible under a Benefit Plan.
Provider's Right to Inform Patients
FCHN may not and FCHN shall require all payors contracting with it to not in any way preclude or discourage
Provider from informing Participants of the care they require, including various treatment options, and whether in
Provider's view such care is consistent with Medical Necessity, medical appropriateness, or otherwise covered by
the Participant's Benefit Plan, nor prohibit, discourage, or penalize a Provider otherwise practicing in compliance
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with the law from advocating on behalf of a Participant with FCHN or a Payor. Nothing in this Agreement shall be
construed to authorize Provider to bind FCHN or its Payors to pay for any services.
FCHN may not and FCHN shall require all Payors contracting with ii to not preclude or discourage Participants or
those paying for their coverage from discussing the comparative merits of different health carriers with their
Providers . This prohibition specifically includes prohibiting or limiting Providers participating in those discussions
even if critical of FCHN or its Payors.
3. 7 Provider's Right to Report to Federal or State Authorities
FCHN shall not and FCHN shall require all Payors contracting with it to not penalize a Participating Provider
because the Provider , in good faith, reports to State or Federal authorities any act or practice by FCHN or its
Payors that jeopardizes patient health or welfare, or that may violate State or Federal law.
3.8 Participants' Contracting for Services Outside of Benefit Plan
Notwithstanding any other provision of law, FCHN mc:1y 11ul µ1uliibil diredly or indirectly Participants from freely
contracting at any time to obtain any health care services outside FCHN on any terms or conditions the
Participants choose. Nothing in this provision shall be construed to bind FCHN Payors to pay for any services
delivered outside of a Participant's Benefit Plan.
FCHN expressly disclaims any and all responsibility on the part of FCHN and Payors for (i) the delivery of health
care services pursuant to any contract to which FCHN or the Payor respectively is not a party or which are outside
the terms of any Benefit Plan, and (ii) the payment of charges for such services. Provider agrees to look only to
the Participant for payment of charges for such services .
3.9 ID Cards
FCHN shall require its Payors to provide each Participant with a Benefit Plan membership identification card
displaying the First Choice Health logo , the Participant's name and identifier, group name and/or number,
telephone number to confirm eligibility and benefit verification, any applicable Co-payment due at time of service,
and utilization management vendor name and telephone number to confirm necessary pre-authorization for
services.
Provider is obligated to accept any individual as a Participant:
a) when the First Choice Health logo appears on the individual's membership identification card ,
b) where the Payor is identified as accessing the FCHN PPO Network on the FCHN website or Payor listing ,
and/or
c) in cases where the Participant of a FCHN Payor has an Emergency Medical Condition and/or requires
Urgent Services and is traveling or out-of-area and does not have a FCHN logo .
3.10 List of Payors
FCHN shall provide Provider with access to a list of Payors, including employer groups, at the time of entering into
this Agreement. This list shall be maintained and posted on the FCHN web site.
3.11 Explanation of Payment/Remittance Advice
FCHN shallrequire Payors to produce an Explanation of Payment (EOP) or Remittance Advice (RA) during the
claim adjudication process which must, at a minimum , identify: FCHN, total billed charges , allowed amount in
accordance with FCHN fee schedules, the amount the Payor is responsible to pay, the amount the Participant is
responsible to pay, and an explanation for non-payment of a particular code or service. Provider may refuse to
give the Payor the benefit of FCHN's fee schedule if the EOP/RA does not display minimum data elements and
the FCHN names and/or logo .
4. CLAIMS SUBMISSION AND PAYMENT
4.1 Claims Submission
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Provider agrees to submit Clean Claims for Covered Services rendered to Participants on standard UB-04 and
CMS-1500 forms, or successors to such forms. Completed UB-04 and CMS-1500 forms shall be submitted
electronically or to the address set forth on the Participant's Benefit Plan identification card. Provider agrees to bill
its usual and customary charges for the services rendered, to properly and accurately complete all required
Provider, Participant, service, and procedure information on the claim form, and to accept payment in full as
described in Section 2.14 of this Agreement. In submitting claims pursuant to this Section, Provider shall certify
that all data submitted is accurate and truthful.
4.1.1 Claims shall be submitted at the earliest possible date after the date Covered Services are rendered .
4.1.2 Payers are not required by FCHN to pay a claim if FCHN or the Payor receives the claim more than
three-hundred-sixty-five (365) calendar days after the date the Covered Service was rendered, or sixty (60)
calendar days after Provider first receives notice that Payor is a secondary payer under applicable coordination of
benefits procedures, whichever shall be later.
4.1.3 Provider may submit, within the timely filing period described in Section 4.1.2 above, corrections to
claims that were submitted with incomplete or invalid information. Incomplete means that information was
missing from the claim, and invalid means that the information submitted was illogical, incorrect, or did not
conform to the required claim format. Payers are not required by FCHN to pay corrected claims received by
FCHN or any Payor more than three hundred sixty-five (365) calendar days after the date the Covered Service
was rendered, or sixty (60) calendar days after Provider first receives notice that Payor is a secondary payer
under applicable coordination of benefits procedures, whichever shall be later.
4.1.4 Provider agrees that requests for adjustments to claims that have been paid or denied, where the claim
submittal failed to include a particular item or service or was otherwise in error, must be received by Payers within
three hundred sixty-five (365) calendar days after the date the claim was denied or an initial payment was made
for the claim. Payers are not required by FCHN to make payments for claims adjustment requests received after
such time. Provider shall be under no obligation to refund incorrect claims payments requested by Payers or
FCHN more than three hundred sixty-five (365) calendar days after the date an initial payment was made for the
claim.
4.2 Payment of Claims
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FCHN shall require all Payers to pay Provider pursuant to Schedule B of this Agreement in accordance with the
applicable Benefit Plan, as soon as practical, subject to the following minimum standards:
4.2.1 Ninety-five percent (95%) of the monthly volume of clean claims shall be paid within thirty (30) days of
receipt; and
4.2.2 Ninety-five percent (95%) of the monthly volume of all claims shall be paid or denied within sixty (60)
days of receipt, except as agreed to in writing by the parties on a claim-by-claim basis.
4.2.3 The receipt date of a claim is the date Payor receives either written or electronic notice of the claim.
4.2.4 Claims may be subject to code review software or correct coding edits. FCHN will request that Payers
inform FCHN of code review or correct coding software and most frequent claims editing issues for
FCHN as needed to facilitate Provider education and training.
FCHN is not the guarantor of, or in any way responsible to Providers for, any claims payments, including charges
and interest due if applicable. FCHN shall meet with Provider as needed to discuss and review FCHN Payers
accounts receivable and to reasonably assist Provider in Provider's efforts to collect payments due and owing
from any such Payor as determined by FCHN to be appropriate.
These standards do not apply to claims about which there is substantial evidence of fraud or misrepresentation by
Provider or Participants, or instances where the Payor has not been granted reasonable access to information
under the Provider's control.
4.3 Coordination of Benefits and Third Party Liability
Provider agrees to cooperate with Payors' coordination of benefits (COB) and third party liability policies and
programs .
When Payer 's Benefit Plan is primary, Provider shall accept payment of the amount for the Covered Services on
the FCHN fee schedule set forth in Schedule B to this Agreement as payment in full from Payor, subject to
Provider's right to collect Co-payments, Deductibles, Coinsurance and payments for non-covered services from
the Participant. When Payor's Benefit Plan is secondary , Provider shall first look to and promptly bill and take
reasonable steps to collect payment from the primary plan . Provider may seek additional payment from a Payor
whose Benefit Plan is secondary in accordance with this Agreement and applicable laws regarding COB ; provided
however that in no event shall a Payor be obligated to pay more than 100 percent of the amount on FCHN fee
schedule set forth in Schedule B to this Agreement and in no event shall Provider be entitled to total
compensation exceeding 100 percent of its billed charges.
When a Payor has a self-funded 0enefit Plan, COB is determined by the Benefit Plan and is not subject to state
insurance laws. A self-funded Benefit Plan may only be required to pay up to the primary payor's allowable
expense depending on the terms of its COB provision. Provider has the right to request a copy of the Payor's
documented COB and third party liability policies and programs.
If Provider receives payment from another plan which is primary under COB, and that payment is equal to or
greater than the contracted rates set forth in this Agreement , Provider agrees to not seek additional
reimbursement from Payor or to promptly refund any amounts already paid to Provider by Payor .
5. MAINTENANCE OF RECORDS, INSPECTION AND AUDIT
5.1 Maintenance of Records
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Provider shall prepare and maintain all appropriate medical, administrative and financial records for each
Participant who receives services from Provider. Such records shall be maintained in such form and manner as is
required by law and generally accepted medical practice and professional ethics .
FCHN shall have the right to request, inspect and audit any and all records of Provider related to a Participant as
permitted by law, and as may be necessary for FCHN or a Payor to perform its obligations under this Agreement.
Where documents are requested by FCHN or a Payor for audit, accreditation and/or oversight review purposes ,
FCHN or the Payor shall reimburse Provider for reasonable costs incurred in providing copies of requested
documents, not to exceed a rate of twenty-five cents ($.25) per page. FCHN or Payor shall not reimburse
Provider for copies of documents requested for purposes of payment of claims, resolution of quality of care or
service concerns , complaints and/or grievances , or Medical Management Program review and coverage
determinations.
Provider shall have the right to request, inspect and audit any and all records of FCHN or Payor directly related to
a Participant as permitted by law, and as may be necessary for Provider to perform its obligations under this
Agreement.
Record Retention
Both parties shall retain all records relating to this Agreement for a minimum of seven (7) years .
External Audits
Both parties agree to cooperate with any external audits mandated by state or federal law , and shall make health
records available to appropriate state and federal authorities involved in assessing the quality of care or
investigating complaints, grievances, appeals , or review of any adverse benefit determinations of Participants,
subject to applicable state and federal laws related to the confidentiality of medical records. Both parties shall
cooperate v.ith review of encounter data in relation to the administration of Payor risk adjustment and reinsurance
programs if applicable.
Claims Audit
9
Provider agrees that Payor will have the right to audit Provider's claims for Medical Necessity and/or review of
Covered Services billed, including documentation and coding of such services. FCHN will require that the
auditing Payor agree to be responsible for reimbursing Provider for any reasonable expenses incurred for an on-
site audit. In all cases, FCHN will make commercially reasonable best efforts to facilitate the timely resolution of
Payor audits as described in sections 5.4.1 through 5.4.3.
5.4.1 With respect to audits for Covered Services billed, if no resolution occurs within 60 days after initiation of
the audit, FCHN will direct the Payor to pay for such services, subject to Payer's right to recoup, pursuant to
Section 4.1.4, the amounts corresponding to any charges later determined to be inappropriate or not payable.
5.4.2 With respect to Payor audits of claims for Medical Necessity, if no resolution occurs within 60 days after
initiation of the audit, FCHN will direct the Payor to pay for such charges as are not in dispute.
5.4.3 With respect to any audit not resolved within 60 days after initiation, upon expiration of the 60 day
period, either (i) the Payor and Provider may by mutual agreement continue to work with FCHN and each other
toward resolution of the dispute using an informal good faith process or (ii) either of Payor or Provider may elect to
resolve the matter pursuant to Section 9, Dispute Resolution, of this Agreement. Notwithstanding an election to
resolve the dispute by way of an informal good faith process, either party may , at any time thereafter, seek
resolution of the matter pursuant to the Dispute Resolution provisions of this Agreement.
6. CONFIDENTIAL AND PROPRIETARY INFORMATION
6.1 Information Relating to this Agreement
6.2
6.3
FCHN-PRO-042016
The existence of this Agreement is not considered to be confidential information. However, FCHN and Provider
each agrees that it shall not, and shall ensure that its personnel do not, whether during or after the term of this
Agreement, use, disclose, or communicate, orally or in writing or in electronic form, to any person or entity, other
than in the proper performance of this Agreement, any Confidential Information, without the prior written consent
of the other party. Nor shall FCHN or Provider, or their respective personnel permit any person to use, examine,
or make copies of any documents, files, data or other information that contain or are derived from Confidential
Information. For purposes of this Agreement, "Confidential Information" means any and all information of FCHN,
Provider, or a Payor that is not generally available to the public , including, but not limited to, fee schedules,
reimbursement rates, the business , strategic, financial, operations, or planning information of FCHN, Provider, or
a Payor, and any other information identified by either party to this Agreement as confidential.
This provision shall not preclude access to information and records reasonably needed to perform either party's
obligations under this Agreement, including the audits, Medical Management Program, and access afforded to
Payers with respect to Covered Services delivered pursuant to this Agreement. In addition, the covenants of this
provision shall not restrict disclosure of this Agreement and related information to an applicable state or federal
regulator or as required by law, court order, or other judicial process.
Participant Health Information
FCHN and Provider acknowledge that as a result of this Agreement, each party may have access to and receive
from one another, individually identifiable health information ("Health Information") as that term is defined under
the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), and applicable state law. Each party to
this Agreement shall ensure that it and its personnel maintain confidentiality of all patient records, charts and other
patient identifying information in accordance with HIPAA and applicable state law, and that it and its personnel
implement and use appropriate safeguards to prevent any unauthorized use or unlawful disclosure of Protected
Health Information ("PHI"), take appropriate action to ensure that other persons appropriately safeguard and use
PHI, report any known improper disclosure or use of PHI, and return or destroy all PHI upon the termination of this
Agreement for any reason. The parties will enter into FCHN's standard Business Associate Agreement set forth
in Schedule A to this Agreement effective as of the Effective Date of this Agreement.
Effect of Termination
FCHN and Provider understand and agree that the requirements of this Section 6 shall survive the expiration or
termination of this Agreement.
IO
7. INDEMNIFICATION
To the extent consistent with applicable state law, FCHN and Provider (each an "Indemnifying Party") shall defend,
indemnify, and hold the other party and its officers, directors, shareholders, members, employees, and agents (the
"Indemnified Party") harmless from and against any and all liabilities and losses, together with any costs and expenses,
including, but not limited to reasonable attorney's fees and costs (collectively, "Damages") arising from claims asserted by a
third party as a result of the Indemnifying Party's, or its officers', directors', shareholders', members', employees', or agents'
actual or alleged (i) negligent acts or omissions, (ii) intentional or wrongful acts or omissions, or (iii) breach or failure of
performance under this Agreement. To the extent consistent with applicable state law, Damages shall not include any
amount resulting from the Indemnified Party's (i) negligent acts or omissions, (ii) intentional or wrongful acts or omissions, or
(iii) breach or failure of performance under this Agreement. The indemnification obligations set forth in this Section 7 shall
survive the expiration or termination of this Agreement.
8. TERM AND TERMINATION
8.1 Term of Agreement
This Agreement shall take effect on the Effective Date first set forth above and shall expire on December 31 of the
year in which the Effective Date falls. On January 1 of the following year and of each year thereafter, this
Agreement shall automatically renew for successive one (1) year terms unless terminated in accordance with the
terms of this Agreement.
8.2 Termination
8.2.1 Termination Without Cause
Either party may terminate this Agreement without cause or penalty, by giving ninety (90) days prior
written notice to the other party.
8.2.2 Termination by FCHN
FCHN may immediately terminate this Agreement with respect to any individual Provider upon the
failure of Provider to meet any of the FCHN credentialing and recredentialing standards and criteria,
including the occurrence of any of the events identified in (i) FCHN's Credentialing and Recredentialing
Policies and Procedures, and (ii) FCHN's Criteria for Provider Denial or Termination. Written notice of
such action shall be given to Provider by FCHN as provided for in such policies and procedures and
shall specify the effective date of termination.
8.2.3 Termination for Cause
Except as otherwise set forth in Section 8.2.2 above, either party may terminate this Agreement for
cause by giving the other party sixty (60) days prior written notice if the receiving party materially
breaches any of the terms of this Agreement or fails to fulfill its obligations hereunder. Such notice shall
specify the reasons for the termination and shall provide the breaching party opportunity to correct the
cause to the reasonable satisfaction of the non-breaching party. Should the cause not be cured within
this sixty (60) day period, this Agreement shall terminate on the last day of such period.
8.3 Effect of Termination -Continuation of Care
FCHN-PRO-042016
This Agreement shall be of no further force or effect as of the effective date of termination except that:
8.3.1
8.3.2
FCHN shall require that Payors pay to Provider any payments accrued to Provider for Covered Services
rendered prior to the effective date of termination and properly billed to Payors within the time required
under this Agreement.
Provider shall not seek compensation from the Participant for any Covered Services provided under the
terms of this Agreement prior to the effective date of termination, except for any applicable Deductible,
Co-payment, or Coinsurance amounts, as specified in Section 2.14 of this Agreement.
11
8.3.3 Provider shall continue the treatment of Participants who were receiving care in an inpatient facility at
the time this Agreement terminated, until one of the following events occurs: (i) the Participant is
discharged from the facility, (ii) the FCHN or Payor's Medical Director determines that the care of the
Participant can be safely transferred to another facility, or (iii) Payor makes arrangements to transfer the
Participant's care to another Participating Provider .
8.3.4 FCHN shall require Payor to cover Covered Services of a Primary Care Provider whose agreement with
FCHN is terminated by FCHN without cause under the terms of this Agreement for at least sixty (60)
days following notice of termination to the Participants or , in group coverage arrangements involving
periods of open enrollment, only until the end of the next open enrollment period. The Provider's
relationship with FCHN or Payor must be continued on the same terms and conditions as those of the
agreement FCHN is terminating, except for any provision requiring that Payor assign new enrollees to
the terminated Provider.
8.4 Notice to Participants
If this Agreement is terminated, FCHN shall require Payers to make a good faith effort to provide written notice of
the termination to all Participants who are patients seen on a regular basis by Provider within fifteen (15) working
days of receipt or issuance of the notice of termination, irrespective of whether the termination was for cause or
without cause. If Provider is a PCP, FCHN shall require Payers to make a good faith effort to assure that notice
is provided to all Participants who are patients of Provider.
9. DISPUTE RESOLUTION
9.1 Dispute Resolution Process
Except as otherwise provided in Section 9.2, the following dispute resolution process will be used to resolve
disputes between Provider and FCHN as well as disputes between Provider and Payers .
9.1.1 Informal Process
Disputes between Provider and FCHN with regard to performance by either party under !hi!; Agreement ,
including questions regarding existence, enforceability , interpretation, or validity of this Agreement, shall
be resolved, to the extent possible, by informal meetings and discussions between Provider and FCHN.
Provider shall promptly notify FCHN and Payor of any failure by a Payor to pay Provider in accordance
with the requirements of Section 4.2 of this Agreement, to provide information regarding Participant
eligibility and benefit confirmation, to provide any other information required under the terms of this
Agreement, or of any disagreement with a determination of Medical Necessity made pursuant to
Provider's billing for Covered Services pursuant to this Agreement. Disputes related to the foregoing
issues, as well as other disputes between Provider and Payors regarding performance under this
Agreement shall be resolved, to the extent possible, by informal meetings and discussions between
Provider and the Payor.
9.1.2 Formal Process
Where either (i) Provider or FCHN, in the case of a dispute between them, or (ii) Provider or a Payor, in
the case of a dispute between them, desires to pursue resolution of a dispute beyond such informal
meetings and discussions, either party to the dispute in question may provide the other party to the
dispute with written notice, describing the nature of the dispute and the proposed resolution with
reasonable particularity, and requesting a response within thirty (30) days after receipt of the notice, or if
the dispute involves a billing dispute, within sixty (60) days after receipt of the notice. If the party in
receipt of a notice of dispute fails to respond in writing within the above described timeframes or
responds in writing disagreeing with the proposed resolution within such timeframes , the party giving
notice of the dispute may request mediation of the dispute as set forth below.
9.1.3 Nonbinding Mediation
Any party giving notice of a dispute which is not resolved pursuant to Section 9.1 .2 may submit the
dispute to nonbinding mediation. After either party to the dispute gives the other a notice of election to
FCHN-PRO-042016 12
mediate, the parties to the dispute will confer and appoint a mutually acceptable mediator. If the parties
are unable to agree upon the selection of a mediator within five (5) days after notice of election to
mediate is given, they shall jointly petition to the Presiding Judge of a state court of competent
jurisdiction to appoint a mediator. Mediation shall be conducted pursuant to the mediation rules and
procedures of the mediator as consistent with applicable state law , or according to any other rules of
mediation agreed to by the parties . Following selection , the mediator shall schedule a mediation
conference with the parties , the duration of which shall be one day , or such longer period as the parties
to the dispute may agree . Unless otherwise agreed, the mediation conference shall be held within
twenty (20) days after appointment of the mediator. The place of mediation shall be a location mutually
agreed upon by the parties to the dispute; however , if the parties cannot agree, the mediation will be
held in Seattle , Washington . The fees and expenses of the mediator shall be borne equally by the
parties to the dispute . Each party shall be responsible for its own costs and expenses incurred in
connection with the mediation .
9.1.4 Other Remedies
In the event the parties to a dispute cannot resolve the dispute through nonbinding mediation, either
party may pursue judicial remedy in a court of competent jurisdiction . The parties agree to exhaust the
dispute resolution process set forth in Sections 9.1 .1, 9.1 .2, and 9.1.3 above before pursuing judicial
remedies, however by mutual consent the parties may agree to forego non-binding mediation and
proceed directly to a judicial remedy. The parties consent to the jurisdiction of the Superior Court of the
State of Washington, King County, and the United States District Court for the Western District of
Washington, for all purposes in connection with this Agreement.
9.2 Provider Disputes Involving Participant Benefit Claims
Disputes between Provider and a Payor with a Benefit Plan subject to the Employee Retirement Income Security
Act of 1974 (ERISA) and not "grandfathered" under the Patient Protection and Affordable Care Act (PPACA) about
an adverse benefit determination as defined in applicable regulations implementing PPACA shall be handled in
accordance with ERISA and PPACA , and applicable implementing regulations, under the Payer 's reasonable claim
procedure and internal and external review process. Disputes between Provider and a Payor with a fully insured
Benefit Plan not "grandfathered" under PPACA about an adverse benefit determination shall be handled in
accordance with PPACA , applicable implementing regulations, and applicable state law and regulations, including
an internal grievance procedure of the Payor and an external review process.
9.3 No Effect on Right of Termination
The provisions of this Section 9 shall not affect either party 's right to terminate this Agreement as provided fo r
under Section 8.2 of this Agreement.
10. GENERAL PROVISIONS
10.1
10.2
FCHN-PRO-042016
State Regulated Payors. With respect to any Payor that is subject to the state insurance laws and regulations ,
the provisions set forth in Schedule C, attached hereto and incorporated into this Agreement , are fully operative
and applicable to FCHN, Provider, and the respective Payers . In the event of any conflict between the provisions
set forth in Schedule C and the other terms of this Agreement , Schedule C shall have priority. If Provider provides
Covered Services to Participants enrolled in Benefit Plans offered or administered by Payers subject to state
insurance laws and regulations of states other than as referenced in Schedule C, the corresponding specific state
Schedules posted on the FCHN website or otherwise made available to Provider are added to the Agreement and
apply to Provider with respect to such Payers , and Provider agrees to comply with the applicable Schedules.
Amendments to Comply with Law
In the event that either party to this Agreement in good faith and upon advice of legal counsel determines that this
Agreement or any practices which are or could be employed in performing under this Agreement are inconsistent
with or do not satisfy the requirements of any applicable state or federal laws or regulations, the parties in good
faith shall undertake to amend this Agreement to comply with such laws and regulations. In the event the parties
are not able to agree upon the revised terms in a timely manner, either party may terminate this Agreement
immediately by giving written notice of termination to the other.
13
10.3 Independent Contractors
Each party to this Agreement shall be acting as an independent contractor. Provider shall not be construed to be
an employee of FCHN and will at all times be acting and performing hereunder as an independent contractor
practicing the profession of medicine or the providing other licensed healthcare services. None of the provisions
of this Agreement are intended to create nor shall they be deemed or construed to create a partnership or joint
venture, or any relationship between the parties hereto other than that of independent entities contracting with
each other solely for the purpose of effecting the provisions of this Agreement. Neither party shall, by entering
into this Agreement, authorize the other party to act as a general or special agent of such other party in any
respect, except as expressly set forth in this Agreement, and neither party shall become liable for any of the
obligations or debts of the other. Provider is not entitled to any of FCHN's employment benefits, such as vacation,
sick leave with pay, paid days off, health insurance, life insurance, accident insurance, or severance pay during or
upon termination of this Agreement.
10.4 Notice
Any notice or other communication given pursuant to this Agreement shall be in writing and shall be deemed to
have been duly given when delivered personally, by courier with delivery receipt, sent by facsimile (with
confirmation of receipt), or when mailed by United States mail, postage prepaid, to FCHN, Inc. at 600 University
Street, Suite 1400, Seattle, WA 98101, fax (206) 667-8062, and to Provider at Provider's then current address of
record and fax number on file with FCHN, or to such other address as either party may specify by notice to the
other party as set forth in this provision.
10.5 Amendment
This Agreement may be amended from time to time by FCHN, by providing Provider not less than sixty (60) days
advance written notice of the amendment unless changes to federal or state law or regulations make such
advance notice impossible, in which case notice shall be provided as soon as possible. If Provider objects to the
amendment, Provider must so advise FCHN in writing within thirty (30) days after receipt of the amendment. If
FCHN receives no written objection from Provider to the amendment within the time described above, the
amendment will become effective at the end of the sixty (60) day notice period. If FCHN does receive from
Provider a written objection to the amendment within the time described above, FCHN may, at its sole option,
withdraw the amendment, and FCHN will notify Provider in writing whether or not the amendment is withdrawn. If
FCHN withdraws the amendment, this Agreement will continue in force without any effect of the amendment. If
FCHN notifies Provider that the amendment is not withdrawn, then the amendment shall become effective at the
end of the sixty (60) day period. If, following notice of non-withdrawal from FCHN, Provider continues to object to
the amendment, Provider may terminate this Agreement as outlined in Section 8.2.3.
10.6 Severability/Conformity with Law
In the event any provision of this Agreement is rendered invalid or unenforceable by any State or Federal law or
regulation, or declared null and void by any court of competent jurisdiction, the remaining provisions of this
Agreement shall remain in full force and effect to the fullest extent possible consistent with the intent and purpose
of this Agreement, unless the severance of any such provision substantially impairs the benefits of the remaining
provisions of this Agreement. This Agreement shall be interpreted, and if necessary, amended, to conform to
applicable federal and state law in effect on or after the Agreement's effective date.
10.7 Entire Agreement
This Agreement, including the attachments hereto and any documents incorporated herein by reference,
constitutes the entire agreement between the parties with respect to the subject matter of this Agreement and
supersedes all prior arrangements and negotiations between the parties, written or oral, express or implied.
10.8 Waiver
Neither the failure nor delay on the part of either party to exercise any right under this Agreement shall serve as a
waiver of that right. A waiver of any provision of this Agreement must be in writing and signed by the party making
such waiver. If either party should waive a breach of any provision of this Agreement, it shall not be deemed or
construed as a waiver of any other breach of the same or different provision.
10.9 Applicable Law
FCHN-PRO-042016 14
This Agreement shall be interpreted, enforced, and governed in accordance with the laws of the State of
Washington, notwithstanding any conflict of law doctrine to the contrary. Venue for any action or proceeding shall
lie in King County, Washington.
10.10 Medical Care
It is hereby understood that Provider is solely responsible for all decisions and liability regarding Provider 's
medical care and treatment of Participants . It is also agreed that the tradit ional relationship between Provider and
patient shall in no way be affected by or interfered with by any of the terms of this Agreement. Provider
understands that any financial determinations made by FCHN or the Payers and any determinations made in
connection with the Medical Management Program or Utilization Review are solely for purposes of determining
whether services are Covered Services under the terms of a Benefit Plan as defined in this Agreement and the
extent to which payments may be made by Payers for such services . Accordingly , such determinations shall in no
way affect the responsibility of Provider to provide appropriate services to Participants.
10.11 Nondiscrimination
Provider agrees not to discriminate against Participants and to render services without regard to race , sex , marital
status , sexual orientation , religion, national origin, color , age , physical or mental handicap, veteran status, or any
other basis upon which discrimination is prohibited under applicable law or regulation.
10.12 Assignment
Neither FCHN nor Provider shall assign this Agreement without the express prior written consent of the other,
except that FCHN may assign this Agreement a successor entity, or to any entity succeeding to the rights and
obligations of FCHN by operation of law, all without the pr ior consent of Provider.
10.13 Force Majeure
Neither party shall be considered in breach of this Agreement for any failure or delay in performance hereunder if
the failure or delay is occasioned by an act of God, act of a governmental authority, or by any other emergency
beyond the reasonable control of the party whose performance is affected , including but not limited to acts of
terrorism , war , natural disaster , or the result of a strike , lockout, or other labor dispute .
10.14 Attorneys' Fees
Except as otherwise set forth in Section 9 of this Agreement , in any suit, action, or proceeding between the part ies
relating to or arising from this Agreement , the prevailing party shall be entitled to recover reasonable attorneys'
fees , costs , and other expenses, including fees and expenses incurred on any appeal and in any bankruptcy
proceeding, in addition to whatever other relief may be awarded.
FCHN-PRO-042016 15
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their authorized representatives
as of the date first set forth above.
First Choice Health Network, Inc.
Address: 600 University Street, Suite 1400
Seattle, WA 98101
s;goaWre 9r• Jf-7 1
Title: President & CEO
First Choice Health Network of Oregon, Inc.
Address: 11000 SW Stratus Street, Suite 325 Beav<i:: 970/
Signature: /j' ,-· .-If-
Title: President & CEO
FCHN-PRO-0420 I 6
Provider Kittitas County Public Health Department
Address:
507 N Nan um Street, Suite 102
16
SCHEDULE A
Business Associate Agreement
Th is Busin ess Associate Agreement (''Agre eme nt") is mad e and entered in to by and betwee n,
Kittitas County Public Health Department (''Covered Entity" or ''CE ''), and First Choice He alth Network-. Inc. ("Business Associate" or "BA").
Covered Entity and Business Associate may be referred to individually as a "Party" and collectively as the "Parties ".
Recitals
WHEREAS, CE and BA have entered into an agreement pursuant to which BA will provide certain services to or on
behalf of CE , and BA may create , receive, maintain, transmit, or have access to Protected Health Information in order to provide
those services ("Services Agreement ");
WHEREAS, the Deportment of Health end Human Services ("HHS") has promulgated regulations at 45 Code
of Federal Regulations ("C .F.R.") Parts 160 and 164 implementing the privacy requirements ("Privacy Rule ") and regulations at
45 C.F.R. Parts 160, 162 and 164 implementing the security requirements ("Security Rule") set forth in the Health Insurance
Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA ") as amended by regulations implementing Subtitle D of
the Health Information Technology for Economic and Clinical Health Act which is Title XIII of the American Recovery and
Reinvestment Act of 2009 (Public Law 111-5);
WHEREAS, the Privacy Rule and Security Rule require CE to enter into a written contract with BA in order to assure
certain protections for the privacy and security of Protected Health Information , and the Privacy Rule and Security Rule prohibit
the disclosure or use of Protected Health Information to or by BA if such a contract is not in place;
WHEREAS, both Parties mutually agree to satisfy the foregoing regulatory requirements and all federal , state and local
confidentiality , privacy, and security laws through this Agreement;
NOW THEREFORE, in consideration of the foregoing and of the mutual promises contained herein , the receipt and
sufficiency of which are hereby acknowledged, CE and BA agree as follows:
1. Definitions.
Terms used , but not otherwise defined in this Agreement shall have the same meaning as those terms in 45 C.F.R. Part 160,
Part 162, and Part 164, then in effect or as amended, which are collectively referred to as the "HIPAA Rules".
1.1 "Breach" shall have the same meaning as the term "Breach" in 45 C.F.R. § 164.402 .
1.2 "Data Aggregation" shall have the meaning given such term in 45 C.F.R. § 164.501.
1.3 "Designated Record Set" shall have the meaning given to such term in 45 C.F.R. § 164 .501.
1.4 "Disclose" and "Disclosure" mean, with respect to Protected Health Information, the release, transfer, provision of,
access to, or divulging in any other manner of Protected Health Information outside BA 's internal operations or to
persons or entities other than members of its workforce .
1.5 "Electronic Protected Health Information" or "EPHI" shall have the meaning found in the Security Rule , 45 C.F .R.
§ 160 .103.
1.6 "HITECH Act" shall mean the Health Information Technology for Economic and Clinical Health Act , found in Title XIII
of the American Recovery and Reinvestment Act of 2009, Public Law 111-005 , and the regulat ions promulgated
thereunder by the Secretary.
1.7 "Individual" shall have the same meaning found in 45 C.F .R. § 160 .103 and shall include a person who qualifies as a
personal representative in accordance with 45 C.F.R. § 164 .502(9).
FCHN-PRO-042016 17
1.8 "Protected Health Information" or "PHI" shall have the same meaning as the term "protected health information" in
45 C.F.R. § 160.103, limited to the information created, received, maintained, or transmitted by BA from or on behalf of
CE pursuant to this Agreement.
1.9 "Required by Law" shall have the same meaning found in 45 C.F.R. § 164.103.
1.10 "Secretary" shall mean the Secretary of the Department of Health and Human Services or his or her designee.
1.11 "Unsecured PHI" shall have the same meaning as the term "unsecured protected health information" in 45 C.F.R. §
164.402 .
1.12 "Use" or "Uses" shall mean, with respect to Protected Health Information, the sharing, employment, application,
utilization, examination, or analysis of such information within BA's internal operations .
2. Authorized Uses and Disclosures by Business Associate.
2.1 General Use and Disclosure
Except as otherwise limited in this Agreement, BA may Use or Disclose PHI on behalf of CE as necessary to provide
services as set forth in the Services Agreement , if such Use or Disclosure of PHI would not violate the Privacy Rule if .
done by CE .
2.2 Business Activities of Business Associate
2.2.1 Unless otherwise limited herein, BA may Use PHI:
(a) As necessary for the proper management and administration of BA or to carry out the legal
responsibilities of BA;
(b) To provide Data Aggregation services as permitted by 42 CFR § 164.504(e)(2)(i)(B);
(c) To De-identify any and all PHI created, received, maintained , or transmitted by BA on behalf of CE
provided that the De-identification conforms to the requirements of the HIPAA Rules . Such
resulting De-identified information is not PHI and is not subject to the terms of this Agreement; and
(d) As Required by Law.
2.2.2 Unless otherwise limited herein, BA may Disclose PHI for the proper management and administration of BA
or to carry out the legal responsibilities of BA provided that:
(a) The Disclosure is Required by Law; or
(b) BA obtains reasonable assurances from the person to whom the PHI is Disclosed that ii will be
held confidentially and Used or further Disclosed only as Required by Law or for the purposes for which ii
was Disclosed to the person, and the person notifies BA of any instances of which ii is aware in which the
confidentiality of the PHI has been breached ,
3. Business Associate Obligations.
3.1 Use of PHI
BA shall not Use or further Disclose PHI other than as permitted or required by the Services Agreement, this
Agreement, or as Required by Law. In Using, Disclosing, or requesting PHI from CE, BA agrees to limit PHI to the
minimum necessary to accomplish the intended purpose of such Use, Disclosure, or request. "Minimum necessary"
shall be interpreted in accordance with the HITECH Act and the HIPAA Rules , and implementing regulation or guidance
on the definition .
3.2 Appropriate Safeguards; Compliance with Security Rule
FCHN-PRO-042016 18
BA shall use appropriate administrative, technical, and physical safeguards to prevent Use or Disclosure of PHI other
than as provided for by this Agreement. BA shall comply with the Security Rule and shall implement administrative,
physical, and technical safeguards (including written policies and procedures) that will reasonably and appropriately
protect the confidentiality, integrity, and availability of the EPHI it creates, receives, maintains, or transmits on behalf of
CE.
3.3 Disclosure to Subcontractors
BA agrees to ensure that any subcontractor that creates , receives , maintains, or transmits PHI on behalf of BA agrees
to comply with the applicable HIPAA Rules and the same restrictions and conditions that apply through this Agreement
to BA with respect to such PHI by entering into a Business Associate Agreement with the subcontractor consistent with
45 C.F.R. 164.502(e).
3,4 Delegation of Covered Entity's Duties
To the extent BA is to carry out one or more of GE's obligations under the Privacy Rule, BA shall comply with the
requirements of the Privacy Rule that apply to CE in the performance of such obligations .
3.5 Disclosure Accounting
BA agrees to document all Disclosures of PHI and information related to such Disclosures as would be required for CE
to respond to a request by an Individual for an accounting of Disclosures in accordance with 45 C.F.R. § 164.528
("Disclosure Information") and to retain such documentation for six (6) years from the date of Disclosure .
Within thirty (30) calendar days after receipt of a written notice from CE of a request by an Individual for an accounting
of Disclosures of PHI, BA shall provide to CE the Disclosure Information to enable CE to meet the Disclosure
accounting obligations under 45 C.F.R. § 164.528. In the event a request for an accounting regarding PHI is delivered
directly to BA or it subcontractors, BA shall within ten (10) calendar days after receipt forward such request to CE.
Within twenty (20) calendar days after forwarding the request to CE, BA shall provide its Disclosure Information to CE.
It shall be GE's responsibility to prepare and deliver any accounting of disclosures to the Individual. BA will include, in
any Disclosure Information, the information listed in 45 C.F.R. § 164.528(b).
3.6 Access to PHI
Within fifteen (15) calendar days following GE's request , BA shall make available to CE or , at the written direction of
CE, to an Individual, for inspection and copying PHI about the Individual that is in a Designated Record Set maintained
by the BA, so that CE may meet its access obligations under 45 C.F.R. §164.524 . If CE requests an electronic copy of
PHI that is maintained by BA electronically in a Designated Record Set, BA will provide an electronic copy in the form
and format specified by CE in accordance with 45 C.F.R . § 164.524(c)(2). Any denial of access to the PHI requested
shall be the responsibility of the CE.
3. 7 Amendment of PHI
Upon receipt of a request from CE, BA shall promptly amend or make available to CE for amendment, an Individual's
PHI maintained by BA in a Designated Record Set to enable CE to meet its obligations under 45 C.F .R. § 164.526.
Any denial of a request by an Individual for amendment of PHI maintained by BA pursuant to the Agreement shall be
the responsibility of CE .
3.8 Government Access to Books and Records
3.9
FCHN-PRO-042016
BA shall make its internal practices, books, and records relating to the Use and Disclosure of PHI received from, or
created or received by BA on behalf of CE, available to the Secretary for purposes of determining GE's compliance
with the HIPAA Rules. Unless prohibited by law or court or order, BA shall provide to CE, (i) prompt written notice of
BA's receipt of any such request from the Secretary, and (ii) a copy of any documentation, books, and records
provided by BA to the Secretary pursuant to the Secretary's request.
Reporting and Mitigation of Unauthorized Use and Disclosure of PHI or Breach of Unsecured PHI
3.9.1 Reporting of Unauthorized Use and Disclosure of PHI. BA shall provide a written report to CE of any Uses or
Disclosures of PHI not authorized by the Services Agreement or this Agreement of which it becomes aware not more
than thirty (30) calendar days after the unauthorized Use or Disclosure is discovered.
19
3.9.2 Reporting of Breach of Unsecured PHI. BA shall notify CE within thirty (30) calendar days following the
discovery of a suspected or actual Breach of Unsecured PHI. A suspected or actual Breach shall be treated as
discovered by BA as of the first day on which the Breach is known, or, by exercising reasonable diligence would have
been known, to the BA. If a delay is requested by a law enforcement official in accordance with 45 C.F.R. § 164.412,
BA may delay notifying CE for the applicable period of time .
3.9.3 Content of Notice. The notice of unauthorized Use or Disclosure, or of Breach of Unsecured PHI, shall
include:
(a) To the extent possible, the identification of each Individual whose Unsecured PHI has been, or is reasonably
believed by BA to have been improperly accessed, acquired, Used or Disclosed;
(b) Information related to the unauthorized person or persons who impermissibly Used the PHI or to whom the
improper Disclosure was made, and whether the PHI was actually acquired or viewed;
(c) The nature of the Breach or other non-permitted Use or Disclosure, including a brief description of what
happened, the date of the non -permitted Use or Disclosure or Breach and the date of discovery;
(d) A description of the types of Unsecured PHI that were involved in the non-permitted Use or Disclosure or Breach,
including the nature of services , types of identifiers , and the likelihood of re-identification, including whether full name, social
security number, credit card number, date of birth, home address, account number, diagnosis, medication, treatment plan, or
other information were involved ;
(e) The corrective or investigative action BA took or will take to prevent further non-permitted Uses or Disclosures, to
protect against future Breaches, and the extent to which the risk to the PHI has been mitigated;
(ij Any details necessary for CE to conduct a risk assessment to determine the probability that the PHI believed to
have been improperly accessed, acquired, Used or Disclosed has been compromised and the steps the affected Individuals
should take to protect themselves; and
(g) Such other information, including a written report , as CE may reasonably request.
3.9.4 Costs of Breach Notification and Mitigation. BA shall, at its own cost and expense, mitigate to the extent practicable,
any harmful effects known to BA of any Use or Disclosure of PHI in violation of the requirements of this Agreement. To the
extent that CE determines that the Breach notification requirements of the HIPAA Rules are triggered by a Breach of Unsecured
PHI, as described in Section 4.3 below, BA shall reimburse CE for all reasonable and necessary costs related to such
notifications.
3.9.5 Security Incidents. BA will report to CE any attempted or successful unauthorized access, Use, Disclosure,
modification, or destruction of Electronic Protected Health Information provided by CE or interference with BA's system
operations in BA's information system of which BA becomes aware. The Parties acknowledge that probes and
reconnaissance scans are commonplace in the industry and, as such, the Parties acknowledge and agree that , to the
extent such probes and reconnaissance scans constitute Security Incidents, this Section 3.9 .5 constitutes notice by BA
to CE of the ongoing existence and occurrence of such Security Incidents for which no additional notice to CE shall be
required, as long as such probes and reconnaissance scans do not result in unauthorized access, Use, or Disclosure
of PHI. Probes and reconnaissance scans include, without limitation, pings and other broadcast attacks on BA's
firewall, port scans, and unsuccessful log-on attempts that do not result in unauthorized access, Use or Disclosure of
PHI.
3.9.6 State Law Requirements. In the event BA has an independent notification obligation related to
impermissible Use or Disclosure of PHI in connection with this Agreement or the Services Agreement, BA shall
promptly notify CE of such obligation and, at least five (5) business days before giving any such notice, BA shall notify
CE of its intent lo provide the required notifications, including any related information required by applicable state law.
3.10 Retention of PHI
FCHN-PRO-042016 20
BA shall retain all PHI throughout the term of this Agreement and shall continue to maintain such information not
otherwise returned or destroyed pursuant to Section 5.4 of this Agreement for a period of six (6) years after the
termination of this Agreement.
3.11 Restrictions on Disclosures
BA will comply with written notice from CE to provide for confidential communications of PHI , or to restrict the Use or
Disclosure of PHI , pursuant to 45 C.F.R. § 164.522 , including any request by an Individual to restrict the Disclosure of
the Individual's PHI to a health plan if the Disclosure is (1) for the purpose of carrying out payment or health care
operations , is not for purposes of carrying out treatment , and it not otherwise Required by Law, and (2) the PHI
pertains solely to a health care item or service for wh ich the Individual, or person other than the health plan on behalf
of the Individual , has paid the CE in full.
3.12 Prohibition on Sale of PHI
Except as otherwise expressly permitted by the HIPAA Rules, BA shall not directly or indirectly receive remuneration,
including financial or non-financial remuneration, in exchange for an Individual's PHI unless CE or BA obtains a valid
authorization that meets the requirements of 45 C.F.R § 164.508 and states that the disclosure will result in
remuneration to the BA .
3.13 Standard Transactions.
BA shall comply with the HIPAA Rules' Standards for Electronic Transactions when conducting any Standard
Transactions on behalf of CE .
4. Covered Entity Obligations.
4.1 With regard to the Use and/or Disclosure of Protected Health Information by BA, CE agrees to :
4.1.1 Notice of Privacy Practices
Provide BA in a timely manner a written or electronic copy of the notice of privacy practices (the "Notice") that
CE prov ides to Individuals in accordance with 45 C.F.R. § 164.520 , including any limitation(s) in such Notices
to the extent that such limitation may affect BA 's Use or Disclosure of PHI.
4.1.2 Restrictions
Notify BA in writing of any restrictions to the Use or Disclosure of PHI that CE has agreed to in accordance
with 45 C.F.R. § 164.522 to the extent that such restriction may affect BA 's Use or Disclosure of PHI. CE will
promptly notify BA in writing of the termination of any such restriction requirement and inform BA whether
any of the PHI will remain subject to the terms of the restriction agreement.
4.1.3 Authorizations
Inform BA , in writing and in a timely manner, of any changes in, or revocation of an authorization provided to
a CE by an Individual to Use or Disclose PHI to the extent that such changes may affect BA's Use or
Disclosure of PHI .
4 .1. 4 Confidential Communications
Notify BA in writing and in a timely manner, of any confidential communications requests related to an
Individual 's PHI that CE has agreed to in accordance with 45 C.F.R. § 164 .522 , to the extent that such
request may affect BA's Use or Disclosure of PHI. CE will promptly notify BA in writing of the termination of
any such confidential communications requ irement.
4.2 CE shall not request BA to Use or Disclose PHI in any manner that would not be permissible under the Privacy Rule if
done by a CE .
4.3 Determination of Breach and Notification Obligations
CE will be solely responsible to determine whether a non-permitted Use or Disclosure constitutes a Breach and will be
responsible to prov ide , to the extent and within the time required by the HIPAA Rules , notice to the affected Individuals ,
the media, and the Secretary of any Breach of Unsecured PHI. If CE determines the non-permitted Use or Disclosure is
a Breach that triggers the HIPAA Rules' breach notification requirements, then BA will reimburse CE for all reasonable
FCHN-PRO-042016 21
and necessary costs related to the notifications of a Breach of Unsecured PHI created, received, maintained or
transmitted by BA.
5. Term and Termination.
5.1 Term and Effective Date
This Agreement shall be effective on the effective date of the Services Agreement and shall continue in effect until all
obligations of the Parties have been met , unless terminated as provided herein or by the mutual agreement of the
Parties .
5.2 Termination far Material Breach
Upon CE's determination, in its sole discretion, that BA has violated a material term of this Agreement, CE will provide
BA with written notice of the violation and either (i) an opportunity to cure the breach or end the violation within thirty
(30) calendar days after BA's receipt of the notice or such other period determined reasonable and appropriate by CE,
or (ii) terminate this Agreement if BA docs not cure the breach or end the violation within such period, or (3)
immediately terminate this Agreement if eliminating the violation or cure of the breach is not possible.
5.3 Termination of Agreement
This Agreement shall automatically terminate without any further action of the Parties upon the termination or
expiration of the Services Agreement.
5.4 Effect of Termination
5.4.1 Upon termination of this Agreement, BA shall return all PHI received from, or created or received by BA on
behalf of CE that is then maintained in any form by BA or its subcontractors, or if expressly requested to do so by CE,
BA shall destroy such PHI and provide CE documentation evidencing such destruction . BA shall retain no copies of
such PHI except as follows. If BA determines that return or destruction of PHI is not feasible , BA shall provide notice to
CE of the conditions that make return or destruction infeasible, and shall extend the protections of this Agreement to
such PHI and limit further Uses and Disclosures of such PHI to those purposes that make the return or destruction
infeasible, for so long as BA maintains such PHI.
5.4.2 In the event this Agreement is terminated for any reason , the Services Agreement will also terminate as of
the effective date of termination of this Agreement.
5.5 Survival
The obligations of BA under this Section 5 shall survive the termination of this Agreement.
6. Miscellaneous.
6.1 Indemnification . Each Party shall indemnify, defend and hold harmless the other Party (including without limitation the
other Party's employees, officers, directors , agents, successors and assigns) from and against any and all claims,
causes of action, liabilities, damages, costs or expenses (including without limitation attorneys' fees, court costs, costs
of administrative or other proceedings, and costs of investigation) arising out of or related to any breach of any of the
terms and provisions of this Agreement by the indemnifying Party or any party acting by or through the indemnifying
Party (including without limitation its employees, agents , representatives or Subcontractors). The obligations of the
Parties under this Section 6.1 shall survive the termination of this Agreement.
6.2 Compliance with Law
BA and CE agree to comply with all federal, state, and local laws applicable to the privacy and security of health
information, including but not limited to the HIPAA Rules and the HITECH Act. Upon the compliance date or other
effective date of any law or final regulation or amendment to final regulation adopted by the Secretary that affects the
obligations of either Party to this Agreement , this Agreement will automatically amend such that the obligations of each
Party under this Agreement remain in compliance with such law or regulation . The Parties agree to take such action
as is necessary to document any such amendment to this Agreement as is necessary for compliance with the
requirements of the HIPAA Rules and the HITECH Act, and any other applicable law or regulation.
FCHN-PRO-042016 22
6.3 No Third Party Beneficiaries
Nothing in this Agreement shall confer any rights, remedies, obligations, or liabilities upon any person or other third
party other than the Parties to this Agreement.
6.4 Disputes
If any controversy, dispute , or claim arises between the Parties with respect to this Agreement , the Parties shall make
good faith efforts to resolve such matters informally and in accordance with the dispute resolution process specified in
the Services Agreement.
6.5 Interpretation
Any ambiguity in this Agreement shall be resolved in favor of a meaning that permits CE and BA to comply with
applicable HIPAA Rules and the HITECH Act. In the event of any inconsistency or conflict between this Agreement
and any other agreement between the Parties , the terms and conditions of th is Agreement shall have pr iority.
6.6 Notice
Any notice to be given hereunder shall be given in writing and in accordance with the applicable terms of the Services
Agreement.
6. 7 Governing Law
This Agreement shall be interpreted , enforced, and governed in accordance with the laws of the State of Washington,
notwithstanding any conflict of law doctrine to the contrary .
6.8 Amendments; Waiver
This Agreement may not be modified or amended , nor shall any provision hereof be waived , except in a writing duly
signed by authorized representatives of the Parties. A waiver with respect to one event shall not be construed as
continuing , or as a bar to or waiver of any right or remedy as to subsequent events. A failure or delay in enforcing
com pli ance wi th any term or condition of this Agreement does not constitute a waiver of such term or condition unless
it is ex pressly Waive d in writing.
6.9 Survival
BA's obligations to protect the privacy and safeguard the security of PHI as set forth in this Agreement shall survive the
termination of this Agreement.
6.10 Severability
The invalidity of unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any
other provision of this Agreement, which shall remain in full force and effect.
6.11 Counterparts ; Electronic Copies
This Agreement may be executed in any number of counterparts, each of which shall be deemed an original and all of
which taken together shall constitute one and the same instrument. Electronic copies of this fully executed Agreement
shall be deemed to be originals.
IN WITNESS WHEREOF , the Parties have duly executed this Agreement as of the effective date of the Services
Agreement.
Business Associate Covered Entity
F.irsl Choice Health Netwo rk. Inc. Kittitas County Public Health Department
S~nawre9r•-+ ~
Title : President & CEO --/ -..
Signature :
Title : Administrator
FCHN-PRO-042016 23
SCHEDULEB
First Choice Health Network
Physician, Nurse Practitioner and Physician Assistant
Fee Schedule
Effective January 1, 2017
CONFIDENTIAL AND PROPRIETARY
2016 RBRVS1, 2
RVU's without Geographic (GPCI) Adjustment
Code Series Code Ran2e Conversion Factor3
E&M/Medical 90281-91299 $47,50
92025-99607
Surgical/Specialty 10021-69990 $47.50
RadioloRv 70010-79999 $47.50
Routine Vision 92002-92020 $40.00
Lab,JPath/HCPCSs 80047-89398 $47.50
A0021-V5364
Anesthesia 00100-01999 $51.00ASA on a four unit hour
1Facility and Non-Facility Site of Service payment rules will apply.
2FCHN reserves the right to assign fair and reasonable reimbursement values to services for
which there is not yet a specific code available or for which the specific code does not yet have
an assigned relative value. These services may be billed using "99" (nonspecific) codes. In
such circumstances FCHN reserves the right to require specific descriptor language for payment
purposes be included in the billing communication as well as reserves the right to assign
reimbursement values to those services.
3Fees for most other codes without Medicare RVU's are calculated using RVU's from the 2016
OPTUM "The Complete RBRVS", otherwise, a 40% default discount will apply. For newer CPT
codes, the R VU from the first year the CPT code was issued and the above conversion factor will
be used. All final fee payments will be the lessor of the fee schedule amount or 90% of billed
charges.
4Fees for Clinical Lab Codes are reimbursed at 90% of the Washington 2016 Medicare Part B
Clinical Lab Fee Schedule.
5HCPC Codes-J-Codes (excluding codes J9000-J9999) shall be reimbursed at 115% of the
current Average Sale Price. J-Codes J9000 to J9999 shall be reimbursed at 135% of Average
Sale Price. J-Code reimbursement will be updated four times a year, on March 1st, June 1 si,
September 1st and December 1st
• All Durable Medical Equipment (DME) codes, excluding V
Codes, shall be reimbursed at 90% of the 2016 Medicare Part B Durable Medical Equipment Fee
Schedule. Vision Hardware shall be reimbursed at 80% of billed charges. Hearing Aids will be
reimbursed at 100% of billed charges.
FCHN-PRO-102013
Sch B-RBRVS
First Choice Health Network Physician, Nurse Practitioner and Physician Assistant Fee Schedule
Sample Reimbursement Rates
Non-
CPT Facility
Code Rate
99201 $58.43
99202 $99.75
99203 $144.40
99204 $220.40
99205 $276.45
99211 $26 .60
99212 $57.95
99213 $97 .38
99214 $143.45
99215 $193 .33
99217 $97.38
99218 $133.48
99219 $181.45
99220 $247.95
99221 $135.85
99222 $183.35
Non-
CPT Facility
Code Rate
10060 $157.70
11100 $138.70
17110 $148.68
20550 $79.33
20610 $81.23
25605 $739.10
29075 $117.80
29881 $740.53
42820 $401.38
43239 $535.80
45300 $166.25
45330 $225.15
49505 $715.83
52000 $275.50
54150 $208.05
55250 $518.23
57454 $205 .68
FCHN-PRO-102013
Sch B-RBRVS
Effective January 1, 2017
EVALUATION AND MANAGEMENT SERVICES
Non-Non-
Facility CPT Facility Facility CPT Facility Facility
Rate Code Rate Rate Code Rate Rate
$35.63 99223 $271.23 $271.23 99315 $97.85 $97.85
$67.45 99231 $52.73 $52.73 99316 $141.55 $141.55
$103.08 99232 $96.43 $96.43 99381 $147.25 $102.60
$174.33 99233 $139.18 $139.18 99382 $153.90 $109.25
$226.58 99234 $179.08 $179.08 99383 $160.55 $116.38
$12.35 99235 $226.10 $226.10 99384 $181.45 $136.80
$33.73 99236 $291.18 $291.18 99385 $175 .28 $131.10
$68.40 99238 $96.90 $96 .90 99386 $203 .78 $159.60
$104 .98 99239 $143.45 $143.45 99387 $220.88 $171.48
$148.68 99281 $28 .50 $28.50 99391 $132.53 $93.58
$97.38 99282 $55.58 $55.58 99392 $141.55 $102.60
$133.48 99283 $83.13 $83.13 99393 $141.08 $102.60
$181.45 99284 $157.70 $157.70 99394 $154.85 $116.38
$247.95 99285 $232.75 $232.75 99395 $158.18 $119.70
$135.85 99291 $368.13 $299.73 99396 $168.63 $130.15
$183.35 99292 $164.35 $150.10 99397 $181.45 $136.80
MEDICAL/ SURGICAL SERVICES
Non-Non-
Facility CPT Facility Facility CPT Facility Facility
Rate Code Rate Rate Code Rate Rate
$131.10 58100 $146.78 $118.28 82977 $12.83 $12.83
$66.50 59025 $65.55 $65.55 83540 $11.88 $11.88
$94.53 59400 $2,858.08 $2,858.08 85014 $4.28 $4.28
$57.00 69210 $66.50 $44.65 85025 $14.25 $14.25
$62.70 69436 $219 .93 $219.93 86403 $18.53 $18.53
$695.88 70210 $39.43 $39.43 87081 $11.88 $11.88
$85 .03 70220 $49 .88 $49.88 87086 $14 .73 $14 .73
$740.53 70450 $155 .33 $155 .33 88150 $19.00 $19 .00
$401.38 71020 $37 .05 $37.05 88305 $98.33 $98.33
$200.93 72040 $44.18 $44.18 90837 $170.05 $168.63
$74.10 72050 $59.85 $59.85 92004 $198.55 $133.95
$77.43 73030 $38.48 $38.48 92014 $165.30 $107.35
$715.83 73140 $41.80 $41.80 92015 $26.60 $26.13
$172.43 73610 $41.33 $41.33 93000 $22.80 $22.80
$133.48 76805 $191.43 $191.43 93015 $102.13 $102.13
$309 .70 81000 $5 .70 $5 .70 94010 $48.45 $48.45
$183 .35 82270 $5 .70 $5.70 95165 $17.10 $4.28
Page 2
SCHEDULE C
PREFERRED PROVIDER/GROUP AGREEMENT
WASHINGTON STATE LAW AND REGULATION PROVISIONS
With respect to any Payor that is a health carrier or carrier as defined in RCW 48.43.005, as it may be revised, renumbered, or
replaced, the provisions set forth in this Schedule C are fully operative and applicable to FCHN , Provider, and the respective
Payors under the Agreement to which this Schedule C is attached . For Payors meeting the definition described above, in the
event of any conflict between the provisions set forth in this Schedule C and the other terms of the Agreement , the provisions of
this Schedule C shall have priority. Except as modified by this Schedule C, all terms and conditions of the Agreement to which
this Schedule C is attached remain in full force and effect.
With respect to any Payor that is a health carrier or carrier as defined in RCW 48.43.005, as it may be revised, renumbered or
replaced:
1. Responsibilities of Provider. Section 2.1 !i of the Agreement is deleted in its enti1ety e111u Ille rulluwi11y is suuslilultlu
FCHN-PRO-042016
SchC-WA
therefor:
2.15 Compliance
Provider agrees to comply with all of the terms of this Agreement , all applicable federal and state laws
and regulations, all applicable rules and standards of accrediting agencies having jurisdiction over and
designated by FCHN , and the ethical standards of the Washington State Medical Association and the
American Medical Association, all of the above as they may be adopted, amended, revised, or
renumbered . As required by Washington State law, Provider agrees to comply with the following hold
harmless requirements:
2.15.1 Provider hereby agrees that in no event, including, but not limited to, non-payment by a Payor,
a Payor 's insolvency, or breach of this Agreement will Provider bill, charge, collect a deposit
from , seek compensation, remuneration, or reimbursement from, or have any recourse
against a Participant or person acting 011 Parlidµe1111's utlhalr, uU1ti1 lhc111 Payur, fur services
provided pursuant to this Agreement. This provision does not prohibit collection of
Deductibles, Co-payments, Coinsurance, or charges for non-covered services , which have not
otherwise been paid by a primary or secondary Payor in accordance with regulatory standards
for coordination of benefits, from Participants in accordance with the terms of the Participant's
Benefit Plan.
2.15.2 Provider agrees, in the event of a Payor's insolvency, to continue to provide the services
promised in this Agreement to Participants for the duration of the period for which premiums
on behalf of the Participant were paid to Payor or until the Participant's discharge from in-
patient facilities, whichever time is greater.
2.15.3 Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be
construed to modify the rights and benefits contained in the Participant 's Benefit Plan.
2.15.4 Provider may not bill the Participant for Covered Services (except for Deductibles, Co-
payments, or Coinsurance) where a Payor denies payments because Provider or a facility has
failed to comply with the terms or conditions of this Agreement.
2.15.5 Provider further agrees that (i) the provisions of paragraphs 2.15.1, 2.15.2 , 2.15.3, and 2.15.4
of this subsection 2.15 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 Participants, and
that this provision supersedes any oral or written contrary agreement now existing or hereafter
entered into between Provider and Participants or persons acting on their behalf.
2.15.6 If Provider contracts with other providers or facilities who agree to provide Covered Services
to Participants with the expectation of receiving payment directly or indirectly from a Payor,
such providers or facil ities must agree to abide by the provisio ns of paragraphs 2.15 .1, 2.15 .2,
2.15 .3, 2.15 .4 , and 2.15 .5 of this subse cti on 2.15 .
2.15.7 Provider acknowledges that willfully collecting or attempting to collect an amount from a
Part icipant knowing that collection to be in violation of th is Agreement constitutes a Class C
felony under RCW 48 .80 .030(5).
2. Eligibility . Section 3.5 is del eted in its entirety and the following is substituted therefo re:
3.5 Eligibility. FCHN shall require all Payors to provide timely information on a Participant's eligibility
for Covered Services, including any limitations or conditions on services or benefits, upon request by
Provider. FCHN shall require that during ordinary business hours, FCHN Payors shall assure reasonable
access, through standard means of communication for the confirmation that services are Covered Services
and a Participant is eligible under a Benefit Plan. FCHN shall require Payors to give Provider full access to
the coverage and services terms of lhe aµµli1,;ault: Bt:11t:lil Plau fur a Participant.
3. RESPONSIBILITIES OF FCHN. A new section is added to Section 3.
3.12 Phannacy Claims. Each Payor that is a health carrier will authorize a limited dispensed amount of
medication that allows time for the processing of a preauthorization request ("Emergency Fill") by the dispensing
pharmacist where a Participant presents at a Payor's contracted pharmacy with an immediate therapeutic need for a
prescribed medication that requires a prior authorization. Claim payment for an Emergency Fill will be approved by
a Payor that is a health carrier when: (i) the dispensing pharmacy cannot reach the Payor's prior authorization
department by phone as it is outside of that department 's business hours; or (ii) the Payor is available to respond to
phone calls from a dispensing pharmacy regarding Covered Services but the Payor cannot reach the prescriber for
full consultation. Each Payor that is a health carrier must disclose if the provider or pharmacy has the right to make
a prior authorization request. Provider must contact each Payor that is a health carrier to obtain such information. If
the Payor requires the authorization number to be transmitted on a pharmaceutical claim, the Payor will provide the
authorization number to the billing pharmacy. The authorization number will be communicated to the billing
pharmacy after approval of a prior authorization request and upon receipt of a claim for that authorized medication.
4. Claims Submission and Payment. Section 4.1.4 is deleted in its entirety and the following is substituted therefor , and the
FCHN-PRO-042016
SchC-WA
following additional paragraph is added to Section 4.2 , immediately following the end of subsection 4.2.4 :
4.1.4 Overpayment and Underpayment Recoveries
Adjustments to claims that have been paid or denied, where the claim submittal failed to include a
particular item or service , or was otherwise in error , must be requested and accomplished as follows ,
and refunds of incorrect claims payments must be requested and accompl ished as follows :
a. Except as provided in paragraphs 4.1.4 b and 4.1.4 c, a Payor may request a refund from
Provider for overpayment of a previously paid claim provided the request is received by the
Provider within 24 months after the initial payment was made . Such a request must be in
writing and specify why Provider owes the refund . Where a request for refund is contested by
Provider, Payor may not request that the refund be paid any sooner than six (6) months from
the date of Provider's receipt of the request.
b. A Payer's request for refund related to coordination of benefits with another entity responsible
for payment of a claim must be received in writing by the Provider within thirty (30) months
after the date the payment was made. The request must specify why Provider owes the
refund and include the name and mailing address of the entity that has primary responsibility
for payment of the claim. Where a request for refund is contested by Provider, Payor may not
request that the refund be paid any sooner than six (6) months from the date of Provider's
receipt of the request.
2
c. A Payor may at any time request a refund from a Provider of payment previously made to
satisfy a claim if a third party, including a government entity, is found responsible for
satisfaction of the claim as a consequence of liability imposed by law and the Payor is unable
to recover directly from the third party because the third party has or will pay Provider for the
services covered by the claim .
d. Provider may contest a refund request described in paragraphs 4.1.4 a or 4.1.4 b in writing to
the Payor within thirty (30) days after receipt in accordance with Section 9, Dispute
Resolution , of this Agreement. If Provider fails to contest a request within this thirty (30) day
period, the request shall be deemed accepted by Provider as due and owing, and Provider
shall pay the refund. If Provider has not paid the refund within thirty (30) days after the
request is deemed accepted, the Payor may recover the amount through an offset to a future
claim.
a. Provider may request an additional payment from ti Pc1yor to satisfy a claim provided the
request is received by the Payor within twenty four (24) months from the date the claim was
denied or payment intended to satisfy the claim was made. Such a request must be in writing ,
specify why Provider believes Payor owes the additional payment, and may not require that
the additional payment be made any sooner than six (6) months from the date of Payor's
receipt of the request. Any dispute arising out of such a request shall be handled in
accordance with Section 9, Dispute Resolution, of this Agreement.
f. A Provider 's request for additional payment related to coordination of benefits with another
entity responsible for payment of a claim must be received in writing by the Payor within thirty
(30) months after the date the claim was denied or payment intended to satisfy the claim was
made. The request must specify why the Payor owes the refund and include the name and
mailing address of the entity that has disclaimed responsibility for payment of the claim. The
request for additional payment may not request that the additional payment be made any
sooner than six (6) months after receipt of the request.
g. As used in this Section, "refund " means the return, either directly or through offset to a future
claim, of some or all of a payment already received by Provider.
h. This Section does not apply to claims for services provided through dental-only Payors or to
claims for services rendered pursuant to the Medicare or Medicaid programs.
4.2.4 FCHN shall require that any Payor failing to pay claims within the above stated standards and
any other standard established by applicable state law or regulation shall pay interest on undenied and
unpaid clean claims more than sixty-one days old until the Payor meets these defined standards.
Interest shall be assessed at the rate of one percent per month , and shall be calculated monthly as
simple interest prorated for any portion of a month. The Payor shall add the interest payable to the
amount of the unpaid claim without the necessity of Provider submitting an additional claim. Any
interest paid under this section shall not be applied by the Payor to a Participant's Deductible, Co-
payment, Coinsurance , or any similar obligation of the Participant.
5. Record Retention. Section 5.2 is deleted in its entirety and the following is substituted therefore:
5.2 Record Retention
Both parties shall retain all records relating to this Agreement for a minimum often (10) years.
6. Notice to Participants. Section 8.4 is deleted in its entirety and the following is substituted therefor:
8.4 Notice to Participants. If this Agreement is terminated, FCHN shall require Payors to make a
good faith effort to provide written notice of the termination to all Participants who are patients of Facility
or Facility based providers and who are seen on a regular basis by a specialist, by a provider for whom they
have a standing referral , or by a primary care provider within thirty (30) days of receipt or issuance of the
FCHN-PRO-042016
Sch C-WA 3
notice of termination, irrespective of whether the termination was for cause or without cause. FCHN shall
require a Payor to make a good faith effort to assure that written notice is provided immediately to
Participants when a termination for cause provides less than thirty (30) days' notice of termination to
Facility.
7. Amendment. Section 10.5 is deleted in its entirety and the following is substituted therefor:
FCHN-PRO-042016
SchC-WA
10.5 Amendment. This Agreement may be amended from time to time by FCHN, by providing
Provider not less than sixty (60) days advance written notice of the amendment unless changes to federal or
state law or regulations make such advance notice impossible, in which case notice shall be provided as
soon as possible. If Provider objects to the amendment, Provider must so advise FCHN in writing within
thirty (30) days after receipt of the amendment. If FCHN receives no written objection from Provider to
the amendment within the time described above, the amendment will become effective at the end of the
sixty (60) day notice period. If FCHN does receive from Provider a written objection to the amendment
within the time described above, FCIIN may, at its sole option, withdraw the amendment, and FCHN will
notify Provider in writing whether or not the amendment is withdrawn. If FCHN withdraws the
amendment, this Agreement will continue in force without any effect of the amendment. If FCHN notifies
Provider that the amendment is not withdrawn, then the amendment shall become effective at the end of the
sixty (60) day period. If, following notice of non-withdrawal from FCHN, Provider continues to object to
the amendment, Provider may terminate this Agreement as outlined in Section 8.2.3.
Notwithstanding the forgoing, if the proposed amendment is a "material amendment" as defined in
applicable state law, the Facility may reject the amendment at any time during the sixty (60) day notice
period and the rejection will not affect the terms of the existing Agreement.
No amendment to this Agreement may be made retroactive without the express written consent of the
Facility.
4
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date Agenda Date
04/23/2018
Fund/Department
116-Public Health
Contract/Grant Information
Contract /Grant Agen cy : First Choice
·#' L/ ;;.1100
~)l~IJ®
~
Period Begin Date: Upon Signature Period End Date: Upon termination by either
p arty
Total Grant/Contract Amount : $
Grant/Contract Number:
Contract/Grant Summary:
The agreement between Kittitas County Public Health Department and First Choice is established so the
department can bill patients health insurance for services provided .
Recommendation for Board of Health and Board of Health Review on
Department Head Signature:~, Administrator Date:~ (1'.'(
Signature of Board of Health member Date
Financial Information
Total Amount$ State Funds $ Federal Funds $
Percentage County Funds Matching Funds $ CFDA#
In-Kind$
Explain
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? Yes D attach budget form No D Why not
New Division Created?
Revenue Code
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date :
Prosecutor Review
I Has the Prosecutor reviewed this agreement? I YesD No D
County Departments Impacted
Auditor Facilities Maintenance
Information Services . Human Resource
Prosecutor Treasurer
Submitted
I Signature:
I Department:
I Date:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer I Date
Grant/Contract Review Page 2