HomeMy WebLinkAboutAsuris AgreementP.O. Bo• Z1Z87
Seattle, WA 88111-3287
Aprll 25, 2018
KITTITAS COUNTY HEAL TH DEPT
607 N NANUM ST
STE 102
ELLENSBURG, WA 98926-2886
Dear KITTITAS COUNTY HEALTH DEPT:
Thank you for your Interest in becoming a partlclpatfng provider with Asuris Northwest Health (Asuris).
Strong provider networ1<s are essential for the delivery of quellly health ca.re to our members. and we
appreciale your wHlingness to join our networks.
Enclosed are the necessary documents required to join our provider network(s). Please review and sign
~ch agreement using the following stepa:
1. Carefully review all documents
2. If you agree with the tenns of the agreement, click "Continuen In the green "Accept Terms" box
3. Follow'the Instructions to electronlcelly sign your agreement
4. A confirmation message wlll display once the terms of the agreement have been accepted
5. A final copy of the agreement wlU be elecfi'onlcally returned to you, along with an eSlgnatura
receipt document containing s gnature information
YOll'll ~elve an email from us that will confirm the network(•) you are participating on and your
effective date ·of pa~lcjpallon.
Important notet:
• Claims submitted before your effective date of participation will be processed as out-of-
network.
• You must agree to the tenns and electronically sign your provider agreement(s) to complete the
contracting proce&&.
• Delays In algnlng your agreement(s) wlll impact your network participation date and may require
that you complete the credentialing process again.
Vleit our provider website at asurjs.con, to view the tools and resource(; evallable to aaslst you fn ,lhe
contracting process. If you have any question&, please contact our Provider Relations team. Contact
lnformaUon is avallable In l),e Contact us section of our website .
Sincerely,
John S. Partin
Vice President
Network Management
Enclosures
Our provldet welffltte, QUfl•.com, ol!Gro a>ttflnlll'19 lnlorme1lon ond roao1,1rca1 to aupport yoi.,,
You can find lnfonnatton abO<JI mornblll confo, pi1t--1uthorlD~ci!I rttquirome~l• end muc;!l moro,•
PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT
between
ASURIS NORTHWEST HEAL TH
and
KITTITAS COUNTY HEALTH DEPT
EFFECTIVE DATE: ____ .....__
ASURIS NORTHWEST HEALTH, a Washington health care service contractor, and any
successor organizations ("Company"), and KITTITAS COUNTY HEAL TH DEPT a Washington
corporation that has entered into contracts with and/or employs pro11iders who are duly licensed to render
health care sen/ices in the state (hereinafter referred to as "Medical Group"). This Agreement Is a master
agreement that may be amended from time to time pursuant lo Section VIII of the Agreement, and
through the addition, alteration or elimination of those Provider Networks in which Medical Group has
agreed to become a Participating Provider.
By virtue of Medical Group's status as a Participating Provider In a given Provider Network, Medical
Group will furnish services to members of those Health Plans offered or administered by the Company (or
another entity with access to the applicable Provider Network pursuant to an agreement with Company as
allowed by Section 5.6) which rely on that Provider Network for the provision of Covered Services.
Medical Group also agrees to provide services to any Member under any Provider Network In which
Medical Group participates pursuant to the terms of this Agreement and any addenda attached hereto,
Nothing In this Agreement gives Medical Group the right to participate in any new Provider Networks or
lines of business developed by Company, unless Medical Group is offered and accepts participation in
ttie new Provider Network or line of business. This Participating Medical Group Agreement and the
applicable terms and conditions for participation in those Provider Networks, in which Medical Group is a
Participating Provider, are collectively referred to herein as the "Agreement." Participation In each
Provider Network is enforceable under the terms and conditions contained in the relevant Provider
Network addendum and, in the event of a conflict between the language of the Agreement and any
addendum relating to a particular Provider Network, the language of the relevant addendum will prevail.
IN CONSIDERATION of mutual covenants and promises stated herein and other good and
valuable consideration, the undersigned have agreed to be bound by this Agreement as of the Effective
Date.
RECITALS
The Company is a Washington non-profit Company registered with the Washington State Office of the
Insurance Commissioner as a health care service contractor, and as such is subject ta laws specifically
applicable to health care service contractors.
The Medical Group is a legal entity comprised of physicians and/or other health care providers all of
whom are licensed and/or certified by the state(s) in which the Medical Group is located.
I. DEFINITIONS
1.1 BENEFITS means payment by the Company for services and supplies covered under a
group or Individual Health Plan.
1.2 CERTIFICATE means the evidence of insurance provided to an Insured under a group or
Individual Health Plan.
Asuria MGA Agreement (Rav. 05/2017) A18816864AA Page 1 0120
1.3 £01N.§UR A~I; means the Member's percentage share for any Covered Service
provided at less than 100 percent.
1.4 QOPAYMENT means a lbcod dollar amount that the Member's Health Plan requires the
Member to pay for a Covered Service.
1.5 COVERED SERVICES are those health services and supplies provided to Members by
P.artlc lpa Hng Providers wnich qualify for payment under the terms or a Member's Health
Plan , as described In the applicable Certificate or policy, includlng any amendments
Uiereto.
1.6 ·CREDENTIALING is the co lledion , ver1fica1lo n and review or ll'lformauon by Company to
determfne whether. a ptoVlder ls eligible to partJclpate in ti,e Provider Ne\works. The
Co mpany shall nave sate dhJcretion in determining whether to participate with any
applicant.
1.7 Q!;DUSaf.BLE means the dollar amount that the Member must pay each calendar year
tie fore ComflllnY beg ins to make payments.
1.8 HEAL TH Pl.Alt means any group or Individual , insured or self.funded health care plan
issued end/or administered by Company, or by ahother entity ,vtlh i:l~ess to the
appllcable Provider Ne\wor~ punn.illnl lo an ag~ement with, Company , Includ ing , but not
I ml\ed to , The Regenee Group, Regence BlueSh eld or any or 11!1 alllllate_s, and or other
state and federal programs .
1.9 MEDICAL GROUP means a group of p"yslr.ians and/ot other health care providers who
pro_vlde services under the same taK idenUlloallon number.
1.1 o MEDICAL GROUP PROVIDER. means a member, e·mployee or contracto r or the Medical
Group who Is duly licensed or legally authorized to render health care &ervices In the
state of Washington and who is obligated, by virtue of his/her membership In, contractual
relatlonship •wllh or employment by Med ical Group, to provide s_ervlces lo Members .
1.11 Mfil)ICAL EMERGENCY la the emerge.nl arid acute onset or e symptom or symptoms,
lnclu~lng ~evere pa in. that would teacl a pru dent lay p1m1on acting reasonably to beUeve
tha t a health condition eKiets that requires Immediate medical attention , and that faUure lo
prov ide medlcaJ attenl on would result Ii, serklus impairment to bodily functions or serious
dysfunction of a 'bodily organ or part. or would place tlie person'e Ilea.Ith In serious
Jeopardy .
1.12 MEDI AL !jg;essn;Y, Except for seNIC88 subject to WAC 284-43-7000 , "Medically
Neceissary" or "Med lca l Necoes lly' means health care services or supplies Iha! a
physic ian or other health care provider, eKetclslng prudent cllnlcal , Judgment, would
provide to a i,atlent for 1he purpose of prevent.Ing , evaluaUng , dfagnoaing or trealfng
an lllnesfi. lnJu(Y. d sesse or Its &ymploms , and that are (a) i.n accordance wlth generally
accepted standards or medical practJce ; (b) clinically aj:)proprla!e , lh terms of type ,
frequency, extent , alt~ ahd du~tjon, and considered effective fo r the patient's illness,
injury Of di&aase ; and {c) not i,rimarily for the convenience or the patient, physic ian, or
other health care provider, end not more ~slly than an alternative cServlce o~
sequence or servlce3 or supply at least as likely 10 produce e-qulvalent therapeulic or
dlagnosuc results as to the dlagnos fs or treatment of that pallent's Illness , Injury or
disease. For lhess purposes, •genef&IIY llccepted standards or med[cal practice• means
sta/ldards lhat are based on cre _alble scleriliflc e111dence publlshed In peer-revlewed
m_ed !car tlterature generally rec ogn ized by the relevant medical community , Physlclan
Spec1.alty, Society recommendations .and Iha views of physic ans and othe r health care
providers practicing In t elallant clln fcal a1eas and · any other relevant factors . Fo r services
subject to WAC 284-43--7000 , "Medical Necess ity' or •Medically Necessary • shall have
the meaning sel'for1h in WAC284-43-7020.
Asurls MGA Agreement (Rev, 0512017) A18816854M Page 2 af 20
1.13 MEMBER means a person who is eligible and has been accepted by the Company for
coverage and for whom the applicable rate has been paid for Benefits under a Health
Plan.
1.14 e.tSTIC ~.AJ NG.. _P.B._OVIDE R means any hospital, physician , other health care
professional, or other provider of medical 1ervices or supplies who (a) is legally qualifted
to provide medical services or supplles under Washington state law; (b) has contracted
with the Company, directly or through intermedll1rles, to furnish Covered Services to
Me mbers as pa rt of one or rn ore of th e Companv's Provider Networks; and (c) Is eligible
for reimbursem en t under a Subscriber Agreeme n t.
1.15 Mfl.!LCIPATI NG PROVIDE NETWOR~ is the colle cii\le 9rou p of hosp itals, fa cHltfes ,
cil ti lcs, phys:l el an s and o~r he alth ca re professionals under con tract w ith the Comp any
to participate in the Compan11's network of providers identified as the Participating
Provider Network.
1.16 PAVO means the entities set forth below that offer or administer a health care plan and
contracts with the Company pursuant to Section 5.6 for access to one or more Provider
Networks in which Medical Group participates. Payers are limited to the follow ing entities
and the ir subcontractors who contract with Payor for accesa to one or more Provider
Networks: subsidiaries and affiliates of the Company as set forth on Exhibit A, a Blue
Cross and/or Blue Shiald Plan, a government program, a trust , and a self-funded health
plan administered by the Company or one of its subsidiaries or affiliates.
1.17 ~~TBAT!VE "MANU AL is a separate reference source developed and issued by
Company rar providers that indudes additional details, policies , procedures and other
information that a Participating Provider will need to know in order to properly perform Its
obligations under this Agreement.
1.1 B PROVID ER NETWORK means the Asll'ls Northwest Health Participating Provider
Network and any other Asurls Northwest Health network of Participating Providers or
lines of business that Provider agrees to participate pursuant to an addendum attached to
this Agreement.
1.19 RECR EDEN TIA U NG Is a period ic process by which the Company may determine, in its
sole discretion, whether to continue participating wilh a Medtcat Group.
1.20 §.LJ,P.SC IBER -AG EEf:.!l ENI Is a contract belween the Company or Payor and an
individual or group in which the Company agrees to provide, indemnify for or administer
health care benefits and which provides a benefit incentive if a subscriber or enrolled
dependent obtains health care services from Participating Providers in the Provider
Network. This Includes, but Is not limited lo, administrative services only (ASO) contracts
ttle Company or Payor enters Into with employers, other out of area Blue Cross/Blue
Shleld Plans and Blue Croas and Blue Shield Association services and state and federal
governmental programs . This may also include Subscriber Agreements issued by the
Company's branches and affiliates as set forth on Exhibit A, In accordance with Section
5.6. as well as Subscriber Agreements Issued by any successor organization of the
Company .
1.21 NON -COVERED S ERV IC E. is a service or supply that is not a Covered Service for any of
the following reasons : (1) the service or supply is lnvesti9ational or not Medically
Necessary; or (2) the service or supply is not an avallable benefit or a Covered Service
under the Subscriber Agreement for any reason.
1.22 lNVESTIGAT IQ.t:®,.: The definition provided in the Subscriber Agreement. To the extent
that the Subscriber Agreement does not provide a definition of lnvestigational , the
following definition shall apply : a health intervention that the Company or Payor has
classified as lnvestigatlonal. The Company will review Scientific Evidence from well-
designed clinical studies found in peer-reviewed medical literature, if available, and
Information obtained from Medical Group regarding the health intervention to determine if
Asurls MGA Agreement (Rev. O!l/2017) A18816854AA Paga 3 Df20
it is lnvestigatlonal . A health Intervention not meeting all of the following criteria , is, In the
Company's Jud_gment, trweallgationa!:
• The Sc enUfic Evidence rnust permit conclusions concerning the effect of the
Health Intervention on health outcomes, which In.elude the dlaease process .
Inj ury or lllnes.s , lengih of Hfe, ablllty lo funciion and quality of llro .
• The health Intervention must Improve net health outcome.
• The Scientific Evidence must show that the health inteiventlon Is as beneficial as
any established alternatives.
• The improvement must be attainable outside the laboratory or clinical research
setting.
For pu rposes of lhls de Rn Ilion. S<;lentlflc Evidence me.ans sci en tific: studies published n
or accepted for pt.lb.If cation by med ca l Journals that meet nat onatty recognized
requrrements for scientific manuscripts and thBt submil moat of their publlshe<I article!! for
review by experts who are not part. of the ed ltorlel elaff;· or findings, studies or research
conducted by or unde r the auspices of federal government agei,cles and nationally
recogn ized federal research ins litutes . However, Solentlf\c Evidence shall nol li'!clude
puhllshad pear--revle'Ned ll lerature sporasored to a significant extenl by a ph-armaceutlcal
manufacturing company or medical device manufacturar or a single study without other
suppol1able studies .
II. PROVISION OF MEDICAL SERVICES
2.1 MEDICAL L 'r'. ...QsSSARV SERVICES -Medical Group will ptovlde Med ically
Necessary Se rvices lo Members In ~rdance wit'1 the h1m,s of th i s Agreement
Company will only be~r llnancial responsibility for Med ically Necessary , Govered
Seivlces fumtshe.d to Members by Med ical Group. Company will' not make retroactille
denials of Covered Services that were pre-certlffed 01 concurrenUy certifleil as medically
nece:s.sary unless the certlllcatron was ~d upon a material m srepresantat on by
Medical Group ,
2.2 COVERED SERVICES -Company will define the Covered Servicas for the Health Plans
,for wt,fch Med ical Group has agreed to prov ide service,.
2.3 STANDARDS OF CARE -The Medlcaf Group &hell provide ·servic~ to Members In
accordance with ganereJly accepted p10fes1 lonal standards or care and medical and
billing praclice& In the c:ommunfly. Med ical Group agrees lo furn ish Covered Services to
Members without regard to the .Member's enroflmenl in lhe Health Plan as a private
purchaser or as a part ici pant in publicly funded programs .
2.4 RELATIONSHIP TH MEMBeRs -Cornpany will not be liable for nor w111 It eKercise
o<>ntrol or dfrectlon over the methods or profesaional judgments relied upon by Medlcal
Group and Medical Group's Pr011iden1, employees· or representatives In provid ing
services putsuant to this Agreement. Med ical Gro\:lp wtll be solely responsible for
supervising "nd controlling Medical Group 's employees to assure that such services are
pro11lded In a manner that compnes With generally accepted slanl:lards of ca1e . Meolcal
Group Provider will be responelble for cllnlcal decisions regarding the medical care and
treatment of Members. Noth ing fi:, lh l a Agreement Omits Med eat Group Provider 's right lo
commun icate freely with Members. fncludJng the rl_gt,I lo Inform Members that Medical
Group Provider tiejleves services are appropriate Of necessary ; even if Company has
determlned the services are not Covered Services.
2.5 t:I.Q.N.QISCRIMINATION • Medical Group wlll provide the Covered Services contemplated
herein without rcgirrd to o,e race , age . sex·. religion , creed , color , national orfg !n er
ancestry of any Member. During the term of this Agreement , Medical Group will not
unlawfully dlscrtmrnate against any employee or appl icant for employment bei:ause or
race , fellglor,, color , national orig in, ancestry , physical handicap, health slatus , marital
Asurla MGA Agreement (Rev. 0612017) A18818854AA Page 4 al 20
status, age or sex. Medical Group will include the non-discrimination compliance
provision of this clause in all subcontracts entered into to fulfill its obligations under this
Agreement.
Ill. PAYMENT FOR MEDICAL SERVICES
3.1 PROVIDER COMP!:; SATION, -Medical Group will be compensated for Medically
Necessary Covered Services provided to Members in accordance with the
compensation arrangements for the applicable Provider Network and the terms of
Members' Health Plans. The compensation arrangements for each Provider Network in
which Medical Group is a Participating Provider is set forth in exhibits and addenda
attached hereto and incorporated herein. The Medical Group agrees to accept the
compensation set forth In the payment exhibits as payment In full for Covered Services
provided to Members, whether that amount is paid in whole or in part by the Company,
the Member or by any combination of payers. The Company reserves the right to
establish and alter the payment methodology and levels from time to time with ninety (90)
days prior notice. Acceptance of reimbursement based on new payment levels or
methodology constitutes consent
The Company shaR pay claims as soon as practical, but subject lo the following minimum
standards -(1) the Comp1my shall pay 95% of the monthly volume of clean claims within
thirty (30) days of receipt by the Company; and (2) the Company shall pay or deny 95%
of the monthly volume of all claims within sixty (60) days of receipt by the Company. For
purposes of this Section 3.1, a "clean claim" means a claim that has no defect or
impropriety, including any lack of any required substantiating documentation, or particular
circumstances requiring special treatment that prevents timely payments from being
made on the claim under applicable Washington law. To the extent required by
Washington law, the Company shall pay simple interest at the rate of one (1%) percent
per month on payable, clean claims not paid by the Company within sixty-one (61) days
of receipt. Such interest shall be calculated based on the amount to be paid to the
Medical Group for the Covered Services and shall be added to the Medical Group's
reimbursement without further claim submission from the Medical Group. Claims for
services provided to Members pursuant to a contract With, or on behalf of, the federal
government, Including but not limited to the Federal Employees Health Benefits Program
(FEHBP), shall not be subject to Interest set forth In this Section 3.1.
3.2 COMPl;NSATION FOR REFE~ LS -Medical Group agrees not to accept any
compensation in return for referring any Member to a Medical Group for the furnishing of
any item or service payable by Company. Medical Group also agrees to refer Members
to providers In accordance with applicable state law and the laws and regulations of the
Medicare program.
3.3 MEMBER IDEN Tlf_K;.8IUW. -Medical Group wlll be responsible for establishing the
identity of all patients who present themselves as Members in any Health Plans and will
promptly report to Company any apparent abuse of the privileges of such Health Plans.
3.4 e].!J.JNG fOBPB.QVIDE R SEfMCtS -Medical Group agrees to submit claims for
Covered Services electronically or as prescribed by company or required by law. Claims
should be submitted within thirty (30) days of the dale of services and, in any event,
shall be submitted no later than twelve (12) months from the date that Members receive
services. Claims not submitted within twelve (12) months of date of service shall be
disallowed and the Medical Group shall not bill the Member or Company for services
or supplies associated with such claims. The Medical Group shall not bill the
Company for more than the Medical Group's usual and customary fee for the services
rendered, nor shall the Medical Group bill services provided to Members al a rate
higher than the Medical Group bills services provided to persons without health care
coverage. The Medical Group agrees to abide by Company directives, whether
communicated by the Company through its Administrative Manual or other
communications and publications.
Asurla MGA Agreement (Rev. 06120171 A1881885'4AA Page 5 of 20
Claims for wh ch the Company is the sec ondary Insurer must be submitted within thirty
(30) days of the primary car rie r's payment or denial.
The Med ica l Grovp agrees to submit cla ims using the m01Jt appropriate , current c1nd
specific cod ing when billing .for serv ices rendefed . The Me<!l_cal Group agrees the.I II will
not engage In ml sleadlng bUllng practice.a or otherwise ln lerfere with Urnely and accurate
cla!rns adJudicallon .
Except for Infrequent and isolated waivers for charimble purposes. '!he Medical. Group
shall charge to and make reasonable attempts to CQUect from the Membe r all coi nsurance
arnClunts owsd by the Member , after fllCIIIVlng a cfa lms adjud lGation determination by the
Company . and may collect all deduclibles a.nd copayments et lhe llme of seNlce .
Because of the difficulty of aacerialning damages resulllng fr-0m breach of th is prov sjon,
the part ies agre e that the Conipany shall l;>e en11tled to deny all or part of cla ims as
llqu dated damages It 111·e Med ical i;3roup la Is lo mal(e a reasonable allempt , using such
steps as 110rmal1y ta.ken to collect Oeductible9; coi nsurance or Copaymenls. In no event
st,all the .Medical Group charge to a Member-for Ded uctibles, co insurance or
Copayment a exceed the amounts -established by the Company . As required by WAC
2.8'1•43-320(3) the Company hereby In fo rm$ the Medic-al ~roup that Wlllftllly collect ing or
attempl fng to collect an amount l<nowlng thal the collectton ls !n v!olatlon of thi s
Agreement cons titutes •8 class C felony under RCW 48 .80 ,030(6). In no event ahaQ the
Medical Group seek. additional re ltnbursement for Covered Serl/Ice~ dellvered to
Members, except for any copayments, deductibles or coinsurance amounts that the
Member may owe, as determined by the Company.
3.5 MEMBERS..IQJ:lj;_HELD I-IARMJ,.e.~~
3.6.1 Toe . Med ica l Group hereby @gree_s lh!Ji lh no event, Including , but not limlted to ,
nonp ayment by the Company , Company's rn solvency o, breaeh of lhls
Agreement, shall the Medical .Gr01Jp bill, charge , collect a depos it from , seek
eompe nsat on, remuneraU on or re!mburs11m ent rrcm , or have any recourse
against Member or person , other than lhe Company, acting on their behalf, for
services provided pursuant to this Agreement. This provision shall not prohlblt
colfectlon of Deduc1lllles, Oopaymehts, Co-Insurance, andlof non-Covered
Seivl°", which have not olher:wse been paid by a pri ma~ry or secondary ca rrier
in accordance with regulatory standards for Coordination of Benefits, from
covered persona in accordance wilh the term·s of the Mem~r's Health Plan .
3.5.2 The Medical Group agre~s . in the event of the Company's insolvency, to
continue to prov ide the services promised In this Agreement to Member'$ tor the
durat on of the period tor which premiums were pa id tp tile Company on the
Me.mbers · ~half, or until the Members ' discharge from Inpatient (acUltles,
whichever time Is greater.
3.5.3 Notwithstanding any other provision of this Agreement, nothing in this Agreement
spall be construed to modify tiie rights and benefits contained In the Member's
Health Plan .
3.5.4 The Med lea l Group may not bill Members for Covered Services (elu;epl for
Oedu.cllbles, Copayme111s or .Co•lm1urance) where the Company, denies
paymen1a beeeuee the Medical ·Group has falled ~o comply With the terms of tt,ia
Agreement.
3.5.5 The Med ical Group further agrees (I ) that the above provisfons 3.6, 1, 3.~.2. 3.5.3,
and 3.5.4 shall sul'\/lve terminall oo of this Agreenjent regardless of the cau.se
glvln.g ris_e to termination end shall be oonstrued to be for the benem ot the
Cornpanyls Membe is. and {II) that this prov slon supersedes any oral or written
contra,y agreement be.tween the Medical GrOUf? and Members or persons acting
on th eir be.hall .
Asurf• MGA Agreement (Rev. 0512017) A18318864AA Paga 6 ol 20
3.5.6 If the Medical Group contracts with other health care providers or facilities who
agree to provide Covered Services to Members with the expectation of receiving
payment directly or indirectly from the Company, such providers or facilities must
agree to abide by the above provisions 3.5.1, 3.5.2, 3.5.3, and 3.5.4 and 3.5.5.
3.6 I.HJ~_Q -PA Y P ME T -Members may be eligible for coverage from another payer
including, but not limited to, other individual or group health plans, liability insurers,
entities providing workers' compensation or occupational disease coverage, Medicare or
other government programs. The parties will inform each other whenever a Member has
coverage from such other payers. Medical Group will collect payment from third-party
payers, using Medical Group's customary collection procedures, whenever such payers
have primary responsibility to provide or pay for Covered Services in accordance with the
Coordination or Benefits and third-party liability requirements of Members' Health Plans.
If Company is required to pay a portion of Medical Group's charges for Covered Services
not covered by other payers, Company will pay Medical Group only that amount which
when added to lhe amounts paid or owed by the other payer and any Copayrnent,
Deductible or Co-Insurance charges for which the Member is responsible, will not exceed
the payment for such services under this Agreement.
3.7 DUPLICATE BILLING -Unless otherwise instructed by Company, Medical Group agrees
to refrain from submitting more than one bill lo Company for Covered Services furnished
to Member pursuant to this Agreement. Medlcal Group will not, under any
circumstances, including a delay in Company's processing of Medical Groop's claims, bill
Members for Covered Services while waiting for payment.
3.8 ADJUSTMENTS -Medical Group will refund to the Company all overpayment amounts
Company has paid to Medical Group because of payment error, duplicate insurance,
Workers' Compensation recovery or other third party liabllity recovery, among other
reasons, up to the amount of the overpayment. Medical Group will refund such
overpayment amounts provided that written notification that a refund is due is received
within twenty-four (24) months of original payment of the claim (thirty (30) months in the
case of claims involving Coordination of Benefits), except if recovery from a third party Is
the cause of the delay. In the case of recovery from a third party, the Company may
request that Medical Group refund a payment or part of a payment at any time if: (a) a
lhird party, including a government entity, Is found legally responsible or liable for
satisfaction of the claim as a consequence of liability imposed by raw (e.g., tort liability);
and (b) the Company is unable to recover directly from the third party because the third
party has either already paid or will pay the Medical Group for the daim. Notwithstanding
the foregoing, Medical Group may contest a refund request made by the Company.
However, if Medical Group fails to contest the refund request, in writing, within thirty (30)
days of receipt of written notification that a refund Is due, Company shall conclude that
Medical Group has accepted the Company's refund request and may deduct from future
payments due to Medical Group the amount equal to the amount of the overpayment,
among other remedies.
Medical Group shall not request from Campany any additional payment to satisfy a claim
unless the request is (a) in a writing that apecifias why Company owes the additional
payment, and (b) made within twenty-four (24) months after the original date the claim
was paid or denied (thirty (30) months In the case of claims Involving Coordination of
Benefits).
None of the aforementioned time limitations apply to requests for refunds or addlllonal
payments involving fraud. All disputes and appeals of billing issues pursuant to Section 9
must be Initiated within the aforementioned time limitations.
3.9 t':!..Qf':J~OVER ED SERVICES
3.9.1 Except as otherwise set forth in this Section 3 9, Medical Group may charge
Member for Non-Covered Services under the Subscriber Agreement without
Asur1s MGA Agreement (Rev. 05/2017) A18818854AA Page 7 of 20
obtaining written Member consent. Neither Company nor Payor shall be Uable
for any health care services or supplies wh ich are determined by Compan.v.
Payor or lhelr dealgnae lo be a Non -C overed Service ; however, ,the Member may
be llable ror Non-Covered Se111lces subject to the lerma set forth lo Settlons
3.9.2 through 3.9.4 herein . l.n no evenl win Company or Payor be respona!ble fur
any amount owed by Member to M_edlcal . Group for Non-Covered Services In the
event that Medical Group Is unable to collect such amount from Member .
3.9.2 Medical Group may btll a Member ro:r services or supplies delem, ned by
Comp.any or Its designee to be not Medically Necessary only II Medical Group
has obtained appropriate Member consent In writing . At a minimum. the written
Member consent must Include the follow!ng information: Member name : specific
service or supply : date of service , if kTiown . a stalemflnt nfoiming .the Member
that lhe serv,ice or supply may; be a Non-C1>vered Service; and a statement
where !he Member agrees l o pay for the Non-Covered Service . The written
Member consent muat be signed by She Member, _Member's .guard l.in or
Membe r's eulhorized hea llh care representative and maintained In Medical
Group's reco<ds . Medical Group agrees to wrlte off and not charge Company ,
Payoi or Member any amount owed for not Med cally Necess_ary services or
supplies if Medical Group falls to oblain suc;h written consent.
3.9.3 For services re ndered 10 Members enrolled in Med icaid that are determined by
Company or Payor 10 be ln11estigetional , Medical Group must obtain the written
Member consent as describ~ In the Heahhy Options Administrative Manual
before re,nderlng services In order to charge lhe Men1ber for the se!Vlces . II
Med fcal Group fails to obtain such written Member consent Medical Group
agrees to write off end not charge Coni,:,any, Payor or Member for such
lnvesfigalional services . Fo r all other Members receiving services that may be
deemed lnvestiga1 onal by co.,,paoy or Payor, a written Member consent Is not
required In order to cJiarge Members for such .services, However, Company still
enaou,-t1ges Medical Group to Inform Member before services are rlltldered that.
suet, se,vlee& may be deemed Non-Covered Secvices by· Company or Payor,
and that If the services are deerned Non•Covered Services the .cost of such
services will be the reaponsl blfity of the Member.
3.9.4 Services or supplies provided to Members aftl!U' they have exhausted their ar,nuaJ
or Nfetlme benefit for such Hrvlces as provided In lhe S1,1bserlber Agreement
shall no longer be subject to lhe terms of this Agreement , except for the clalm or
ciafm line (a s epplicable) that results In the heneRt maximum to be exc_eeded ,
For that claim or claim line (as applfcable), M~lcal Group agre11s that any,
bala~ce billed to the Member shall be the lesser of billed charges or the allowed
amuunl undttr thi.s Agreement less any amount paid by Company or Payor. The
"clalm llne•· language 16 appllc·abfl;! where servi~ or supplies are pa id
lndlvldually . Tile "claim ~ language i& applicab le for services paJd based on an
episode of care .
3 .9 .6 Medical Group shall nor bill Members for C9vered Services (except for
deductibles , copaymenl,s or colnS11rance) where Company or Payor der,les
paymenl because Medical Gro up ha s failed to ccmply with the terms ol this
Agreement.
3. 1 0 IMEllGIBLE MEMM.B..$ -Company is nol obligated to make payment t.o Mer:flcal Group
for serv ice s provided to an indivi dual who is not, al the time such services are rece ived, a
duly ellglble Member . The fact l~al an htdlvid ual !)Oaaesses an ldenllncation oard wl ll not
obllgate Company to pay or provide services If on the dale(s) lhal such seNice11 were
rendered , the Individual Is, or la later to have found to !Jave been. lnellglbte for medical
benefits; eKcept in cc1ses where ·the ·Compar,y has provided prior authorlzatJon lo the
Medical Group for a requested service . Authorization by company rar a re ql.lesled
service does not guarantee that the Member Is eligi ble or will conl!nue to be ellglble for
Asuria MGA Agreement (Rev. 0512017) A 188 t 6854AA Page 8 ol 20
benefits on the date(s) thal such services are rendered.
3.11 GO V.sB_NJll1l;N T _ ROG~A..M S -Medical Group agrees to accept the Medicaid
re imbursement made by the Co mpa ny, or th e Company's relm bu rs.emenl, as paym ent In
fu ll to r Cove re d Servic es rendered to Me mbera enrolled In 111e State of W,asli ngto_n1
Oepa~t menl of So ci al and Hea lth Services Medic.ii Assistance Prog rams (Med icaid).
This provision is intended to cover those Medicaid Members who receive care outside of
their assigned Provider Network. In no event shall the Medical Group seek additional
reimbursement for Covered Services rendered to such Members . All claims tor Medicaid
Members must be submitted within three hundred sixty nve (385) days from the date of
service. The Medical Group is not obligated to accept all or any Medicaid Members
referred to it, nor is the Medical Group automatically a Participating Provider in the
Company's Medicaid programs by accepting the Medicaid reimbursement. Medical
Group agrees to report to Company any occurrence in which a Medicaid member is billed
for a Covered Service or Non-Covered Service, regardless of Member consent to
assume financial liability.
IV . COMPLIANCE WITH COMPANY'S POLICIES AND PROGRAMS
4 .1 ~..QfESSIONAL REQY..I~~!;:N1_S. -Medical Group and Medical Group Providers will
rema in In full compliance with all applicable laws and regulations governing the practice
of medicine and will be duly licensed, in good standing, to practice medicine in Medical
Group's respective Jurisdlction(s), including such jurisdictions as may be required by
virtue of Medical Group's participation in a Provider Network. Evidence of such llcensure
and of Medical Group's DEA certification wlll be made available to Company upon
request The Medical Group agrees that it and its subconlractors and employees shall
comply with all applicable statutes, laws and regulations, including those set forth in WAC
284-43 and those that govern health care service delivery to Members.
Medical Group agrees lo notify Company, In writing, within five (5) working days of any
material change in the status of Medical Group which is likely to impair or Interfere with
Medical Group's performance under this Agreement Including, but not limited to : (i) loss
or suspension of Mcensure or certification ; (ii) placement on probation by professional
licensing or certification agency ; (iU) loas or restriction of full active admitting privileges at
any hospital; (i11) the iasuance of any formal charges against Medical Group by any
governmental agencies, or any other licensing or accreditation organization wtllch would,
if sustained, materially impair Medical Group's abiUty to comply wl1h Medical Group's
duties and obligations under lhls Agreement; and (v) suspension or expUlsion from the
Medicare or Medicaid programs.
4 .2 AOMlli.i_S.IB~TIVE Mi?.N.U-81. -The Company shall make available to the Medical
Group copies of the Company's Adminialrative Manual, electronically, which outlines
billing requirements, general benefits Information, Medical Management requirements
and other updated information. The Medical Group agrees to comply with the policies
and procedures set forth in the Administrative Manual and that compliance is necessary
to meet the obligations under lhis Agreement. The Company may revise and update the
Administrative Manual from time lo time with ninety (90) days' notice to lhe Medical
Group . The Medical Group agrees that such revh1ions become a part of the
Administrative Manual and the Medical Group agrees to comply with any such
revisions . The Medical Group agrees to abide by Company directives, whether
communicated by the Company through its Administrative Manual or other
communications and publications. Notwithstanding the foregoing, the parties
understarid that If there are any conflicts with the Administrative Manual and the
Agreement , this Agreement shall prevail.
4 .3 ,UTILl~TIQN MANA GE.M~L AND QUALITY LMP ROVEM~fil -To lhe extent that
Medical Group participates in Provider Networks ror Health Plans which have
Implemented utilization management and/or quality improvement policies and programs,
Medical Group will fully comply with such policies and programs, the details of which are
Asurts MGA Agreement (Rev. 0~12017) A18618854AA Page 9 of 20
described in lhe applicable addenda or the Administrative Manual.
4.4 MAINTENAJ:IIC J; _NJJ .. ~ETENTION OF RECORDS -MedlcaJ Group will maintain
medical, fina11.ciaJ and administrative records concerning sesvloes provided to Members in
accordance •wilh Co111pany ·s requirements, applicable federal and a_tate laws and
generally accepted bu&lness and professional practices. Medical Group WIii ensure that
a medical record is established and maintained for each Member who receives services
from Medical Group in accordance with Company's standards. This record will be
opened at the time of a Member's first visit and shall include contemporaneous , written
documentation of the Member's condition, the treatment and services provided, the date
on wh ch the ser:vices were prov ded , and the identity of the provider rendering the
services. Alterations or S!'flendments lo records must include the date and time of the
alteration or amendment and the signature of the person mak ng the alteration or
amendment. Company may deny cla ims In those cases wt,ere, in the Company's sole
discretion , there_ Is Inadequate documentation of the .services r~ndered , In wh ich case lhe
Medical Group shall not blll lhe Member. Medical Group will maintain such records for a
period of at leas! ten (10) years from the date of service or from the date a Member
aNalns the age of majorit11, Whichever is later, The obligations of Medical Group under
th is section will survive the term ination of U,ls Agreement, regardless of the cause giving
rise to such termination.
4.5.1 Company, its aulhoriied representalllles and govemment agencies, will have the
right to audit and make .or obtain cop es of medical, financial al'ld administrative
re co rds , directly rela ed ,to servi ces rendered to Membeni rar purpo5es •that may
nc;l ude, but nol be Umlted · to: accuracy of claims , coverage for services, medical
necessity, proper utlllzatlon, appropriateness of seivices, CredenOailng and
R.ecredentlallng, and quality Improvement and appropriateness of bllllng, upon
reasonable notice, during regular bc.isiness hours of Company. The . Company
also mav conduct desl< audits of !lie Medical Group'il racillly(las) and Member's
records. Company. shall provide Medical Group with at least three (3) btlslnes:s
clays advance no ice of s1,1cll a_udlt unless Company determines there Is a
s gniflcant quality of care IISue ot risk tttat documents may be altered, createo or
destroyed. In such case . Co111panv may conduct an audtt upon twenty-tour (24)
·hour's adlll!noo notice . Notice of the audit shell appr se lhe Medlcal Group of the
period of time for which records are to be audited . The provider agrees to have
all records for that period avallable at the time ol the audit Records not
produced at the time of the audit will be deemed non-existent. Audils shall be
conducted n a manner 1hat, to lh~ greatesrextent possible, ,avoids di!jtupt!on of
the provider's business affairs and minimizes the burden on the Medical Group .
Audits wlll comply with all law$, sllltute.s and regulalfons perta fn lng to the
confiden!lality of medical and financial records. Copie.s of records requested by.
the Company or Ila representalive will be furn ished lo the Comp~ny upon request
and wllhout charge lo lhe Company or Members, except ro , records related to
utilftallon management review, which shall be 'reimbursed al \he rates set fotth fn
the Administrative Manual.
4.5,2
Insofar as Members are required to execute an authorization for the release of
their medical records to Company upon becoming Members, Medical Group
agrees to accept from Company, as a legally sufficient release of Members'
med cal records, Members' participation In Healih Plans of Company and
Company will not be required to obhtin an additjo1,1al medical rele!fse fonn from
Members in order lo Inspect, review, or make copies of Members' medical
records. This provision will survive the termination of this Agreement, regardless
of the cause giving riae to such termination.
Companfs remedies for the Medl~I Group's failure to cooperate With an aud it or
for insufficient documentatJon , lnBJ)proprlate billing, or substandard quall1y of care
Aaurfa MGA Agniemant (Rell. 05/Z017) A1881685-4AA Pnae 10 of 20
discovered as a result of an audit shall include, but not be limited to: (i) recovery
of payments made by Company for improperly billed claims through lump sum
payments or deductions from future payments subject to the terms and
conditions set forth in Section 3.8; (ii) pre-payment review of all Medical Group's
claims; (111) a requirement that Medical Group submit medical records with claims;
and/or (iv) immediate termination of Medical Group's agreements. When
Company denies claims for inappropriate billing: the Medical Group shall not bill
the Member.
4.5.3 The Medical Group shall have the right lo audit Company's records related to
adjudication of the Medical Group's claims. The audit may be performed either
by the Medical Group or by the independent auditor selected by the Medical
Group. Such audits shall be conducted during Company's regular business
hours at Company's office and shall be limlted to records neces&ary to perform
the audit. The Medical Group shall give Company at least three (3) business
days advance notice of such audit and shall inform Company of the records to be
audited. Company shall have the records for that tlme period available for the
auditors at the lime of the audit. Such audits shall be conducted in a manner
that, to the greatest extent possible, avoids disruption of Company's business
affairs and minimizes the burden on the Company. Audits wm comply wilh all
laws, statutes and regulations pertaining to the confidentiality of medical and
financial records.
4.5.4 Failure by a party to cooperate with an audit shall be a breach of this Agreement.
The audit rights set forth in this Section 4.5 shall survive termination of this
Agreement.
4.6 C · NFilDE T ITV OF E CAL RECORDS -Company and Medical Group will
maintain the confidentiality of infonnation contained in Members' medical records and wHI
only release such information as permitted or required by applicable state and federal
laws and regulations governing the confidentiality of personal health information.
4.7 fil~~TORY UPDATES -Medical Group agrees lo comply with Company policies and
procedures related to furnishing information, including but not limited to Information on
which providers are accepting new patients, the provider's location, contact information,
specialty, medical group and any institutional affiliations, necessary to ensure provider
directories are up-to-dale, accurate, and complete pursuant to federal and state law,
including 45 C.F.R. 156.230(b).
V. RELATIONSHIP OF THE PARTIES
5.1 INDEPENDENT __ CONTRACTOR -Medical Group and Company are independent
contractors. This Agreement is not intended to create an employer-employee partnership
or joint venture relationship between Company and Medical Group or their respective
directors, officers, employees or agents.
5.2 US ~8.MJ; -Each party will have the right to use the name of the other party to
inform existing or potential Members, patients and other providers under contract with
Company that Medlcal Group Is a Participating Provider in one or more of Company's
Provider Networks.
5.3 ~-~~ARTICIPATION APPLICATION -Medical Group acknowledges that in
reviewing and o·fferlng Medical Group participation In any of Company's Provider
Networks, Company has relied to a material e)(tent upon the statements and information
supplied by Medical Group in Medical Group's participation application. Medical Group
warrants that such statements and information are true and complete to the best of
Medical Group's knowledge and beNef. Medical Group agrees to hold Company
harmless with respect to any clalms which may arise from statements and information
supplied by Medical Group.
ABuris MGA Allreement (Rev. 0512017) A 18818854AA Page 11 or 20
5.4 RTICIPATION Of OTHEJ;t e.R ... Q¥.!Q§B§..!.!lL!:8ACTICg -Medical Group underarands
and agraes that continued partlclpallon n any of Company's Provider Networks requires
lha\ all Mecllcel Group Providers must apply and be accepted for participation in the
Provider Network . The failure of one or more at the health care providers in Medical
Group to be accepted for participation or their relusat to apply for or, upo(l approval ,
accept such participation, may result In termination of th s Agre _ernent pursuant to ·se<:1!0n
7.3. Accordingly, Medical Group must provide Company with at least th irty (30) days'
advance notice if one or more phys icians/health care pro11iders intend lo Join Medical
Group.
5.5 NON-EXQ.USIVITY -This Agreement wlQ not be construed to be an exciusi11e
agreemenl between Company and Medical Group. Nothing in this Agreement or any
related documents wilt be construed to restr ict lhe particip ation of any of the parties in
any olher health ca.re delivery system or payment plan.
5.6 ~___Qll!.Q.~V!CES IQ Ml;M 6~F PAYQ~ -Medical Group understands and
agrees lhat the Company may enter Into .an <1greement with Payors that want access to
and use of I hose Provider N_e\work.s in wh l,ch Medical Group participates . Medical Group
hereby authorizes Payors contracting with Company to offer Medical Group's services to
groups ot employees or Individuals In accordance with the terms of this Agreement and
the pr011ision of any Subscriber Agreement offered or acO:ninl_stered by Payor for the
payment of Covered Services. Medical Group agrees to furnish services to Members of
such Payers when those Members utilize the Company's Provider Networks in
accordance With the same terms and condlllons of partlclpatiOfl and comJM!nsallon as
apply when such services are furn ished to Members under th s Agreement. A list of the
Company 's subsidlarles and atflllates i s set for1h on Exhibit A hereto. Company will
provide Medical Group with ad11ance written notice shoula the list of affiliate$ and
subsidiaries in Exhibit 'A change and If Company enters Into an agreement with a Payor
that la not specifically named in Sectio n 1. 16 or Exhibit A hereto.
5.7 U§E OF NETWORK PROVIDERS --Unless Covered Services are unavailable from
Participating Providers , Med cal Group will refer to and accept all coverage from
providers who are participaUng In Company's Prov id er Network.
5.8 RATE INFORMATIQ.~ -Both parties agree that, unless required by law or authorized
by this Agreement, a party shall not disclose the reimbursement rates set forth in this
Agre_ernent without prior WI Uen ctlnsent of the other party . The pairtles acknowledge that
the unauthorized discfosure of rate lnforrTtatTon may cause Irreparable damage to the
other party . Notwlthslandlng the above, Company may disclose to Partee paling
Prov ders in Medical Group's service area the information and data required to _allow
those Participating Providers to effec1t11ely manage the quality, care and cost of Members
Company has altrlbuled to them . Company may also disclose health care claims and cost
data to commun ity organizations; such a& Puget Sound Health Alliance (PSHA) that seek
·to Improve health care quality and affordability by reporting agg regated data to
i,urchaS'Ors of health care serv ices.
5.9 DISCLOSURE OF ES TO MEMBEB§ -Notwithstanding any other pro11ision of this
Agreement to the contrary, either party may disclose to Members the reimbursement rate
or allowed amount set forth In this Agreement for a Co11ered Service and/or the Member's
actual or ettlmated cost-.sh arlng amount (e .g., copayment , deductibl e, and/or
coinsurance) for a Covered Service lo expla in cla ims payment and lo facilllale informed
decisions regarding health care ser11lces use and cost
VI. INSURANCE AND INDEMNIFICATION
6.1 PROFESSIONAL LIABILITY COVERAGE -Medical Group will obtain, at Medical
Group's own cost, and keep in force . adequate policies provldlrtg cornprehen:,lve general
lfablll ty , prore9slonal lrablllty Gild other Insurance , as may be necessary ta lnsore Medical
Group, Medical Group_'s Providers, age nts and employees agai nst any cla im or cla ims for
damages arising out of the rende ri ng of or failure to render proresslonat service~
Asuria MGA Agreement (Rev, 0512D17) A1881886•AA Page 12 of20
pursuant to this Agreement Policy limits of professional malpractice coverage must be
no less than $1 million per occurrence and $3 million aggregate, unless the parties
otherwise agree In writing, Medical Group will maintain policies of general liability and
other insurance In amounts consistent with Medical Group practice standards. Evidence
of the insurance coverage required under this section wilt be made available to Company
upon request. Medical Group will give Campany at least fifteen (15) days advance notice
of cancellation of any modification of such medical malpractice insurance.
6.2 f'{Q,TICE OF CLA)MS -Medical Group will notify Campany immediately of the filing of
any claims against Medical Group or other person(s) for whose acts or omlasions Medical
Group is responsible, filed by any Member with respect lo any Member. Company wilt
promptly notify Medical Group of the initiation of legal action against Company by a
Member concerning or relating to services rendered by Medical Group hereunder.
6.3 INDEMNIFICATIO~ -Within the limits of their respective policies of professional and
general liability Insurance, and to the extent not otherwise inconsistent with the laws of
the appUcabte jurisdiction, each party will indemnify and hold harmless the other, its
appointed boards, officers, employees, agents and subagents, individually and
collectively, from all fines, claims, demands, suits or actions of any kind or nature arising
by reason of the indemnifying party's acts or omissions in the course of its performance
of its obligations under this Agreement. Nothing in this Agreement or in its performance
will be construed to result in any person being the officer, servant, agent or employee of
the other party when such person, absent this Agreement and its performance, would not
in law have had such status.
VII. TERM AND TERMINATION
7 .1 TERM -This Agreement wilt take effect on the effective date set forth above and will
continue in effect unless and until terminated by either party. WhUe termination of the
Agreement will terminate Medical Group's participation in all of Company's Provider
Networks, termination of Medtcat Group's participation in any one or more of Company's
Provider Networks may, at Company's discretion, result in the termination of Medical
Group's participation in other Provider Networks in which Medical Group participates.
7.2 TERMl NATIO N -The parties agree that they are contracting at wilt. Either party may
terminate this Agreement or any addendum attached thereto at any lime and for any
reason, with or without cause, upon ninety (90) days written notice to the other party. The
terminating party has sole discretion to determine whether a cause exists for
termination and whether that cause justifies termination. When the Company terminates
this Agreement or any addendum thereto, the Company will offer the applicable provider
appeals process for the Medical Group to obtain the Company's reconsideration of
the basis for the Company's decision, but the Company retains sole and ulllmate
discretion to decide whether a cause exists and justifies termination. tn the event of a
termination, the parties shall have no right to claim and do hereby waive and release any
claim for damages that may result from or arise out of that termination, other than any
claim that the parties may have for services rendered to Members prior to the
effective date of the notice of termination.
7 .3 'IMMEDIATE tE8MINAI !9N -Notwithstanding any other provision of this Agreement,
Company may terminate lhis Agreement immediately upon notice to Medical Group in the
case of any or the following:
7.3.1 Medical Group Provider's license lo practice medicine Is put on probation,
suspended or revoked;
7.3.2 Medical Group Provider's right to prescribe controlled substances is put on
probation, suspended or revoked;
7.3.3 Medical Group Provider is arrested or indicted for or convicted of a crime;
Asurls MGA Agreement (Rev. 05/2017) A18816854AA Page 13 ol 20
7.3.4 Medical Group's professional liability insurance. as required by this Agreement, i&
cancelled or terminated wilhoul replacement coverage hav.1,ig been secured ;
7.3.5 Loss or restriction of Medical Group Provider's prtvlleges at any hospital;
7.3.6 Med ical "Group or Med ical Group Provider fails or refuses to prov id e or arrange
for the prov is ion of Covered Services to Members in a professionally acceptable
manner:
7 .3. 7 Medical Group or Medical Group Prov der is suspended or e,cpelled from
Medicare , Med ica id or o.lher govemme nt programs;
7 .3.8 Medical Group Provider fails to meet Company's Credentialing criteria al any
time.
7.4 ~Q.N~~T T fLCWlREO-Thi s Agreement may be terminated without the consent of
any Member, Partrdpallng Provider or-any other third party.
7 .5 !;F.FE Ll.l;,BMINa 1O,N -Termirrci,t on will have no effect upon the rights and
ob!lgatloos of the parties arisfng out of any tr.ensactlons .occurring · prior to Iha effective
dale of te rminati on . The Medical Group may notify their Members Ir term nat ed. as a
Part.iclpating Provid er. The Medlcal Gro1:1p n,ay accon,plish tl\ls not ce with in fift een (15)
working. days or Issuance or a notice of term lnal ion lo or riom the Company and will
provide lhe Company with a copy of the notiflcallon sent lo lls Members . In addition , the
Company shaU make ·a ,good fall h effort lo assure, that wrllten not ice of a term ination
within fifteen (15) working days of receipt or Issuance of a notice of terminaUon is
provide d to all Members who are -seen on a regular bas is by the· Med ica l Group. If
Med ical Group has one o more practi tl oner9 wh.o are primary care providers , the
Company shall make a good faith effort t.o assure that notice Is prov ided to all Members
of that primary care provider .
Medical Group wm cooperate with ·company In lhe orderly tf'ilnafer of Members · care .
Including ecords, to other Pa rtic ipating Providers in the IIJlplicable Provider Network.
The part ies wlll cooi;ierale on promptly re.soMng an~ outs tanding financial. -adm!"lsb'atlve
or patient care 15:sues upon the term ln allon or this Agreement or Medical Group's
Pa,11clpatlng Provt~er status In any one or more or Company 's Provi der Networks .
Ourtng the lerm of lti ls Agreement, a.rid following its terminal.ion or te rminalion or Medical
Group's Participating Provider status· In any one or more of Company's Provider
Network's , Med ical Group agrees to refrain from any action that Interferes wilh tne
relationship between Company and its .exi sting or progpectlve Members. o~ other
providers.
7.6 0 T U TION Q f. SE."VICES AND PAYMENTS -Upon 1ermlnatlon of this ·
Agreement without cause , Medical Group will ·continue to render Covered Services as If
still a Participating Provider, ,o primary care Membars ur,til the earl/est of the following : 1)
the date lllirvlces be ing re ndered lo lhe-Member by Medical Group are completed or
medically appropriate pro11lslona have been made ror another provider to as:sume
responslblUty for providing such services ; 2) sJxly (BO) days following notice lo Members
or, lfle term fnall on of Medlcal Group's status as a Part icipating Provider; or 3) the end of
the Member's group health plan open enrollment period . Toe provision Of such serv rces
and the re lmbursement to Medical Group fur these services wm be subject to all
appllcrabte terms of th )s Agreement on the same basi s as those servlcff prov ided during
the term of this A_groemen t.
7. 7 PBIOR AC,:T~ -In the event or term nation of this Agreement, for whatever reason , each
party wlll remain li able for its acllvities or the activities of Its employees or representa Iv es
during the term o(the Agreement
Asutls Ml3A Agreemer,t (Rev . 05/2017) A1BB1685>4AA Page 14 ot 20
VIII. AMENDMENTS
8.1 The Agreement: any addenda, atlachments, fee schedules or exhibits thereto; any
policies or procedure5 incorporated into the Agreement by reference; the provider
administrative manual; and medical and reimbursement policies may be amended by
lhe Company by giving ninety (90) days prior written notice to the Medical Group of
such amendment(s). If the Medical Group objects to the amendment, the Medical Group
may terminate this Agreement by giving the Company written notice no later than thirty
(30) days after receipt of the written notice of the amendment. Said termination will be
effective at the end of the ninety (90) day notice period, unless within sixty-five (85)
days of the date of the notice of amendment, the Company gives the Medical Group
written notice that the Company will not implement the amendment.
In the event slate or federal laws are enacted, or state or federal regulations are
promulgated, which Company determines renders this Agreement, or any provision,
illegal or this Agreement is otherwise deemed by a state or federal regulatory agency
to violate such laws or regulations, this Agreement shall be immediately reformed to
comply with such laws or regulations or terminated. Amendments required because of
legls latf11e, re gulatory or legal require men ts do not require IJ:le cons.ent of the Me~ical
Group. and wltl be effective Immediately upon notice to the Med ical Gro up of the effective
date thereof. Company will, as prompUy as possible, provide notice to the Medical Group
of such amendments.
IX. DISPUTE RESOLUTION
9.1 M_E~COM.eLAtNTS -Medical Group agrees to cooperate fully with the Company in
the investigation and resolution of Member complaints and grievances concerning
Covered Services provided under this Agreement. Upon request, Medical Group wlll
furnish the Company with a copy of its procedures for handling Member complaints.
9.2 INTERNAL PROV IDER 'p EA PROC S ~ -Company shall maintain one or more
Internal provider appeal processes lo adjudicate disputes that may arise between Medical
Group and the Company. The Company's Internal provider appeal processes are set
forth in Exhibit D to this Agreement and incorporated herein by reference. Unless
otherwise indicated herein or in Exhibit 0, Medical Group must exhaust the applicable
provider appeals process before initiating any of the post-appeal processes set forth
below.
In the event the Company rejects a Medical Group's request to dispute an Issue, or falls
to notify Medical Group that Medical Group's request to dispute an isaue has been
accepted, within thirty (30) days from the date the request is made, Medical Group may
bypass the applicable provider appeals process and proceed directly to mandatory non-
binding mediation, which shall be conducted In accordance with RCW chapter 7.07.
Medical Group and Company shall each bear their own costs of mediation and shall split
equally the costs of the third-party mediator.
In addition, if Medical Group submits a dispute to the Provider Billing Dispute Appeal
Process, and the Company fails to timely render a decision based on the time frames
described in Exhibit D, Medical Group may bypass the Provider BIiiing Dispute Appeal
Process and proceed directly to one or more of the post-appeal processes described
below.
9.3 eQST-APPEAL PRO C;&SJ;~ -If, after the exhaustion of the applicable internal provider
appeals process, either party is dissatisfied with the outcome of the internal provider
appeal and wants to further dispute the tssue(s), the disputed lssue(s) must be submitted
to one or more of the processes as described below. Any prerequisites to Initiating one
of the proceS8es described below must be met before the process can be Initiated.
Alternative dispute resolution, unless so elected by the Medical Group as provided
herein, is not required to the excluslon of Judicial remedies.
Asurl& MGA Agreement (Rav. 05/2017) A1881B854M Page 19 of 20
9.3 .1 jNDING EXTERNAL !i~ -For disputes that have eJChausted the Pro111der
BiUl,:,9 Dlspule and Medfcal Necesslty/lnvesllgational Procedure Appeal Process,
Medical Group may elect blrtd lng c,cternal review to resollle lhe dlspu~d isouo(s),
It certain conditions are met. In all cases if a dispute I., -subm itted to external
rev.lew, .the deeislo11 of t!,e extemal reviewe r Is blhdlng and the flnel dec ision 011
the d[9puted Issue. Disputes submitted to external review shall not be subrnilled
to med iation . arbitration or jud icial remedy as Pf0VJded herelfl . A desortptlon Qf
the eKternal review pror.ess and any p_re1equisiies 10 lnltlatfng the external relliew
process Ci3.n be found In Exh ibit 0 . Disputes that do not meet the criteria to be
submitted to binding external review may be s1.1bmitled to binding externa l re\l lew
only upon mutual wnL!e n agreem~nt of the parties .
9.3.2 MANOATOR)'. NON•WOOJING MEDIATION -For disputes that have not been or
cannot be submi tted to external rev iew, lhe dlsputc.d issue(s) must be subm itted
to mandatory non-bi nding medh;illon prior to seek ing bind ing arbitration .or
Jud lclat reme.dy, except as otherwise provided he,ein. Mandatory non•bi nding
mediation must be roquested with in shc:ty (60) days foUowlng the date of ll't e
Co111f1any 's de ci sion on Med ica l Gro up•s lc1st internal proviaer appeal. Where
t:,:led ical Group Is allowed to bypass the Internal provider appeal process as
provided he rei n, mandatory non-binding mediation mus t be requested wllh1n sixty
(60) days from the last day the Company has to Umely respor,d to a dispute or a
request for a disp ute . Med ical Group and the Compa ny shaD each bear the ir
own costs of med labon and shall split equally the costs of the third-party
m.ed lotor.
9.3.3 4,_UDICIAL ..B.s.M._~Q U B.eJ: RA~ -If. after exhausti ng the Company's
Internal pro.vlder appeals process and compleling manl1alory no n-binding
mediation , either party Is s.1111 dis9atislied with tt,e outcome arrd wan!S to furthe r
dispute the lsS\le(s), the disputing party shall elect to resolve the disputed
lssue(s) through Judicial remedy or binding a1bitration .
9.3.3 .1 ..!!,!Q!g,AL REMEDY -If, after completing any pre requis \8!1 to Judl ol al
re me.dy _as provided here in, the di.spu Ung. party elects to resolve the
dispute through Jud lcal remedy , -the parties · agree lo comply with the
terms set forti, In Sectio n 10, 7.
9.3.3 .2 ~ ARBI TRATION -If, after complell.ng any prerequisites 10
binding ·arbitration as provided herein, the Medical Group elects to
resorve 11:i e disput e through final and bind ing artJ ltrallon 1 arb ilrat i on must
be Initiated by making a written dema nd for arbltraUo.n on ,the Company .
The demand for arbitration mu st identify all ,l iSues on whlc;h the Medlc:al
Group seeks arbllratJon , the contractual provisions on wh ich the Medical
Group relies , Ille amount In dis pute , and the rel ier requested .
Asurls MGA Agreement (Rev. 0512017)
The arbftradq n shall be conducted w!lhlh O11 e hundred and fifty (150 )
miles or Med ical Group's principal office address where notices under
lhe Agreement are sent un le&9 the pa.rt fes mutually -agree to conduct the
arbitration fn a different location. The parties agree tha t the dispute .shall·
be submitted to one (1) arb itrator selecetad by mutual agreement of \he
parti es . If lhe part ies cannot agree on an arbitrator, tttey shall obta in a /!st
of ten (1 O) possible arbitrators fr.orn a neut ral source , such as the
American Arb ilratton Aa_S(lcfallon , and shall strike arbitrators from the fist
In tun,, beginn ng wi lh the pa.rty who won a coi n toH, until orily ono
arbitrato r, remains , Tt,e rema ining arb itrator shall hear the dJspute ,
1.1nless either, party shows suoh bias as would d\s"quatlfy a judge fro l'll
hearing the proceed ing, in wh ich case lhe arb itrator shall be the next to
lirst name sllicke n. The part l~s shall share eq ually the fee of the
artl trato(, exclud ing the filing fee , if any, Incurred In oommern:errw1nt ol
1he proceed ing . The parties-shall have Iha right lo ma ke substan ti ve
A18816854AA Page 16 ol 20
motions. The arbitrator shall be bound by applicable federal and state
law and shall render a written decision within thirty (30) days of the
hearing . The arbitrator shall award the prevaHing party any applicable
fiUng fees and arbitrator's fees paid by the prevailing party . The
arbitrator also may award the prevailing party attorneys' fees and costs
associated with the arbitration proceeding . Judgment upon an award
rendered by the arbitrator may be entered in any court having jurisdiction
thereof.
The parties agree that the joinder or consolidation of an arbitration
proceeding under the Agreement with an arbitration of diaputes or claims
of any non-party to the Agreement is prohibited, regard le&& of the nature
of the issues or disputes Involved .
9 .4 fAlLURE TO TI MELY AP PEAL -It the disputing party (the party that demands or
initiates the internal provider appeal, external review, mediation, arbitration, or judicial
remedy) fails to demand or initiate an internal provider appeal, external review,
mediation, arbitration or Judicial remedy as required by this Agreement and within the
time framea prescribed in Exhibit D and this Agreement , the Company's last
determination on the disputed lssue(s) shall be deemed final and binding . In 11ddition , the
disputed issue(s) shall be conclusively deemed to have been waived by the disputing
party and shall not be the subject of any further internal, external, judicial, or other
dispute resolution process. Once the decision is deemed nnal, nothing in this Agreement
shall prevent the prevailing party from pursuing remedies available to it, including without
Wmltation a Judlcial remedy, to collect any amounts owed to it by the other party. Also ,
nothing In this Agreement shall prevent a party from asserting defenses, claims, causes
of action or demands in response to an internal appeal, mediation, arbitration or judicial
remedy initiated by the disputing party . This provision shall aurvive termination of this
Agreement.
9 .5 PREC EDE.lllllA L EFF CT DEC l ~ION S -The parties agree that any dlaputes that
ariae under this Agreement shan be considered independently and on their own merits
without regard for any other determination made by a third-party through one of the post-
appeal processes or by Company through the internal provider appeal process or
otherwise. The parties agree that none of the determinations made under this
Agreement through one of the dispute resolution processes described above shall be
used as precedent for other dispute& that may arise between Company and Medical
Group or between Company and any third-party. This provision shall survive termination
of this Agreement.
9 .6 QTHER APPEALS -In the event a dispute arises that does not meet the requirements to
be reviewed through one of the other dispute resolution proceHe& set forth herein,
Medical Group may contact Medical Group's provider consultant to attempt to resolve the
dispute informally or Medical Group may send a written request as outlined rurther in the
Company's Administrative Manual. The Administrative Manual provides detailed contact
information. If the dispute cannot be resolved, Medical Group may make a formal
request for a meeting on the disputed issue(s) no later than ninety (90) days from the
date Medical Group first raised the dispute with the Company . The request must be made
in writing and provide details on the disputed issue(s) and the relief requested . The
meeting may be by phone or in person and should be held within forty-five (45) days of
the Company's receipt of the meeting request.
The Company Will provide Medical Group with a written determination of its position on
the disputed issue(s) no tater than thirty (30) days after the meeting .
X. GENERAL PROVISIONS
10.1 SEVER ..rul,_tJ)'. -If any provision of this Agreement Is rendered Invalid or unenforceable
by any state or federal statute or regulations or declared null and void by any court of
Asuris MGA Agreelllenl (Rev. Oe/2017) A18816854AA Page 17 of20
GOmpetent jurisdiction, the remaining provisions of this Agreement will remaining In full
rorce and effect.
10 .2 ~NMENI -This A9reernel1t, .-nd any rights or obligations hereunder, shall nol be
assigned , delegated or transferred by Medical Group without !he 11rl0r written con~nt of
Company . Company may assign this Agreement to any entity that controli;, Is controll ed
by, or Is under common con trol with Company, or which 1weceeds lo its buslne~s ttuough
a sa le, merger nr olher corporeJe transaction .
10 .3 IND N FFECT -This Agreement will be binding upon and inure to the benefit of the
respective successors and assigns of Company and Medical Group.
10.4 W~F BB!;8Q!:1 -Waiver of breach of any provision of this Agreement will not be
dBf!med a wa ive of any other breac h of the same or different provision.
10.5 FORCE MAJE UR E -Neither party WIii be deemeo to be i,:1 violation of this Agreement .If it
Is prevented from perfbrmlng Its ob llgallon s by events beyond Us control lnclud ng,
without !Imitations; acts or God or of the public enemy , ffocd or, storm , stlikes, or. statute .
rule or action or the government or agency . The parties wm make a good feilh effort
however, to assure ;tt,al Members have a.ccess to Medical Groop'.s services, consistent
with applicable law, despite such events.
10.6 NO fil! ~ M.!.lliJ_gA TION BETWl;.!ili_ltl.1;.e~T@ • The rollowing provisions
will apply lo notices and communications between lhe parties to this Agreeme11t.
10.6 .1 Gsf!Rm Notices Be l!ired Under T h s AgrQ!i.lll!l.(\I The following nolices must be
sent vli'i overnight deli very with delivery co nRrmatton or certifled mail, return
receipt requested :
a . all notices for termination of this Agreement;
b. all requests for mediation; and
c. all requests for arbitration.
10.6.2 ~J!flt1 Commu it;atlons. All other nolicea and communications
petwaen lhe parties which are necessary ror the proper admin istration of this
Agreement (Including nolices required wflhin this :Agre.ement wh ch are not
Included lh SecUon '10 .6.1 above) may be communicated vie regular U.S. mall ,
cqnflr:med racslmlle , or electronic mall.
In addlUon , Company may notify Medical Group or policy changes. Adm lnfatra~ve
Manual ciiange:s, and ott,er general eommunlcatfoos throogh ils Provider Web
Sile , as long as Company sends nollee by U.S. mall . faeslml!e , or electronic malf ,
(1) Informing Medical Group that Company has published a policy ct,ange,
Admlf')lstratlve Manual change , o.r other .general communlca.lio n on Its Web Site ,
and (2) directing Medlcal Group to Iha locat ion of the policy chahge ,
Admin islrattve Manoal c:hange , or other general commllnicallon on Company's
Provider Web Sile. Notice In this manner stiall constllute notice under the
Agre.iment.
10.s.s ~nlial.ancl ... .P e.c.~_J:lst;iJ.11J....!.D.fm11~.l!!Ul • Ir a notice o~ communlca~on
Includes lnf-ormali(!n which s co11fldentlal or propr e.tary to e lher or both partles and/or
which include s Protected He alth Information ('PHI ') as defined under Health li,surance
Portability. and Aecount.abillly Acl of 1·996 (42 . U.S,C. 201 et seq .), then lhe following
reslrlc\lons mUst be ~bserved when comrnunlcal ng such Information:
10.6.3 .1
10.6.3.2
Aaurfs MGA Agreement (R11v. 05/2017)
U.S. Mail/Certified Mail/Overnight Delivery -No additional
requirements .
Fae.simile TransmlBBion-The informa l1 on must be prefaced by a
formal cover sheet noting the confldentlalily of such lnfonnallon.
A18816854AA Paga 18 0120
10.6.3,3
10.6.3.4
Web Site -Not a permitted method of notice or communication for
confidential information and PHI, unless the Web Site is secured or
the information is appropriately encrypted.
Electronic Mail -Not a permitted method of notice or communication
for confidential information and PHI, unless the electronic mall is
secured or the information is appropriately encrypted.
10.6.3 ~s fofJ:,J QU.c.es, Notices to Medical Group shall be sent to: (1) the facsimile
or postal address of Medical Group's billing service la<:ation or any other revised
postal address or facsimile provided by Medical Group to Company in writing, or
(2) the electronic mail address designated by Medical Group for electronic
notices. Notices to Company shall be sent to the address set forth in this
Agreement or any revised address provided to the Medical Group in writing. The
facsimile, postal address or electronic mail address for notices may be changed
upon prior written notice to the other party.
10.6.4 When Made. For notices described under Section 10.6.1 above, the notice will
be deem.ad-to have been made on the date it was delivered. For notices and
communications described under Section 10.6.2, the notice or communication
will be deemed to have been made when sent or mailed.
10.7 GOVERNING LAWNENUE -The validity of this Agreement and of any or its terms and
provisions, as well as the rights and duties of the parties hereunder, shall be interpreted
and enforced pursuant to and in accordance with the laws of tne Slate of Washington and
other applicable Slate and Federal laws. In the event any legal proceedings are
instituted between the parties arising out of this Agreement, such legal proceedings shall
be subject to the mandatory mediation requirements set forth in Section 9.3 above and
Instituted in the courts of the County of Spokane, state of Washington. Each of the
parties agrees to submit to the jurisdiction of such courts.
10.8 HEADING§ -The headings contained in this Agreement are for reference purposes only
and will not affect the meaning or interpretation of this Agreement.
Asuris MGA Agreema~t (Rev. 0512017) A1881686"4AA Page 19 of20
10.9 ENT E AGRE M.t;NTIS P .Qs§filQ.~ -This Agreement, its e11hibits, addenda and
any .imendmenle lhete_fo prQmulgaled pursuant to Se_ction VIII afthis ·Agreement and any
documents l~co1pora\&d by referenc~ conslitute lhe entire -agreemenl between Company
and Medlcat Group . It supersede& all prior wr itten or 01al understanding between the
parties relat ing lo the sub(ect matter of thi s Agreemen
IN WITNESS WHEREOF, the parties have caused this Agreement lo be signed on the date and
year written below.
:{I -G,co 1349
Tax Identification Number
Alurls MGA Agreement (Re11. 05/2017)
John Partin ___ _
Print Name
___ \~ I 1!>Lt _i ___ _
Date
Q..f[ce addrea stc,, lle__,,__u.,.,-""· ·"-"''-'-'"'=""
Asuri9 Northwest Health
Attention: Provider Network Management
528 e. Spokane Falls Blvd., Suite 301
Spokane, WA 99202
A18816864AA Page20 of 20
EXHIBIT A
ASURIS NORTHWEST HEAL TH AFFILIATES & SUBSIDIARIES
Aa of the effective date of this Agreement, listed below are the affiliates of Asuris Northwest Health. This
list also includes each afflliate's subsidiaries that provide services related to health care as referenced in
Section 5.6. Asuris Northwest Health will notify Medical Group if lhis 11st changes.
Regence Blue Cross Blue Shield of Oregon, Portland, Oregon•
LifeMap Assurance Company
Regence Blue Shleld of Idaho, Lewiston, Idaho••
Regence BlueShield, Seattle, Washington•••
Healthcare Management Administrators
BridgeSpan Health Company
• Regence BlueCross BlueShield of Oregon is an affiliate only for providers with practice locations in
Benton County, in the State of Weshington.
••Regence BlueShleld of Idaho is an affiliate only tor providers with practice locations In Pend Oreille,
Spokane and Whitman Counties, in the State of Washington.
•••Regence BlueShield is an affiliate only for providers with practice locations in Okanogan, Chelan,
Kittitas, Grant, Benton, Franklin and Whitman Counties, io the State of Washington.
Aeu~a MBdlcll Slanel1H!I MGA Exhlbl1 A AffiHates & Subaldlarlas A18816854AA Page 1 of 1
EXHIBITB
Ust of Madlcal Group Providers Covered by this Agreement
(To be completed by tha Madlc•I Group)
Allu~a Medlc:al Standard MGA Elthlbll B LIit ol Provldllfl A1881881UAA Page 1 of 1
EXHIBITC
ASURIS NORTHWEST HEALTH
PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT
REIMBURSEMENT METHODOLOGY AND FEE SCHEDULE
THIS EXHIBIT TO THE PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT (the
"Agreement") is effective for dates of service on or after the effective date of the Agreement and replaces
and supersedes any pr1or payment andfor rate exhibits. Any term not defined herein shall have the
meaning set forth in the Agreement.
I. DEFINITIONS
1.1 Billed Charges -charges submitted by Medical Group for Covered Services.
1.2 Maximum Allowable -the amount that Company agrees to pay, subject to standard
Company administrative guidelines, reimbursement policies and payment methodologies,
including but not limited to reimbursement for CPT® code modifiers.
1.3 Anesthesia services -services described by CPT® codes to which the American Society
of Anesthesiologists has assigned a base unit.
1.4 Total Anesthesia Units -ASA base unit for a CPT® code plus time units, which are defined
as total time for a service in 15-minute increments. Sixty minutes is 4 time units. Per the
Company's reimbursement policy, after one minule, Company rounds units up to the next
15-minute increment.
1.5 CMS RVU& -the Centers for Medicare and Medicaid Services (CIIAS) site-of-service based
(facility or non-facility), non-GPCI adjusted Relative Value Units (RVUs), which are updated
annually in the Federal Register. The Company shall provide notice as descrlbect In Article
V below of the CMS RVUs In effect for a particular date ofservice.
1.6 lngenlx RVUs -(formerly known as St. Anthony's RVU's) the site-of-service based (facility
or non-facility), non-GPCI adjusted Relative Value Units In The Essential RBRVS • A
Comprehensive Listing of RBRVS Values for CPT® and HCPCS Codes, published by
lngenix. The Company shall provide notice as described in Article V below of the lngenix
RVUs in effect for a particular dale or service.
II. FEE SCHEDULE/PAYMENT METHODOLOGY
Applies to Participating and Preferred Plan Provider Networks when applicable by
appropriate network participation.
2.1 Medical Group agrees to accept as payment in full the lesser of Billed Charges or the
Maximum Allowable for Covered Services provided to Members.
2.2 The Maximum Allowable for covered Anesthesia Services shall be calculated by multiplying
the anesthesia conversion factor established by the Company for the date of service, times
the Total Anesthesia Units for the service.
2.3 The Maximum Allowable for Covered Services provided by MDs and DOs shall be calculated
by multiplying the MDIDO conversion factor established by the Company for the dale of
service limes the CMS RVU, except as noted below. The Maximum Allowable for Covered
Services provided by ARNPs and PAs shan be calculated by multiplying the ARNPIPA
conversion ractor established by the Company for the date of service limes the CMS RVU,
except as noted below:
2.3.1 For services with professional and technical components, the associated global
Maximum Allowable for Covered Services will equal the sum of these components.
2.3.2 The Maximum Allowable for Covered Services included In Medicare'& Clinical
Diagnostic laboratory fee schedule shall be a percentage, as established by the
Company for the date of service, of the most current version of that fee schedule.
2.3.3 The Maximum Allowable for Covered Services for the following shall be the amount
set forth on the Company's fee schedule:
Asuris Medical Standard MGA EMhlbll C A18818854AA Page 1 012
2.3.3.1
2.3.3.2
2.3.3.3
2.3.3.4
2.3.3.5
2.3.3.6
2.3.3.7
2.3,3.8
Technical component of MRI (Magnetic Resonance Imaging), MRA (Magnetic
RcsooonceAnglography) and CT (Computed Tomography)
PET (Positron Emission Tomography) Scans
Durable medical equipment, medical supplies, orthotics and prosthetics
Physical and Occupational Therapy, Speech Therapy and Audiology
Acupuncture and Chiropractic Services
Technical component of Sleep Study Medicine
Vision Exam
Those CPT codes identified as Policy Codes by the Campany
2.3 .4 The Maximum Allowable for drugs and medications, including but not limited to
biologicals, immune globulins, vaccines and immunizations, shall be the Company's
medication fee schedule In effect on the date of service.
2.4 For services for which no RW has been established by CMS, the Maximum Allowable for
Covered Services shall be determined using lngenlx RVUs.
2.5 For services for which no RVU has been established by CMS or by lngenlx the Maximum
Allowable for Covered Services shall be the Company's participating fee schedule in effect
on the date of se,vice.
2.6 The Max imum Allowable tor Covered Services rendered by behavioral he.ilth providers shall
be the Company's participating fee schetlul e in effect on the da\e of se~lce .
2 .7 Forse.rvfces rendered by other ,Jicensed praeuuonera not specifically identified In Sect on 2.3
·above , lhs Maximum Allowabfe for Covered Services shall be the Compa.ny 's fee schedule
specific to the praclltioner lype In effect on tho date of service ,
2.8 Conversion factor(s), fee schedules showing common Covered Services or a11y other
reimbursement factor referenced here in VJ1ll be provided to the Mod/cal Group. The
Maximum Allowable fO? Covered SeNlces not set forth 011 a lee schedule shall be provided
upon request. The Company has no obllgatlon to . provide lees , com1erslon factars or o!he r
reknbursemenl rates to Medical Group for Covered Se,vices not typically performed by the
Medical Group.
Ill. COPAYMENT, COINSURANCE, DEDUCTIBLE
3.1 Where-the Subscriber Ag reement J)ro1.1rdes for payment of c opayment, coinsuranc e or
d~ductible.s by U,a Patient. payment by Company for Cove111d Services shall be less the
appUcable copayment-; co nsura11ce or deductible .
IV. NOTICE OF UPDATES
4.1 1 he Company shall provide Medlcal Group ninety (90) days prior notice of changes to the
Company's reimbursement mBlhodqlogy, RVU conversion factor, C,MS Of lngenh, RVU year,
tlie percentage rererenced !n 2.3 .2 ., or Company fee-schedules, excluding changes lo fees
lied to CMS fee schedules .
V. NON -DISCLOSURE
5.1 Medical Group agrees that unless required by law or otherwise allowed by the Agreement,
Medloal Group shaU not disclose the reimbu rsement retes establla\'1ed by the Company
without pr or written consent of Compa11y. 'Medical Group rurther agrees not lo dlaelose the
reimbursement rates to l ndivldl1al health care practi ti oners , other than those health care
practitioners on lta Board, If ap1>l!cable, in any fol'l11at. Medical Group acJ<nowledgu that the
unauthc rized di~l~sure of lhl_s Information may cauae Irrepa rable damage to the Company ,
and Medical Group agrees !hat lhe Con,pany may seek relief far breach of this pro.11ls lon .
Asurts Medical S1andard MGA Exhibit C A18816B5-4AA Pago2 of2.
EXHIBITD
PROVIDER DISPUTE RESOLUTION PROCESSES
Glossary
Advel'IJe Determination: For purpose of the appeal process means any of the following: a denial,
reduction, or termination of, or a failure to provide or make payment (in whole or In part) for, a benefit,
Including any such denial, reduction, termination, or railure to provide or make payment that is based on a
determination of any of the following:
• application of utilization review;
• determination that a treatment is not Medically Necessary; or
• Billfng Dispute.
Appeal Record: Includes all information which was relied upon in making the payment determination; or
was submitted, considered, or generated in the course of making the payment determination, whether or
not such document, record, or other information was relied upon in making the payment determination; or
demonstrates compliance with the Company's Claims procedures, administrative processes and
safeguards; or constitutes a statement of policy or guidance with respect to the payment determination.
Billing Dispute: A dispute with a Provider arising from Covered Services provided to Members by such
Provider concerning:
• Iha Company's application of coding and payment rules and methodologies for fee for service
claims (ineluding bundling and downcoding),
• application of a Current Procedural Terminology (CPT@l) modifier, and/or other reassignment of a
code by the Company to patient specific factual situations, including the appropriate payment
when two or more CPT Codes are billed together, or
• whether a payment enhancing modifier Is appropriate.
Claims: A ProVider's request for payment submitted in the usual course of business between the
Provider and the Company.
External Review: Review of a Bining Dispute Appeal or a Medical Necessity Procedure Appeal submitted
to the E><temal Review Organization with which the Company has contracted to provide these review
services by a Provider In compliance with the terms of the Adverse Determination Appeal Process.
External Review Organization (uERO"): An independent organization employing physicians and other
medically qualified individuals or experts, which acts as the decision maker for External Reviews, through
an independent contractor relationship with the Company.
Provider: Provider means practitioner, clinic, provider, or other health care provider as defined in the
Agreement.
"Our" or "We": References to our or we mean Asuris Northwest Health or the Company.
''You" or "Your": References lo you or your mean Medical Group as defined in the Agreement.
A1url1 Standard MGA El<hiblt D D15pute Resolulion Process A18816854AA Page 1 or 9
Provider Bllllng Dispute and
Medical Necessity Procedure Determination Appeal Process
Introduction
A. Appllcabillty
The Company Provider Billing Dispute and Medical Necessity Procedure Determination Appeal
Process (Adverse Determination Appeal Process) will apply when the Provider Is at financial risk
for the cost or the claim. The member appeal process will apply when the member is or may be at
financial risk for the cost of the claim. For purposes of Billing Disputes only, the definition of
Provider shall include providers who contract With Company as Participating Providers and non-
contracted providers.
Internal Review Process
A. Time Period for Submission of an Adverse Determination Appeal by Provider
An Adverse Determination Appeal must be submitted in writing within the following timeframes.
1. For Washington Providers, within 24 months after payment of the claim or notice that the
claim was denied or 30 months for claims subject to coordination of benefits.
2 . If a Provider Wishes to appeal a refund request initiated by Company, that Provider can
submit an Adverse Determination Appeal within the same timeframe as other Adverse
Determination Appeals as Usted above. Note: The timeframe begins when the written
request for refund Is sent to the Provider
Failure to request review within the slated time period (absent a finding which, In our sole
discretion, sets rorth acceptable extenuating circu mstances) will preclude the right to appeal and
may Jeopardize the right to contest the decision In any fo,um.
B. Process for Subml&&lon of an Adverse Determination Appeal
1. A Provider may use the Provider Adverse Determination Appeal form, which can be found on
Company's Provider Web Site: www.asuris.com/provider
2. The ~ppeal form for Provider Billing Dispu te s and Medical Necesslty denials or a written
descripl!on of the lssue(s) on the appeal must be submitted to Company, as further outlined
on Compa ny's i:ro11ider web site .
3. The following lnfomiallon must be submitted with the Provider Adverse Determination Appeal
form or the written description of the fssue(s) on appeal :
(a) A detailed description of the disputed IHue(s);
(b) The basis for disagreement with the decision : and
(c) AR evidence and clinical documentation supporting your position.
Asuris Standard MGA E•hlM O Dl •pute RasoluUon Process A188Hl864AA Pago 2 of9
C. Review Proces•
1. The individual reviewing the issue(s) on appeal will meet the following criteria:
(a) Is not an individual who made or consulted In the initial detenninalion,
(b) Is not a subordinate of an individual involved in the initial determination.
2. If the initlal determination is upheld, you have the option to seek External Review or one of
the other dispute resolution processes set forth in the Agreement. A description of the
External Review option will be supplied, Including the time limit for requesting External
Review. The time limit for requesting External Review is ninety (90) calendar days after the
written Internal Review determination.
3. Company will communicate a written decision on an Internal Review of an Adverse
Determination Appeal within thirty (30) calendar days of our receipt of all documentation
reasonably needed to make the determination. A description of the External Review option
will be supplied wfth the written decision, including the time limit for requesting Ex1ernal
Review.
D. Adverse Determinations Not Ellgibte for Adverse Determination Appeals
The following will not be considered to be eligible appeals:
1. Except for BIiiing Disputes, appeals made by non contracting providers. Appeals by non
contracting providers may be eligible for the member appeal process .
2. Appeals of post service claims where the member or Provider sought a pre-service appeal of
the same claim.
3. Appeal of a post service claim where the member has appealed the same claim.
4 . The member has filed suit under Section 502 of ERISA or other suit for denial of the health
care services or supplies regarding an Adverse Determination .
E. Qualified Reviewer
For an Internal Review pertaining to an Adverse Determination Appeal (not to include Billing
Disputes), only a medical or dental practitioner holding an active. unrestricted license, who
possesses the appropriate level of training and/or expertise required to evaluate the necessity of
the service under review, and who is other than the one that made the initial Adverse
Determina1ion, may deny the appeal of the Provider who treated the condition. A nurse or other
health care professional employed by Company may review the Adverse Determination Appeal
and may grant but not deny it. If the nurse or other health care professional does not grant the
appeal, then a Qualified Reviewer, designated by Company, other than the one that made the
initial Adverse Determination, shall review and decide the Adverse Determination Appeal in
accordance with our medical and reimbursement guidelines.
Provider External Review Process
If the initial determination is upheld through the Internal Review process, the option to seek External
Review of the determination will be made available.
A. Prerequisites for External Review
1. The Internal Review process must be exhausted before requesting an External Review of the
determJnaUon unless both Companv and the Provider agree in writing to forego the Internal
Review process and proceed directly to External Review.
2. A Provider who chooses Extemal Review will submit a written notice to Company within
ninety (90) calendar days from the date of the Internal Review Determination.
Asuris Slandard MGA Exhibll D Ol1pute Resolullan Proceu A18818864AA Pag• 3 of9
I. e. Extamal Review Provlalon11:
1. An Adverse Determination Appeal may be submitted for External Review when the amount In
dispute exceeds S500 unless the Provider notifies the Company tha,t the Provider intends to
submit 11ddltional Adverse Determlnatlon Appeals for External Review on the same or slmllar
Iss ues during tl'le on~year period ro!lowlhg the submission or the orig inal Adllerse
Determination Appeal and the cumulatrve amount In dispute over the one.year per iod
exceeds $50.0. The request fo r External Review Is at the oplion of the Provlder 1 who may
Instead choose any other dl spute reaolu tlon a'lloWed by the Agreement . If Clho~en , the
Exterrnil Revlew st,aU be bind ing ;
2. The Adverse Determination Appeal mu.st be &u~mltted to Comp_any in writing. The
AdmlnfstraUve Manual and ·u:-e Appeal Form for Provider BIiiing Dispute and Madlca/
Neces.sily Denial provides detailed contact info rma ti on .
3. Company will forward Adverse Determ inat ion Appeals that meet the prerequisites as listed in
sec tion A above lo a designated External Review Organization .
4. The Provtde r shall pay a fl1 ng fee of$50.00 ior each Adverse Oeterrnlnatlon Appeal.
(a) The Company shall notil'y the Prov id11r the filing ree ls due
(b) Payment must be e.ubmltted before the External Review begins; provided, howevor,
that the Provider sha ll be entitled to .a refund of such payment in the event that lhe
Provid.er prevails In the External Rev iew process .
(c) Provider shall subml the filing fee within sixty (6-0) calend~r days of notice from the
Company that flllng fee Is due or the External Review request will be closed .
5. Upon recelpt of a timely flllng fee, Company wiU provide to the External Review Organization
the Appeal Record.
6. The Eirternal Review Organl2alion wm process the Aciverse Determ ination .Appeal and notify
the ProVider and Company of Its reoommendat on with in thirty (30) calendar days of rece ip t of
the filing fee . The decieton wilt be bindb,g on Company and the Provi der.
7. In the event ll,at the External Review declalon requires payment by ·Company, such payment
shall be Initialed within nfleen (15) calendar days after we receive noUce or the determlnallon .
Extamal Audit and lnveatlgatlon Appeal Procesa
The External Audit and Investigation Appeal Procell& is Intended to give you an opport\ln fty to requetl
recons ideration of audit findings lswed by our External Audit and lnve_sllgation Department ood lo ensure
we have reviewed all inforrr,a llo n relevant to the audit findings. Please note that contract terminations
resulting from audit findings must follow the Provider Contract Termination Appeal ProceSB.
II. A. Racon1ldaratlon Requaat
Upon rece Jp t of our audit findings, you have forty-flva (45) business days to review and dispute \hese
find ings before the audit becomes final. In order lo appeal the find ings, you must submit a written reque111
for a reconsideration of audit findings. You will be glllen the address for where to send your
reconsideration request with your audit findings.
Asurla Standard MGA ExhlM D Dlapute ReaoluUan Process A1881665<1AA Page • a/9
The request must be received by Company within forty-five (45) business day• of your receipt of the
audit findings and must include, at a minimum, the following:
•
•
•
A detailed statement of the issue(s) In dispute
At the election of the Provider, notification of a request for a meeting with the panel re11iewing the
i&&ue(s) in dispute
Any documents which the Pro11ider contends supports hia/her position
(Exception : Please note that all documentation required to Justify your billing, including but not
limited to chart notes, must be present in your files at the time of an audit. Additions to file
documentation and/or the production of flies that were not made available to us at the time of an
audit wlU not be considered in connection with an appeal involving adverse audit findings. We will ,
however , consider your explanation as to why the documentation was not present at the time of
the audit.)
If we do not receive such a reconsideration request within forty-five (45) business days of your receipt of
the audit findings, the findings will be final.
The request ror reconsideration will be re11iewed by the manager of our External Audit and Investigation
Department, ln11e1tigators within that department, and other Company representatives, as determined by
the manager of the department (hereinafter referred lo as the 'Panel"). At the discretion of the Panel, a
Company Medical Director may be consulted prior to the final decision.
A meeting, prior to the Panel's review of your reque•t for reconsideration, can be arranged either at your
office or a Company office, as mutually convenient. You must request this meeting when submitting your
request for reconsideration.
At the meeting, you may appear in person and may be accompanied by an attorney or other
representali11e. You and your representative may make an oral statement to the Panel and respond to
questions from the Panel. The purpose of 1h19 meeting is to gh1e you an opportunity to present your
position to the Panel in person.
If the Panel needs additional documentation to reach a decision, the additional documentation must be
submitted within twenty (20) calendar days of the date of the Panel's written request for information,
unless your written request for a reasonable extension of lime is granted.
• If the requested documentation Is received on time, it will be included in the request for
reconsideration.
• If the documentation is not received on time, the request for reconsideration will continue and a
decision wlll be made based on the information originally submitted .
You will be sent written notice of the decision within forty-five (45) business days following the meeting
with the Panel or, If no such meeting was requested, within forty-five (45) business days of our receipt
of the audit reconsideration request, not induding the time waiting for additional information from you.
During the period of time in which we are waiting for additional information, the appeal decision time
frame is suspended until the information is received or the time to respond to the request hes expired.
The decision on an audit reconslderallon request is deemed final forty-five (451 buslnus days
after your receipt of the Panel's decision, unless a tlmaly written request for a Medical Director
Review la nH:elved,
Ill. a. Medical Director Review
If you are not satisfied wrth the decision made following the reconsideration request to the Panel, you may
request a Medical Director Review of the audit findings. The written request for a Medical Director Review
and any supporting Information must be received by Company within forty-five (45) business days of
your receipt of the ?anel's decl&ion. The address where to send your request wlll be Included in our
response to your request for reconsideration .
The Medical Director Review will be held no more than forty-five (45) business days following receipt of
the request, not Including the Ume in which the Company is waiting far additional information from you.
The review will be conducted by a Medical Director who was not Involved in an earlier review of the audit
findings.
Aauns Standard MGA Exhibit O Dispute Resolution Procen A18ll16854AA Page~ ol9
If the Medical Director needs additional documentation to reach a decision, the additional documentation
must be submitted within twenty (20) calender days of the date of the Medical Director's written request
for lnfor1TU1Uon , unlees your written request ror a reasonable extension of time is granted.
• If the requested documentation is received on time. it will be included in the Medical Director
Review.
• If the documentation Is not received on time, the Medical Director Review will conUnue and a
decision will be made based on the information originally submitted.
During the period of time In which the Company Is waiting for additional information, the forty-five (45)
business day clock to complete the Medical Director Review is suspended until the information is received
or the time to respond to the request has e11pired .
You will be sent written notice of the decision within forty.five (45) business days following the Medical
Director Review_
The Medical Director Revle-w ls the fins.I stop In the External Audll and lnvesti911tt on Appeal
Proc&1.a , once a decision hos been made by th o Modlcal Director, the Externa l Audlt and
Investigation Appeal Process ha& boon completed and tho declalon shall be deemed nnel. If you
are not satisfied with the Company's decision ofter completing fhe External Audit and
Investigation Appeal Process and want lo oonUnue to dispute the issue(s), you must initiate the
appropriate process(es) as outlined in your Provider contract.
Provider Contract Termination Appeals
A contracll!d provider may Initiate an appea l of a contract termination decision made by Company
through the Provider Contract Termination Appeal Process.
IV. A. Level One Appeal
To request a level One Appeal, you mus_! send a written reque-91 to the Company's Cred erttlall ng
Department, at the address listed below wi thin thirty (30) buslf\HS days of receipt of the termination
no)lfiClll[on .
Provider Contract Termination Appeal • Level One
Attention: Crwdentlallng Department
P.O. Box 21287, MIS S-555
Seattle, WA 98111-3267
A request for an appeal regarding a contract terminalion must include, at a minimum :
• •
•
•
A detailed description of the disputed issue(s)
The basis for your disagreement with the deci9lon
All evidence and documentation supporting yaur posrtlon
(ExceptJon : Please note that ail documentation raqulred to jus~ry your billlng, including, but not
limited to. chart notes, lo be present In your files al the lime or an audit. Addillons to file
documenlatlon or the produeUon or flies that were not made available to Company at the time of
an audJI will not be considered in connection with an appeal lnvotvlng adverse audit fi ndings. We
will, however, consider your explanation as to why the documentation was not prese nt at the time
or lhe audll )
Your requested outcome
Upon receipt of the Level One Appeal request, we will send you an acknowledgement letter within fifteen
(15) business d&J$,
The Le.vel One Appeal Papel Is comprls:ed or at least three (3) indll/fduals that have not been d irectly
lnvolv!!d in the Credentialing CommiJle;e or ler:rnin ellon decision and have the appropriate level of
knowledge and traln ln,g to understand the Issues presented. At least one panel member must be a
Participating Provider.
Aauria Standard MGA EIChlbit O Dispute Resolutio~ Proce11 A1881685<1AA Page6 ofg
Level One Appeals meetings are held on a bl-monthly basis . Your appeal will be scheduled for review al
the ne>tt avallable Level One Ap peal Panel m ee Ung, subject to the lime that your appeal request and any
add ll lonal Information la receiv ed and the volume of appeals being reviewed by the panel.
If add itional information is requested , it must be submitted wHhin fifteen (151 business days of the date
of the written request for information, unless a written request for a reasonable extension of time ls
granted .
• If the information is not received on time, a decision will be made at the next Level One Appeal
Panel meeting, based on the limited Information available.
• If the additianal information is received on time, the new Information will be taken Into
consideration at the next Level One Appeal Panel meeting .
Information not submitted within the time limit will not be considered for the Level One Appeal, unless
otherwise allowed by the Level One Appeal Panel.
You will receive a written determination within ten (10) businaas days of the Level One Appeal Panel
decision .
The Level One Appeal decision ts deemed final on the thirtieth (30111 ) business day after you
receive It, unless a written request for a Leval Two Appeal Is received timely.
B. Level Two Appeal -"In-Person Hearing"
If you are not satisfied With the results of the Level One Appeal, you may submit a written request to the
Credentialing Department , at the address listed below, for a Level Two Appeal, 'in-person hearing ' no
later than thirty (301 business days after your receipt of the Level One Appeal decision .
Provider Contract Termination Appeal • Level Two
Attention: Credentialing Department
P.O. BoK 21287, M/8 S-555
Seattle, WA 98111-3287
The Level Two Appeal Panel is comprised of at least three (3) individuals that have not been directly
involved in the Level One Appeal, the Credentialing Committee, or the termination decision and have the
appropriate level of knowledge and training to undersland the issues pre:,ented . At least one panel
member must be a Participating Provider.
The request for a Level Two Appeal must Identify In detail the following:
•
• .
.
All issues on which you request re-evaluation
At election of the Provider, notification that more than two (2) hours is needed for the hearing
Information not previously submitted to the Level One Appeal panel, if any
(Exception : We expect all documantation required to justify your bllllng, Including, but not limited
to, chart notes, to be present in your flies at the time of an audit Additions to file documentation
or the production of Illes that were not made a11ailable to Company at the Ume of an audit will not
be considered in connection wltt, an appeal involving adverse audit findings. We wlll, hoW9ver,
consider your explanation as to why the documentation was not present at the time of the audit)
Your requested outcome
The hearing is generally completed within two (2) hours and will be scheduled for two (2) hours, unless
you notify us when requesting your Level Two Appeal that additional time is needed. We will make our
best efforts lo accommodate reasonable requests for addillonal time, as long as we are notified when you
request the Level Two Appeal.
Upon receipt of the Level Two Appeal request, we will send you an ackno_wledgement letter within fifteen
(15t business days.
Aaurls Standard MGA Exhibit D Dlspule ResoluUon Process A18.!118854AA Paga 7 of9
Level Two Appeals meetings are scheduled upon request. We will make our best efforts to provide
proposed tJmes and dales within sixty (60) business days of the Company's receipt of your Level Two
Appeal request. Once you have been provided the proposed times and dales you will have five (5)
business days to notify us of your preferred time and date for the Level Two Appeal hearing . If you rail to
notify us or your preferred Ume and dale for the Leve l, Two Appeal hearing with in five (5) business days of
receiving the proposed times and dates, the hearlng wlU be set on one of the proposed times and dates .
Prior to the Level Two Appeal hearing, you will receive a "Notice of Hearing." The "Notice of Hearing'
will Indicate Ille followin g:
• Date of the hearing
• Time or the hearing
• Location of the hearing
• Names of the members of the Level Two Appeal panel
• Reasons for the adverse action
• Names of witnesses who will testify on Company's behalr al the hearing
• Your rights at the hearing
At the hearing, you have the following rights:
• To have representation by an attomey or other person of your choice
• To have a court reporter make a record of the proceedings at an additional cost to you. Costs
associated with the court reporter must be paid by you prior to receiving a copy of the transcript
• To call witnesses and to examine/cross-examine witnesses
• To present relevant evidence (as determined by the panel)
• To submit a written statement at the close of the hearing
Approximately thirty (30) calendar days before tho scheduled dale of the hearing, a Level Two Appeal
binder will be sent to you or your representative _ The binder will include, among olher th ings, the
documentation reviewed by the Credenlla(lng Com mittee Initially and at the Level One Appeal. as well as
ariy documenr,Jlion submitted by yc,u , 1r you wtsh ,lo submit additfonaJ information to further supplement
the Level Two Appeal binder, this Informat ion , ae well as a list of wllllesses that you plan to call, examine,
and cross ex.imlne at the hearing , must be received no later than fourteen (14) calendar day& pri9r to
the hearing date. Unloas otherwise allowed by the level Two Appeal panel, doc~menlation and wllnruises
not submitted at least fourteen (14) calendar daye prior lo the hearing date will not be considered by lNe
Level Two Appeal panel and should not be brought lo the heating for ~h_e panel's eonslderation. The only
exception Is that you may submJt a written statement at the close of the hearing.
If lhe Le11el Two Appeal binder is later supplemented with new or revised Information prior to the heating,
you will receive copies of the new or revised material as soon as practicable before the scheduled date of
lhe hearing. After the Level Two Appeal bi nder has been finalized, it will be forwarded to lhe Level TWO
Appeal panel foF rev iew prior lo the hearlng. Neither you nor Company may supplement the l>lnder within
thirteen (13) catendar days prior lo (He hearing, unless a written request for an excepUon is approved b.y
lhe Chalr of lhe Level Two Appeal panel.
You will receive written notification of the Level Two Appeal decision within fifteen 115) business days of
the hearing If the Level Two Appeal panel cannot reach a decision within fifteen f15) buslnasa days, or
If additional informatl on Is needed to reach a decision, you will be informed of any additional informaUon
needed and a new date by which the decision will be made.
Decisions of tJha Level Two Appeal panel related to contract terminatione are deemed final. Once a
decialon has been made by the Level Two Appeal panel, you have completed the Provider
Contract Tennlnation Appeals process. If you are not aatlsflod with our decision after completlng
the Provider Cont, ct Termination Appeal procmu1 and want to continue t.o dispute the issue(s),
you must lnl6at, the appropriate proces (e11i as ouUlned In your Provider con1racl
A,url& Standard MGA Exhibit O Dispute Resotu11on Process A18816864AA Pa11e 8 ofQ
C. Addltlonal Information Regarding the Provider Contract Tennination Appeals Procesa
a. Provider Status During a Contract Termination Appeal
You will continue as a Partlelpaling Provider, however you will be temporarily removed from an
provider directories and any pending action by Company is put in abeyance until the appeal is
resolved and a final decision is made. If, however, the basis for the termination decision relates to
the health, safely or welfare of our members , or If the we have exercised our right to Immediately
terminate the Provider contract for reasons allowed by the Provider contract, your participation
status will be terminated for the duration of the appeal process and reinstated only If you prevail
during Iha Provider Contract Termination Appeal process.
b. The Data Bank Reportable Actlona
Company is required by law to report certain adverse actions or decisions against you to the
National Practitioner Data Bank (Data Bank). If our termination decision stands, either by virtue
of you choosing not to appeal or if the decision Is upheld by the appeals panel, we may be
obligated to report this termination to the Data Bank, as applicable. You may not "self-term" to
avoid being reported lo the Data Bank_ Additional Information on these reporting requirements is
available on the Data Bank website, at www.npdb.hrsa.gov.
AaurlI Standard MGA Exhibit D Dlspul11 Resolution Process A18811185~AA Paga II ore
ASURIS NORTHWEST HEAL TH
PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT
PREFERRED PLAN PROVIDER NETWORK ADDENDUM
EFFECTIVE DATE:
r nis Addendum lo the Paftlcfpating Provider Med/cal Group Agreement, herein referred to as the
"Medical Group Agreement", amends the Med ical Group Agreement between Asur is Nor1hwest
Health (the "Company ") and KITTITAS COUNTY HEALTH DEPT ("Medical Group"), to recognize
additional provisions Which apply to the Preferred Plan Provider Network . and to provide ror the
recognnfon of health care services, and for payment ot benefits for health care services , provided
to Prererred Members . Except as specifically amended he rein , all terms and condit Qns of the
Medical Group Agreement remain in effect.
I. DEFINITIONS
A. 'Preferred Member" Is any subscriber or enrolled dependent entitled to benefits under a
Preferred Plan offered or administered by the Company or Payor, or any sub,crlber or
enrolled de pendent entitled to benefits under a Subs.crlber Agreemanl offered or
adml li stereo by the Company or Payor that provides lncen Uves for Members to seek
seTVices from Prefer red Plan Providers and Participating Providers in the Company's
Partici pating Provider Network.
B. "Preferred Plan" la any Subscriber Agreement that provides a benefit incentive for
subscribers or enrolled dependents lo seek health care services from Preferred Plan
Providers .
C. Preferred Plan Provider" is a Participating Provider in the Company's Preferred Plan
Provi der Network.
D. 'Preferred Plan Provider Network' is lhe collecllve group oT hosp itals , facilities, cllrrfcs .
physicians and olher t\ealth -care profeaslonals under contract with the Company through
a Preferred Plan Prov der Network Addendum .
II. PROVISIONS
A. Medloal Gmup agrees to be a Preferred Plan Provider, part icipate in the Preferred Plan
Provider Network and provide health oare services to Pref!lrred Members.
B. The Company shall acti vely market Preferred Plana that provide lncentiv«iis for Preferred
Membe.rs to se,ek services from Preferred Plan Prov ders with the Company's Preferred
Plan Provider Network .
C. The Company shall 11lso aoUvely market a Subscriber Agreement that provides lru;ent111e.s
for Members to seek services rrom Preferred Plan Providers and Particl pe Ung Providers
in the Company's Par11cfpating Provide~ Network . If Medical Group provides services for
Member s w1'0 are covered l\nder sucn a subscriber Agreement, the rates and terms
asaoclaled with the Preferred Pl.an Prov ider Network , as well as the oost snaring amounts
and terms in the Subscriber Agreerrient assoc iated with the Preferred Plan Prollfder
Network, shall be used to determine the reimbursement amount for Medical Group.
Aaurls Medical Standard MGA Prvlerred Plan Addendum A18816854AA Paga 1 of'Z
D. Medical Group agrees to maintain Participating Provider status in the Company'$
Participating Provider Network.
E. Medical Group agrees to comply with the terms and conditions for Preferred Plan
Providers set forth In the Adm inistrative Manual, which can be found on the Company 's
website at http ://www.asuris.com/providernibrarylmanual/index. html.
F. If a Medical Group Provider has admitting privileges, the Medical Group Provider shall
maintain admitting privileges In at least one hospital within the Preferred Plan Provider
Network .
G, Medical Group shall admit or arrange for hospital admissions and referral serv ices of
Preferred Members only to Preferred Plan Providers, unless the Preferred Member is
covered under a Subscriber Agreement that provides incentives for Preferred Members
to seek services from Preferred Plan Providers and Participating Providers in the
Company's Participating Provider Network and the Preferred Member is being admllted
or referred to a Participating Provider in the Company's Participating Provider Network;
the Preferred Member's condition makes II impossible; the service is not available
through the Preferred Plan Provider Network ; or the Preferred Member chooses care
outside the Preferred Plan Provider Network. Medical Group should advise the Preferred
Member whenever health care services are to be obtained outside of the Preferred Plan
Provider Network that the Preferred Member may be subject to additional out-of-pocket
expense. Any questions regarding network participation and benefit levels should be
directed to the Company.
H Medical Group agrees to a~ept the Preferred payment set forth on the payment exhibit
as payment in full for covered services rendered to Preferred Members.
I. This Addendum shall continue in effect, unless terminated according to the proce&& set forth
in the Medical Group Agreement . Either party may terminate this Addendum w ithout
terminating the remainder of the Medical Group Agreement However, in the evenl either
party temiinates the Medical Group Agreement, this Addendum terminates as well.
The terms of this Addendum shall become a part of, and shall be specificaHy incorporated Into . the
terms of the Medical Group Agreement. In the event of any conflict or inconsistency between the
terms of this Addendum and the terms of the Medical Group Agreement, the terms or this Addendum
shaH prevail.
.C OUNTY HEAL TH DEPT
ytce President. Network Mana9.!!!lent __ _
Title
l~I---Signature /
Il'l tl lJt Y1-~-, -· --
Print Name
) n ±ev1 m AA mi r11 tmtw
Title
_\~LL~-\-r.~---
oate
_\ \ q l
Da te
Aauris Medical Standard MGA Preferred Plan AddandUtn A18816864AA Page 2 of 2
Aaurlu Northweat Health
Medicare Provider Compllance Addendum
This ,fs ·a Medica re Provtder Compliance Addend~ITJ Uhe 'Compliance Aodendum') to the Participating
Agreements and any and all amendments, addenda, aUachments or exhibits thereto (coUectively , the
'Agreem11nt8" and each lndlvidually, the "Agreement'), between ~uris NorthWe!II Health ('Asuris") and (the
"Prov ider" or 'FDR" as lhose terms are depned beloW), effec:tive th is First day ot October, 2016.
WHEREAS, Asuris has contracts to administer Medicare Advantage Plans and/or Medicare Part D plans
(collectively "Medicare') for the Centers for Medicare & Medicaid Services ('CMS') of the U.S. Department of
Health and Human Services ("HHS') to administer Medicare benefits within certain counties;
WHEREAS , the first lier, downstream or related entity ("FOR") has entered into an Agreement to provide
heaflhcare and or administrative services relatei;t to Asurts'& Medfcare business; and
WHEREAS, CMS requires Asurls to incorporate additional Medicare Compliance contrad language into its
agreements with first tier, downstream, and related entities.
NOW, THEREFORE, in consideration, and with full understanding that these provisions may be outlined in
the main Agreement or addendum, the parties agree and will abide by the Compliance Addendum, as follows:
1. Compliance w u, Mecfica(!]J,.a ~s~.Bs9J,!.!.rul..~..s!lli!...Q.M§..§!!!if.M2!!: FDR agrees to comply with all
applicable Medicare laws, regulations, and CMS guidance. 42 C.F.R §§422.5040)(4}(v) and
423.S0S(i)(4)(iv).
2. Mm!i~J'.~~ndards !lllirul.Y.<J.Lll!!d Policies and Prqcedur~!.!; FOR agrees to meke available
Standards of Conduct and policies and procedures to all of its employees who provide admlnlstralive
services or heahh care services fQr Asuris's Medicare business pursuant to this Agreement at the
lime of hire and annuaHy thereafter. FDR may either provide (a) Asuris's standards of Conduct and
policies and procedures to FDR's employees, or (b) FDR's own comparable Standards of Conduct
and policies and procedures to FDR 's emp loyees. Medicare Managed Care Manual ('MMC Manual"),
Chapter 21, §§ 50.1.3 and 50.3.1; and Medicare Presaiption Drug Benefit Manual ('PDB Manual"),
Chapter 9, §§ 50.1.3 and 50.3.1.
3. Conlljct of lnteres1: POR agrees to comply with Aaurls!s Conflict of Interest Poli<.-y or its own Connie!
of tn1erest Policy that complies with CMS requirements . FOR will requltu_ 11!1 governing body, officera,
and senior leadership (as applicable) to sign a connlcl of interest at the t me of hire and annually
thereafter certifying lhal they are free from an1 conmct of interellt related to Medicare. 42 C.F.R. §§
422 .503(b)(4)(vl)(A) and 423.504(b)(4)(Vl)(A).
4. r ~ and CFWA•l and General ~,:ig: FOR agrees that all of its
e1r1ptoyees who provide actmlntS1taUve services or health care seNlces for Asurls's Medicare
bualne89 pursuant to the Agreement participate In Meclicar11 Parts ,C end D FWMreining and
Medicare Parts C and D General Compliance training with in ninety (90) days or hire and annually
thereafter. Required FWA and General Compliance training Is developed and provided by CMS and
Is available through the CMS Medicare Learning Network (MLN) at
hit :/NNJW. !llJ.,99v/MLNProd1Jcl.§. FDRs who have met the FWA certification requirements through
enrollment into the Medicare program or acc:redltatlon as a Durable Medical Equipment, Prosthetics,
Orthottcs, and Supplies (DMEPOS) are deemed lo have met the training and educational
requirements for fraud, waste . and abuse only . FDR must main fain documentation sufficient to
demonstrate to AsUrts that FDR fulfilled the FWA end General Compliance training requirement.
MMC Ma,iual, Chapter 21, § 50,3.2; PDB Manual , Chapter 9, § 50.3.2; 42 C .F.R. §§
422.503(b)(4)(vi)(A) & (C) and 422.504(b)(4)(\tl)'(A) & {F).
5. RAAQL\inQ.l&mrulance and FWA Conce rns: FDR agrees to report compliance or FWA concerns lo
CMS or Asuils. Reporting shouJd occur within five (5) days of discovery ; If there Is an lmmedfate
Impact to beneficiary access to care and/or a financlal strain , please report lmmedi.ately but al least
wllhin twe,,ty-four (24) hours. Asurls has-a no-tolerance policy ror ~tallaUon or retribution against any
employee or FDR for g(!Od-fa ilh reporting of FWA. 42 C.F.R. §§ 4-22 .503(b)(4)(vt)(O) -and
423.504(b)(4)(vl)(O),
AsurJa MA CompHance Addendum 1012015 A18816864AA Page 1 or 3
6. IDl!2t~n:Le,U_g_LQ!i~lRlilliID._filanc;Lal31!: FDR agrees to establish and publish its own disciplinary
alandards , wh ch include its e,cpectation that employees report compliance issues and uneth ical or
Illegal behavior. FDR's disciplinary standards must state that any violation of these standards will
result in appropria te dlsc!i:illnary aclion, 1,1p to and ll'clvdlng term in ation of employmi\tnt. FDR's
violation of th s proviislon may result In As.uris's termination of the Agreement . 42 C.F .R. §§
422-503(b)(4)(vi)(E) and 423.504(b)(4)(\/i)(E).
7 9IG E!!P.!Ja!Q.IJ-/ G A Oebann~nl'. Pursuant to Federal law, FDR certifies that nellher it nor any of its
ernployees or govern ing body members are on: (11) the List of exclU<led Individ ual~ and Enlilles
("LEIE") from lhe I !HS Office of Inspector General ("OIG")i and {b) lhe General Services
Administration ("GS A') Debarment Li si . If an employee or governing bo.dy membe r is on either fist,
FOR wm Immedia tely remove tl\at person from any work rela~d directly-ot l ndl recUy to any Federal
hea lthcare program . FDR agrees-lo clieek oo.tll lists pr 9r to hire and on a monthly basis to ensu re
that none of (ts employees have become excluded from participation in Fede ral programs. The term
"employ.ees ' includes temporary employees , volunteers , and consultants . If applicable. FD R will
eslabllsh a process to ldenUfy and _prevent payment ro~ clalrn.s al po l nt-of-5ale fo~ any drugi; o.r
.sei'vicl:!S i:)tescrlbed , dispensed or delivered by excluded providers. 42 C.F.R. §§ 422 .503(b)(4){vf)(F),
422.752(a}(B), 423.504(b)(4)(vi)(F), 423 .752(a)(6); and 42 C.F.R. § 1001.1901.
8. Record Retenjlol'land Audjl]lighls : FDR agrees to retain any books, contracts, records, and
documents related to Asuris's wntract with CMS ror a period of ten (10) years from the final date of
the contract period or the ~ompletion of any audit, whichever Is later. FDR a.9rees io comply with any
document requests by Asuri& pursuant to an aud it or to monitor FDR's compllance with the terms of
this Agreement or Compliance Addendum. FDR will provide these documents to Asuris without
charge. 42 C.F .R. §§ 422.504(d), 422.504(e), 422.504(i)(4)(iii), 423.504(d)(2), 423.505(I)(4)(iii).
9. !:!l:!.S--1ll!QIL~!l\ll: FDR agrees to allow HHS, the Comptroller General, or their designees to audit
and Inspect any books, contracts, computer or other electronic systems, including medical records
and documentation. related to Asuris's contract with CMS. This right to audit and inspect any
pertinent information for any particular contract period will exist through ten (1 O) years, from the final
date of the contract period or from the date of completion or any audit, whictiever is later. 42 C.F .R §§
422.504(1)(2) and 423.505(i)(2). FDR's failure to comply with this section could result in referral to law
enforcement and/or implementation of corrective action . 42 C.F.R. Subpart 0.
10. Enroll _Pr9tectio1J..~: FDR agrees that it will not hold any of Asuris's Medicare enrollees liable for the
payment of any fees that are the legal obligation of Asuris. Asurls agrees to Indemnify its Medicare
e~lees for the pay.men I of any fee.8 that are the legal obligation of Asuris for serv ices furnished by
provldem who do not contract, or who have not entered Into an agreement with Asuris , to provide
services to Asuris's members. For Asuris's Medicare enrollees that are hospitalized as or the
termination date of AsurJs's agreement wllh CMS, FOR will continue to provide covered services
through such enrollee's date of discharge. 42 C.F.R §§ 422 .504(g), 422 .504{i}(3)(i), and 423.505(g).
11 . ~q]!_l)g: Aaurts will either (a) review the credentials of medical professionals affiliated with FDR ;
or (b) review and approve a credenllallng process, which Asuris may audit on an ongoing basis. 42
C.F.R § 422.504(I)(4)(iv).
12. 8~yntabill)Y_Prci11Ision : Asuris agrees that ii may only delegate functions to FDRs in a manner
consistent with 42 C.F .R §§ 422.504(i)(3)(ii), 422.504(1)(4), 423.505(i)(3)(ii), and 423.505(1)(4).
13. M2nl!QrJn ,and Ierminatron: Asurls wiU monitor FDR's performance under the Agreement on an
ongoing basis , Asuris has the option to terminate the Agreement with FDR if CMS or Asuris
determines that FDR has (a) not performed satisfactorily under the terms of the Agreement or
Compliance Addendum, (b) failed to maintain compliance, or (c) engaged In FWA. 42 C.F.R §§
422.504(~(4)(il), 423.505(i)(4)(il), and 423.505 (I)(4 )(iii).
14. fl ow,Down Pr~y~or.i: FDR shall Incorporate the terms of this Compliance Addendum into any and all
subcontracts eritered Into delegating any of FDR's obligations to Asuris under the Agreement or
compliance Addendum. 42 C.F.R §§ 422.504 (1)(3),422.504 (i)(4)(v) 423.505 (I)(3)(iii), and
423.505(1)(4).
15. ~tlfu1~oJl~r of ~: FOR shall comply with the applicable confidentiality and
enrollee accuracy requirements, including: (a) all applicable Federal and State Jaws regarding
Aaurfs MA Compliance Addendum 10/2016 A18818864M Page 2 of3
conllde nffalily and disclosure of medical records, including disclosures pursuant to court orders and
subpoenas ; and (bl timely access by enrollee,s to the ir records arid information , 42 C.F.R, §§ 422 .1 18
and 422 ,604(a)(13).
18, D~I~~; It FDR Isa health care provider, FDR agrees lhat all emrolleei. eligible forbolli
Medicare and Medicaid will not be held Hable for Medicare Part A and B cost sharing ,When the State
I responsib le lor payln,g !iU¢h amount$. As a provider , FOR wlll ba Informed of Medicare and
Medicaid benefits and rules for enrollees elig ib le for Medlcare and Med icaid. ahd may not. impose
cos-t-sharlng that exceeds the amount lhat would be permitted for an ,-idl11ldual 1,1nder Medicaid If the
Ind ividual were not enrolled In such a plan. Provider will (a) accept Asur l s's payment as payment n
ru11, or {b) bill Che 11ppropriate Stale source . 42 C,F,R . §§ 422 .504(9)(1 )(111) and 422 ,604(1)(3)(1).
17 , A sy ris's can rao ~JJml!aolio,m;; FDR's -services and aclMlles pursuant to fhe Agreement are
cons istent and comply with Asuris's COi'ltrac:tval obl igations. 42 C.F ,R. § 422.504Q)(3)(Tii),
18 . Prompt wmeJ!t II FDR Is a health care provider , Asuris's contract or written agreement with FDR
will Include a.prompt payment prov l&i!ln , 42 C,F .R. §§ 422,504(c), 422.520, 422,S20(b),
423.506(i)(3)(1,), and 423 .520 . ·
19. !1ti1~g~tlrui: If Asuris delegates to anothe, organization the selecl!on of providers, con tractors . cir
subcontractors , Asu ris retains the ri ght to approve , suspend , or terminate any such arrangement 42
C.F .R. § 422.504(1)(5,).
20 , fillJ§MIJ) nts re_cu !J,w.d ~ If Medicare laws, regulat lon:t, or CN'(S au ldJ1nce requ re ._a change to
any prov ision of this Complla11ce Addendum, th is Compllan.ce Addendum wlll be deemed amended to
conform with the law, r~ulaUon, or gu idance on the date !la id re q1,uramenls become effective . Asur ls
,viii make reasonable bus iness efforts lo notlry FDR ol thos.e changes, tlul tn no event does any lack
of notice cl'lange the eppliC11b Illy of rederal law, ·
21 ~f Se ce : FDR agrees that It shall not perform runctrons offshore. o delegate functions to
offshore entities O!' pe sons , ,wlthoul obtaining advanced appf()ll!ll ln vnilfng from Asu rfs and
demonstrating compliance '#Ith CMS guldeHnes and Asuris policies, terms -, and conditions ,
22 . Nru:!:Qi.§crimination : FDR agrees 1.0 PfOV de cove l ~d services to mem~rs without regard lo race,
ethnicity . nat ional orig in, religion , gender, age, mental or ptJys fcal disability , sexual orientation,
.,genetic inforrnallon or source of payments . M¥C Manual , Chapter 4, § 10.5.
Any term not defined herein shall have ·the mean ing aetforth in the Agreemenl The terms of this Compllance
Ac(dendum shall become a part of. and shall be spec iflcafly ncorporated ltito. lhe terms oflhe Agreement. In
the event of any conflict or fnconsi&t~ncy betwee r, the terms of tM Compliance Addendum end the term&-of
the '°!greemeht or any Medicare Adva,-itage Addendum(s), the terms of the most current Compliance
Addendum shall apply .
IN WITNESS WHEREOF, the parties hereto enler into this Compliance Addendum effecUve on the Effective
Dale set forth above,
Asurla Northwest Health
Sincerely,
John Partin
VP, Network Management
Aaurls MA CompHmnce Addendum 1012018 A18818854AA Pa~e 3 of3
ASURIS NORTHWEST HEALTH
2013 MEDICARE ADVANTAGE AMENDMENT
EFFECTIVE DATE: December 31, 9999
This 2013 Medicare Advantage Amendment (IM "Amendment') amends the following agreements
(collee!lvely, the "Agreements· and each in dividuylfy, the *Agreement'") and any and all amendments,
addenda, attachments or exhibits to those Agreements, between Asurls Northwest Health ("Company")
and Provider, as that term is defined below :
1. Participating Provider Agreement
2. Participating Provider Medical Group Agreement
3. Participating Faclllty Agreement
4 . Participating Hospital Agreement
5 . Participating Organizational Provider (Home Medical Equipment) Agreement
6 . Participating Organizallonal Provider (Laboratory) Agreement
RECITALS
A. The Provider and Company are parties to one or more of the Agreements .
B. The Company desires to amend the Agreements to address changes in Provider compensation
payable under the Medicare Advantage program to account for (i) the federal sequestration
announced for 2013, and Oi) other Mure unplanned, unforeseen, or unusual events.
C. Therefore, in consideration of those premises and other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, the parties agree to the terms and
conditions set forth in this Amendment
AGREEMENT
1. Definitions. For purposes of this Amendment, the following terms will have the following stated
meanings. Any term not defined in this Amendment will have the meaning given to the term in
the Agreement.
'Advanc e ·Monlhly CMS Payments' means the advance monthly payments that are made by
CMS to Company, in Company 's capac ity as a Medicare Advanlage organlzaUor,, in ratu m for
providing Covered Services to MA Members during those months.
Advance Psyinent Adjustment· means the amount or 11ny reduct ion In the Aovance Mont.lily
CMS Payme·nts that are made by CMS lo Com pany , ex:pressed as a percentyge reduction from
the afTlo unt of the Advance Monthly OMS Payments that Company would ha ve other.vise
received lh tne absence. or th e reducllon , .ind that Is caused by or that results from any
unplanned , unforeseen, or unusual budgetary event that was not contemplated by Company , or
that was not contemplated by Provider, or 1hat was not contemplated by both Company and
Provide r, when Company Bnd Provider agree d upon the Medicare Advantage Compensation that
s otherwise applicable or payable to Provider un.der the Agreement . Unplanned, unforeseen, or
unusual events Include without llmltat on any state or federal budgetary sequestrations , any
changes In state or federal law or policy , any mid-year budget adJus1me111s , or any unaolfclpated
taxes or hies that cause a reduction in the Advance Monthly CMS Payments otherwise due to, or
expected to be received by, Company.
Aaurla Medlc9I Standard 2013 Medicare Advantao• Sequestration Amendment A1881S854AA Page1
"Madlcam Advantage Compon11aUon• means lhe compensa tion payable under the Agreement,
by Company to Provider in retum for providliig Covered Servicell to MA Members .
"Provider" means "Medical Group \ "Hospital", "Facility", or "Provider'' as those terms are used
and defined in the relevant Agreement where-they are used.
2. The Med i~~ire Advantage Compensatlon paid to Prov der for Covered Services received by MA
M.embers during a pal1lcu/ar month wm be reduced by lhe same percentage ~. ar by such ·rower
percentage as Company may detetmlne In Companv's sale dlscret lon , any Advance Payment
AdJUalment lmJIOse.d IJPon or levied against the Advance Monthly CMS Payments lhal are paid to
Company di.Iring that month . For example , ff a federal budgetary sequestration reduces the
Advance Monthly CMS Payments paid to Company by 2% during the months ol Ap ril and May of
a particular year. lhsn lt,e Medicare Advantage Compensation payable under the Agree ment to
Provider for any Covered Services reee lved by MA Mem.bers during Ap_rll and May of that year
will also be reduced by 2%, or by such other lower percentage tha t Company may determ ine In
company's sole discretion.
3. Other Provi1 ona, The prou lslon11 of the Agreement tt,at are not amended or deleted by this
Amendment rema l n unchanged ar,d in fuU fore& and effeot ,
Asurla Medical Standard 2013 Medicare Adllanta11e Sequaatralion Amendment A18B18854AA Pag112
OOPARTMl!NT OP HEAL TH It. HUMAN SERVICES
Centers for Medicare & Medicaid 5en,1c;es
7500 S@curity BoulQva,d, Mall Stop C4-23-D7
Balt imore, Maryland l12~4-l8S0
Date :
To:
From:
Subject:
June 17, 2015
All Medicare Advantage Organizations and Prescription Drug Plan Sponsors
Gerard Mulcahy, Director
Medicare Parts C and O Oversight and Enforcement Group
Update • Red ucing the Burden of the Compliance Program Training
Requ irement&
On May 23, 2014 the Centers for Medicare & Medicaid Services (CMS) published CMS-4159-F,
Medicare Program; Contract Year 2015 Policy and Technical Changes to th11 Medicare Advantage and
the Medicare Prescription Drug Benefit Programs. This memo provides guidance for how your
organization can satisfy the requirements related to ''Reducing the Burden of the Compliance Program
Training Requirements" for sponsors and first-tier, downstream and related entitles (FORs) that was
detailed In that final rule. See also (§§ 422 .503(b)(4)(vi)(C)(3) and 423.504(b)(4)(vi)(C)(4)).
Sponsors must provide general compliance and fraud, waste and abuse (FWA) training for all
employees of their organization and entities they partner/contract with to pro11ide tM!nefits or services.
Starting January 1, 2016 , to comply with training requirements sponsors must accept from FDRs
certificates of completion or CMS' training localed on the Medicare Leaming Network (MLN).
CMS developed web-based compllance trainlng to 11na11re the requirement is met and to reduce the
largely duplicative training required of FDRs by the multiple organizations with whom they contract . The
compliance and FWA training topics Include:
• Relevant laws and regulations related to Medicare Parts C and D FWA.
• An overview of compliance expectations, how to ask compliance questions, request
compHance clarification, hotllne reporting.
• Types of non-compliance and FWA that can occur In the settings in which sponsor and FDR
employees work .
• ProceHes for Sponsors and FOR employees to report suspected Medicare program non-
compliance and FWA to the sponsor.
• Case examples and resources.
CMS recognizes that many organizations use sophisticated training mechanisms and Invest substantial
resources to d11liver and track their employee's compliance with CMS requirements. In the final rule,
CMS stated that we would consider and determine If the CMS training module& could be available In a
fonnat for downloading Into organizations' existing training systems . To further minimize the
administrative burden on Sponsors and FDRs, CMS Is broadening the availability of the CMS
compliance program training .
A1uria Medicare Compliance CMS Memo 2015 A 18816854AA P111e 1 of 2
Sponsors Will have two (2) options for enSYrtng Ila FORa ~ncluding the FOR'e employees) hava setlsfled
the general compliance and FWA training requ lrt1ment that must be completed ea days after lnlllel
hire/contracting and annually thereafter as described In the regulations and sub-regulatory guidelines.
( t) FDRs 1ind Its employees can complete the general compliance and/or FWA training modules
located on the CMS Medicare Leaming Network (MLN). Once the Individual completes the
training, the system wlll generate a certificate of completlon. The MLN certl!lcate of completion
must be accepted by all Sponsors.
(2) FDRs may download, view or print the content of the CMS standardlZed training modules from
the CMS website to incorporate into their organization's existing compliance training
materials/systems. The CMS training content cannot be modified to ensure the integrity and
completenesa of the training. However, an organization can add to the CMS training to cover
topics specific lo their organlZallon. Training materials are available at the following path:
http ://www .cms .gov/Outreach-and-Education/Medicare-Learning-Network-
M LN/MLNProduclsl ProviderComp liance html
CMS will accept either the MLN aystem generated certificates of completion, or, an atte9tation confirming
that the organization has completed the appropriate compliance and FWA training. Attestations must
include language specifying the entity compiles wlth CMS compliance and FWA training requirements,
and, if choosing to implement option (2) the training provided includes CMS content without modification.
Further, sponsors and FDRs must maintain certlffcates· or documentation of training completion and will
furnish upon request a certificate of training such as certificates of completion, training logs, system
generated reports, spreadsheets etc . FDR11 providing training logs, reports, etc. must include at least
employee names, date11 of employment, datea or completion, passing acores (If captured) to clearly
document training completion.
Sponsors are required to validate that aN of the general compliance and FWA tralning requirements are
oompleled by their FDRs. In addltlon, Sponsors are accountable for maintaining records for a period or 10
years of the lime and must require lheJr FDRs to maintain training records of the FCRa' employees.
While use of lhe web-baaed training via the CMS MLN website Is opllonal for Sponsors employees , a
benefit of using lhe web-based training and education modules Is the ablttty to receive cohtlm,dng
education cred lta for oourse compleUon.
Addltional compUance Information Is avallable at:
htlps:t/www.cms.gov/Medlcare/Compliance•and•AudJts/Part-C-and-Part-D-Complience-and•
Audits/ComplianceProgramPolicyandGuidance.html
More guidance regarding tra ining and education requirements can be found In the Compliance Program
Guldef fnea located In lhe tntemet Only Manual (IOM) Pub. 100-16, Medicare Managed Care Manual
Chapter 21 , and ICM Pub.100-18, Medicare Prescription Drug Benefit Manual Chapter 9. Additional
guidance on the specfflcaticna and new location of the web-based compliance training modul111 la
forthcoming.
For compllanc•tralning related questions please contact : Parts_c_and_D_CP _Guldellnes@cms.hhs.gov
For FWA training-related questions, please contact : FW ATraining@cms.hhs.gov
Aaurla IIA•dlcale Compliance CMS Memo 2015 Page2 Of 2
Thia checkNst wtll help ensure you are compliant with the Medicare requirements for first tier, downstream, and related
entities (FDRa). You must maintain documentation sufficient to demonstrate to us or Medicare that these elements are met.
Before hiring a new employee or
governing body member
0 Checis both the Office of Inspector Gene.rat (OIG)
and General ~ervlce.s Admtn strallon (GSA) federal
exclusi on llsts to ens ure that no emplpYeea are
excluded from participation In federal programs.
The term "employees" tncludes. ternporary •
employees , volunteer s-!Ind consullant ll . Ir
applicable, establish a process to Identify and
prevent payment tor clalms at. point-ct-sal e for any
drugs or servloes prescribed , di spensed or
delivered by e)(cluded providers .
• GSA excluSion list: sam.gov
• OIG exclusion 11st: oig.hha.govtexcluaions
Within 90 days of hire
• Provrde Standards of Conduct and pollc es
and procedure11 to all employe11S who provide
admlnfatrallvi!J aen(lces or heattt, care services
for Asuria Medicare buslne88.
• Require govemlng body, officers and aenlor
leadenihlp (as applicable) to sign a conflict of
interest dlacloaure.
• Provide Medicare parts C and D fraud, waste and
abuse (FWA) lralnlng to all employees who provide
administrative services or health care services for
Asurts ' Med icare bus lnecSa. Note: FDRs wtio
have met the FWA certfflcatlon requirements
through enrollment Into Parts A or 8 of the
Medicare program or through accreditation aa a
supplier of DMEPOS are deemed to have met lhe
FWA training and education requirements.
• Provide Medicare parts C and O General
Compliance training lo all employees who provide
administrative services or health care services for
Asurla Medicare bualneas.
November 2015
Monthly for all employees and
governing body members
• Check both the OIG and GSA federal
exclusion lisls to ensure that no employees
have become excluded from participation In
federal programs.
• GSA exclusion 11st: sam.gov
• OIG exclusfon 11st: 011.hhs.aov/excluslons
Annually for all employees and governing
body members
• Provide Standards of Conduct and pollcles and
procedures to all employees who provide
administrative services or health care services for
Asuris Medicare business.
a Require governing body. officer& and senior
leadership (es applicable) to sign a conflict of Interest
disclosure.
• Provide Medicare parts C and D fraud, waste and
abuse training and Medicare parts C and D General
Compliance to an employees who provide
admlniltrative services or health care nrvices for
Asuris Medicare buslnesa.
Report all compliance concerns
For concerns regarding ethics, compliance or fraud,
contact us through one of these confldentlal
options :
• Fraud, waate and abuse: 1 (BDO) 323°1893
• Anonymous reporting line: 1 (BIB) 384-3577
• Medicare compliance, privacy, HIPAA
compliance or ethlca: 1 (877) 878-2273
Visit our FOR resource page at regenca.com/
fdr•resourcea.
j\SURIS ·
I , • •
ASURIS NORTWEST HEAL TH
MEDICARE ADVANTAGE PPO REIMBURSEMENT ADDENDUM
This 19 an Acldendum ("Addendu,n "), effective on Docember 31, 9999, to the Partk:lpallng Agreement
("Agreemenr), by end between Asurfs NorOlwest Health rcornpeny~) and KITTITAS COUNTY
HEAL TH DEPT ("Provider"), All references herein to 'Provider' shall mean •Provider," or "Medi cal
Group : as those terms are used and defined n the Agreemant(s).
WHEREAS . Company has a conlract to serve as a Medi care Advantage (MA) plan for the U.S.
Departmenl of Heal th and Human Serv. ees (HHS)., Centers tor Medicare and Med cad Services
(CMS), to adm1t:1ister Medicare benefits within certain counties in the Company serv ice areas;
WHEREAS, Provi der llas an eXJ stlng Agreement to provide medlcal services to Members , as more
particularly set forth in t11e Agreen,enl;
WHEREAS, Provider is entering into this Addendum to provide medical services lo MA PPO
Members :
NOW THEREFORE , in consideration of the foregoing premises and other good and valua,ble
cons lderat lon, receipt anc:I sufficiency of whleh are acknowledged, !he parties hereb y agree as follows :
A. REIMBURSEMENT PROVISIONS
The following re mbursement provisions and ree schedule amounts shall apply lo Provider for
Covered Services ·rendered to MA PPO Me mbers:
1, The fee schedule lo r profess onal providers fs slrU~tured on the most recent edition of the OPT
coding n,anual. Fo, mosl procedures , Company wlll determine Ma,dmum Allowable Fees usir:ig
the Reaource Based Relative Value Scale (RB RVS) pub lishe d by the Center, for M11dlcare &
Medicaid Services (CMS). In ll'ie ab!l(!nce of CMS RBRVS unit value:a for specific procedums ,
Company wlO establish auch unit values for purpose$ of Its Maxlmum Nlowable Fee
delerrnlnation . For cer1afn procedures , the Maximum Aflowable Fee will be lnd iv dually
determined at Company 's discretion . Procedures assigned ''by report" status are paid ar.
determined by Corr111any'11 Medical Olrocton
2. The allowa nce for each CPT proced ure code is the le11er of 1/ie charge or lhe -(ee asslgoe d lo
that proced1.1re code under the fee schedule. Payment for Covered Services. Is b,ased upon this
allowance.
3. For Covered Services provided'by MOs , OOs , OPMs, and ODs, the fee schedule shall be based
upon one hundred and two p_erc en t (102%) of the currenl Medicare fee schedule for the locale
where the sef:Vice la rendered .
4. For Covered Services pro11ided by Advanced Practice Profess onal Nurses and Physician
A"lslants, the fee sched ule shall be based upoo eighty-five pe rcent (85%) of the
MD/00/0PM/OO rate listed above. Payments ror Physician Ass istants and Certified Reg lst.e.red
Nurse Firs t As,s ls tants assisting at surgery shell be reimbursed based on Medicare guidelines .
5. For Covered SelV ces provided by other provider typee (i .e., 1121 MOs, Dos , OPMs , OD s, NP s
ar,d PAs), nctudlng but not flmited to : PT, OT, ST, CRNAs , DCs 1 the fae scnedule shall be based
upon the current Medicare allO\oJable fa" the pro11 lder type ba.sed on the locate where ttte servll::e
is rendered. Company follows Chapter 12 of the Med icare Cl!ilms Processing Manual for the
prov ider type , e)(ample : Ucensed Clinlc.il Social Wo,ker {\.CSW) is paid seventy-five pt?rcent
(75%) ot the Me~lcare phyi,lcian fee schedllle .
6. For Covered Service~ ror Laboratory and Fl ethology services for which Medicare has established
a fee throll.9h ll s Cllnlcal Laboratory Fee Schedule , reimbursement shap be ba.6C d upon nlnely
percent (90%) of lhe current Medicare fee sched ule for the local e where the service Is render.ed.
7. Durable Medical Eq uipment, Proslhe!lcs, 0rthotics, Supplies (DMEPOS) and Drugs will be
rein,bu.md accord ing lo Co mpan y re lmbu~menl policy.
MA PPO Profanlonal Ralmburaamenl Addendum Asurio1 A18816854M Page 1 of 2
B. MISCELLANEOUS PROVISIONS
1, Company will not make a!'ly addltlonal payment for fecllity or process ional seNlces based upo!'I a
ru1'11 1 health care desl gnatlon under 1h13 Medlnare program, l"cludfng any designation $l:ICh as a
Cr Ucal Access Hospital (CAH), Physician Scarc;lty A~ (PSA) or any other des gnaUon . unless
Iha res u!llng paymenl l!i agreed to by Company n advan ce and In writing .
2. Provl,d~r ag(ees 1010,ok sole ly to Company for compensalion for ·Cavered Services provided to
Members . Ptovlder agrees to collect directly from Member any outpatient co-payment whic h may
be establlsl]ed from time to lime by Company ror !3J!,Ch office cell and for eaeh ·home visit. The co•
pay ment st1all , be a cred!l against the amount di.le from Oorn p-any for Covered Serv ces rendered
lo a Me rTJper, without regard to whether the ProvidBr has actually collocted any co.-pavme nt .
3. for purposes of prompt payment of clJilms under this MA Addendum only , claimg for Covered
Servi ces prov ided to MA Members under this Addend um shall l.'1 · ! be aUbjectto any late fees,
inte rest, or other penallies as established by the Agreement o r by stale law. See 42 CFR §
422,520(b).
4. Cons,slenl with all other MA Member Agreements offered by Company , Compnnvwill follow
CMS's standards Ir, determining Medrcal Necessity , lnclu dJng , without limlla tlot;1 1,Medlcare 's
national co ve rage t;1ec1slons ·(N CDs) and-appHca.ble local medic.al review polic ies (LMRPs),
5. This Addendum shall continue , unless terminated acc01dlng to 11\e process set forth in the
·Agreemenl Ellhef party may terminate this AddendL(m without teffl'I na.ting the remainder of the
Agreement However , Ir:, the event either party 1ermlnates the Agreemi,n lhis Addendum terminates
as well.
Ar1y term not defined herein shall hav& the meaning set forth in the Agreemen t. The l~rms or this
Addendum shall become a part of, and shall be. speoiflcally i ncorporated ln'to, the terms of, the
Ag1eemenl In the e vept of tiny c:onRlct or lnc011sistency b~en the term& of th is Addendum and the
terms of the Ag r.eeme nt, the terms of this Addendum &hall apply. This Addendum supersedes and
repl aces In Ifs entirety any prior MA Addenda between the parties.
MA PPO Profeasional Reimbursement Addendum Asuri• 1 A18818854AA Page 2 or 2
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
Fund/Department
116-Public Health
Contract/Grant Information
Contract /Grant Agency: Asuris
Period Begin Date: June 5c, 2018
Total Gra nt/Contract Amount: None
Grant/Contract Number:
Contract/Grant Summary:
Agenda Date
Period End Date: 15 days after notice of
termination
The agreement between Kittitas County Public Health Department and Asuris Northwest Health is
established to allow the health department to bill insurance for services provided.
Recommendation for Board of Health and Board of Health Review on
Department Head Signature: ~ Administrator
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Date
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-repo r ting requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes O 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
j Has the Prosecutor reviewed this agreement? J Yes D No D
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature:
Department:
I Date :
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
J Reviewer I Date
Grant/Contract Review Page 2