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HomeMy WebLinkAboutPD11-310 - Original - Interplan Health Group, Inc. - PPO Services - 03/01/2011 Records M --gFe rn KENT _=== Document N A S H I N G T G N -_- - CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed. If you have questions, please contact City Clerk's Office. Vendor Name: Interplan Health Group, Inc. Vendor Number: 154762 JD Edwards Number Contract Number: Po ) 1 - 31 D This is assigned by City Clerk's Office Project Name: PPO Services Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ® Contract ❑ Other: Contract Effective Date: 3/1/2011 Termination Date: 3/1/2012 Contract Renewal Notice (Days): 90 Number of days required notice for termination or renewal or amendment Contract Manager: Jon Straus Department: Police Corrections Detail: (i.e. address, location, parcel number, tax id, etc.): 5•Public\Records Management\Forms\ContractCover\adcc7832 1 11108 i CLIENT SERVICE AGREEMENT FOR PROVIDER NETWORK ACCESS This Client Service Agreement (hereinafter referred to as "Agreement") is made this 1st day of March, 2011 (the "Effective Date") by and between Interplan Health Group, Inc on behalf of itself and those Affiliates described in Exhibit "A" (collectively, "PPO") and City of Kent Corrections as Plan Sponsor and/or Administrator of a self-funded Benefit Plan (hereinafter, referred to as"Client") WHEREAS, the purpose of this Agreement is to state the terms and conditions under which PPO will provide services to Client and under which Client will compensate PPO for services performed WHEREAS, PPO and its Affiliates negotiate discount arrangements with healthcare providers in many areas on an on-going basis in an attempt to maximize discounted rates from such healthcare providers, and WHEREAS, Client, in the course of its business, offers and administers healthcare benefits to covered individuals and wishes to utilize the services of PPO Further, Client may wish to access certain other services offered by entities affiliated with PPO Now therefore, in consideration of the mutual covenants and agreements contained herein, the receipt and sufficiency of which are hereby acknowledged, Client and PPO agree as follows ARTICLE I. DEFINITIONS 1.01 Definitions. The following terms shall have the meanings set forth below when referenced herein (a) "Affiliate" or"Affiliates" shall mean an entity directly or indirectly associated with PPO who, via contract or otherwise has agreed to allow Covered Persons access to its services and/or proprietary network of Participating Providers pursuant to this Agreement, subject to certain additional access requirements (b) "Clean Claim" shall have the meaning assigned to it by applicable law and/or Provider Contract When no such definition is available, Clean Claim means a claim form which has no defect or impropriety, does not lack any required substantiating documentation, or does not have any particular circumstances requiring special treatment that prevents timely processing (c) "Covered Person" means any individual, or eligible dependent of such individual, who is eligible for Covered Services pursuant to Client's plan (d) "Covered Services" means those health care services for which a Client has the contractual or legal obligation for payment, or arrange for the payment of such services, in accordance with Client's plan (e) "HIPAA" means the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), as codified at 42 U S C §§ 1320d-8 and as further delineated in regulations within Parts 142 160 and 164 of 45 C F R and any applicable requirements under applicable state law that exceed HIPAA standards (f) "Participating Providers" means those health care providers, including, without limitation, physicians, facilities, ancillary health care and allied health care providers, 1 Confidential Rev. 03/11 sue. who (i) have directly, or indirectly through PPO agreements with Affiliates or other networks ("Leased Networks"), entered into an agreement with PPO to perform the Covered Services (g) "Provider Contract" means a contract between a Participating Provider and PPO or between a Participating Provider and a Leased Network (h) "Savings" means the difference between a Participating Provider's billed charges and the discounted rate payable after application of the negotiated discount ARTICLE IL PPO SERVICES AND RESPONSIBILITIES 2.01 PPO Services. PPO will negotiate or has negotiated with Participating Providers to obtain preferred rates and/or discounts for certain medical services to be provided to Client's Covered Persons based upon information and data provided to PPO by Client PPO shall credential Participating Providers in accordance with written standards and processes of PPO which are available for review by Client upon written request 2.02 Affiliate Access PPO may extend access to other networks and services of Affiliates, where applicable, and upon certain additional terms and conditions being met by Client for access to said network(s) and services (i a logo identification, benefit differential, etc) Access to additional networks and services not identified on Exhibit A may only be accomplished with mutual written agreement of the parties 2.03 Documented Savings Report. Upon written request, PPO will prepare and provide to Client a documented savings report of the total documented savings for Client's Covered Persons accumulated from claims evaluated during the requested time period 2.04 Compensation By Incentive. Where applicable, there will be no incentive compensation related to utilization management services provided that would be based on reduction of services or the charges thereof, reduction of length of stay or utilization of alternative treatment settings as part of the system of compensation between payers and PPO 2.05 Availability of Services PPO makes no warranty, express or implied, as to the availability of or access to services through PPO that eligible Covered Persons seek from Participating Providers In no event shall this Agreement be construed to guarantee the availability to Covered Persons of a particular service or of a certain number of beds at a Participating Provider, nor to grant priority to Covered Persons over other patients in instances where the demand for services or beds exceeds the number available Neither PPO nor Participating Provider shall be liable to Client or Covered Persons in connection with a Participating Provider's inability to provide a service to a Covered Person or in connection with a Participating Provider's decision, under the circumstances described above, not to admit eligible Covered Persons 2.06 PPO Provider Network. The provider network created and maintained by PPO shall be the property of PPO and shall at all times remain in PPO's possession Client shall be entitled to receive the benefits of the provider arrangements negotiated with each of the healthcare providers in the PPO provider network during the term of this Agreement subject to the terms and conditions outlined herein 207 Practice of Medicine It is expressly understood that PPO is not a provider of medical care services PPO has entered into contractual arrangements with providers of medical care services, 2 Confidential Rev. 03/11 which providers are entities and contractors wholly independent of PPO and are not the employees, agents or representatives of PPO for any purposes PPO shall not be responsible for the acts, omissions, representations or other conduct of any such provider of medical care services, and such providers will be solely and exclusively responsible for the quality and level or frequency of the medical services provided Nothing in this Agreement shall be construed to interfere with a Covered Person's freedom of choice to receive medical services from PPO or non-PPO providers 2.08 Patient Relationship Participating Providers are exclusively responsible for the maintenance of the provider-patient relationship with Covered Persons and are solely responsible to such patients for all services Furthermore, nothing contained in this Agreement shall be construed to create any liability on the part of any Participating Provider arising as a result of services rendered by other Participating Providers To the extent that Client or its agent conducts a utilization review program or is involved directly or indirectly in any aspect of the PPO program that affects the manner, direction or intensity of services rendered to Covered Persons by Participating Providers, Client covenants and agrees to defend, indemnify and hold PPO harmless from damages, expenses and costs, including attorney fees, arising out of actions or investigations in connection with such conduct ARTICLE III: ACCESS REQUIREMENTS AND CLIENT RESPONSIBILITIES 3.01 Client Access and Compliance with Provider Agreements. Client agrees to comply with the applicable terms of PPO's Provider Contracts, including any payment timeframes established therein ("Payment Timeframes") Failure to comply with the Provider Contract or to meet the contracted Payment Timeframe on a Clean Claim may result in the loss of applicable discount for the claim in question Upon specific request, PPO shall make available to Client the applicable Payment Timeframes for a Participating Provider Client further acknowledges that, as a condition to accessing certain Participating Providers, Client may be responsible for executing a separate addendum, which will be provided to Client upon request for access to such Participating Providers Client will also be responsible for promptly providing necessary information and/or documentation as required by PPO to accommodate Client's request for access to Participating Providers Failure to execute any required addenda or timely provide information requested by PPO will result in benefits being paid at the out-of-network benefit level at those facilities and/or providers 3.02 Licensure Client certifies that it maintains (and will continue to maintain for the term of this Agreement) current applicable license(s), certificates and/or approved filing with appropriate State or Federal agencies 3.03 Client Implementation Form, Client Education. Client shall fully complete a Client Implementation Form in the form of Exhibit B, attached hereto, designating each service offering to be accessed by such Client PPO shall be entitled to rely upon information provided in the Client Implementation Form ARTICLE IV: COMPENSATION 4.01 PPO Compensation For services rendered pursuant to this Agreement, PPO will be compensated by Client as described in the Fee Schedule, attached hereto as Exhibit A PPO retains the right to adjust the Fee Schedule upon thirty (30) days written notice to Client, but in no event will there be more than one fee adjustment annually PPO will invoice Client on a monthly basis for services rendered hereunder Payment is due no later than thirty (30) days following the date of each invoice Should 3 Confidential Rev. 03/11 M Client fail to make payment to PPO within this time period, PPO may, in its sole discretion, automatically suspend all services hereunder and retroactively reverse the discount taken on those claims incurred by Client to the last date payment was received in full Such suspension and/or retroactive adjustments shall continue until all past due amounts are brought current Notwithstanding the foregoing, any amount due hereunder that is not paid when due shall bear interest until paid at a rate of interest equal to three percent (3%) per annum more than the prime rate established by Citibank N A of New York, or the maximum rate permitted by law, whichever is less Client is responsible for prompt payment to PPO Collection fees, when necessary,will be paid by Client In addition, Client hereby acknowledges that, as a part of PPOs contractual arrangement with certain participating network providers, PPO and its Affiliates may receive compensation for administrative services performed for the benefit of Participating Providers during the term of this Agreement Such fees may be in the form of direct payment by the Participating Provider to the PPO or in the form of a differential in reimbursement amounts (the "Differential Model") In a Differential Model scenario, the reimbursement amount paid for a claim under this Agreement may not be identical to the amount of compensation a Participating Provider receives or retains in connection with providing health care services Client acknowledges, subject to the requirements of applicable law, that reimbursement amounts paid to Participating Providers under this Agreement may not be identical to the amount of compensation a Participating Provider receives or retains Solely PPO and Participating Provider establish the applicable reimbursement amount in the Differential Model, and the compensation which PPO and Affiliates shall be paid, which shall be fair market value for services rendered Neither Client nor any Customer of Client shall be entitled to any portion of such administrative fees paid by a Participating Provider 4.02 Refunds. Requests by Client for refund of PPO access fees will not be accepted if said refund request is 60 days beyond PPO invoice date ARTICLE V- CONFIDENTIAL INFORMATION 5.01 Authorizations. Client authorizes PPO to have access to all relevant medical, financial, and personal data and other documents and information pertaining to Covered Persons, including any general statistical or summary data, and coverage description or plan documents helpful to the particular services requested Client authorizes PPO, where appropriate, to secure waiver or consent directly from the Covered Person Client agrees, upon reasonable request, to provide Participating Providers with enrollment or eligibility information for Covered Persons accessing that Participating Provider for medical services 5.02 Confidentiality of Information. All information provided by PPO to Client not otherwise expressly stated by PPO in writing to be available for public distribution, will be deemed to be proprietary to PPO and of a highly confidential nature including, but not limited to, information concerning any PPO or Affiliate provider networks, other systems, fee schedules, programs, processes and methods used by PPO or its Affiliates (collectively referred to as the "Information"), all of which it is agreed have substantial value to PPO Client shall not disclose to any third party or utilize for its own benefit (other than the use as specifically provided for this Agreement), in whole or in part or reformulated in any other type of report or filing, any of the Information which it may obtain, directly or indirectly from PPO without PPG's prior written authorization 5.03 Confidentiality of Medical Records Each party agrees to treat Covered Person records as confidential and to comply with all federal and state confidentiality laws, including HIPAA Each party agrees to not disclose medical information regarding a Plan Covered Person without first obtaining proper authorization from the Plan Covered Person, except as provided above, or as permitted by applicable law Nothing in this Agreement prohibits or restricts Providers from giving 4 Confidential Rev. 03/11 Covered Persons (or their authorized representatives), information regarding treatment or discussing with the Covered Persons (or authorized representatives), the Plan Covered Person's overall medical needs including treatment options or recommendations not included as Covered Services under the applicable Plan 5.04 Trademarks and Copyrights/Licensing PPO and Client acknowledge the other parties' sole and exclusive ownership of its respective trade names, commercial symbols, trademarks and service marks, whether presently existing or later established (collectively "Marks") Neither PPO nor Client shall use the other parties' Marks in advertising or promotional materials or otherwise without the owner's prior written consent All uses of any Mark shall inure exclusively to the benefit of the Mark's owner Each party reserves the right to terminate any consent previously given for the use of a Mark by providing the other party with written notice of such termination In no event shall the use of a Mark continue after termination of this Agreement PPO and Client acknowledge that any use of the other parties' Mark without the consent of such other party would cause the owner of such Mark irreparable injury, entitling it to obtain injunctive relief and such other remedies from the infringer as may be appropriate Each party hereby grants the other party the right to use its name, address and telephone number in connection with the obligations of the other party hereunder e ARTICLE VI: TERM AND TERMINATION 6.01 Term. This Agreement shall become effective as of the Effective Date and shall remain in effect thereafter for an initial period of one (1) year (the "Initial Term") Following the Initial Term, this Agreement shall automatically renew for successive periods of one (1) year each, unless terminated pursuant to the terms of this Article Any subsequent renewal period following the expiration of a Client's initial access term shall also be for no less than one 1 ( ) Year 6.02 Termination. This Agreement may be terminated i b either art upon the expiration of the Initial Term or an subsequent renewal term () Y party P p Y eQ by providing written notice to the other party at least ninety (90) days prior to the end of that term (u) by either party upon written notice (a) thirty (30) days after written notice to the other party that said party is in breach of a material term or condition of this Agreement and has failed to remedy that breach, or (b) immediately, if a party is placed into conservatorship, receivership, or bankruptcy, or makes a general assignment for the benefit of its creditors (ui) immediately by PPO in the event that Client becomes the subject of any regulatory action and/or is determined to be unable to fund payments to providers for any reason, including, without limitation, State Department of Insurance or DOL intervention, lack of funding by reinsurance carrier, etc PPO may immediately and indefinitely suspend repricing services in the event Client falls more than sixty (60) days past due on remittance of access fees In the event access fees are not paid within fifteen (15) days of such suspension of repricing services, and in addition to any other remedies available to it, PPO may immediately terminate Client's access to PPO's network 6.03 Run Out Claim Service. Upon termination, run-out network coverage and repricing may be provided by PPO, in its sole discretion, following writ ten request of Client Fees for claims run out services are described in Exhibit A attached hereto Notwithstanding, PPO may in its sole discretion, elect not to provide claims run out service for Client following termination 6.04 Effect of Termination. Termination of this Agreement shall not affect any payment due to PPO or a PPO Participating Provider for services rendered prior to or being rendered at the time of termination If this Agreement is terminated, its provisions will continue in effect with respect to Covered 5 Confidential Rev. 03/11 Persons who are inpatients at a health care facility on the date of termination until these Covered Persons are discharged or until such ongoing inpatient services have been provided for thirty (30) days past termination ARTICLE VII: LIABILITY 7.01 Liability for Claim Decisions and Payments; Limitation of Liability The duties of PPO are limited to those specifically set forth in this Agreement PPO does not determine eligibility or benefit availability for Covered Persons PPO does not exercise any control with respect to Plan assets, policies, practices procedures or payment of claims Client shall be responsible for all claims decisions and for the payment of all claims pursuant to a Plan PPO shall not be liable for any claims decisions or for the payment of any claims submitted by Participating Provider related to the furnishing of Covered Services or non-Covered Services to eligible Covered Persons, or any breach by a Participating Provider of a Provider Contract If PPO performs repricing services for Client's Plan, the liability of PPO for any inaccurate or incomplete repricing or adjustments to claims, information, or reports shall be limited to the correction of, completion of, or assisting Client to correct or complete, any such repricing and to using its best efforts to prevent such issues from occurring in the future PPO assumes no responsibility for retroactive claims changes and/or adjustments PPO will reprice altered and/or adjusted claims as received and return to Client Participating Providers shall look solely to Client for payment for Covered Services Notwithstanding anything in this Agreement to the contrary, if Client or anyone claiming under or through Client should make any claim against PPO or its Affiliates arising out of or related to this Agreement (including, without limitation, for breach of contract, breach of warranty, breach of any indemnity or any tort claim), PPO's liability will be limited to the actual direct damages caused by PPG's actions, not to exceed (in the aggregate for all claims) the amount that Client paid PPO for services rendered in the preceding twelve (12) months 7.02 Final pp Payment Decision. When applicable, PPO (and/or each of its vendors), in the v course and scope of providing precertification services, has no authority to determine eligibility or for payment of a claim but is only acting as a vendor resource for information to the carrier/plan who has the final decision authority on payment 7.03 Indemnification. Subject to the limitations contained herein, each party shall indemnify, defend, and hold the other harmless from all claims, losses, damages, judgments, liabilities, causes, expenses or obligations (including but not limited to reasonable attorney's fees and expenses) arising out of or resulting from the indemnitor's own negligent or other wrongful act or omission or that of any of its officers, shareholders, directors, agents, representatives or employees acting within the scope of his or her employment If any action, suit or other proceeding is commenced, or any claim or demand is asserted, relating to or in respect of which a party (an"Indemnitee") demands indemnification pursuant to this Section (each a "Claim"), the Indemnitee shall, with reasonable promptness, notify the party from which such indemnification is demanded (the "Indemnitor") of such Claim Such notice shall describe the nature of such Claim in reasonable detail and include such written information that the Indemnitee has received with regard to the Claim as may be reasonably necessary for the Indemnitor to evaluate such Claim The Indemnitee's failure to give such notice to the Indemnitor shall not relieve the Indemnitor from any of its or his obligations under this Agreement, except to the extent such failure materially and substantially prejudices the defense of the action or proceeding by the Indemnitor The Indemnitor shall have the right to control the defense of any action, suit or other proceeding brought by a third party that constitutes a Claim (each a "Third Party Claim") with counsel approved by the Indemnitee, which approval shall not be unreasonably withheld, conditioned or delayed, all at the Indemnitor's sole cost and expense The Indemnitor may not settle any such Third Party Claim without the Indemnitee's consent, which consent shall not be not unreasonably withheld, conditioned or delayed 6 Confidential Rev. 03/11 (provided, however that Indemnitor shall not be required to consent to any admission of guilt or criminal wrongdoing as part of any settlement), and the Indemnitee, at his or its sole cost and expense, may employ separate counsel and participate in the defense thereof The Indemmtee and Indemnitor shall reasonably cooperate with each other in connection with each Third Party Claim 7.04 Disclaimer. While the duty of PPO under this Agreement is to provide certain information designed to assist Client in providing better services to Covered Persons, such duty of PPO in no way affects Client's fiduciary responsibility to Covered Persons, damages that may result from disputes (or judgments resulting from disputes) that arise between Client and any Covered Persons, insureds, clients employees and/or their dependents, or with providers, or any other payee or other person in a contractual relationship with Client ARTICLE Vill: GENERAL PROVISIONS 8.01 Insurance. During the term of this Agreement, each party is responsible for maintaining policies of general liability insurance, as well as E&O and D&O insurance, sufficient to protect from claims of personal injury or property damage that may arise from each respective party's activities under this Agreement 8.02 Governing Law: Venue. The laws of the State of Texas (without regard to its choice of law principles that might apply the law of another jurisdiction) shall govern the validity of this Agreement, the construction of its terms, and the interpretation and enforcement of the rights and duties of the Parties If any action is brought in connection with this Agreement, the exclusive venue for such action shall be any federal or state court located in Dallas County, Texas Each of the Parties hereto expressly submits to jurisdiction in any federal or state court located in Dallas County, Texas, and waives any claim of improper jurisdiction or lack of venue in connection with any such matter 8.03 Solicitation of Providers Client will not, voluntarily or involuntarily, contact any Preferred Providers during the term of this Agreement, or for a period of one (1) year after termination of this Agreement or the Client's access of the network, as applicable, for the purpose of establishing, directly or indirectly, a comparable network of providers 8.04 Counterparts. This Agreement may be executed simultaneously in one or more counterparts with the same effect as if the signatories executing the several counterparts had executed one counterpart 8.05 Relationship of the Parties. Each of the Participating Providers, as well as PPO and Client, are independent contractors This Agreement is not intended to create an employer-employee relationship, partnership or joint venture between any of the parties Furthermore, this Agreement shall not be deemed to create any rights or remedies in persons who are not parties to this Agreement 8.06 Severability. If any part of any provision of this Agreement is held to be invalid or unenforceable under applicable law, said part or provision shall be ineffective to the extent of such invalidity or unenforceability, without in any way affecting the remaining parts of the Agreement, which shall be construed and enforced as if such invalid or unenforceable part or provision had not been inserted 8.07 Merger Clause This Agreement constitutes the entire agreement of the parties hereto with respect to the matters covered by this Agreement, and correctly sets forth the rights, duties and obligations of the parties as of its date Any prior agreements, promises, negotiations or representations, be they written or oral, not set forth in this Agreement, are of no force and effect, and are superseded by 7 Confidential Rev. 03/11 this Agreement 8.08 Force Maieure. In the event that the performance by either party hereto of any of its obligations or undertakings hereunder shall be interrupted or delayed by any occurrence and not occasioned by the conduct of either party hereto, whether such occurrence be an act of God or the common enemy or the result of war, riot, civil commotion sovereign conduct or the act or conduct of any person or persons not a party or privy hereto, then it shall be excused from such performance for such period of time as it is reasonably necessary after such occurrence to remedy the effects thereof 809 Notice. All notices and communications under this Agreement shall be in writing and shall be deemed to have been duly given to a party (Q when delivered to such party if hand delivered, (u) one (1) day after having been deposited for delivery with an overnight courier, or (iu) three (3) business days after such notice is enclosed in a properly sealed envelope, certified or registered, and deposited "postage and certification or registration prepaid" in a post office or collection facility regularly maintained by the United States Postal Service and addressed as follows If to PPO Interplan Health Group, Inc Attention Legal Department 222 West Las Colinas Blvd, Suite 600N Irving, TX 75039 (806)473-2500 If to Client City of Kent Corrections Attention Commander of the Kent Corrections Facility 1230 Central Avenue S Kent, WA 98032-7426 8.10 Amendments. Except as otherwise provided herein, this Agreement may be amended or modified only by a further instrument in writing executed by the parties hereto 8.11 Assignment. This Agreement may be not be assigned by either party without the express written consent of the other party, provided that either party shall, without the obligation to obtain the prior written consent of the other party, be entitled to assign this Agreement or all or any part of its rights or obligations hereunder to an affiliate of a party, or to the purchaser of all or substantially all of the assets or capital stock of a party or to an entity into which a party is merged, provided, further that no such assignment shall relieve the party from its obligations hereunder 8.12 Waiver of Breach. The waiver by either party of a breach or violation of any provision of this Agreement shall not operate as, or be construed to be, a waiver of any subsequent breach of the same or other provision 8.13 Legal Fees and Costs In the event either party elects to incur legal expenses to judicially enforce or interpret any provision of this Agreement, the prevailing party will be entitled to recover from the other party such legal expenses, including attorney's fees, costs and necessary disbursements, in addition to any other relief to which such party shall be entitled IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their duly authorized representatives as of the date first above written 8 Confidential Rev. 03/11 PPO. INTERPLAN HEALTH GROUP, INC. BY Aw(�2,tttp(, SignaturEo /I io2�`�P ire u. Title L�rl�a �a1(irxr- Printed Nam CLIENT: ClT OF T CORRECTIONS ; BY Signature Qn etc cm k Title Printed Name 9 Confidential Rev. 03/11 EXHIBIT A FEES AND SERVICES The fees and costs payable by Client for services rendered pursuant to this Exhibit A shall be as set forth below Prior to Client implementation, a census of all eligible inmates must be provided to PPO The rates identified herein are subject to change pursuant to Section 4 01 1. PPO NETWORK ACCESS A. PPO shall be compensated monthly at the rate identified below for access to each applicable network under the Client Service Agreement Access Fee Rate ■ Interplan Health Group,Inc. 25%of savings B. For an additional rate of 25% of Savings, Client may elect access to the HealthSmart Payors Organization, LP ("HPO") provider network via PPO's Affiliate relationship with HPO Participation in the HPO product may require a separate HPO logo on participant identification cards Access to the HPO Network shall be governed by the same terms and conditions outlined within this Agreement Client acknowledges that access to HPO discounts is at all times subject to applicable law and the provisions of the governing provider agreement II.ADDITIONAL PPO NETWORK SERVICES AVAILABLE Upon mutual agreement between the parties, the following services may be made available to Client according to the following rates Client acknowledges that PPO may subcontract all or a portion of the services described below A. CLAIM NEGOTIATION 25% of Savings B. RUN-OUT CLAIM SERVICES 25% of Documented Savings* *Contingent upon PPO's agreement to provide Run-Out Claim Services pursuant to Section 6 03 F } 10 Confidential Rev. 03/11 EXHIBIT B CLIENT IMPLEMENTATION FORM NEW CHANGE EFFECTIVE SUBMIT DATE D BY (HS Employee) BAYLOR(see specifics below under Network CHECK ONE Products) GROUP HEALTH AUTO TRAVEL AGGREGA DENTAL TOR OTHER GROUP INFORMATION SELF FUNDED FULLY INSURED RENEWAL NMS EHN HSP MONTH # # C# #OF GROUPNAME EPS GROUP/BENEFI T#S CONTACT ADDRESS CITY/STATE/ZIP COUNTY EMAI PHONE I FAX L UM/UR VENDOR&800#(if not HealthSmart CLAIMS PAYOR INFORMATION *If reporting an address change, indicate if this is a new address or replaced existing address(es)and which group numbers it applies to in comments field. CONTRACT NMS EHN HSP HOLDER? 17 YES # # C# CLAIM PAYOR ADDRESS CITY/STATE/ZIP CLAIM ADDRESS CITY/STATE/ZIP PHONE FAX 11 Confidential Rev 03/11 CLAIM MANAGER EMAIL ELIGIBILITY CLAIM INQUIRY NUMBER PHONE ACCT MANAGER EMAIL INVOICES -INVOICES SHOULD BE MAILED TO: COMPANY CONTACT EMAIL ADDRESS CITY/STATE/ZIP PHONE FAX AGENT I CONSULTANT/ BROKER/MGA AGENT BROKER MGA COMMISSION`?P PEPM % i COMPANY ADDRESS CITY/STATE/ZIP PHONE FAX Comments, Notes a a NETWORK PRODUCTS Emerald __ - _= ___-- =- PEPM Member Geographic Emerald Information POS fee PHS through AHPO Emerald Central fee AHPO Northeast Southeast "Requires separate logos and Southwes "Accel fees Northwest t EHN Facility INCLUDE Claims Contract Market ML2 ACS EHN Professional Claims Contract Market HealthSlrtarfti rMiditidnat _= „k ,,;_ _e =a ,a,_e =&e_ < _ - HealthSmart = PEPM HealthSmart PPO DFW GEPO Beech POS fee Must hst INCLUDE HSPC Wrap Only locations HS PPOM PPOPIus ACS 12 Confidential Rev. 03/11 a s k E HSPC Work Baylor Eff Comp Only HPN '* Baylor u Date The states below are available through the HSPC affiliate for domiciled lives,&require the logo to access the discount *Requires add't logo no City Zip Lives add't fee **Requires separate Arkansas logos and fees ***Requires Signed Idaho Amendment Iowa Louisiana Mississippi Montana Nebraska Washington West Virginia flealfhSmart-interplan-rnotudes all iHG Standard and$AS Ppcks and a"s--is as =rdentiflecron-theGrid _ = PEPM IHG Professional **Accel POS fee *'Mayo Health IHG Ancillary System **Sutter Health Baylor Eff IHG Facilities System ***Baylor Date HSP-Aurora Steerage'70'pla *Requires separate logos Class n) INCLUDE ACS and fees **Requires separate addendum ***Requires Signed Dental FICA Only Amendment IH Liv G Lives IHG Lives IHG es South Arizona Kentucky Dakota Tennesse California Michigan e Florida Nebraska Texas Washingt Illinois IHG Nevada on West Illinois PPI North Dakota Virginia Indiana Ohio Wisconsin Iowa Oregon Other* Describe Other HealthS an`-_ PEPM Re ular Preferred POS fee PEPM *HPO logo on Card' HPO HPO Affiliates Check if Yes POS fee 13 Confidential Rev. 03/11 14 1 1 HPS PEPM HPS POS fee jfta/thSmaft Nationat Affr#tat se orate farm peraffi#Wtabe completeddy--_-- ementattonlearn - PEPM Network ST Lives Network ST Lives POS fee CLAIM PRICING EDI To CareVu Transfer To EHN Fee SBR 03 To IHG* Value Web Based Pricing* Returned Returned Hard Copy claims Paper EDI Medicare Tribal Pricing Process Fee *Claim processes not available for Dental Claims Claims Received Cleannghou Claims Returned Cleanrgho From se To use TPA TPA Providers Providers Group Group Is claim Run In required? Yes No Run In Effective Date i Run In Reason OON Forward form to HSCMS if this product is NEGOTIATIONS purchased %of Savings Payor Contact Inpatient CON Threshold Phone Fax Outpatient CON a Threshold Email CARE Forward form to HSCMS if this product is MANAGEMENT purchased 14 Confidential Rev. 03/11 i Core Services: Fee: Optional Services: Fee: Inpatient Hospital Precertification Disease Management(DM) Outpatient Notification DM with Predictive Modeling Case Mother and Child Maternity Management Management Specialty/ Retro Review Inpt Psychiatric/Substance Abuse Review Physical Therapy Wellness Coach Wellness Assessment Health Advice Line ELIGIBILITY - Required for all groups,all networks Group ID numbers submitted in eligibility file Type of member ID number on ID cards SSN Unique ID EXTRACTS - Rate extract require separate Sr.Mgmt approval process Demographic File 18 months history included Active Only File Recipient Contact Info Email Name address Phone i 9 ♦ d 15 Confidential Rev. 03/11 G REGULATORY ADDENDUM FOR THE STATE OF ILLINOIS The provisions set forth in this Addendum are being added to the Agreement in order to comply with 50 IL ADMIN CODE § 2051 260 and Its corresponding regulations To the extent that such Illinois laws and regulations are applicable and/or not otherwise preempted by federal law, the provisions set forth in this Addendum shall apply and, to the extent of a conflict with a provisions in the Agreement, shall control with respect to PPO access in the State of Illinois i 1 In the event a Covered Person seeks medically necessary services for which PPO cannot provide access to a credentialed hospital, physician or ancillary provider, Covered Person shall incur no greater out-of-pocket liability for such medically necessary services than had the Covered Person received services from a Participating Provider Notwithstanding, any Covered Person who willfully chooses to access a non-preferred provider for health care services that are available by accessing PPO will be subject to any out-of-pocket liabilities as prescribed by Client's health benefit Plan 2 Subject to PPG's prior review and approval in accordance with the Agreement, Client shall prominently display the full name and toll-free (800) telephone number of Client, including PPO, on all Covered Persons' identification cards issued by Client 3 If any part of any provision of this Addendum is held to be invalid or unenforceable under applicable law, said part or provision shall be ineffective to the extent of such invalidity or unenforceability, without in any way affecting the remaining parts of this Addendum or the Agreement, which shall be construed and enforced as if such invalid or unenforceable part or provision had not been inserted 4 The parties acknowledge that only Client, and not PPO, may assume underwriting risk when that risk is part of the delivery of services z 7 >a i 16 Confidential Rev. 03/11 a