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Public ealt
is
615 Sheridan Street
Port Townsend, WA 98368
www.JeffersonCountyPublicHealth.org
Consent Agenda
October 12, 2015
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
TO:
FROM:
DATE:
SUBJECT:
AGENDA REQUEST
Board of County Commissioners
Philip Morley, County Administrator
Jean Baldwin, Director
Jessica Syska, Insurance Billing
Agenda Item — Medical Service Agreement Renewal, Croup Health
Cooperative; January 1, 2016 December 31, 2017 Automatic
renewal; Insurance compensation.
STATEMENT OF ISSUE:
Jefferson County Public Health requests Board approval of the Medical Service Agreement Renewal, Group
Health Cooperative; January 1, 2016 — December 31, 2017, Automatic Renewal
AN�IL 1 S�S STRATIG.L'er+ G7Y.aFAS PROS Ind CN�Sw
The Medical Service Agreement Renewal with Group Health allows Jefferson County Public Health to deliver
services to Group Health insurance participants in exchange for compensation by Group Health for services
rendered. JCPH shall be compensated by Group Health for covered services less coinsurance, copayments,
and deductibles.
FISCAL. IMPACT COST BENEFIT ANALYSIS:
This renewal has no impact on the general fund and is a revenue neutral agreement.
RECOMMENDATION
JCPH management request approval of the Medical Service Agreement Renewal, Group Health Cooperative;
January 1, 2016 — December 31, 2017; Automatic Renewal.
.y'§
p Morl,y,. ialnty Administrator Date
Community Health
Developmental Disabilities
360-385-9400
360-385-9401 (f) Always working for a safer and healthier community
Environmental Health
Water Quality
360-385-9444
(f) 360-379-4487
MEDICAL SERVICE AGREEMENT
This Agreement is entered into this 1st day of January, 2016, between Group Health Cooperative, a nonprofit
corporation organized and existing under the laws of the State of Washington (hereinafter referred to as GHC),
and Jefferson County Auditor dba Jefferson County Public Health (hereinafter referred to as Contractor).
I. '"ur )osc
GHC is an organization that provides managed health care services to Managed Care Members either
directly or through contracts with health care providers.
The purpose of this Agreement is to make available public health & general preventive medicine
specialty care Covered Services to certain Managed Care Members according to the terms and
conditions set forth below. Contractor hereby authorizes and appoints GHC to offer Contractor's
professional services to all groups of employees and individuals covered under Medical Coverage
Agreements entered into or designated by GHC.
II. Definitions
Approved Mediator A mediator who is mutually agreeable to GHC and Contractor and who
has been selected from an independent mediation service made available
to Contractor under the dispute resolution process provided for in this
Agreement.
Authorization Form A form used by GHC or Health Carrier to define the authorized scope of,
and time period for, Covered Services to be provided to Managed Care
Members.
Coinsurance An amount required under a Managed Care Member's Medical Coverage
Agreement to be paid by a Managed Care Member for Covered Services.
Consultative Specialist A Physician or Health Care Professional who, subject to completion of
the applicable GHC credentialing process, provides authorized Covered
Services to Managed Care Members through Contractor.
Contractor An individual, professional association, corporation, partnership or non-
profit organization contracting with GHC through this Agreement to
provide Covered Services to Managed Care Members through one or
more Consultative Specialists.
Copayment A specific amount of money required under a Managed Care Member's
Medical Coverage Agreement that must be paid by a Managed Care
Member for certain Covered Services that are not fully prepaid.
Covered Services Those health care services to which a Managed Care Member is entitled
under the terms of a Medical Coverage Agreement.
Deductible A specific amount that must be paid by a Managed Care Member during
a specified period in accordance with the Managed Care Member's
Medical Coverage Agreement before benciit.s for Covered Sel-vices are
payable by a Health Carrier.
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GHC Provider A Physician, Health Care Professional, hospital, ancillary service
provider, outpatient ambulatory facility or other health care facility that
is authorized by GHC to provide Covered Services to Managed Care
Members.
Health Care Professional A health professional., other than a Physician, who is licensed, certified
or registered in the state in which he/she practices and who is employed
by or under contract with Contractor.
Health Carrier An insurer, health maintenance organization, health care service
contractor, self-insured welfare benefit plan, plan sponsor or other
medical plan owned by or under contract with GHC to offer medical
coverage to Managed Care Members. (;IJC is a Health Carrier wile"
providing Covered Set -vices as a health maintenance organization. Use
or the terms G1.1IC and 14calth 1(I"arrier herein shall be deemed to include
reference to wholly owned subsidiaries of GHC when the context so
reasonably requires.
Managed Care Member An individual who, under the terms of a Medical Coverage Agreement,
is eligible to receive Covered Services from GHC. This includes, but is
not limited to, all eligible Medicare beneficiaries.
Medical Coverage A contract, including an Evidence of Coverage, that describes a benefit
Agreement prograu-n offered by a Health Carrier and specifies those health care
services to be provided to individuals lawfully participating in that
benefit program.
Physician An individual licensed in the state of Washington under Chapters 18.71
RCW or 18.57 RCW or by law in the state in which such person
practices as an allopathic or osteopathic physician.
Provider Manual The "Group Health Provider Manual" provided by GHC to Contractor.
The Provider Manual provides detailed information regarding
implementation of this Agreement and shall be subJect to modification
by GHC, with or without advance notice to Contractor, provided such
modification does not conflict with the provisions of this Agreement.
III. Services
A. Contractor shall, within the time period specified on the applicable Authorization Form, when
such authorization is required, provide to Managed Care Members, at locations approved by
GHC, authorized Covered Services appropriate to Contractor's and Consultative Specialist's
specialty or expertise in a manner consistent with this Agreement, the Provider Manual, the
Member Rights and Responsibilities, and policies and procedures established by GHC.
Contractor shall provide services at facilities in accordance with the terms and conditions of
applicable agreement between GHC and such facility, if applicable.
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1 GHC will notify Contractor at least sixty (60) days prior to implementing any material
changes to the Provider Manual, the Member Rights and Responsibilities or policies
and procedures if such changes affect Contractor compensation or provision of
Covered Services. If such changes are mandated by law or regulation, and GHC does
not receive sufficient notice from government to fulfill this notice requirement, GHC
shall provide notice of such changes to Contractor as soon as possible. Contractor may
terminate this Agreement according to the provisions in Section XII.C. if Contractor
does not agree with such changes, but such changes shall apply during the term of this
Agreement.
2. Contractor shall provide twenty-four (24) hour, seven (7) days a week call coverage
through Physicians or Health Care Professionals in a manner prescribed and approved
by GHC.
B. GHC shall provide access to information on patient eligibility for health care services and
health plan benefits, including any limitations or conditions on services or benefits as required
by WAC 284-43-320(1) and as set forth in the Provider Manual. Additionally, GHC shall
assure the provision of an Authorization Form defining services to be provided by Contractor
when applicable. The Authorization Form shall specify coverage limitations, time limitations,
and special circumstances such as coordination of benefits, Coinsurance, Copayment or
Deductible requirements.
C. Contractor shall, if required, obtain prior authorization from the referring GHC Provider, GHC,
or GHC's designee before delivering any services beyond those originally authorized.
Contractor shall refer Managed Care Member to the referring GHC Provider for management
of any medical or surgical problems for which treatment authorization has not been obtained.
Except in the event of emergency or with respect to Covered Services for which a Managed
Care Member may self -refer by law, GHC is not obligated to compensate Contractor for
services provided when Contractor has not first obtained prior authorization or approval from
GHC. Contractor shall not prohibit Managed Care Members from self -referring for Covered
Services which, by law, may be obtained without authorization.
When prior authorization is required, the procedure described in C. above is applicable.
D. Nothing in this Agreement prohibits Contractor from providing non -Covered Services or
Covered Services beyond those authorized, when such authorization is required, if the Managed
Care Member agrees in writing prior to their delivery to fully pay for such specific non -
Covered Services or Covered Services beyond those authorized to be provided to the Managed
Care Member. GHC honors the Contractor's right to advocate on behalf of a Managed Care
Member, including communication with Managed Care Members regarding treatment options
regardless of Covered Service limitation.
E. As deemed appropriate by GHC, Contractor shall submit to GHC or GHC's approved designee
a consult summary, progress notes, and surgical, pathology and laboratory reports describing
Contractor's examination, diagnosis, treatment provided, and treatment plan. The consult
summary shall be submitted in a format acceptable to GHC within ten (10) days after each
service. In lieu of the consult summary and progress notes, a legible, signed, dated copy of the
medical record may be sent, provided it includes the Managed Care Member's name, consumer
number, and GHC authorization number.
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F. Contractor shall provide Covered Services to Managed Care Members of the same quality and
in the same manner as rendered to other persons by Contractor and, at a minimum, shall comply
with the community standards of accessibility of such services. Covered Services shall be
provided without regard to the Managed Care Member's enrollment in a privately or publicly
financed program of health care services.
G. In performing the obligations of this Agreement, Contractor and Consultative Specialists shall
comply with all applicable state and federal laws and regulations, provide services within their
legal scope of practice and exercise a degree of care, skill and learning expected of a
reasonably prudent health care provider acting in the same or similar circumstance in the state
where care is provided.
H. Nothing in this Agreement shall be construed to alter the duty of Contractor or Consultative
Specialist to exercise his/her independent professional judgment in the care of Managed Care
Members.
Contractor shall ensure that no Managed Care Member is involved in research or participates
in, or is otherwise subject to, any experimental or investigational procedures conducted by
Contractor unless the Managed Care Member has given prior written authorization, and a copy
of such authorization is forwarded to GHC for payment and care coordination purposes.
Contractor shall notify GHC prior to initiating a clinical trial using the authorization request
process identified in the Provider Manual. Contractor shall supply a list of services that are
provided in the trial, identifying which services are for the purpose of delivering the trialed
service/agent or measuring the effect of the trialed service/agent. GHC follows WAC 284-43-
850 when authorizing routine services consistent with those that would typically be provided to
a non -participant.
Unless otherwise authorized by GHC, Contractor shall use the appropriate Health Carrier
formulary when prescribing medications for Managed Care Members and refer Managed Care
Members to a GHC authorized pharmacy to have prescriptions filled. Prescriptions may not
exceed the maximum supply authorized by the Managed Care Member's Health Carrier without
prior authorization. Additionally, in accordance with Section 6405 of the Affordable Care Act
and CMS final rule CMS -4159-F, Contractor must be enrolled in an approved status with
Medicare in order to prescribe covered Part D drugs to Managed Care Members enrolled under
a Medicare Advantage Medical Coverage Agreement.
IV. l elatia nship of Pattie
Contractor and GHC are independent contracting parties. Except as expressly provided herein, neither
party shall be considered an agent or employee of the other party for any purpose. Each party shall be
solely and entirely responsible for its employees, subcontractors or agents in the performance of
services under this Agreement.
V. Licensure +C:;aredentialin x and I ecredentialin r
A. Consultative Specialists shall maintain appropriate state licensure, certification or registration
and other credentials necessary to practice in the state in which they practice including, if
applicable, local hospital privileges and shall immediately notify GHC of any loss or restriction
of such credentials or privileges.
Contractor must have a CLIA (Clinical Laboratory Improvement Amendments) certificate to
provide laboratory services to GHC Managed Care Members under the terms of this
Agreement. Contractors holding a limited CLIA certificate (Certificate of Waiver or
Certificate for Provider Performed Microscopy Procedures) may provide only those tests
permitted by the limited CLIA certificate. If Contractor is not the performing entity for
laboratory services, Contractor may not bill GHC for any laboratory services and must use
designated GHC Providers specified by GHC for laboratory services.
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B. Consultative Specialists shall meet applicable requirements of GHC credentialing and
recredentialing which may include, but not be limited to, completion of medical practice audits
by GHC, submission of application, curriculum vitae, copies of licenses and certifications, and
a signed authorization to permit release of information to GHC from professional liability
carriers, hospitals, and others who have information regarding training, experience, credentials,
professional competence, ability to deliver safe and efficient quality care, professional liability
claims history and/or insurance, peer review, and utilization information.
C. Nothing herein contained shall be deemed to: 1) require Contractor or GHC to release
information obtained during peer review processes to third parties except as required by law, or
2) require the release of a Managed Care Member's medical record in violation of any
applicable state or federal law or regulation.
D. This Agreement shall not apply to individual Consultative Specialists until GHC has confirmed
with the individual that he/she has successfully completed credentialing. Contractor shall
provide GHC with a list of Consultative Specialists and promptly notify GHC in writing
pursuant to Section XVI. of any individual Consultative Specialist membership changes. Such
individuals shall be subject to approval by GHC, meet the requirements of the applicable GHC
credentialing and recredentialing as provided under this section, and shall not provide services
to Managed Care Members prior to approval.
E. Should an individual health care practitioner be denied credentialing as provided under this
section based upon quality of care findings, he/she may initiate a dispute resolution process as
described in GHC policies and procedures which is separate from the contractor dispute
resolution process provided ' in this Agreement. This does not apply if the health care
practitioner fails to meet requirements established under A and B of this section. This process
as defined in the Provider Manual will not preclude Contractor from pursuing judicial remedies
in compliance with RCW 48.43.055 and WAC 284-43-322 regarding alternative dispute
resolution provisions in provider contracts.
VI. Insurance and Lialtilit
A. Contractor shall maintain and provide evidence of general liability insurance coverage in the
amount of at least ONE MILLION DOLLARS ($1,000,000) per occurrence and THREE
MILLION DOLLARS ($3,000,000) in the annual aggregate on an occurrence or claims made
form.
B. Contractor shall maintain and provide evidence of professional liability insurance coverage and
extended reporting insurance coverage (if applicable) to insure Contractor, Consultative
Specialists, employees, agents and subcontractors against claims for damage arising by reason
of injury or death, occasioned directly or indirectly by the performance of any service arising
out of this Agreement. Contractor and Consultative Specialists shall maintain and provide
evidence of professional liability coverage with the minimum limits as follows:
Contractor shall maintain and provide evidence of professional liability insurance coverage in
the amount of at least ONE MILLION DOLLARS ($1,000,000) per occurrence and THREE
MILLION DOLLARS ($3,000,000) in the annual aggregate on an occurrence or claims made
form.
Contractor shall ensure that each Health Care Professional maintains and provides evidence of
professional liability insurance coverage in the amount of at least ONE MILLION DOLLARS
($1,000,000) per occurrence and ONE MILLION DOLLARS ($1,000,000) in the annual
aggregate on an occurrence or claims made form.
C. Contractor shall promptly notify GHC in writing pursuant to Section XVI. of any material
changes in the type or levels of liability insurance coverage.
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D. Contractor shall inform GHC, by notice as specified in Section XVI., of: 1) any state or federal
administrative sanctions on Contractor or Consultative Specialist, and such notice shall occur
promptly, and 2) the commencement or resolution of malpractice actions by Managed Care
Members and all malpractice settlements by any patients within fifteen (15) days. Malpractice
settlement information involving patients who are not Managed Care Members may be reported
in a de -identified manner.
E. It is understood and agreed by the parties that any issues of professional liability arising from
patient care rendered pursuant to this Agreement shall be resolved between the parties in
accordance with the laws of the state where patient care was provided.
F. Contractor shall be solely responsible for expenses connected with the defense, settlement or
payment of monetary damages in any action or claim arising from the willful or negligent acts
or omissions of Contractor, its agents or employees. To the fullest extent permitted by law,
Contractor shall defend, indemnify and hold GHC, its directors, trustees, officers, agents,
contractors, and employees, harmless from and against any and all claims, demands, liabilities,
damages, and expenses (including attorneys' fees) arising out of or resulting from the acts or
omissions of Contractor, its employees or agents, regardless of whether any such claim,
demand, liability, damage, or expense is alleged to have been caused in whole or in part by a
party indemnified hereunder. The liability of Contractor for indemnity hereunder shall extend
only to the extent of the negligence of Contractor, its employees, or agents, including in the
case of any concurrent negligence on the part of the party or parties indemnified hereunder.
Such obligation shall not be construed to negate, abridge, or otherwise reduce any other right or
obligation or indemnity that would otherwise exist as to any party or person described in this
section. This indemnity provision is not limited to, but specifically applies to, any situation in
which GHC is sought to be held vicariously liable for the acts or omissions of Contractor, its
employees, or agents to the fullest extent permitted by law.
G. GHC shall be solely responsible for expenses connected with the defense, settlement or
payment of monetary damages in any action or claim arising from the willful or negligent acts
or omissions of GHC, its agents or employees. To the fullest extent permitted by law, GHC
shall defend, indemnify and hold Contractor, its directors, trustees, officers, agents, and
employees, harmless from and against any and all claims, demands, liabilities, damages, and
expenses (including attorneys' fees) arising out of or resulting from the acts or omissions of
GHC, its employees or agents, regardless of whether any such claim, demand, liability, damage,
or expense is alleged to have been caused in whole or in part by a party indemnified hereunder.
The liability of GHC for indemnity hereunder shall extend only to the extent of the negligence
of GHC, its employees or agents, including in the case of any concurrent negligence on the part
of the party or parties indemnified hereunder. Such obligation shall not be construed to negate,
abridge, or otherwise reduce any other right or obligation or indemnity that would otherwise
exist as to any party or person described in this section. This indemnity provision is not limited
to, but specifically applies to, any situation in which Contractor is sought to be held vicariously
liable for the acts or omissions of GHC, its employees, or agents to the fullest extent permitted
by law.
VII. Payment for Services
A. P itna� y„inent:
Health Carrier shall compensate Contractor as specified in the Financial Terms
attachment(s) of this Agreement and in accordance with this section for authorized
Covered Services and for Covered Services for which an authorization is not required
by law. Contractor shall accept such payment as full payment for Covered Services
less any Coinsurance, Copayments and Deductibles as required by the Medical
Coverage Agreement.
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2. Contractor shall be responsible for collecting from Managed Care Member any
applicable Coinsurance, Copayments, and Deductibles in accordance with the terms of
the Managed Care Member's Medical Coverage Agreement; provided, however, that
any Coinsurance or Deductible amount collected at the time of service must be a good
faith estimate of the amount due based on the contracted rate of reimbursement for the
service and plan design. Furthermore, once the actual Managed Care Member
responsibility is determined, Contractor agrees to refund any overpayments to Managed
Care Member within thirty (30) days of the date the Contractor receives an explanation
of payment or explanation of benefits. Health Carrier shall be responsible only for the
amount due for Covered Services rendered to Managed Care Member less the Managed
Care Member's Copayment, Coinsurance and Deductible, as applicable, without regard
to whether Contractor has actually collected such Copayment, Coinsurance and
Deductible. Contractor agrees that it may request, but will not require, payment of any
applicable Copayment, Coinsurance or Deductible as a prerequisite to providing
Covered Services.
3, If authorization for Covered Services is required under the terms of the Managed Care
Member's Medical Coverage Agreement but not obtained by Contractor, Contractor
agrees not to bill Health Carrier or Managed Care Member for such services, except
Managed Care Member may be billed in accordance with written agreement obtained
pursuant to Section IIID. of this Agreement. In the event the Managed Care Member
was not eligible for Covered Services on the date of service, Health Carrier, to the
extent required by state law, shall be financially liable only for Covered Services that
had prior authorization from the Health Carrier and were not provided or obtained
through material misrepresentation.
4. GHC and Contractor mutually agree to comply with payment recovery standards as
defined in RCW 48.43.600 and 48.43.605 and set forth in the Provider Manual.
B. ' ccogd al y,m Payment,: Notwithstanding Subsection D of this section, when information
reasonably available to Contractor indicates that coverage with Health Carrier is secondary,
Contractor shall look first to the primary payer for payment and to the secondary Health Carrier
for any additional payment in accordance with this Agreement, the Medical Coverage
Agreement and with applicable laws and regulations regarding coordination of benefits (COB).
Contractor shall cooperate with Health Carrier in COB efforts when a Managed Care Member
has received services from Contractor. All Health Carrier prior authorization requirements
generally apply, regardless of whether Health Carrier is the primary or secondary payer. When
Medicare is the primary payer, Contractor must follow all applicable Medicare laws and
regulations, including coverage and billing requirements, and bill Health Carrier only for any
additional payment in accordance with this Agreement.
C. Workers'(';°tanapensgio.n: When Contractor provides services to Managed Care Members and
those services are covered under state or federal industrial or self-insured workers'
compensation plans, Contractor shall bill claims as may be required by applicable laws and
regulations and retain all amounts paid thereon as payment in full for services provided to
Managed Care Members.
D. Subr'o )g For subrogation purposes, Contractor shall not bill third party insurers for
Covered Services and agrees to inform and assist GHC in handling claims when third party
liability may exist, including the timely provision to GHC of needed information to process
third party billings.
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E,. Billing: Contractor shall submit usual and customary charges on CMS 1500 billing form or
most current version of the form as specified in the Provider Manual. Billing forms shall be
submitted by Contractor within twelve (12) months from date of service. If Contractor fails to
submit billing forms as required, Health Carrier shall have no obligation to pay Contractor nor
may Contractor bill the Managed Care Member for such services.
F. CIainis Processi�t ;,.W t r othe>° ihan a�pitation_,pa a tl :
Health Carrier shall pay claims in a timely manner not to exceed thirty (30) calendar
days from the date of Health Carrier's receipt of a clean claim form or Health Carrier's
determination it is the primary payer. For the purposes of this Section VII.F., a clean
claim form shall be a CMS 1500 claim form, UB claim form, or HIPAA compliant
electronic transaction which, in Health Carrier's opinion, 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 payment.
Health Carrier shall pay or deny all claims within sixty (60) days of receipt or Health
Carrier's determination it is the primary payer, except such time may be extended as
agreed upon in writing by Health Carrier and Contractor on a claim -by -claim basis.
Payment according to the terms of Section VILE shall not apply to claims about which
there is substantial evidence of fraud or misrepresentations by Contractor, or for
instances when Health Carrier has not been granted reasonable access to information
under Contractor's control. The date of receipt of a claim is the date Health Carrier
receives either written or electronic notice of claim. Health Carrier shall establish a
reasonable method for confirming receipt of claims and to respond to Contractor
inquiries about claims. Denial of claims must be communicated to Contractor and must
include specific reasons for the denial. When claims are denied for reasons of medical
necessity, Health Carrier must be prepared to disclose the supporting basis for the
decision. Health Carrier assumes ultimate responsibility for assuring provisions of this
section are in compliance should claims payment be delegated to a third party.
If Health Carrier fails to: a) pay ninety-five percent (95%) of Contractor's total
monthly volume of clean non -Medicare claims submitted under this Agreement within
thirty (30) days of receipt or Health Carrier's determination it is the primary payer, and
b) pay or deny ninety-five percent (95%) of Contractor's total monthly volume of all
non -Medicare claims within sixty (60) days of receipt or Health Carrier's determination
it is the primary payer, Health Carrier shall pay interest to Contractor as calculated and
set forth herein. Health Carrier shall pay Contractor simple interest at the rate of one
percent (1%) per month on any clean non -Medicare claims not paid or denied within
sixty (60) days of receipt from Contractor. Interest shall start accruing on the sixty-first
(61) day after the receipt of a clean non -Medicare claim by Health Carrier and shall be
prorated for any portion of a month outstanding. Health Carrier shall add the interest
payable to the amount of the unpaid non -Medicare claim.
VIII. Recordkeeping Reguil-CUIC11ts
A. Contractor shall document health care services provided to Managed Care Members and
maintain health care information of Managed Care Members in the form and manner required
by law, acceptable medical practice and professional ethics.
B. Contractor and GHC shall maintain and protect the confidentiality of health care information as
provided by state and federal law.
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C. Either party shall have the right, upon reasonable request and at no expense to the other party,
to inspect any accounting, administrative, billing and health care information maintained by
Contractor or GHC which specifically pertain to services rendered to Managed Care Members
pursuant to this Agreement. Contractor and GHC agree not to charge the other party for the
first copy of each record requested.
D. Contractor shall make health care information available to GHC and appropriate state and
federal authorities involved in assessing the quality of care or investigating the grievances or
complaints of Managed Care Members, including those required under 42 CFR 422.562(a),
subject to applicable state and federal laws governing confidentiality of such records.
E. Contractor shall collect and submit all Managed Care Member encounter data required under
42 CFR 422.310, 42 CFR 422.516 and state Medicaid requirements. Pursuant to 42 CFR
422.504(1)(3) Contractor further certifies that by signing this Agreement, Contractor attests to
the accuracy, completeness and truthfulness of encounter data that Contractor submits as
required by 42 CFR part 422.
IX. Trainine. Education and Orientation
The parties agree to arrange for an orientation to the clinical and administrative procedures of the GHC
system, including those described in the Provider Manual, and the services covered under the Medical
Coverage Agreement for all Consultative Specialists and other employees or representatives of
Contractor who may have a need to know. GHC shall make available to Contractor a copy of the
Provider Manual and other policies and procedures that describe administrative requirements necessary
for Contractor to meet the terms and conditions of this Agreement.
GHC is required by law to ensure that entities with whom it contracts receive certain training and
education regarding the fraud, waste and abuse compliance requirements. Entities who have met fraud,
waste and abuse certification requirements through enrollment in the Medicare program are deemed to
have met these requirements. Contractor shall ensure that its employees and subcontractors also receive
such training as required by CMS. For more information on fraud, waste and abuse examples as well as
how to report a concern to GHC, please see the Provider Manual.
X. Quality lnn prOventent and ,'are Mane ement
Contractor shall cooperate with Health Carrier in care management activities, quality assurance
programs, health care information audits, and other activities deemed appropriate by Health Carrier for
ensuring quality of care and patient satisfaction. Contractor further shall comply fully with Health
Carrier's Medicare enrollee grievance process as required under Subpart M of 42 CFR part 422. Health
Carrier consults with Physicians who provide services to Managed Care Members regarding quality
assurance, care management and other such activities for assuring the provision of quality services.
GHC and Contractor acknowledge that GHC retains the responsibility for notifying Managed Care
Members when a practitioner leaves Contractor or when the Agreement with Contractor is terminated.
XI. Medicaid and Medicare Contracting Requirements
uirements
A. Contractor agrees that by signing this Agreement, Contractor has not entered into an
employment arrangement or subcontract with Physicians which includes financial incentives
reportable to CMS or HCA as required in Sections 1876(1)(8), 1903(m)(2)(A)(x) and
1903(m)(5)(A)(v) of the Social Security Act and in accordance with regulations developed in
42 CFR 43 4.70, 42 CFR 422.208 and 42 CFR 422.210.
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Contractor shall notify GHC in writing pursuant to Section XVI, if during the term of this
Agreement Contractor enters into employment relationships or subcontracts which are
reportable to CMS or HCA. In the event Contractor fails to provide information to GHC about
such employment arrangements or subcontracts during the term of this Agreement, this
Agreement may be immediately terminated by GHC. Contractor shall fully reimburse GHC for
any penalties assessed to GHC by CMS or I4CA because of Contractor's failure to inform
GHC.
B. Contractor further agrees that, consistent with federal law, Contractor will not use
reimbursements to Physician employees or subcontractors as an inducement to limit or deny
medically necessary services to Managed Care Members.
C. When Contractor provides services to Washington State Medicaid enrollees who are Managed
Care Members, Contractor shall comply with all applicable Medicaid primary care
requirements including, but not limited to, those set forth in the Provider Manual.
D, When Contractor provides services to Medicaid enrollees who are Managed Care Members,
Contractor shall comply with all applicable state and federal regulations governing the state
Medicaid program, including 42 CFR 438.106(c), 438.6 (1), 438.230, and 438.204(a), and
WAC 182-502-0160, and as set forth in the Provider Manual, which prohibit Contractor from
charging, balance billing or holding liable Medicaid enrollees for covered services.
E. Contractor shall require its employees and subcontractors to comply with the requirements in
this section and applicable Medicare requirements in accordance with 42 CFR parts 422 and
423.
F. Contractor acknowledges that GHC is accountable to CMS and HCA for assuring compliance
with Medicare and Medicaid standards and regulations. This Agreement, or any Contractor
subcontracts, does not terminate GHC's accountability.
G. Pursuant to Section 1128 of the Social Security Act, Contractor hereby certifies by signing this
Agreement that Contractor has not been convicted of crimes as specified in Section 1128,
excluded from participation in the Medicare or Medicaid program, or assessed a civil penalty
under the provisions of Section 1128. Contractor stipulates that it does not have a GHC
authorized subcontract with an entity convicted of a crime specified in Section 1128.
Contractor further certifies that pursuant to Section 1932 (d)(1) of the Social Security Act,
Contractor does not knowingly have a director, officer, partner, employee, consultant,
subcontractor or person who is significant or material to the provision of services under this
Agreement, who has been, or is affiliated with someone who has been, debarred, suspended, or
otherwise excluded by any federal agency, nor has Contractor been debarred or excluded from
any federal program.
H. GHC and Contractor agree that all activities performed under the Agreement will be clearly
defined and include any associated reporting responsibilities as required under 42 CFR
422.504(i)(3)(ii) and 42 CFR 422.504(i)(4)(i).
Contractor acknowledges the obligation and authority of GHC and CMS to monitor the
performance and revoke where necessary any applicable activities performed under the
Agreement if the activities as defined in the Agreement are determined to be unsatisfactory as
outlined in 42 CFR 422.504(i)(3)(ii) and 42 CFR 422.504(i)(4)(ii)-(iii).
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In accordance with 42 CFR 422.504(g)(1)(iii), Managed Care Members eligible for both
Medicare and Medicaid will not be held liable for Medicare Part A and B cost-sharing
(Coinsurance, Copayments and Deductibles) when the State is responsible for paying such
amounts. GHC sets forth in the Provider Manual information about Medicare and Medicaid
benefits and rules for Managed Care Members eligible for Medicare and Medicaid. Contractor
may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted
with respect to the Managed Care Member under title XIX if the individual were not enrolled in
such a plan. Contractor will: (1) accept Health Carrier payment as payment in full, or (2) bill
the appropriate State source.
XII. Duration and Termination
A. The term of this Agreement shall be for a period of two (2) years, commencing January 1,
2016, and expiring December 31, 2017. This Agreement will automatically renew from year to
year thereafter unless either party has given the other party ninety (90) days prior written notice
of its intent not to renew the Agreement.
B. The material breach of any part of this Agreement, which includes, but is not limited to,
imposition of any state or federal sanctions on Contractor or Contractor's inability to provide
services hereunder, shall be grounds for its immediate termination. In addition, in the event of
a change in the organization of a party that results in creation of a successor organization, the
other party shall have the right to terminate the Agreement upon ninety (90) days' prior written
notice under Section XIII.C.
C. Either party may terminate this Agreement without cause upon giving ninety (90) days' prior
written notice of its intent to terminate. This Agreement may also be terminated upon the
mutual written agreement of the parties.
D. Notwithstanding other provisions of this Agreement, this Agreement shall terminate as to
specific Consultative Specialists as a result of the following:
1. This Agreement shall terminate immediately with respect to a Consultative Specialist
when: a) his/her state license, certification or registration to practice is revoked,
terminated or suspended for any reason, or he/she is subject to any federal or state
administrative sanction, b) he/she ceases to actively practice medicine, c) he/she
terminates employment with Contractor, or d) if, in the opinion of GHC, continued
service to Managed Care Members by him/her would reasonably constitute a threat to
the well-being of any Managed Care Member. With regard to Subsections a) through
c) Contractor shall give notice to GHC within three (3) days in the manner specified in
Section XVI. of this Agreement. With regard to Subsection d), GHC shall notify
Contractor when GHC determines, in its sole discretion, that a Consultative Specialist
reasonably constitutes a threat to the well-being of any Managed Care Member.
2. If this Agreement terminates with respect to one or more Consultative Specialists under
this section, Contractor shall immediately ensure that no Covered Services are provided
to Managed Care Members by the terminated Consultative Specialist. Contractor shall
immediately inform GHC if Covered Services cannot be adequately provided to
Managed Care Members.
E. If, in the opinion of GHC, continued service to Managed Care Members by Contractor would
reasonably constitute a threat to the well-being of any Managed Care Member, GHC may
immediately terminate this Agreement.
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F, If this Agreement is terminated under any circumstances, Contractor shall cooperate fully with
GHC to ensure the transfer of Managed Care Members to other contractors.
& In addition to the foregoing requirements, in the event of termination of this Agreement,
Contractor shall complete active treatment as directed by GHC for any Managed Care Member
currently under Contractor's care at the time of termination, limited to a maximum period of
ninety (90) days with the exception of maternity services. GHC shall compensate Contractor
for such Managed Care Members according to the terms and conditions of this Agreement.
XIII. General Provisions
Ad Nondiscrimination: The parties agree not to discriminate against persons and to render services
without regard to race, sex, gender or gender identity, marital status, religion, creed, national
origin, color, age, health status, physical or mental disability, Vietnam Era veteran or disabled
veteran status or other groups protected by law. Additionally, the parties agree to develop and
maintain policies and procedures that demonstrate they do not discriminate in the delivery of
health care services.
B. ,A s,ttmcat,: This Agreement may not be assigned or transferred by Contractor or GHC
without prior written consent of the other party. GHC may not assign this Agreement without
the prior written consent of the Washington Health Care Authority (HCA), if required when
Managed Care Members include Washington State Medicaid enrollees. Subcontracts relating
to the provision of services subject to this Agreement to Managed Care Members shall not be
assigned without the approval of GHC and HCA, when applicable, except when such
subcontracts are assigned to a wholly owned affiliate or controlled subsidiary or parent
corporation. The terms of this Agreement shall be binding upon and inure to the benefit of the
parties hereto and their respective heirs, and successors in interest.
C. Si!cce ,sorship: In the event of a change in the organization of Contractor or GHC that results
in the creation of a successor organization to Contractor or GHC, the party experiencing the
change shall provide the other party with sixty (60) days' prior written notice pursuant to
Section XVI. During the sixty (60) day notice period, the party receiving notice may consent to
the assignment of this Agreement to such successor organization (pursuant to Section XIII.B.
above) or may withhold such consent and choose to terminate this Agreement upon giving
ninety (90) days' prior written notice.
D. Records Retention and lns pe t9p: Both parties shall comply with 42 U.S.C. 1395x(v)(1)(I)(i),
42 CFR 420.302, 42 CFR 434.6, and 42 CFR 422.504 as currently stated or as may be
amended. The acts, among other things, provide that GHC agrees, and shall require all related
entities, contractors or subcontractors to agree to cooperate with audits performed by duly
authorized representatives of the State of Washington, the federal Department of Health and
Human Services, auditors from the federal Government Accountability Office, federal office of
the Inspector General, and federal Office of Management and Budget. The duly authorized
representative's (as listed above) right to audit, evaluate and inspect any pertinent information
including, but not limited to, any books, contracts, computer or other electronic systems
(including medical records and documentation) of Contractor and any subcontractors for any
particular contract period will exist through ten (10) years from the final date of the contract
period or from the date of completion of any audit whichever is later. Contractor shall retain,
and require subcontractors to retain, such records for the period of time necessary to comply
with these requirements.
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E. Attorney Fees: Except as provided for under Section VI., in the event of any action for relief,
declaratory or otherwise, which arises between the parties, the prevailing party shall recover
reasonable attorney's fees and costs.
F. Non-exclusive: Contractor and GHC expressly acknowledge that nothing in this Agreement
shall be construed to prevent GHC or Contractor from simultaneously contracting with, or
otherwise obtaining or providing services from or to any other person or entity.
G. !Conl 'entiality,: Except as authorized by both Contractor and GHC, as required by applicable
laws and regulations, or as necessary to effectively carry out this Agreement, the terms of this
Agreement shall not be divulged, in whole or part, by either party, its agents, employees, or
subcontractors to any third party other than by GHC to a Health Carrier, a reinsurer, or a third-
party consultant under contract with either GHC, a plan sponsor or a self-insured welfare
benefit plan.
H. ConiniunicalJons: Any publicity by Contractor mentioning this Agreement or provision of
health care services as a result of this Agreement shall be agreed upon by GHC in writing prior
to release.
L Mar tin Del Ariy tisir : Contractor shall allow Health Carrier to include information about
Contractor's participation in the Health Carrier's provider network in marketing, advertising,
educational and other materials necessary to inform Managed Care Members. Health Carrier
has sole discretion to decide whether to include Contractor in any such written or electronic
materials.
J. Suns_: The parties may agree to install appropriate signage as requested by Health Carrier to
identify Contractor as a Health Carrier-designated provider. Size, color, dimensions, location
and other decisions regarding actual installation shall be subject to mutual agreement by the
parties.
K. Modil"aealion: This Agreement supersedes any and all other agreements, either oral or in
writing, between the parties with respect to the subject matter hereof. This Agreement,
including attachments, signed by the parties hereto constitutes the entire understanding of the
parties. GHC may amend this Agreement at any time by sending the amendment in writing to
Contractor at least sixty (60) days in advance of the amendment's effective date. Such
amendment shall be deemed to be accepted unless Contractor gives written notice to GHC at
least thirty (30) days prior to the effective date of the amendment.
L. Survival: The provisions set forth in Sections VI., VII., VIII., XII.F., XII.G., XIII.D., XIII.G.
and XIV. shall survive termination or expiration of this Agreement.
M. Waiver: Waiver of any breach of any provision of this Agreement shall not be deemed to be a
waiver of any subsequent breach and shall not be construed to be a modification of the terms of
this Agreement. Further, GHC's failure to insist on strict compliance with any of the terms of
this Agreement, or GHC's failure to pursue a right under this Agreement, shall not be deemed
to be a waiver, nor shall any such failure at any time be deemed to be a waiver at any other time
of any right under this Agreement.
N. tv onformy: If state or federal laws or regulations change and affect any provision of this
Agreement, this Agreement will be deemed amended to conform with those changes the date
the law or regulation becomes effective.
O. ily: Nothing contained in this Agreement shall be construed to require either party to
act contrary to law. Whenever there is a conflict between any provision of this Agreement and
any present or future statute, law, ordinance, or regulation, the affected provisions of this
Agreement shall be severed to the extent necessary to bring the Agreement within the
requirements of the law or regulation.
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R Abuse cportil : Contractor shall comply with applicable state and federal laws regarding
abuse of children, adult dependent persons, developmentally disabled persons and vulnerable
adults.
Q, 1�ol e Mgj tkpq: Neither party shall be deemed to be in violation of this Agreement if it is
prevented from performing its obligations for reasons beyond its control, including but not
limited to, acts of God or of a public enemy, flood or storm, strikes or statute, or rule or action
of any Federal, State or Local government or agency.
R. Governili&_U��<�� : This Agreement is made in accordance with, and shall be interpreted under,
the laws of the State of Washington.
S. Subcontracting: Contractor shall not subcontract with third parties for any Covered Service
provided to Managed Care Members without the prior authorization by GHC. Contractor shall
assure that contracts between Contractor and a subcontractor, or between a subcontractor and
another subcontractor, to perform all or a portion of the duties and obligations Contractor is
obligated to perform under the terms of this Agreement comply with the terms and conditions
of this Agreement as specified by GHC and in accordance with applicable requirements of
WAC 284-43, Medicare, including provisions found under 42 CFR parts 422 and 423, and
Medicaid requirements and other state and federal requirements. Contracts between Contractor
and subcontractors for Covered Services to Managed Care Members shall be in writing, signed
and dated; include payment terms; provide at least ninety (90) days' notice for any subcontract
termination without cause; and include the following provisions required of Contractor in this
Agreement and which shall be written substantially similar to those of this Agreement: Section
III.A., Section III.C. concerning legally allowed self -referrals, Section III.F., Section III.G.,
Section III.H., Section VII.A.I. prohibiting the collection of certain Coinsurance, Copayments
and Deductibles, Section VII.F., Section VIII., Section IX. concerning fraud, waste and abuse
training and education requirements under 42 CFR 422.503(b)(4), Section X., Section XI.
concerning physician financial incentive requirements under 42 CFR 422.208 and 42 CFR
422.210, concerning accountability provisions under 42 CFR 422.504, and concerning cost-
sharing for Managed Care Members eligible for both Medicare and Medicaid, Section XIII.A.,
Section XIII.D., Section XIII.T. and other provisions required under this Agreement as they
may also be required under 42 CFR part 422. GHC reserves the right to review, approve,
suspend or terminate any subcontracts as they pertain to Covered Services provided to
Managed Care Members. Subcontracts shall include provisions acknowledging and agreeing to
GHC's right of review.
T. Additional Governmental ental l .cc Lii em_ont : Contractor and Consultative Specialists shall comply
with all applicable state and federal laws and regulations. Payment made by Health Carrier to
Contractor under this Agreement may include federal funds and accordingly, Contractor
acknowledges and agrees that Contractor and subcontractors are therefore subject to certain
laws that are applicable to individuals and entities receiving federal funds. Contractor agrees to
comply with GHC policies intended to meet the fraud and abuse requirements established under
Medicare, Medicaid and other government payment programs. Contractor agrees to hold
harmless HCA and its employees, and all Managed Care Members served under the terms of
the Medicaid Program agreement in the event of non-payment by Health Carrier. Contractor
further agrees to indemnify and hold harmless HCA and its employees against all injuries,
deaths, losses, damages, claims, suits, liabilities, judgments, costs and expenses which may in
any manner accrue against HCA or its employees through the intentional misconduct,
negligence or omission of Contractor, its agents, officers, employees or subcontractors relating
to the provision of services under this Agreement.
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XIV. Prohibitions on Balance Billing and Illegal Collections Including 1"t-ovisions Mandated and,
� �roweal ura+alar i�V"�eI" 214-4,3�2t1 and. IL+�"" 4g.811.1.111' a
A. Contractor hereby agrees that in no event, including, but not limited to nonpayment by Health
Carrier, Health Carrier's insolvency, or breach of this Agreement shall Contractor bill, charge,
collect a deposit from, seek compensation, remuneration or reimbursement from, or have any
recourse against a Managed Care Member or person acting on their behalf, other than Health
Carrier, for services provided pursuant to this Agreement. This provision shall not prohibit
collection of Deductibles, Copayments, Coinsurance and/or non -Covered Services, which have
not otherwise been paid by a primary or secondary carrier in accordance with regulatory
standards for coordination of benefits, from Managed Care Members in accordance with the
terms of the Managed Care Member's Medical Coverage Agreement.
B. Contractor agrees, in the event of the Health Carrier's insolvency, to continue to provide the
services promised in this Agreement to Managed Care Members of Health Carrier for the
duration of the period for which premiums on behalf of the Managed Care Member were paid
to Health Carrier or until the Managed Care Member's discharge from inpatient facilities,
whichever time is greater.
C. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be
construed to modify the rights and benefits contained in the Managed Care Member's Medical
Coverage Agreement.
D. Contractor may only bill Managed Care Members for Deductibles, Copayments, or
Coinsurance associated with Covered Services and agrees not to bill Managed Care Members
where Health Carrier denies payments because the provider or facility has failed to comply
with the terms or conditions of this Agreement.
E. Contractor further agrees 1) that: the above provisions A, B, C and D of this section shall
survive termination of this Agreernent regardless of t e cause giving rise to termination and
shaalI be construed to be for the benefit or Flealth Carriers Managed Care Members, and 2) that:
this provision supersedes any oral or written contrary agreement now existing or hereafter
entered into between Contractor and Managed Care Members or persons acting on their behalf.
F. If Contractor contracts with other health care providers or facilities who agree to provide
Covered Services to Managed Care Members of Health Carrier with the expectation of
receiving payment directly or indirectly from Health Carrier, such providers or facilities must
agree to abide by the above provisions A, B, C, D and E of this section.
G. In Washington state, willful collection or attempted collection by Contractor of an amount from
a Managed Care Member knowing that collection to be in violation of this Agreement
constitutes a class C felony under RCW 48.80.030(5).
XV. Contractor Dispute Resolution
A. s,cojq_qlmpr atm. 1 ,��ctlautton @tq� : This process sets forth the process for the consideration
and resolution of disputes between GHC and Contractor, except individual Consultative
Specialists may have additional dispute resolution rights as provided under Section V.E. of this
Agreement.
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B. nigIjmtc Resolution Process:
1. Scope of Disputes Subject to This Process: A Contractor may initiate the process set
forth in this section only to address a dispute arising out of this Agreement.
2. Review by GHC: To request review of a dispute, a Contractor must present the dispute
as set forth in this section.
a. To pursue a dispute under this procedure a Contractor must submit a written
request for review to GHC's Medical Director, through his/her designee the
Vice President, Network Management and Provider Relations, at the mailing
address in Section XVI., no later than thirty (30) calendar days following
GHC's act or omission on which the dispute is based. The written request
must set forth a clear and concise statement of GHC's acts and/or omissions on
which Contractor bases the dispute, the specific provisions of this Agreement
that are alleged to have been violated, and a statement of the remedy requested
by Contractor.
Contractor may request that GHC's Vice President, Network Management and
Provider Relations, or his/her authorized designee, meet with Contractor, or
his/her authorized representative, regarding the dispute. Such request for a
meeting must be made at the time the dispute is presented to GHC's Vice
President, Network Management and Provider Relations and Contractor must
otherwise meet the requirements of this section.
b. In the absence of a request for a meeting under this section, GHC's Vice
President, Network Management and Provider Relations, or his/her authorized
designee, may elect to engage in discussions with Contractor regarding the
dispute, or the Vice President may issue a response without such discussions.
C. GHC's Vice President, Network Management and Provider Relations, or
his/her authorized designee, will provide Contractor with a written response to
the dispute no later than the later of i) twenty (20) days following the
completion of discussions (if Contractor requests a meeting or the Vice
President, or designee, elects to engage in discussions) or after meeting with
Contractor or his/her representative as provided in this section, or ii) thirty (30)
days after the Vice President's receipt of the request for review (if Contractor
does not request a meeting and the Vice President elects not to engage in
discussions). This response will set forth the Vice President's final
determination regarding the dispute and, if appropriate, the remedy to be
awarded. If GHC fails to grant or reject a dispute within thirty (30) days of
submission of such dispute, the Contractor may proceed as if the dispute had
been rejected.
d. Billing Disputes: GHC will render a decision on billing disputes within sixty
(60) days of its receipt of the complaint.
Appeals: If the Vice President, Network Management and Provider Relations denies
Contractor's request under Subsection 2 of this section, and Contractor qualifies under
42 CFR 422.202(a) or 42 CFR 422.202(d) as an individual physician or as management
and members of a group of physicians, and the dispute involves actions covered under
42 CFR 422.202(a) or 42 CFR 422.202(d) related to rules of participation and
suspension or termination of a contract, Contractor may appeal such decision before a
hearing panel.
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4. Mediation: If a Contractor has first exhausted the process of review and appeal set
forth above, if applicable and is not satisfied with the final determination of the Vice
President, Contractor may request nonbinding mediation under this section. The
Contractor may also request mediation under this section if GHC failed to grant or
reject the dispute within thirty (30) days from the submission of such dispute. Such
mediation will not preclude Contractor from pursuing judicial remedies.
a. To request mediation, Contractor must siibmit a written request for mediation
to GHC's Vice President, Network Management and Provider Relations (at the
mailing address in Section VL) no later than twenty (20) days following
receipt of the Vice President's final determination under this section.
Contractor's request for mediation will constitute a promise to pay one -hall the
cost of the mediation service and Contractor shall be liable for payment one-
half the cost of the mediation service.
b. The Vice President, Network Management and Provider Relations will forward
Contractor's request for mediation to an Approved Mediator. The Approved
Mediator will be available to conduct the mediation session no later than thirty
(30) days following his/her selection.
The Approved Mediator shall schedule and conduct the mediation no later than
thirty (30) days following his/her selection, unless both GHC and Contractor
agree to a later date.
d. If the mediation process results in an agreement between GHC and Contractor
that resolves the dispute, the terms of that agreement shall be reduced to
writing and implemented by GHC and Contractor. If the mediation process
does not result in an agreement between GHC and Contractor that resolves the
dispute, completion of the mediation process terminates GHC's dispute
resolution process.
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XVI. Notices
All written notices which are required or permitted under this Agreement shall be sent by United States
mail, postage prepaid; delivered by prepaid messenger service; transmitted by facsimile; transmitted by
electronic mail to the recipient's email address, provided below; or delivered in person and shall be
addressed to the respective parties as follows:
To GHC: Vice President
Network Management and Provider Relations
Group Health Cooperative
PO Box 34262
Seattle, WA 98124-1262
Telephone: (206) 988-2000
Facsimile: (206) 988-2001
Email: prnotification@ghc.org
To Contractor: Jefferson County Auditor dba Jefferson County Public Health
David Sullivan, Chairman
615 Sheridan St
Port Townsend, WA 98368
Telephone: (360) 385-9400
Facsimile: (360) 385-9401
Email: OPT OUT
XVII. Subcontractor Disclosure and Approval of A reente i
A. The undersigned represents and warrants that he/she is duly authorized to execute and deliver
this Agreement as set forth below and that this Agreement is binding upon that party in
accordance with its terms.
B. Contractor agrees that by signing this Agreement below, Contractor does not have
subcontracting arrangements with third parties that provide Covered Services to Managed Care
Members.
Group Health Cooperative
Seattle, Washington
Steven Thompson
Title: Vice !'resident, Netw0[k )jgMpjpgR nc� Provider ®Relations
Date:
Jefferson County Auditor dba Jefferson County Public Health
David Sullivan
Title:_ .___. .....
�'haarman .._........_..
Date:
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d
a
ATTACHMENT
Financial Terms
The following terms shall govern payment for services provided by Contractor:
I. Lesser of Billed Charges
Contractor shall be compensated, in accordance with Section VII of this Agreement, with the allowable
amount calculated as the lesser of payment per contract payment terms specified below or billed
charges, less any applicable Coinsurance, Copayments and Deductible amounts.
II. Provider Reimbursement
Provider reimbursement shall be based upon the GHC Provider Reimbursement Schedule. GHC
reserves the right to periodically update the GHC Provider Reimbursement Schedule.
III. Payment terms above apply to the following lines of business:
A. Group Health Options PPO
B. GHO Point of Service (Out of Network)
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