ANCILLARY SERVICE AGREEMENT

Beech Network means the network of Participating Providers.

Copayment, Coinsurance or Deductible means a payment that is the financial responsibility of the Eligible Person for Covered Services as defined under the applicable Plan.

Covered Services means the health care services provided pursuant to a Plan.

Eligible Persons means the persons entitled to receive Covered Services pursuant to a Plan.

Medically Necessary or Medical Necessity means services or supplies that satisfy the Medical Necessity requirements under the applicable Plan.

Network Access Agreement means an agreement between a Payor or one or more intermediaries and Beech or a Beech Affiliate to access the Beech Network.

Participating Providers means those health care providers that have directly or indirectly entered into an agreement with Beech or a Beech Affiliate to provide Covered Services with regard to the Plan applicable to the Eligible Person.

Payors means the parties responsible for the payment of Covered Services rendered to Eligible Persons who have access to the Beech Network pursuant to a Network Access Agreement.

Plans means individual and group health benefit contracts or policies, workers’ compensation programs, managed care and preferred provider organization programs, government programs, other plans or policies that include coverage of or reimbursement for health care expenses, and/or programs paid for by Eligible Persons.

Provider means the provider listed on the signature page of this Agreement and includes any persons employed by such provider and any persons or entities that provide Covered Services under such provider’s tax identification number.

Provider Manual means the manual Beech develops of programs, procedures and policies in order to assist Participating Providers in the orderly flow of communications, claims reimbursement and other critical elements for participation in the Beech Network.  The Provider Manual is available on the internet for the convenience of Participating Providers.  Occasionally, as technology, procedures, and programs change, Beech will update the Provider Manual.  Provider will periodically review the Provider Manual on the internet for updates.

Quality Management Program means the program summarized in the Provider Manual relating to the quality of Covered Services provided to Eligible Persons which program includes, but is not limited to, Beech’s credentialing and recredentialing program.

Utilization Management Program means either the utilization management program established and administered or subcontracted by Beech summarized in the Provider Manual or any utilization management program required by a Payor.

Information.  Provider agrees that Beech and Beech Affiliates may lease, rent or otherwise grant access to Provider’s services under this Agreement to Payors that have access to this Agreement through a Network Access Agreement.  Beech shall make available information regarding the parties that have entered into Network Access Agreements via the internet.  As applicable to the individual Plan, Payors or their designee will provide Eligible Persons with an identification card that bears the name(s) or logo(s) identified by Beech to Provider and/or indicate that Eligible Persons have accessed the Beech Network using the name(s) identified by Beech to Provider on the explanation of payment or remittance advice.

Liability for claims Decisions.  Payors shall be liable for claims decisions and for the payment of Payors’ portions of claims pursuant to the applicable Plan.  Beech is not a Payor and shall not be responsible or liable for any claims decisions or for the payment of any claims submitted by Provider for furnishing Covered Services or non-Covered Services to Eligible Persons.  Beech shall not be an insurer, guarantor or underwriter of the responsibility or liability of any Payor or any other party to provide benefits pursuant to any Plan.

Services and Obligations.  Provider shall:

 

1.

Notification of Charge Master Increases.  Should any charges for Covered Services under this Agreement increase during the term of this Agreement, Beech must be provided with 30 days prior written notice via certified letter signed by the chief financial officer or other responsible officer.  Beech must also be provided with an electronic file of the new charge master list.

 

2.

Adjustment to Discount Rates.  Any percentage discount calculated from those charges may be changed appropriately to ensure that Payor’s reimbursement for a given service remains fixed throughout the term of this Agreement.

 

3.

Right to Audit.  Beech shall have the right to audit records relating to charges for Covered Services under this Agreement in order to assure compliance with and to enforce this provision.  Beech may also audit its own records relating to such charges.  If audit findings indicate an increase in charges, Beech shall provide notice of its findings and any adjustments to the percentage discount.

(1)

To the extent applicable, Payors will comply with all applicable Texas statues and rules pertaining to prompt payment of clean claims with respect to payment or Covered Services under the Agreement, including but not limited to, 28 T.A.C. Section 21.2801, et seq.

(2)

Beech’s claims submission processes are set forth in the Provider Manual.

(3)

Upon request and to the extent required by Texas law, Beech will provide Provider with the information necessary to determine what Provider is being compensated in accordance with this Agreement.  The information shall provide a level of detail sufficient to enable a reasonable person with sufficient training, experience and competence in claims processing to determine the payment to be made to Provider for Covered Services rendered pursuant to this Agreement.  The information shall include a summary and explanation of the payment and reimbursement methodologies used to pay Clean Claims submitted by Provider, including but not limited to fee schedules, coding methodologies, bundling processes, down coding policies, descriptions of any other applicable policy or procedure used by Beech that may affect payment to Provider, and any addenda, schedules, exhibits or policies used by Bee ch in carrying out the calculation of payment of Clean Claims submitted by Provider.  If source information outside the control of Beech, such as state Medicaid or federal Medicare fee schedules, is the basis for fee computation under this Agreement, Beech will identify such source and explain the procedures by which Provider may readily access the source electronically, telephonically, or as otherwise agreed to by the parties.  In complying with this section, Beech shall not be required to provide specific information that would violate any applicable copyright law or licensing agreement.  In such circumstances, Beech shall provide a summary of the information withheld which will allow a reasonable and sufficiently trained and experienced person to determine the payments to be made under this Agreement.  Beech may provide the information by any reasonable method, including by email, computer disks, paper copies, or access to an electronic database and shall provide th e information within thirty (30) days after Beech receives the Provider’s request.  Beech will provide ninety (90) days prior written notice of any amendments, revisions, or substitutions of the information required to be provided by Beech under this section.  Provider is prohibited by law and by this Agreement from using or disclosing the information provided by Beech pursuant to this section for any purpose other than Provider’s practice management, billing activities, and other business operations, or communications with a governmental agency involved in the regulation of health care or insurance.  Provider may not use the information provided by Beech to knowingly submit a claim for payment that does not accurately represent the level, type or amount of services that were actually provided to an Eligible Person or to misrepresent any aspect of the services.  Provider may not rely upon information provided by Beech pursuant to this section about a servic e as a representation that an Eligible Person is covered for that service under the terms of the Eligible Person’s Plan.

(4)

If Provider is compensated on a discounted fee basis, the Eligible Person’s financial obligation for Deductibles or Coinsurance shall be determined based upon the discounted fee and not upon the full billed charge.

(5)

If an Eligible Person is covered under a Plan that requires the selection of a Primary Care Physician and the Eligible Person does not select a Primary Care Physician at the time of application or enrollment, Payor may assign the Eligible Person to a Primary Care Physician if applicable under the Eligible Person’s Plan.  If Payor elects to assign an Eligible Person to a Primary Care Physician, the assignment shall be made to a Primary Care Physician located within the zip code nearest the Eligible Person’s residence or place of employment and, to the extent practicable given the zip code limitation, shall be done in a manner that results in a fair and equal distribution of Eligible Persons among the Primary Care Physicians in the applicable network.  Payor shall inform an Eligible Person of the name, address and telephone number of the Primary Care Physician to whom th e Eligible Person has been assigned and of the Eligible Person’s right to select a different Primary Care Physician.  An Eligible Person shall have the right at any time to reject the Primary Care Physician assigned and to select another physician from the list of Primary Care Physicians for the applicable network.  An election by an Eligible Person to reject an assigned physician shall not be counted as a change in providers under the Texas Insurance Code.  Payor shall notify the Primary Care Physician of the selection of such Primary Care Physician by an Eligible Person within thirty (30) working days of the selection or assignment of the Eligible Person to a Primary Care Physician by Payor.  In the event that Provider is reimbursed on a capitated basis based on the Eligible Person’s Primary Care Physician selection, Payor will begin making payments calculated from that the date of the Eligible Person’s enrollment which shall be no later than sixty (60) days following the date the Eligible Person selected or has been assigned to a Primary Care Physician.  If no such selection or assignment has been made within such sixty (60) day period, the applicable capitation reimbursement shall be held by Payor in reserve until such time as there is a selection and retroactive payments can be made.  Payor will make capitation payments to Primary Care Physicians reimbursed on a capitated basis on or before the fifteenth (15) working day of the month in which services are provided.

(6)

This Agreement does not contain any financial incentive or make any payment that acts directly or indirectly as an inducement to limit Medically Necessary services.  This provision shall not prohibit the savings from cost effective utilization of health services by contracting physicians or health care providers from being shared with physicians or health care providers in the aggregate.

(7)

Provider shall post a notice to Eligible Persons at the Provider’s location on the process for resolving complaints with Beech.  The notice must include the Texas Department of Insurance’s toll-free telephone number for filing complaints.

(8)

Beech shall not engage in retaliatory action, including termination of or refusal to renew this Agreement, because Provider, on behalf of an Eligible Person, reasonably filed a complaint against Beech or has appealed a decision of Beech.

(9)

Beech will not as a condition of this Agreement or in any other manner prohibit, attempt to prohibit or discourage Provider from discussing with or communicating in good faith to an Eligible Person who is a current, prospective or former patient or a party designated by such Eligible Person, with respect to: a) information or opinions regarding the Eligible Person’s health care including the Eligible Person’s medical condition or treatment options; b) information or opinions regarding the provisions, terms, requirements or services of the Eligible Person’s health benefit plan as they relate to the medical needs of the Eligible Person; c) the fact that a Provider’s participation with Beech has terminated or that Provider will otherwise no longer be providing care to Eligible Persons; or d) the fact that, if Medically Necessary Covered Services are not available through Particip ating Providers, Payors must, upon the request of the Provider, and within time appropriate to the circumstances relating to the delivery of the services and the condition of the Eligible Person, but in no event to exceed five (5) business days after receipt of reasonably requested documentation, allow referral to a non-Participating Provider.  Beech will not in any way penalize or terminate Provider and Payors will not refuse to compensate Provider for Covered Services for communicating with an Eligible Person who is a current, prospective or former patient, or a party designated by Eligible Person, in any manner protected by this provision.

(10)

The Termination section of the Agreement is amended to the following extent:

 

(A)

For Cause.  Notwithstanding anything to the contrary set forth in the Agreement, a party may only terminate the Agreement for cause upon ninety (90) days prior written notice, except that Beech may terminate the Agreement immediately for the following reasons:  (a) cases involving imminent harm to patient health, (b) an action by a state medical board, other medical licensing board, or other licensing board or other government agency, that effectively impairs the Provider’s ability to practice, or (c) a case of fraud or malfeasance.

 

(B)

With Notice.  This Agreement may only be terminated with notice upon at least ninety (90) days’ prior written notice by either party.  To the extent that the Agreement provides for a longer notification period with regard to a termination with notice, that notification period will apply.

 

(C)

Notice and Hearing. If Beech should choose to terminate this Agreement, Beech will notify Provider of this decision in writing.  The notice will include the reason(s) for the termination and a notice of the right to request a hearing or review.  On request and before the effective date of the termination, but within a period not to exceed sixty (60) days, Provider shall be entitled to a review of the proposed termination by an advisory review panel.  If the termination affects participation with respect to HMO Plans, the advisory review panel shall be composed of providers appointed by Beech, including at least one representative in the affected provider’s specialty or a similar specialty, if available, who serve on a standing Quality Management committee or Utilization Management committee.  0;When an advisory review panel decision is requested, Eligible Persons will not be notified of the termination until such advisory review panel decision is rendered unless the case involves imminent harm.  The decision of the advisory review panel must be considered but is not binding on Beech.  On request, a copy of the recommendation of the advisory review panel and Beech’s determination shall be given to the Provider.  If Provider is unsatisfied with the determination, Provider may appeal the decision further pursuant to the Dispute Resolution procedures specified in the Agreement and Provider Manual.

 

(D)

Imminent Harm, disciplinary actions and fraud.  The requirements requiring notice and hearing set forth in Section C. above do not apply in cases involving imminent harm to patient health, an action by a state medical board, other medical licensing board, or other licensing board or other governmental agency that effectively impairs Provider’s ability to practice, or fraud or malfeasance.

 

(E)

In the event of a termination, Provider shall give reasonable advance notice of such termination to those Eligible Persons whom Provider is currently treating and who are affected by the termination.  Payor will provide assistance to Provider to the extent required by Texas law.

 

(F)

If Provider is a physician group or PHO, sections (A) through (E) above shall also apply to the termination of a Represented Physician’s or other Represented Provider’s participation under the Agreement.  With respect to such Represented Physicians or Represented Providers, the references to Provider in section (A) through (E) above shall mean Represented Physician or Represented Provider, as applicable.

 

(1)

This Agreement is between Provider and Beech.  Beech is contracting on behalf of Payors and/or their representatives to provide such Payors with access to Provider’s services at the contracted reimbursement rate for Covered Services rendered to injured Eligible Persons under a workers’ compensation Plan.  A list of parties that have entered into a Network Access Agreement and may access Provider’s services under this Agreement for workers’ compensation Plans is set forth at the Beech internet site.

 

(2)

Provider has agreed to provide treatment to injured Eligible Persons who obtain Covered Services through the Beech workers’ compensation health care network under the terms and conditions of the Agreement, as amended.

 

(3)

With respect to Covered Services rendered to Eligible Persons in a workers’ compensation Plan, the following provisions shall apply to the extent required under Texas law:

 

a)

Except as provided in Texas Insurance Code §1305.451(b)(6), Provider and Beech will not bill or attempt to collect any amount of payment from an Eligible Person for Covered Services under any circumstances, including the insolvency of the workers’ compensation insurance carrier or Beech;

 

b)

Provider agrees to participate in the medical case management process as required by Beech or its designee, including participation in return to work planning.  Provider agrees to follow treatment guidelines, return-to-work guidelines and individual treatment protocols adopted by Beech or its designee pursuant to 28 TAC 10.83 (relating to Guidelines and Protocols), as applicable to an Eligible Person’s injury;

 

c)

Treatment shall not be denied solely on the basis that the treatment for the compensable injury in question is not specifically addressed by the treatment guidelines referenced in subsection (b) above.

 

d)

Beech will not engage in retaliatory action, including termination of or refusal to renew a contract, against Provider because Provider has, on behalf of an Eligible Person reasonably filed a complaint against, or appealed a decision of, Beech, or requested reconsideration or independent review of an adverse determination;

 

e)

Upon termination of Provider’s participation in Beech’s workers’ compensation network, 1) upon Provider’s request, Payor shall continue to reimburse Provider for a period not to exceed 90 days at the contracted rate for Covered Services rendered to an Eligible Person with a life-threatening condition or an acute condition for which disruption of care would harm the Eligible Person; and 2) any dispute concerning continuity of care shall be resolved through the complaint resolution process under Texas Insurance Code §§1305.401 – 1305.405 and 28 TAX 10.120, et seq. relating to complaints;

 

f)

In the event that Beech terminates Provider’s participation in its workers’ compensation network, except for a termination due to contract expiration, 1) Beech will provide at least 90 days advance notice of the termination; 2) upon receipt of the written notification of termination, Provider may request a review by an advisory review panel not later than 30 days after receipt of the notification of termination; 3) the advisory review panel will consist of at least three providers of the same licensure and the same or similar specialty as Provider and the advisory panel review must be completed before the effective date of the termination; 4) Beech may not notify Eligible Persons of the termination until the earlier of the effective date of the termination or the date the advisory review panel makes a formal recommendation; and 5) in the case of imminent harm to patient health, suspension or loss of license to practice, or fraud, Beech may terminate Provider immediately and affected Eligible Persons will be notified immediately of the termination.

 

g)

If Provider terminates Provider’s participation in Beech’s workers’ compensation network, Beech will provide notification of the termination to Eligible Persons receiving care from Provider.  Beech shall give such notice immediately upon receipt of Provider’s termination request or as soon as reasonably possible before the effective date of termination;

 

h)

Provider will post, in the office of Provider, a notice to employees on the process for resolving workers’ compensation health care network complaints in accordance with Texas Insurance Code §1305.405.  The notice must include the department’s toll-free telephone number for filing a complaint and must list all workers’ compensation health care networks with which Provider contracts;

 

i)

Beech or its designee will furnish to Provider, and Provider agrees to abide by, the list of any treatments and services that require Beech’s or its designee’s preauthorization and any procedures to obtain preauthorization;

 

j)

This Agreement and any subcontract shall not be interpreted to involve a transfer of risk as defined under Texas insurance Code §1305.004(a)(26);

 

k)

Provider and any permitted subcontracting provider must comply with all applicable statutory and regulatory requirements under federal and state law;

 

l)

Provider shall be reimbursed for Covered Services based on the reimbursement terms specified in the Agreement.  Such terms may be different from the state workers’ compensation fee schedule.  Additional information about reimbursement is available upon request to Beech;

 

m)

To the extent that Provider is a primary care physician, Provider agrees to be a network treating doctor and to comply with the requirements applicable to network treating doctors under applicable federal and state law;

 

n)

Billing by and payment to Provider will be made in accordance with Labor Code §408.027 and other applicable statutes and rules; and

 

o)

Provider shall make referrals to other Participating Providers or request referrals to non-Participating Providers if Medically Necessary services are not available from Participating Providers.  To the extent permitted by law, any such referral to a non-Participating Provider must be approved by Beech or its designee.  Beech or its designee will respond to such referral request not later than the 7th day after it is requested or sooner if circumstances require it to be expedited.  If such referral request is denied, the Eligible Person may appeal the decision pursuant to the appeal process specified in Insurance Code 1305 Subchapter 1.

 

(4)

Nothing in this Addendum shall be construed to limit in any way the rights or obligations of the parties as set forth in the Agreement unless required by law.  Any defined terms referenced in this Amendment shall have the same meaning as in the Agreement, unless otherwise defined in this Amendment or another definition is required by law.