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HomeMy WebLinkAboutAmerigroup-12/7/2015ArnE.rigrtu • AOAn(IwrTI Corflpany Attn: Network Development P0 Box 62605 Virginia Beach, VA 2346&9965 August 7, 2015 Waterloo Fire Rescue 425 E 3rd St Waterloo, !A 50703-3511 Dear Health Care Provider: Amerigroup Iowa (Amerigroup) responded to the Request for Proposal (RFP) from the owa Department of Human Services to provide managed hcalth care services for enrollees of the Iowa High Quality Healthcare lnitiative program - a coordinated care program for owa Medicaid beneficiaries. We request your support and invite you to consider becoming part of our provider rietwork to help us deliver care to those who need it most. Reasons to considerjoining our network Amerigroup focuses exdusively on Medicaid, SCHIP, Long Term Services & Supports (LTSS), Behavioral I-Iealth and Medicare progranls. - The Amerigroup family of companies has more than 19 years of experiencc managing Medicaid programs for approximately 5.6 rnillion lives, and we understand the unique needs of the Medicaid population - particularly pregnant women, children, seniors and people with disabilities. - We help providers promote a higher quality of health care through our direct outreach efforts and preventive programs for prenatal care and people with asthma or other conditions. - We are recognized by the National Committee for Quality Assurance for our industry-Ieading disease management programs. - We have extensive experience in providing services and supports to LTSS members in over seven states and tailor our programs to each state. We expand access to home- and community-based care and services that foster independence. We achieve this through a comprehensive service coordination process aimed at improving health outcomes for our rnembers. - We focus on the whole person and recognize a clear need to combine physical and behavioral health care. Doing so improves health outcomes and reduces cost. We've supported thousands of members in achieving their own recovery goals through health care system integratiori by creating health programs and care management plans that address physical and behavioral health needs, as well as social supports for members and their families. • Network providers are our customers, too. - We offer extensive provider services, including fast and accurate electronic claims submission and payment; online eligibility verification, claims submission and preauthorizations; ocal support through Provider Relations representatives and telephonic customer care services 24 hours a day, 7 days a week. July 2015 IAPEC-0007-15 We want you to join us! The enclosed packet contains an Amerigroup lowa agreement and supporting forms (credentialing information), as well as more lnformation about AmerigroUp programs. It is important to note that the agreement will only become binding if Amerigroup Iowa 15 awarded the Medicaid busiriess by the Iowa Department of Human Services. Please take the first step to join our network by completing and signing alt appropriate information and faxing it to 1-855-832-7289 or emailing it to j0amedicaidamerigroUp.c0m. Alternatively, you may use the enclosed postage -paid envelope to return your completed agreement by mail. We must receive your signed agreement by September 14th 2015. If you have questions, please caII our Network Development department at 1-855-789-7989. Amerigroup 15 excited about the prospect of working with you to serve lowa High Quality Health Care Initiative program beneficiaries. We hope you will join us, and we thank you for your time and consideration. Sincerely, Melisa Hinders, BA, BSN StaffVice President, Network Devetopment AmerigroUp Iowa, Inc. July 2015 IAPEC-0007-15 AMERIGROUP PROVIDER AGREEMENT WITH Waterloo Fire Rescue A Ancillary I-lybrid Agreement 08-2015 AMERIGROIJP PROVIDER AGREEMENT This Provider Agreement (hereiriafter Agreement") is made and entered into by and between ArnerigrOUp owa, Inc. (hereinafter Amerigroup') and Watertoo Fire Rescue (hereinafter IrproviderII), effective as of INe date set farth immediate!y below Anierigroup'S signature (the 'Effective Date"). ARTICLE 1 DEFINITIONS 'Affdiate" rneans any entity that is: (1) owned or controUed, either directly or through a parent or subsidiary entity, by Arnerigroup, or any entity which controls or is under carnmon control with Amerigroup and/or (ii) that is identified as an Affihiate an a designated web site. Unless otherwise set farth in the Participation Attachment(s), Affihiate may access the rates terrns and canditionS af this Agreement. "Agency" means a federal, state ar Iocal agency, administration, board or other governing body with jurisdiction over the governance or adrninistratiOn of a Health Benefit Ptan. "Audit" rnearis a review af the Claim(s) and supporting clinical infarmation subrnitted by Provider to ensure payment accuracy. The review ensures Claim(s) comply with all pertinent aspects af payment including, but nat hmited to, contractual terms, Regulatory Requirements, Coded Service Identifiers (as defined in the PIan Campensation Schedule ("PCS")) guidelines and irtstructions, Amerigroup medical policies and clinical utilization rnanagement guidelines, reimbursement policies, and generaily accepted medical practices. Audit does not include medical record review for quality and risk adjustment initiatives. "Claint' means either the uniform bill claim form or electronic claini forrn in the format prescribed by Plansubmitted by a provider for payrnent by a PIan for Health Services rendered to a Member. "CMS" means the Centers for Medicare & Medicaid Services, an administrative agency within the United States Department of Health & Hurnan Services ("HHS"). "Amerigroup Rate" means the lesser of Provider's Charges for Covered Services, ar the total reimbursement arnount that Provider and Amerigroup have agreed upon as set forth iri the P05. The Amerigroup Rate includes applicable Cost Shares, and shall represent payment in full to Providerfor Covered Services. "Cost Share" means, with respect to Covered Services, an amount which a Member is required to pay under the terms af the applicable Health Benefit Plan. Such payment may be referred to as an allowance, coinsurance, copaynient, deductible, penalty or other Member payment responsibility, and may be a fixed amount or a percentage of applicable payment for Covered Services rendered to the Meniber. "Covcred Services" rneans Medically Necessary Health Services, as determined by Plan and described in the applicable Health Benefit PIan, for which a Member is eligible for coverage. Covered Services do not include the preventable adverse events as set forth in the provider manual(s). "Government Contract" means the contract between AmerigroUp and an applicable party such as an Agency, which governs the delivery of Health Services by Amerigroup to Meniber(s) pursuant to a Government Program. "Governrnent Program" means any federal or state funded program under Title XVIII, Title XIX or Title XXI of the Social Security Act, and any other federal or state funded prograrn or product as designated by Amerigroup. "Health Benefit PIan" means the dacurnent(s) that set forth Covered Services rules, exclusions, terms and conditions of coverage. Such document(s) niay include but are not Iimited to a Member handbook, a health certificate pf coverage, ar evidence af coverage. "Health Service" means those services, supplies or items that a health care pravider is licensed, equipped and staffed to pravide and which 1 custarnarily provides to ar arranges far individuals. "Medically Necessary" ar "Medical Necessity" means the deflnition as set forth in the applicable Participation Attachment(s). 2 IA Ancillarv Hvbrid Agreernent 08-2015 hMember means any ridividual who is eiigible, as determined by Plan, to receive Govered Services under a Health Benefit PIan. For all purposes re!ated to this Ayreement including all schedules, attachments, exhibits, provider manual(s), notices and communications related to this Agreement, the term "Membor may be used nterchangeably with the terms Insured Covered Person, Covered Individuat Enrollee, Subscriber, Dependent SpouselDomestic Partner, Child, Beneficiary or Contract Holder, and the nieaning of each 15 synonyrnous with any such other. 'Network" means a group of providers that support, through a direct or ndirect contractual relationship, one or more product(s) and/or progranl(S) in which Members are enrolled. "Other Payors" means persons or entities, pursuant to an agreement with Amerigroup or an Affihiate, that access the rates, terms or conditions of this Agreement with respect to certain Network(s), excluding Government Programs unless otherwise set forth in any Participation Attachment(S) for Governnient Programs. Other Payors include, without imitation, other Biue Cross and/or BIue Shield Plans that are not Affiliates, and employers or insurers providing Health Benefit Plans pursuant to partiatly or wholly insured, self-adniinistered or self-insured programs. "Participating Provider" rneans a person or eritity, or an eniployee or subcontractOr of such person or entity, that is party to an agreement to provide Covered Services to Mernbers that has met all applicable PIan credentialing requirements or standards of participatiori for the services the Participating Provider provicles, and that is designated by PIan to participate in one or more Network(s). l'articipation Attachment(5Y' means the document(s) attached hereto and incorporated herein, artd which identifies the additional duties and/or obligatioris related to Network(s), Government Program(s), Health Benefit Plans, and/or PIan programs such as quality and/or incentive prograrns. "PIan1' means AmerigroUp, an Affitiate, and/or an Other Payor. For purposes of this Agreernent, when the term PIan" applies to an entity other than AmerigroUp "PIan" shall be construed to only mean such entity. HPIan Compensation Schedule" ('PCS') means the document(s) attached hereto and incorporated herein, and which sets forth the Amerigroup Rate(s) and compensation related terms for the Network(s) in which Provider partidpates. The PCS may include additional Provider obligations and specific Amerigroup cornpensatiori related terms and requirements. "Regulatory Requirements° means any requirements, as amendedfroni tinie to time, imposed by applicable federal, state or Iocal laws, rules, regulations, guidelines, instruotions, Government Contract, or otherwise imposed by an Agency or government regutator in connection with the procurement development or operation of a HeaRh Benefit PIan, or the performance required by either party under this Agreement. The ornission from this Agreement of an express referenoe to a Regulatory Requirement applicable to either party in connection with their duties and responsibilities shall in no way limit such party's obligation to comply with such RegulatorY Requirernent. ARTICLE 11 SERVICESIOBLIGATIONS 2.1 Member !dentiflcatiofl. Amerigroup shall ensure that PIan provides a means of identifying Member either by issuing a paper, plastio, electronic, or other identiflcation document to Member or by a telephonic, paper or electrOflio comrnunication to Provider. This identification neeci not inelude all inforrnation necessary to determine Meniber's eligibility at the time a Health Service is rendered, but shall include information necessary to contact PIan to deterrnine Meniber's participation in the applicable Health Renefit PIan. Provider acknowledges and agrees that possession of such identiflcation document or ability to access etigibility information telephonically or electronically in and of itself, does not quaIi' the holder thereof as a Mernber, nor does the lack thereof mean that the person is not a Member. 2.2 Provider Non-discrimination. Provider shall provide Health Services to Members in a rnanner similar to and within the same time availability in which Provider provides Health Services to any other individual. Provider will not differentiate, or discriminate against any Member as a result of his/her enrollment in a Health Benetit PIan, or because of race, color, creed, national origin, ancestry, religion, sex, marital status, age, disability, payment source, state of health need for Health Services, status as a titigant, status as a Medicare or Medicaid beneficiary, sexual orientation, gender identity, or any other basis prohibited by Iaw. Provider shall not be required to provide any type, or kind of Health SeMce to Mernbers that it does not customarily provide to others. Additionat requirements may be set forth in the applicab!e Participation Attachment(s). IA Anciltary Hybrid Agreement 08-2015 3 2.3 Publication and Use of Provider lnformation. Provider agrees khat AmerigroUP Plans or thefr designees niay use, publish disc(ose, and dispiay, for commercially reasonabte general business purposes either directly or through a third party, inforrnation related to Providor, incluciing but not imited to demographio nforrnation informafion regarding credentialirtg affiliatioriS, artd performance data. 2.4 Use of Svmbos and Marks. Neither party to this Agreenlent shall publish copy, reproduce or use in any way the other partys synibols service mark(s) or trademark(S) without the prior written consent af such other party. Notwthstandiflg the foregoing, the parties agree that they may identlfy Provider as a participant in the Network(s) in which it participates. 2.5 Submission and Adiudication af Claims. provider shall submit and Plan shall ad]udicate Claims in accordanCe with the applicable ParticipatiOn Attachment(S), the PCS, the provider manual(s) and RegulatorY Requiremeflts. 2.6 payment in Full and Hold Harmless. 2.6.1 Provider agrees to accept as payment in full, in all circumstanCes, the applicable AmerigrouP Rate whether such payment is in the forrn of a Cost Share, a payment by Plan, or a payrnent by another source, such as through coordinatiOn of benefits or subrogatiofl. Provider shall bill, collect, and accept coinpensatiOfl for Cost Shares. Provider agrees to make reasonable efforts to verify Cost Shares prior to bilting t�t siThFF ( r� t6tfiS. In no event shall Plan be obligated to pay Provider or any person acting on behalf oftc, Provider for services that are not Covered Services or any amounts in excess of the AmerigrOup Rate less Cost Shares or payment by another source, as set forth above. Consistent with the foregoing, Provider " agrees to accept the AmerigrouP Rate as payment in fufl if the Member has not yet satisfied bis/her deductible. 2.6.2 Except as expreSsly perrnitted under RegulatOry Requirements, Provider agrees that in no event, including but not Iimited to, nonpayment by applicable Plan, insolvency of applicabe Plan, breach of this Agreernent or Caim payment denials or adjustmeflt requests or recouptTleflts based on niiscoding ar other billing errors of any type, whether or not fraudulent or abusive shall Provider, or any person acting on behalf of Provider, bill, charge, cdllect a deposit from, seek compensation fram, or have any other recourse against a Member, or a person legaily acting on the Meniber's behalf, for Covered Services provided pursuant to this AgreerTlent. This section does not prohibit Provider frorn collecting reimbursemeflt for the foliowing from the Member: 2.6.2.1 Cost Shares, ifapplicable 2.62.2 Health Services that are not Covered Services. However, Provider may seek paynient for a Health Service that is not MedicaUY NecessarY or is 0perimental/inVe5tigati0 only if Provider obtains a written waiver that meets the foliowing criteria: a) The waiver notifies the Nlember that the Health Service is likely to be deemed not Medically NecessarY, or perimentaI/inVeStigat10n b) The waiver notifies the Mernber of the Health Service being provided and the date(s) of service c) The waiver notilies the Member of the approxirnate cost of the I-lealth Service; d) The waiver is signed by the Member, or a person legaily acting on the Meniber's behalf, prior to receipt of the Heath Service. 2.6.2.3 Any reduction in or denial of payment as a result of the Member's failure to comply with his/her utilization managernent program pursuant to his her/her Health Benetit Plan, except when Provider has been designated by AmerigroUP to coniply with utilization managetTlent for the Health Services provided by Provider to the Member. 2.7 RecouPment/OffseuAnuiustmenit for overpavrnents. AmerigrOUP shall be entitled to offset and recoup an amount equal to any overpayments or iniproper payments made by ArnerigroUP to Provider against any payments due and payable by AmerigrouP to Provider under this Agreemeflt. Provider shall voluntarily refund all duplicate or erroneous Claim payments regardless of the cause, including, but not limited to, paytTients for Claims whore the Claim was miscoded, non-compliant with industry standards, or otherwise billed in error, whether or not the billing error was fraudulent, abusive or wasteful. Upon determinatiOn by Amerigroup that any recoupment, improper payment, or overpayrnent is due from Provider, Provider must refund to the Amerigroup within thirty (30) days of when Amerigroup notifies Frovider. If such reimbursement is not received by Anlerigroup within the 4 (A Ancillary Hybrid Agreernent 08-2015 thirty (30) days foliowing the date of such riotice, Amerigroup shal! be entitled to offset such overpayment aganst other amounts due and payable by Amer!group to Provder in accordance with RegulatorY Requiremeflts. AmerigrouP reserves the right to emp!oy a third party coIIecton agency in the event of non- payrTlent. 2.8 Use of SubcontraCtOrS. Provider and PIan may fu!flht some of their duties under this Agreement through SubcontractOrs. For purposes of this provisiofl subcontraCtOrS shall include, but are not hrnited to, vendors and non -Participating Providers that provide supphes, equipment, staffing and other services to Menibers at the request of, under the supervision of, and/or at the p!ace of business of Provider. Provider shall provide AmerigrouP with thirty (30) days prior notice of any Hea!th Services subcontractOrS with which Frovider may contract to perform Provider's duties and obligations under this Agreement, and Provider shall remain responsible to PIan for the compliance of its subcontractOrS with the terms and conditionS of this Agreement as app!icable, induding, but not Iimited to, the Payment in Full and HoId Harm(ess provisions herein. AmerigrOUP shall not be iable for any reirnburselTlent in addition to the applicable AmerigroUP Rate as a result of Provider's use of a subcontractor. Frovider shall be solely responsible to pay subcontractors for any Health ServiceS, and shall via written corttract, contractually prohibit such subcontraCtOrs from billing, collecting or attempting to co!Iect frorn AmerigrOUP, PIan or Menibers. Notwithstaflding the foregoing, ifArnerigroUP has a direct contract with the subcontractOr ("direct contract") the direct contract shall prevail over this Agreement and the subcontractOr shal! bill An,erigrOUP under the direct contract for any subcontracted services, un!ess otherwise agreed to by the parties. 2.9 Compliance with Provider Manual(S) and Policies, Proqrams and ProcedureS. Provider agrees to cooperate and comp!y with, AmerigrOup'S provider manual(s), and all other pollcies, programs and procedures (col!ectivety "Policies") established and inip!emented by PIan, ineluding but not Iirnited to, credentiaUng, utiflzation niartagement quality improvement, grievances, peer review, coordination of benefits, third party Iiability and care managernent programs. ArnerigroUp or its designees may rnodify the provider manual(s) and Policies by rnaking a good faith effort to provide notice to Provider at east thirty (30) days in advance of the effective date of rnaterial modificatioris thereto. 210 Referral incentives/Kickbacks. Provider represents and warrants that Provider does not give, provide condone or receive any incentives or kickbacks, nionetary or otherwise, in exchange for the referra of a Member and if a Claim for paynient is attributable to an instance in which Provider provided or received an incentive or kickback in exchange for the referral, such Claim shall not be payable and, if paid in error, shall be refunded to AmerigroUp. 2.11 Prourafls and Provider Pane!s. Provider acknow!edgeS that as of the Effective Date, it participates on!y in those Networks designated on the Provider Networks Attachment of this Agreenleflt. Provider acknowledges that PIan may have, develop, or contract to deve!op, various networks or programs that have a variety of provider panels, program componetits and other requirements and that P!an may discontinue. or modify such networks or programS. In addition to and separate from Networks that support some or all of PIan's product(s) and/or program(S) (e,g., HMO, PPO and Lndemnity products), Provider further acknowledges that certain Hea!th Services, induding by way of example only laboratory services may be provided exclusive!Y by designated Participating Providers (a 'Health Servioes Designated Network"), as deterniined by PIan. Provider agrees to refer Members to Participating Providers in a Health Services Designated Network tor the provision of certain Health Services even if Provider performs such services. Notwithstanding any Out of Network Compensation provisiofl of this Agreement if Provider provides a Hea!th Service to a Mernber for which Provider is not a designated Participating Provider in a Health Services Designated Network, then Provider agrees that it shall not be reimbursed for such services by AmerigrouP, PIan or the Member, unless Provider was authorized to provide such Health SeTvice by P!an. In addition to those Networks designated on the Provider Networks Attachment, Amerigroup may also identify Provider as a Participating Provider in additiona! Networks and/or products designated in writing from time to time by Amerigroup. The terms and conditions of Provider's participation as a Participating Provider in such Networks and/or products shall be on the terms and conditions as set forth in this Agreement unless otherwise agreed to in writing by Provider and Amerigroup. 2.12 Chancle in Provider Information. Provider shall immediately send written notice, in accordanCe with the Notice section of this Agreernent, to Amerigroup of: 2.12.1 Any legal, governmental or other action or investigation invotving Provider which could affect Provider's credentialing status with PIan, or materially irnpair the ability to carry out the duties and obligations under this Agreement, except for teniporary emergenCy diversion situations; or: IA AncitIary Hybrid Agreenlent 08-2015 5 2.12.2 Any change in Provider accreditatiOfl affi(iation, hospital privileges (if appflcable), insurance Iicensufe cerfificatiofl or eligibility status, or other relevant information regarding Provides practice or status iri the medical comrnunity. 2.13 CredentiaUncl, Standards of Participati�rl and Accreditation. Provider warrants that he/she/it meets all appIicabe PIan credentialing requirernents standards of participatiOfl, and accreditation requirements for the Networks in which Provider participates as set forth in the provider manual(s). Provider acknowledges that untfl such tirne as Provider has been determiried to have fully met such applicable credentialing and standards of participation requirements, Provider shall not be entitlecl to the benefits of participation under this Agreemeflt, including without limitation the Amerigroup Rates setforth in the PCS attached hereto. 2.14 Provider Staffinq. Provider agrees to maintain professional staffing levels to meet community access standards. 2.15 FaciIity-based providers. Provider agrees to require its contracted facility -based providers or those with privileges to obtain and niaintain compliarice with Amerigroup's credentialing requirements. In addition, until such time as facility - based providers enter into agreernerits with Amerigroup, Provider agrees to fully cooperate with AmerigrOUP to prevent Members from being biHed amounts irt excess of the appllcable Amerigroup non -participating reirnbursement for such Covered Services. For purposeS of this section "facility -based providers"_means provider specialties which includes but 5 not Iirnited to, anesthesiologists, radioiogists, pathologists, neonatologistS, hospitalists and emergency room physicians. 2.16 Adiustment Requests. If Provider believes a Clairn has been irnproperly adjudicated for Covered Service for which Provider timely submitted a Claim to PIan, Provicler must submit a request for an adjustment to P!an in accordance with the provider manual(s). 2.17 Sunervision of Services. Frovider agrees that all Heaith Services provided to Members under this Agreemerlt shall be provided by Provider or by a qualified person under Provider's direction. Provider warrants that any nurses or other health professionals employed by or providirtg services for Provider shall be duly licensed or certified under applicab!e Iaw. 2.18 CoordinatiOn of BenefitsfSubrOqatiOfl. Subject to Regulatory Requirements, Provider agrees to cooperate with PIan regarding subrogation and coordination of beneflts, as set forth in Policies and the provider manual(s), and to notify PIan promptly after receipt of information regarding any Member who may have a Claim involving subrogatiOn or coordination of beneflts. 2.19 Cost Effective Care. Provider shall provide Covered Services in the most cost effective, clinically appropriate setflng and manner. ARTICLE 111 CONEIDENTIALITY/REC0RDS 3.1 ProprietarV Information. Except as otherwise provided herein, all information and material provided by either party in contemplatiOn of or in connection with this AgreelTtent remains proprietary to the disclosing party. This Agreement, including but not Iimited to the AmerigroUP Rates, 5 Arnerigroup'S proprietary inforrnatiOn. Neither party shall disclose any inforrnation proprietary to the other, or use such information or material except: (1) as otherwise set forth in thisAgreement (2) as may be required to perform obligations hereunder; (3) as required to deliver Heaith Services or adrninister a Health Benefit PIan; (4) to PIan or its designees; (5) upon the express written consent ofthe parties; or (6) as required by Regu!atory Requirements. Notwithstanding the foregoing, either party may disclose such information to its legal advisors, lenders and business advisors, provided that such legal advisors, lenders and business advisors agree to maintain confidentiality of such inforniation. Provider and AmerigrouP shall each have a system in place that meets all applicable Regulatory Requirements to protect all records and all other docurnents relating to this Agreement which are deenied confldential by law. Any disclosure or transfer of confidential information by Provider or AmdrigrouP will be in accorclance with applicable Regulatory RequirementS. Provider shall immediately notify AmerigrouP if Provider is required to disclose any proprietary information at the request of an Agency or pursuant to any federat or state freedom of information act request. A AnciIIary Hybrid Agreernent 08-2015 6 3.2 ConficlentiaIitV of Member lnformation. Both parties qree10 comply W(th the Health Insurarice Portabiiity and AccountabilItY Act of 1996 ("HIPAA") and the HeaIth Information Technolcgy for Econornic and CIinical Health Act ("HITECH Act"), and as both may be amerided, as well as any other applicable Regulatory Requirements regarding confidenflality, usa, disclosure, security and access af the Members persorially Identiflabie information (P11') and protected health nformation C'PHI"), (coIIectivaIy, Member Informaflon"). Provider shall review ali Member information received from Amerigroup to ensure no misrouted Member nforrnation is ncluded. Misrouted Member Information includes but 15 not limited to, informaUon about a Member that provider 15 not currently treating. Provider shall imrnediately destroy any misrouted Meniber Information or safeguard the Member lnformation for as long as It is retained. In no event shall Provider be permitted to misuse or re -disclose misrouted Member Information. If Provider cannot destroy or safeguard misrouted Member Information, Provder must contact AmerigrouP to report receipt of misrouted Member Information. 3.3 Network Provider/Patieflt Dlscussions. Notwithstaflding any other provision in this Agreement and regardless of any benefit or coverage exclusions or Iimitations associated with a Health Benef't Plan, Provider shal! not be prohibited frorn discussing fully with a Member any issues related to the Meniber's health includirig recommended treatments, treatment alternatives, treattTlent risks and the consequenceS of any benefit coverage or payment decisions made by PIan or any other party. Nothing in this Agreement shall prohibit Provider froni disclosing to the Member the general methodology by which Provider 15 compensated under this Agreement, such as for example, whether Provider 15 paid on a fee for service, capitation or Percentage Per Diern, Case Rate or DRG basis. PIan shall not refuse to allow or to continue the participation of any otherwie eligible provider, or refuse to compensate Provider in connection with services rendered, sotely because Provider has in good faith cornmunicated wfth one or more of his/her/its current, former or prospective patients regarding the provisions, terms or requirements of a Health Benetit PIan as they relate to the health needs of such patient. Nothing in this section shall be construed to permit Provider to disolose Amerigroup Rates or specific terms of the conipensation arrangement under this Agreement. 3.4 Plan Access to and Requests for Provider Records. Provider and its designees shall comply with all applicable state and federal record keeping and retention requirements, and, as set forth in the provider rnanual(s) and/or Participation Attachment(S), shall permut Plan or its designeeS to have, with appropriate working space and without charge, on-site access to and the right to perforrn an Audit, examine, copy, excerpt and transcribe any books, documents, papers, and records related to Member's rnedical and billing information within the possession of Provider and inspect Provider's operations, which involve transactiofls reiating to Members and as may be reasonably required by PIan in carrying out its responsibilities and progranls ineluding, but not Iiniited to, assessing quality of care, conip!ying with quality nItiatives/measUres, Medicai Necessity, concurrent review, appropriateness of care, accuraoy of payrnent, compliance with this Agreement, and for research. In Iieu of on- site access, at PIan's request, Provider or its designees shall submit records to Plan, or their designees vi? photocopy or electronic transmittal, within thirty (30) days, at no charge to PIan from either Provider or ts designee. Provider shall make such records available to the state and federal authorities involved in assessiflg quality of care or investigating Meniber grievances or cornplaints in compliance with Regulatory Requirements. Any examination or Audit of Provider records shall be performed using generaily accepted, statistically valid or industry standard methodology. Provider acknowledges that failure to subniit records to PIan in accordance with this provision and/or the provider manual(s), and/or Participation Attaohment(s) may result in a denial of a Claim under review, whether on pre-payrnent or post -payment review, or a payment retraction on a paid Claim, and Provider 5 prohibited from balance billing the Member in any of the foregoing circumstances. 3.5 Transfer of Medical Records. Foliowing a request, Provider shall transfer a Member's medical records in a timely nianner, or within such other time period required under applicable Regulatory Requirements, to other health care providers treating a Member at no cost to Amerigroilp, PIan, the Member, or other treating health care providers. ARTICLE IV INSURANCE 4.1 Ameriqroup Insurance. Amerigroup shall self -insure or maintain insurance as required under apphcable Regulatory Requirements to insure AmerigrouP and its employees, acting within the scope of their duties. 4.2 Provider lnsurance. Provider shall self -insure or rnaintain insurance in types and amounts acceptable to ArnerigrouP as set forth in the provider manual(s), or as required under applicable Regulatory Requirements. ARTICLEV RELATI0NsH;P OF THE PARTIES 5.1 Relationship of the Parties. For purposes of this Agreenient, Anierigroup and Provider are and will act at all times as independent contractors. Nothing in this Agreement shall be construed, or be deemed to create, a relationship of employer or employee or principal and agent, partnership. joint venture, or any relationship other than that of independent entities contracting with each other for the purposes of effectuating this Agreement. In no way shall 7 IA Ancillary Hybrld Agreement 08-2015 Amer3grouP or Ptan be construed to be providers of Health Services or resportsible for, exercise control, or have direction over the provison of such Health Services. Provider shati be solely resporisible to the Member for treatment, medical care, and advice with respect to the provision of Health Services. Nothing in this Agreement shall, or shall be construed to, create any financial incentive for Provider to withhold Covered Services. 5.2 Contractiflq Party. If Provider is a partnership corporation, or any other entity other than an individual, all references herein to "Provider" shell also mean and refer to each individual within such entity who Provider certifles is owned or empoyed by Provider, and who has applied for and been accepted by PIan as a Participating Provider. ARTICLE VI IF4DEMNIFICATION AND LIMITATION OF LIABILITY 6.1 IndemnificatiOn. Arrterigrotlp and Provider shall each indemnify, defend and hold harmless the other party, and its directors, offlcers, employees, agents, Affiliates and subsidiaries, from and against any and all Iosses, claims, damages, habilities, costs and expenses (including without Iiniitation, reasonable attorneys' fees and costs) arising from third party claims resulting from the indemnifying party's or its failure to perform the indemnifying party's obligations under this Agreement, artd/or the indeninifying party's or ts agent's violation of any law, statute, ordinance, order standard of care, rute or regulation. The obligation to provide indemnit]catiOfl under this Agreement shall be contingent upon the party seeking indemniflcaliOn providing the indemnifying party with prompt written notice of any claim for which indemnificatiOn is sought, allowing the indemnifying party to control the defense and settlement of such claim, provided however that the indemnifying party agrees not to enter into any settlement or comprornise of any claim or action in a manner that admits fault or irnposes any restrictionS or obhgations on an indemnified party without that indeninifled party's prior written consent which will not be unreasonabty withheld, and cooperating fulty with the indemnifying party in connection with such defense and settlement. Notwithstanding the foregoing, if a claim is brought by a governmental entity against PIan, and Plan seeks indemnificatiOfl frorn Provider pursuant to this section, then Provider shall not engage in any direct communiCation with such governmental entity regarding such clairn without Plan's prior consent. 6.2 Limitation of Liabilitv. RegardleSs of whether there is a total and fundamental breach of this Agreerrient or whether any remedy provided in this Agreement fafls of its essential purpose, in no event shall either of the parties hereto be tiable for any amounts representing loss of revenues, Ioss of profits, loss of business, the multipte portion of any multiplied damage award, or incidental, indirecL consequential, special or punitive danlages, whether arising in contract, tort (inctuding negligence), or otherwise regardtess of whether the parties have been advised of the possibility of such damages, arising in any way out of or relating to this Agreement. Further, in no event shati PIan be liabte to Provider for any extracontractual damages relating to any clairn or cause of action assigned to Provider by any person or entity. Notwithstafldiflg the foregoing if a claim is brought by an Agency against Ptan, the foregoing limitations of liability shall not apply. 6.3 Period of Limitations. Unless otherwise provied for in this Agreement, a Heatth Beneflt Plan, the provider manual(s), Policies, Participation Attachmeflt(S), and excluding fraud, waste, or abuse, neither party shall cornmence any action at law or equity, including but not Iimited to, an arbitration demand, against the other to recover on any legal or equitable claim arising out of this Agreement more than two (2) years after the events which gave rise to such claim. The deadline for initiating an action shall not be tolled by the appeai process, provider dispute resolution process or any other administrative process To the extent a dispute is timely corrmenced, it will be administered in accordance with Article VIl of thisAgreenlent ARTICLE VIt DISPUTE RESOLUTION AND ARBITRATION 7.1 Dispute Resolution. Alt disputes between Amerigroup and Provider arising out of or related in any manner to this Agreement shalt be resolved using the dispute resolution and arbitration procedures as set forth below. Provider shall exhaust any other applicable provider appeal/provider dispute resolution procedures under this Agreenlent and any applicable exhaustion requirements imposed by Regulatory Requirements as a condition precedent to Provider's right to pursue the dispute resolution and arbitration procedures as set forth below. 7.1.1 In order to invoke the dispute resolution procedures in this Agreement, a party tirst shall send to the other party a written demand letter that contains a detailed description of the dispute and alt relevant underlying facts, a detailed description of the amount(s) in dispute and how they have been calculated and any other information that the AmerigrouP provider manual(s) may require Provider to submit with respect to such dispute. If the total amount in dispute as set forth in the demand Ietter is less than two hundred thousand dollars ($200,000), exclusive of interest, costs, and attorneys' fees, then within twenty (20) days foltowing the date on which the receiving party receives the deniand Ietter, 8 IA Anelilary Hybrid Agreenlent 08-2015 representatiV�s of each party's choosing shali meet to discuss the dispute in person or telephonically in an effort to resolve the dispute. If the total amount in dispute as set forth in the demand tetter is two hundred thousand clailars ($200,000) or more exelusive of interest costs and attorneys' fees, then within ninety (90) days fouowing the date of the dernand etter, the parties shall engage in non-bindino mediation in an effort to resoive the dispute unless both parties agree in writing to waive the niediation requiremerit. The parties shail mutually agree upon a mediator, and failing to do so, Judicial Arbitration and Mediation Services ("JAMS") shall be authorized to appoint a mediator. 7.2 ArbitratiOfl. Any dispute within the scope of subsection 7.1.1 that remains unresotved at the conclusion of the applicable process outlined in subsection 7.1.1 shall be resolved by binding arbitration in the manner as set forth betow. Except to the extent as set forth below, the arbitration shall be conducted pursuant to the JAMS ComprehenSiVe Arbitration Rules and Procedures, provided, however, that the parties may agree in writing to further modify the JAMS ComprehensiVe Arbitration Rules and Procedures. The parties agree to be bound by the findings of the arbitrator(s) with respect to such dispute, subject to the right of the parties to appeal such findings as set forth herein. No arbitration demand shall be fiied until after the parties have completed the dispute resolution efforts described in section 7.1 above. Ifthe dispute resolution efforts described in section 7.1 cannot be completed within the deadlines specified for such efforts despite the parties' good faith efforts to meet such deadlines, such deadlines may be extended as necessary upon mutual agreernent of the parties. Enforcemeflt of this arbitration dause, including the waiver of class actions, shall be determined under the Federal Arbitration Act ('FM"), including the FAA's preernptiVe effect on state law. The parties agree that the arbitration shall be conducted on a confidential basis pursuant to Rule 26 of the JAMS ComprehenSiVe ArbitratiOn Rules and Procedures. Subject to any disolosures that may be required or requested under Regulatory Requirements the parties further agree that they shall maintain the confidential nature of the arbitration, inoluding without limitation, the existence of the arbitration, information exchanged during the arbitration, and the award of the arbitrator(s). Nothing in this provision, however, shall preclude either party from disciosing any such details regarding the arbitration to its accountants, auditors brokers, insurers, reinsurers or retrocesSiOnaires. 7.2.1 Location of ArbitratiOfl. The arbitratiOfl hearing shaH be he!d in the city and state in which the ArnerigroUP office identitied in the address biock on the signature page of this Agreement is located, except that if there is no address biock on the signature page, then the arbitration hearing shail be held in the city and state in which the Anthem entity that is a party to this Agreement has its principal place of business. Notwithstanding the foregoing, both parties can agree in writing to hold the arbitration hearing in some other location. 7.2.2 Selection and Renlacement of Arbitrator(S. If the total amount in dispute is Iess than four million dollars ($4,000,000), exclusive of interest, costs, and attorneys' fees, the dispute shall be decided by a single arbitrator selected, and reptaced when required, in the manner described in the JAMS ComprehensiVe Arbitration Rules and Procedures. If the total amount in dispute is four rnillion donars ($4,000,000) or more, exclusive of interest, costs, and attorneys' fees, the dispute shall be decided by an arbitration panel consisting of three (3) arbitrators, unless the parties agree in writing that the dispute shall be decided by a single arbitrator. 7.2.3 Anpeal. If the total amount of the arbitration award is five mililion dollars ($5,000,000) or more, inctusive of interest, costs, and attorneys' fees, or if the arbitrator(s) issues an injunction against a party, the parties shall have the right to appeal the decision of the arbitrator(s) pursuant to the JAMS Optional Arbitration Appeal Procedure. A decision that has been appealed shall not be enforceable while the appeal is pending. In reviewing a decision of the arbitrator(s), the appeal panel shall apply the same standard of review that a United States Court of Appeals wou!d apply in reviewing a similar decision issued by a United States District Court in thejurisdiction in which the arbitration hearing was held. 7.2.4 Waiver of Certain Claims. The parties, on behalf of theniselves and those that they may now or hereafter represent, each agree to and do hereby waive any right to join or consolidate claims in arbitration by or against other individuals or entities or to pursue, on a class basis, any dispute; provided however, if there is a dispute regarding the applicability or enforcement of the waiver provision in this subsection 7.2.4, that dispute shall be decided by a court of competent jurisdiction. If a court of competent jurisdiction determines that such waiver is unenforceable for any reason with respect to a particular dispute, then the parties agree that section 7.2 shall not apply to such dispute and that such dispute shall be decided instead in a court of competentjurisdiction. 7.2.5 Limitations on niunctive Relief. The parties, on behalf of themselves and those that they may now or hereafter represent, each agree that any injunctive relief sought against the other party shall be Iimited to the conduct retevant to the parties to the arbitration and shall not be sought for the benetit of individuals or entities who are not parties to the arbitration. The arbitrator(s) are not authorized to issue IA AnciIlarV Hybrid Agreement 08-2015 9 injunctive rellef for the benefit of an individual or entity who 15 not a party to the arbitratiOfl. The arbitrator shall be Iimited to issuing njunctive relief related to the specific issues in the arbitration. 7.3 Attornev's Fees and Costs. The shared fees and costs of the nonbinding mediation and arbitration (e.g. fee af the mediator, fee of the indeperident arbitrator) wil! be shared equally between the parties. Each party shall be responsible for the payment of its own speciflc fees and costs (e.g. the party's own attorney'S fees the fees of the party se!ected arbitrator etc.) and any costs assoc!ated with conducting the non-binding rnediation or arbitration that the party chooses to ncur (e.g. expert witriess fees, depositions etc.). Notwithstanthflg this provision, the arbitrator may issue an order in accordance with Federal Rule of CiviI Procedure Rule 11. ARTICLE Vill TERM AND TERMINATION 8.1 Initia! Term of Aureement. The initial term of this Agreement shal! commence at 12:01 AM on the Effective Date for a term of one (1) year, and shail continue in effect thereafter for a term of three (3) years C'!nitiaI Term"). automaticallY renewing for consecutive one (1) year terms un!ess otherwise terminated as provided herein. 8.2 TerminatiOn Without Cause. Either party may terminate this Agreenient without cause at any time by giving at Ieast one hundred eighty (180) days priorwritten notice of terminatiofl to the other party. 8.3 Breach of Aqreement. Except for circuiTlstanCes giving rise to the !mmediate Termination section 11 either party fai!s to comply with or perform when due any rnaterial terrn or condition of this Agreement the other party shall noti' the breaching party of its breach in writing stating the speciflc nature of the rnaterial breach and the breaching party shall have thirty (30) days to cure the breach. If the breach is not cured to the reasonable satisfaction of the non - breaching party within said thirty (30) day period. the non -breaching party may terminate this Agreemeflt by providing written notice of such termiriation to the other party. The effective date of such termination shal! be no sooner than sixty (60) days after such notice of termination. 8.4 rnmediate TerminatiOn. 8,4.1 This Agreement or any Participation Attachmeflt(s) may be terminated imrnediately by AmrigrOuP if: 8.4.1.1 Provider commits any act ar conduct for which its !icense(s), permit(s) or any governmenta! or board authorizatiOn(S) or approval(s) necessary for business operations or to provide Heaith Services are lost or voluntarily surrendered in who!e or in part; or 8.4.1.2 Provider commits fraud or n'iakes any materia! misstatements or omissions on any documentS related to this Agreement which Provider submits to Amerigroup or to a third party; or 8.4.1.3 Provider files a petition in bankruptcY for !iquidation or reorganizatiOn by or against Frovider, if Provider beconles insolvent or makes an assignment for the benefit of its creditors without AmerigrOUP'S wr!tten consent or if a receiver is appointed for Provider or its properts'; or - 8.4.1.4 Provider's insurance coverage as required by this Agreenlent Iapses for any reason; or 8.4.1.5 Provider falls to maintain compliance with PIan's credentialing standards, or app!icable accreditation requirenients or 8.4.1.6 AmerigrOuP reasonably believes based on Provider's conduct or inaction, or al!egations of such conduct or inaction, that the weII-being of patients may be jeopardized; or 8.4.1.7 Provider has been abusive to a Member, a AmerigrOUP employee or representatiVe or 8.4.1.8 Provider and/or its employees, contractorS, subcontractOrs, or agents are identif'ied as ineligible persons who are terminated, barred, suspended, ineligible, or otherwise exc!uded from participatiofl on the General Services Administration Iist of Parties Exc!uded from Federal Programs and/or HHS/OIG List of Excluded ndivlduals/Entitles, and/or on an applicable state Iist of exc!uded providers and in the case of an employee, contractor, subcontraCtor or agent, Provider fai!s to remove such indiv!dua from responsibi!itY for, or involvement with, the Provider's business operations re!ated to this Agreernent or If Provider has voluntarily withdrawn its participation in any program uncler Tities VX!II, XIX or XX of the Socia! Security Act as the resu!t of a settlement agreement; or IA Anciflary Hybrid Agreernent 08-2015 10 8.4.1.9 Provider is convicted ar has been firtally adjudcated to have committed a felony or misdemeanor, other than a non -DUI reiated trafflc violation. 8.4.2 This Agreement may be terminated immediately by Frovider if: 8.4.2.1 AmerigroUp conirnits any act or conduet forwhich its Iicense(s), permit(s), or any governmental ar board authorization(S) or approval(s) necessary for business operatiOfls are ost or voluntarily surrendered in whole or in part; or 8.4.2.2 An-ierigroup cornrnhts fraud or makes any material misstatelTteflts or omissiOfls on any documentS related to this Agreement which it subrnits to Provider or to a third party; or 8.4.2.3 Amerigroup files for bankruptcy, or if a receiver is appointed. 8.5 TerminatiOn of lndividual Providers. If applicable Anierigroup reserves the right to terminate individual providers under the terms of this Article Vill while continuing the Agreemeflt for one or more providers in a group. 8.6 TransactiOfls Prior to TerminatiOn. Except as otherwise set forth in this Agreernent terrnination shaH have no effect on the rights and obligations of the parties arising out of any trarisaction under this Agreement occurring prior to the date of such termination. 8.7 Continuation of Care Upon Termination. 8.7.1 UnCess otherwise set forth in the Health Benetit Plan or required by Regulatory Requiremerlts, Provider shall, upon termination of this Agreement for reasons other than the grounds set forth in the "immediate TerminatiOn" section of this Agreement, contiriue to provide Covered Services rendered to MemberS receiving treatment at the time of termination under the terrns and conditions of this Agreement untU the earlier of ninety (90) days or such time that: (1) the Member has completed the course oftreatnlerlt and if applicable, was discharged; or 2) reasonable and rnedically appropriate arrangements have been made for a Parlicipating Provider to render Covered Services to the Member. During such continualion period, Provider agrees to: (i) accept reimbursemeflt from AmerigroUP for all Covered Services furnished hereunder in accordance with this Agreement and at the rates set forth in the PCS attached hereto; and (H) Provider shall adhere to AmerigrOUp'S Policies, iricluding but not imited to, Policies regarding quality assuranCe requirements referrals, pre -authorization and treatment planning. 8.7.2 Notwithstanding the foregoing, for Members who: (i) have entered the second or third trimester of pregnancy at the tirne of such terniination, or (11) are deflned as terminally ill under § 1861 (dd) (3) (A) of the Social Security Act at the time of such termination, this continuance of care section and all ather provisions of this Agreement shall remain in effect for such pregnant Members through the provision of postpartuni care directly related to their delivery, and for such terminally 11 Members for the remainder of their hfe for care directly related to the treatment of the terminal illness. 8.8 $ijjyival. The provisions of this Agreement set forth below shall survive termination or expiration of this Agreemeflt 8.8.1 Publication and Use of Provider Informatiofl; 8.8.2 Payment in Full and HoId Harmless; 8.8.3 Recoupment/OffsetJAdiUStmt for Overpayments; 8.8.4 Confidentiality/ReCords; 8.8.5 ndemniflcation and Limitation of Liability; 8.8.6 Dispute Resolution and Arbitration; 8.8.7 Continuation of Care Upon Termination; and 8.8.8 Any other provisions required in order to coniply with Regulatory Requirements. 8.9 Effect of Termination of this Aqreement. Notwithstanding any provisionS in this Agreement or Participation Attachment(S), in no event shall Participation Attachment(S) continue in effect if this Agreement expires or is terminated for any reason. IA AncilIary Hybrid Agreement 08-2015 11 ARTICLE IX GENERAL PROVISIONS 9.1 Amendnierit. Except as otherwise provided for in this Agreement, Amerigroup retains the right to amend this Agreemerit, any attachments or addenda by rnaking a good faith effort to provide notice to Provider at least thirty (30) days in advance of the effective date of the amendment. Except to the extent that Amerigroup determines an amendment is necessary to effectuate Regulatory Requirements if Provider objects to the amendment then Provider has the right to terminate this Agreement, and such termination shall take effect on the later of the amendment effecflve date identified by Amerigroup or one hundred eighty (180) days from the date Provider has provided notice of its iritention to terminate the Agreement pursuant to this section. Failure of Provider to provide such notioe to Amerigroup withiri the time frames described herein will constitute acceptance of the amendment by Provider. 9.2 Assiqnrnent. This Agreeniertt may not be assigned by Provider without the prior written corisent of Amerigroup. Any assignment by Provider without such prior consent shall be voidable at the sole cliscretion of Amerigroup. Amerigroup may assign this Agreenient in whole or in part. In the event of a partial assignment of this Agreement by Amerigroup, the obligations of the Provider shall be performed for Amerigroup with respect to the part retained and shall be performed for Amerigroup's assignee with respect to the part assigned and such assignee 15 solely responsible to perforrn alt obflgations of Amerigroup with respeet to the part assigned. The rights and obligatioris of the parties hereunder shall inure to the benetit of, and shall be biriding upon, any perrnitted successors and assigns of the parties hereto. 9.3 ScopesfChancie in Status. 9.3.1 Amerigroup and Provider agree that this Agreement applies to Health Servioes rendered by Provider at Provider's Iocation(s) provided as part 01 Amerigroup's credentialing application process. Amerigroup may lirnit this Agreement to Provider's locations, operations, business or corporate form, status or structure iri existence on the Effective Date 01 this Agreenient and prior to the occurrence 01 any 01 the foliowing events set forth below. in addition, Frovider must give Amerigroup one hundred twerity (120) days' advanced notice should any 01 the foliowing occur: 9.3.1.1 Provider plans to sell all or substantially alt of his/her/its assets; 9.3.1.2 Provider plans to change its locations, business or operations, corporate form or status, tax identiflcation number, mailing address or similar demographic information; 9.3.1.3 Provider plans to transfer control of its management or operations to any third party, including Provider entering into a management contract with another entity or with a physician practice management Amerigroup which does not rnanage Provider as of the Effective Date of this Agreement, or there is a subsequent change in controt of Provider's current rnanagernent Anierigroup; 9.3.1.4 Provider plans to acquire or control any other medical practice, facility, service, beds or entity, or plans to create or otherwise operate a Iicensed health maintenance organization or commercial health plan (whether such creation or operation is direct or through a Provider affiliate); 9.3.1.5 Provider (a) plans to sell, transfer or convey its business or any substantial portion of its business assets to another entity through any nianner including but not limited to a stock, real estate or asset transaction or other type of transfer; (b) is otherwise acquired or controlled by any other entity through any manner, including but not Iimited to purchase, merger, consoIidation alliance, joint venture, partriership, association, or expansion; or 9.3.1.6 Providers plans to add/remove providers who are part of a group, 1 applicable. 9.3,2 Notwithstandirig the termination provisions of Article VIll, and without limiting any of Amerigroup's rights as set forth elsewhere in this Agreement, Amerigroup shall have the right to terminate this Agreenient upon thirty (30) days written notice to Provider if Amerigroup determines, that as a result of any of the transactionS Iisted in subsection 9.3.1, Provider cannot satisfactorily perform the obligations of Provider hereunder, or cannot comply with one or more of the terms and conditions of this Agreement, ineluding but not limited to the confldentiality provisions herein; or as a result of one or more of the events as set forth in subsection 9.3.1, Amerigroup elects in its reasonable business discretion not to do business with Frovider, the successor entity or new management Amerigroup. 12 IA Ancillary }-lybrid Agreernent 08-2015 9.3.3 If Provider is acquired by, acquires or merges with another entlty, and such entity already has an agreement with Amerigroup, Anierigroup will determine in its sole discretion which Agreement will prevait. 9.4 Deflnitions. Unless otherwise speciflcally noted the defiriltions as set forth in Article 1 of this Agreement will have the same meaning when used in any attachment the provider manual(s) and Pollcies. 9.5 Entire Aqreement. This Agreenlent, exhibits attachmerits and amendments hereto. together with any itenis incorporated herein by reference, constitute the entire understanding between the parties and supersedes alt prlor oral or written agreements between them with respect to the matters provided for herein, If there are any conflicts between any of the provisions of this AgreelTlent and the provider rriartual(s) this Agreement will take precedente. 9.6 Force Maieure. Neither party shall be deerned to be in violation af this Agreernent If such party Is prevented from performing any of its obligations hereunder for any reason beyond its reasonable control, including without limitation, acts of God, natural or man-made disasters, acts of any public enerny, statutory or other laws, regutations, rules, orders, or actions of the federal, state, or Iocal government or any agency thereof. 9.7 Compliance with RequlatOrv RequirerrtefltS. AmerigrOuP and Provider agree to compty with all applicable RegulatorY RequirementS, as arnended froni time to tirne, relating to their obligations under this Agreemeflt, and maintain in effect all perrnits, Iicenses and governmental and board authorizationS and approvals as necessary for business operations. Provider warrarits that as of the Effective Date, it is and shall remain Iicensed and certifled for the term of this Agreernent in accordance with all Regulatory RequiremefltS (induding those applicable to utilization review and Claims payment) relating to the provisiofl of Heatth Services to Members. Provider shall supply evidence of such Iicensure, cornpliance and certifications to AmerigrouP upon request. If there is a conflict between this section and any other provision in this Agreement, then this section shall controt. 9.7.1 In addition to the foregoing, Provider warrants and represents that at the time of entering mb ftuis Agreement, neither it nor any of its employees, contractors subcontractOrS or agents are ineligibte persons identified on the General Services AdmmnistratiOns' List of Parbies Excluded from Federal Programs (availabte through the internet at jp://wwW.ePIs,qOVt or its successor), on the HHS/OIG List of Excluded Individuals/EfltitieS (available through the Internet at ff0;//,0jq.hhs.QOV/fraUd/eXClU5b0n6a50 or its successor), on an applicable state Iist of excluded providers, or as otherwise designated by federal or state authorities. Provider shall remain continuousiy responsible for ensuring that its employees, contractorS, subcontractOrs or agents are not inetigible persons. If Provider or any employees, subcontraCtOrs or agents thereof becomes an ineligible person after entering into this Agreement or otherwise falis to disclose its ineligible person status, Provider shali have an obligation to (1) irnmediately notify ArnerigrouP of such ineligibte person status and (2) within ten (10) days of such notice, remove such mndividual from responsibility for, or invotvement with, Providers business operations related to this Agreement. 9.8 Governincl Law. This Agreement shall be governed by and construed in accordance with the laws of the state where AmerigrOUP has its primary place of business, unIess such state laws are otherwise preempted by federal Iaw. However, coverage issues specific to a Health Beneflt PIan are governed by the state laws where the Heaith Benetit PIan is issued, unless such state iaws are otherwise preempted by federaI aw. 9.9 Intent of the Parties. It is the mntent of the parties that this Agreement is to be effective only in regards to their rights and obtigations with respect to each other; it is expressty not the intent of the parties to ereate any independent rights in any third party or to make any third party a third party beneficiary of this Agreernent, except to the extent specified in the Payment in FuII and HoId Harmtess section of this Agreernent or in a Participation Attachment(s). 9.10 Non-ExciusiVe Participation. None of the provisions of this Agreement shail prevent Provider or PIan from participating in or contracting with any provider, preferred provider organization, heaIth maintenance organization/heaIth insuring corporation, or any other heaIth delivery or insurance program. Provider acknoWledges that PIan does not warrant or guarantee that Provider will be utilized by any particular number of Mernbers. 9.11 Upj]ce. Any notice required to be given pursuant to the terms and provisions of this Agreement shall be in writing and shati be delivered by hand, facsimiIe, eIectronic mail, or mail. Notice shall be deemed to be effective: (a) when delivered by hand, (b) upon transmittal when transmitted by facsimuIe transmission or by eIectronic mail, (c) upon receipt by registered or certified mali, postage prepaid, (d) on the next businss day if transmitted by nationa! �vernight courier, or (e) if sent by regular mail, tive (5) days from the date set forth on the correspondence. Uniess specified otherwise in v4riting by a party, Amerigroup shall send Provider notice toan address that Amerigroup has on file for Provider, and Provider shail send Amerigroup notice to Amerigroup's address as set forth IA Anciiiary Hybrid Agreement 08-2015 13 on the signature page. Notwithstaridiflg the foregoing and unless otherwise required by Regulatory Requirements, Amerigroup may post updates to its provider manual(s) artd Polioles on its web site. 9.12 Severabilitv. In case any one or more of the provisions of this Agreement shall be invalid, UIegaI, or unenforceable in any respect, the remaining provisions shall be construed hberally in order to effectuate the purposes hereof, and the validity, egaUty and enforceability of the remaining provisions shall not in any way be affected or impaired thereby. If one or more provisions of the Agreement are invalid, iliegal or unenforceable and an amendment to the Agreement is necessary to maintain ts integrity, the parties shall make commerciafly reasonable efforts to negotiate an amendment to this Agreement and any attachments or addenda to this Agreement which could reasonably be construed not to contravene such statute, regulation, or interpretation. In addition, if such invalid, unenforceabte or materially affected provision(s) may be severed from this Agreement andfor attachments or addenda to this Agreement without materially affecting the parties' intent when this AgreetTtent was executed, then such provision(S) shall be severed rather than terminating the Agreement or any attachrnerits or addenda to this Agreement. 9.13 Waiver. Neither the waiver by either of the parties of a breach of any of the provisions of this Agreement nor the failure of either of the parties, on one or more occasion, to enforce any of the provisions of this Agreement shall thereafter be construed as a waiver of any subsequent breach of any of the provisions of this Agreement. 9.14 ConstructiOfl. This Agreement shall be construed without regard to any presuniption or other rule requiring construction against the party causing this Agreement to be drafted. 9.15 Counterparts and Electronic Siqnatures. 9.15.1 This Agreenient and any amendnient hereto may be executed in two (2) or more counterparts, each of which shall be deemed to be an original and all of which taken together shall constitute one and the same agreement. 9.15.2 Either party may execute this Agreement or any amendments by valid electronic signature, and such signature shal! have the sarne legal effect of a signed original. 14 IA Anci!Iary I-Iybrid Agreement 08-2015 Each party warrants that it has full power and authority to enter into this Agreement and the persori signing this Agreemeflt on behalf of either party warrants thfliThhe has been duly authorized and empowered to enter into this Agreenient THIS AGREEMENT CONTAINS A BINDING ARBITRATIOJV PROV!S!ON WI-IICH MAYBE ENFORCED BY THE PARTIES PROVIDER By: Printed: Address: r , Signature Authorized RepresentatiVe of Provider(s) Name Street Taxldentiflcatlofl NumberIN) LJ_3 5 AMERIGROUP By: Printei:.3 Address: ‚ D te Title City State Zip Signature, Authorized RepresefltatiVe ofAmerigrOuP Date Narne TitIe City Street A Ancillary Hybrid Agreernent 08-2015 State Zip 15 PROVIDER NETWORKS ATTACI-IMENT As af the EffectiVe Date af this Agreemeflt Providerwill be designated as Participating Provider in the foliowing: GoverniTient ProqranlS: Health Benetit Plans issued pursuant to an agreement betweefl PIan and Agency in which Members have access to a network af providers and receive an enhanced level of benefits when they obtain Covered ServiCeS frorn Participating Providers regardless of product licensUre status- Provider participates in the foliowing Networks which support such Health Benetit PIans: Medieaid Iowa High Quality Heaith Care lnitiative IA AnciIIarY Hybrid Agreenlent 08-2015 16 MEDIGAIO PARTICIPATION ATTACI-IMEWT TO TI -IE AMERIGROUP IOWA, INC. PROVIDER AGREEMENT This isa Medicaid Participation Attachmeflt CAttachmeflt") to the AmerigroUp Provider Agreerneflt') entered into by and between AmerigrOUp and Provider and 15 incorporated into the Agreemeflt- ARTICLE 1 DEEINITIONS The foltowing deflnitions shall apply to this Attachment. Terms not otherwise defined in this Attachmeflt shaU carry the meaning set forth in the Agreemerit. "Clean CIaim" rneans a claim that has no defect or mpropriety (includiflg any lack of required substantiating documentatiOn) or particutar circumstanCe requiring specia! treatment that prevents tirnely payment of the claim It does not iriclude a claim from a provider who is under investigation for fraud or abuse or a claim under review for medical necessity. "Functionalty Necessary° and "Functional Necessity" mean reasonable and necessary services to eriable independent hvirtg such as assistance with activities of daily living and instrumental activities of daily living. °Medicaid Program(S)" means for purposes of this Attachment, a medical assistance provided under a Health Beneflt Plan approved under Title XVI, Title XIX andlor Titte XXI of the Social Security Act or any other federal or state funded program or product as designated by AmerigroUP. !Medicaid Covered Services" rneans, for purposes of this Attachnlent, only those Covered Services provjded under Plan's Medicaid Prograrn(s). Medicaid Member nleans, for purposeS of this Attachment, a Men3ber who 5 enrolled in PIan's Medicaid Program(s). Medically Necessary/MediCaI Necessity" means those Covered Services that are, under the terrns and conditiorts of the Government Contract, determined through Plan utilizatiort management to be: (1) Appropriate and necessary for the symptoms diagnosis or treatment of the conclitipn of the Mernber; (2) Provided for the diagnosis or direct care and treatment of the condition of Member enabling the Member to make reasoriable progresS in treatment; (3) Within standards of professiOnal practice and given at the appropriate time and in the appropriate setting; (4) Not primarily for the convenience of the Medicaid Member, the Medicaid Meniber's physician or other Participating Provider; and The most appropriate level of Medicaid Covered ServiceS, which can safely be provided. This definition is also expanded to include Functionally NecessarY and Functional Necessity services and products that will keep a Medicaid Member as iridepetident and hving in their own environment Historically, such services have been considered social services, community based services or local access resources. In an effort to rnaintain individuals in the comrnunity and not in Iicensed facilities, the term Medically NecessarY will now include non-niedical services, products and resources. "State Agency" means the Iowa Departmeflt of Public Health (IDPH), the lowa Department of Human Services (DHS) or other duly authorized state agency. (5) 7 IA AnciIIary Hybrid Agreement 08-2015 ARTICLE 11 SERVICES!OBLIGAT10NS 2,1 participationMediCaid Network. As a participant iri Amerigroup'S Medicaid Network, Provider will render Medicaid Covered ServiceS to Medicaid Members enrolled in AmerioroUpS Medicaid Netvork in accordance with the terms and conditions of the Agreernent and this Attachnleflt Such Medicaid Covered ServiceS provided shall be within the scope of Provider's IicensUre, expertise, and usual and custoniary range of services pursuant to the terms and conditions of the Agreement and this Attachment and Provider shali be responsible to AnierigroUP for his/her/its performaflCe hereunder. Except as set forth in this Attachrnent or the Plan CompensatiOfl Schedule ("PCS") all terms and conditions of the Agreement will appiy to Provider's participation in Amerigroup'S Medicaid Network. The terrns and conditions set forth in this Attachment are Iiniited to the provision of and payment for Health Services provided to Methcaid Members. 2.2 Duties and Obliqations to Medicaid Members. All of Provider's duties and obligations to Members set forth in the Agreemeflt shall also apply to Medicaid MemberS. To the extent mandated by Regulatory Requiremeflts Provider shall ensUre that Medipaid Members have access to 24 hour-perdaY, 7 dayper-Week urgent and EmergencY ServiceS, as defined in the PCS. Provider shall not discriminate in the acceptance of Medicaid Merobers for treatment and shall provide to Medicaid Menibers the sanie access to services including but not Iimited to, hours of operation, as Provider gives to all other patients. Provider shall furnish AnierigrouP with at Ieast ninety (90) days prior written notice if Provider plans to dose its practice to new patients or ceases to continue in Provider's current practice. 2.3 Provider ResponsibilitV. Amerigroup shall not be Hable for, nor will it exercise control or direction over, the nianner or method by which Provider provides Health Seruices to Medicaid MemberS. Provider shalt be solely responsible for all medical advice and services provided by Frovider to Medicaid Members. Provider acknowledgeS and agrees that AmerigrOUP may deny payrnent for services rendered to a Medicaid Member which it deterrnifleS are not Medically NecesSary, are not Medicaid Covered Services under the appticable Medicaid Program(S) or are not otherwise provided or billed in accordanCe with the AgreelTleflt and/or this AttachlTlent. A denial of payment or any action taken by AmerigroUP pursuant to a utilization review referral, discharge panning program or claims ad]udicatiOn shall not be construed as a waiver of Provider's obligation to provide appropriate Health Services to a Medicaid Member under applicabie RegulatOry RequirementS and any code of professional responsibilitY. However, this provision does not require Provider to provide Health Services if Provider objects to such service on moral or religious grounds. 2.4 Reporlinfl Fraud and Abuse. Provider shall cooperate with ArnerigroUpS anti -fraud compliance program. If Provider identifies any actual or suspected fraud, abuse or miscondUct in connection with the services rendered hereunder in violation of RegulatOry Requirements, Provider shall promptly report such activity directty to the compliance officer of AmerigroUP or through the coniplianCe hotline in accordance with the provider nianuaks). In addition, Provider is not limited in any respect in reporting other actual or suspected fraud, abuse, or misconduct to AmerigroUP. 2.5 PIan Marketinq/InfOrmation ReciUirements. Provider agrees to abide by PIan's marketing/information requirementS. Provider shall forward to PIan for prior approva! all flyers, brochureS, Ietters and pamphlets Provider intends to distribUte to Medicaid Members concerning its payor affihations, or changes in affiliation or relating directly to the Medicaid population. Provider will not distribute any marketing or recipient informing materials without the consent of PIan or the applicable State Agency. 2.6 Schedute of Beneflts and Determination of Medicaid Covered Services. Amerigroup shall make available upon Provider's request schedules of Medicaid Covered Services for applicable Medicaid Program(s). and will notify Frovider in a timety manner of any material arnendments or modiflcations to such schedules. 2.7 Revocation of Deleclated Activities. Amerigroup may revoke delegation of any activities and reporting responsibilitieS or impose other sanctions if Provider's performance is inadequate. Such revocation shall be consistent with the terrninatipn provisions of this Attachrnent. 2.8 ReportinQ ReuiretTlentS. Provider agrees to compiy with the reporting requireiTlents Iisted in 42 CFR § 447.26(d) as a condition of payment from Amerigroup. 2.9 Third Partv Liability. provider agrees to identify third party Iiability coverage, including Medicare and long-terni care insurance as applicable, and except as otherwise required, seek such third party Iiability payment before sublTlitting clairns to Anierigroup. 18 IA AnciIIarY Hybrid Agreenieflt 08-2015 210 Medicaid Member Verification. Provider shall establish a Medicaid Members eIigib4 for Medicaid Covered Services prior to rendering services, except in the case of an Emergency Medical Gondition, as defined in the PCS, where such verificatiorl may not be possible. In the case of an Emergericy Medicat Condition, Provider shall estabhsh a Medicaid Members eligibillty as soon as reasonably practical. Plan shall provide a system for Providers to contact Plan to verify a Medicaid Member's eligibility 24 hours a day, 7 days per week. Mothing contained in this Attaohment or the Agreemertt shall, or shall be construed to, require advance notice, coverage verification, or pre-authorizatiOfl for Emergency Services, as defined in the PCS, provided in accordance with the federal EmergenoY Medical Treatment and Active Labor Act CEMTALA") prior to Provider's rendering such Emergency Services. 211 Hospital Affihiation and Privileqes. To the extent required under Plan's credentialing requirenients, Provider or any Participating Providers employed by or under contract or subcontract with Provider shaU maintaifl privileges to practice at one or more of AmerigroUp'S participatirtg hospitals. In addition, in accordance with the Change in Provider lnformation Provider Section of the Agreement, Provider shall immediately notify AmerigrouP in the event any such hospital privileges are revoked limited, surrendered, or suspended at any hospital or heatth care facility. 2.12 participatinq Provider Reciuiremeflts. If Provider is a group provider, Provider shalt require that all Participatirig Providers emptoyed by or under contract subcontract with Provider comply with all terms and conditions of the Agreement and this Attachment. Notwithstanding the foregoing Provider acknowledges and agrees that AmerigrOUP 18 not obligated to accept as Participating Providers all providers employed by or under contract or subcontract with Provider. 2.13 Coordinated and Manacied Care, Provider shall participate in utilization management and care management prograrns designed to facititate the coordination of services as referenced in the applicable provider manual(s). 2.14 RepresentatiOns and Warranties. Provider represents and warrants that alt information provided to AmerigrOUP is true and correct as of the date such information is furnished, and that Provider 5 unaware of any undisclosed facts or circulTtstaflces that wouid make such information inaccurate or misteading. Provider further represents and warrants that Provider: (1) is legaily authorized to provide the services contemplated hereunder; (ii) IS qualifled to participate in alt appticable Medicaid Program(s); (Ui) is not in violation of any licensure or accreditatiofl requirement applicable to Provider under Regutatory Requirements (iv) has not been convicted of bribery or attempted bribery of any official or employee of the jurisdiction in which Provider operates, nor made an admission of gulit of such conduct which is a matter of record; (v) 15 capable of providing alt data related to the serviceS provided hereunder in a timely manner as reasonably required by AmerigrouP to satisfy its internal requirements and Regulatory Requirements including, without hmitation, data required under the Health Employer Oata and Information Set ("HEDIS") and Nlational Comrnittee for Quality Assurance ("NCQA") requirements; and (vi) is not, to Provider's best knowledge, the subject of an irtquiry or investigation that could foreseeably result in Provider failing to coniply with the representations set forth herein. In accordanceWith the Change in Provider Information Section of the Agreement Provider shall immediately provide AmerigrouP with written notice of any material changes to such information. ARTICLE itt COMPENSATION AND AUDIT 3.1 Submission and Adiudication of Medicaid Claims. Unless otherwise ipstructed, or required by Regutatory Requirerflents Provider shall submit Claims to Ptan, using appropriate and current Coded Service ldentifier(s), within ninety (90) days from the date the Heatth Services are rendered or Plan niay refuse payment. If Plan is the secondary payor, the ninety (90) day period will not begin until Provider receives notiflcation of primary payor's responsibility. 3.1.1 Provider agrees to provide to AmerigrouP, untess otherwise instructed, at no cost to AmerigrOUP. PIan or the Medicaid Meniber, all inforniation necessary for Plan to determine its payment liability. Such information includes, without timitation, accurate and Clean Clainis for Covered Services. Once AmerigroUP determines Ptan has any payment liabitity, all Clean Claims will be paid in accordanCe with the terms and conditions of the Medicaid Member's Heatth Benefit Plan, the PCS, and the provider manuat(s). 3.1.2 Provider agrees to submit Claims in a format consistent with industry standards and acceptable to Plan either (a) etectronicatty through etectronic data interchange (EDI"), or (b) if electronic submission 18 not avaitable, utilizing paper forms as defined by the Nationat Uniform Ctaim Conirnittee CNUCC"). 19 IA Ancittary Hybrid Agreement 08-2015 3.1.3 1 AmerigrouP or Plan asks for additional rtformatiOfl so that Plan may process the Claim, Provider must provide that irtformatiofl within sixty (60) days, or before the expiration of the ninety (90) day period referenced in section 3.1 above, whichever is tonger. 3.1.4 An,erigrOUP shall adjudicate a Clean Claim, in accordaflce with, and within the tirne frames under, the Regulatory Requirements appllcable to F'lan's Medicaid Program(s). 3.2 tvledicaid Affiliate Services. Provider acknowledges that AmerigrOUP is affihiated with health plans that offer sirnilar benetits under similar programs as the programs covered hereunder C'Medicaid Affiliates"). The parties acknowledge that Provider is not a Participating Provider in Medicaid Affiliate's t4etwork for purposes of rendering services to Medicaid Members. However, in the event Provider treats a Medicaid Mernber of a Medicaid Afflhiate, subject to Regutatory Requirertletlts Provider shaU accept as payment in full the rates established by the Medicaid Affiliate's state program governing care to Medicaid Members, Sueh services must be Medicaid Covered Services under the Nledicaid Affitiate's state prograrn, and shall require prior authorization, except for EmergencY Services and services for which a Medicaid Member is entitled to self -refer. Upon request, AmerigrOuP shall coordinate and provide information as necessary between Provider and Medicaid Affrliate for services rendered to Medicaid Member. Notwithstafldiflg the foregoing, Affiliate shall not be considered Medicaid Affiliates and Affiliate's Member's shall not have access to the rates under this Agreemeflt. 3.3 Audit for Compliance with State Aqencv and CMS Guidelines. Notwithstandiflg any other ternis and conditions of the Agreement, this Attaehment, or the PCS, PIan has the same rights as the State Agency and CMS, to review and/or Audit and, to the extent necessary recover payments on any claim for Medicaid Covered Services rendered pursuant to this Attachment and the Agreement to ensure compliance with State Agency and CMS Regulatory Requirements. 3.3.1 Provider agrees to cooperate with ArnerigrOUP audits and monitoring of Provider's data, data submission and performanCe as well as any additional oversight mechanisrflS which monitor performance and compliance with Government Contract requirements on an ongoing basis. Provider further agrees to cooperate with forrnal reviews which shall be conducted at Ieast quarterty. 3.3.2 Provider agrees to cooperate with DHS audits of Provider's data. Whenever deficiencies or areas of improvenient are identified AmerigrOUP and Provider shall take corrective action. AmerigroUP shall provide to DHS the findings of all Provider performance monitoring and reviews upon request and shall notify the OHS any time Provider is placed on correetiVe action. 3.3.3 Provider agrees to cooperate with ArnerigrOuP'S audit and oversight of Provider's obligations under the Agreement. this AttachlTtent and the PCS. If AmerigroUp identifies deficiencies, AmerigrouP may issue a corrective action plan to Provider. Provider shail comply with the corrective action plan to rectify the deflciencies identified therein within the time frame set forth. 3.4 Phvsician-HOsPitaI OrqanizationS. If Provider 5 a physician-hosPital organization or another entity that accepts financial risk for serviCes that AmerigrouP does not directly provide, Pro'iider rnust monitor the financial stability of subcontractor(S) whose payments are equal to or greater than five percent (5%) of preniium/reVenue. Provider must provide Amerigroup at Ieast quarterly with requested information which shall be used to monitOr Provide?s performance including but not Iimited to the foliowing: (i) a statement of revenues and expenses; (ii) a balance sheet; (Hi) cash fiows and changes in equity/fund balance; and (iv) incurred but not received (IBNR) estimates. 3.5 Qualitv lmprovement. Provider shati impletTtent quality improvernent goals and perforlTlance improvement activities specific to the types of services provided by Provider. 3.6 Encounter Data. If Provider is paid on a capitated basis, Provider shall submit encounter data within ninety (90) days of the date of service. 3.7 Critical Incident Reportinq. Provider agrees to: (i) report critical incidents; (H) respond to critical incidents; (Ui) document critical incidents; and (iv) to cooperate with any investigation conducted by the Amerigroup or an outside agency. 3.8 Enforcement of q6032 of the 2005 tjeficit Reduction Act (DRM. If Provider receives one million ($1,000,000) dotlars or more in Medicaid payments in a federal fiscal year, Provider shall have written poticies for all ernployees, including management, and for alt employees of any contractor or agent that provide alt detailed inforrnation required by the DRA. IAAnciIIarY Hybrid Agreemeflt 0S2O15 20 ARTICLE tV COMPLIANCE WITH FEDERAL REGULATORY REQUIREMENTS 4.1 Federal Funds, Provider acknowledges that paynients Provider receives from Plan to provide Medicaid Covered Services to Medicaid Members are, in whole or part, from federal funds. Therefore, Provider and any of his/her/its subcontractOrs are subject to certain laws that are applicable to individuals and entties receiving federal funds, which may inolude hut are not limited to, Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR Part 84; the Age Diserimination Act of 1975 as implemented by 45 CFR Part 91; the Americans with Disabilities Act; the RehabilitatiOfl Act of 1973, lobbying restrictionS as implemented by 45 CFR Pari 93 and 31 USC 1352, Title IX of the Educational Amendmeflts of 1972, as arnended (30 U.S.C. sections 1661, 1783, and 1685-1686) and any other regutations applicable to recipients of federal funds. 4.2 Suretv Bond Reauirernent. If Provider provides home health services or durable medical equipment, Provider shall comply with alt applicabte provisions of Section 4724(b) of the Balanced Budget Act of 1997, including, without timitation, any applicable requirernents related to the posting of a surety bond. 4.3 Nationat Provider ldentitier (NPF) Number. Provider shall maintaifl an NPI number which shall be consistent with 45 CFR 162.410. 4.4 Laboratorv ompIiance. If Provider renders lab services in the office, it must maintain a valid Clinical LaboratOry lmprovement Amendmeflts ("CLIA") certiflcate for alt laboratory testing sites and coniply with CLIA regutatioflS at 42 CFR Part 493 for alt laboratory testing sites performing Heatth Services pursuant to this Attachment. ARTICLE V COMPLIANCE WITH STATE REGULATORY REQUIREMENTS 5.1 lrideniniflcation ofState. In addition to the lndemnifiCation provision of the Agreement, Provider shall indemnify and hold harmless the State, its agencies, officers, and employees froni all claims and suits, including court costs, attorney's fees, and other expenses, brought because of injuries or darnages received or sustained by any person, persons, or property that is caused by any act or oniission of Provider. 5.2 Medicaid Hotd HarmleSs. Provider agrees that Plan's payrnent constitutes payment in full for any Medicaid Covered Services rendered to Medicaid Members. Provider agrees it shall not seek payment from the Medicaid Member, his/her representative or the State for any Heatth Services rendered pursuant to this Attachment, with the exception of Cost Shares, if any, or payment for non -Medicaid Covered Services otherwise requested by, and provided to, the Medicaid Member if the Medicaid Member agrees in writing to pay for the service prior to the service being rendered. The form of agreement must speciflcally state the admissions, seMces or procedures that are non-MediCaid Covered Services and the approximate arnount of out of pocket expense to be incurred by the Medicaid Member. Provider agrees not to bill Medicaid MemberSfOr missed appointments while enrolted in the Medicaid Program(s). This provision shall remain in effect even in the eyent Plan becomes insotvent. 5.3 Member lnabilitv to Pav. Provider shall not deny care or services to any Medicaid Member because of his or her inability to pay the copayrTlent. 5.4 State Aqencv Contract. Provider shall comply with the terms applicable to providers set forth in the lowa Department of Human Services Request for Proposal lowa High Quality Healthcare lnitiative RFP# MED-16- OO9RFP (RFP), the Governrnent Contract, including incorporated documents, between Plan and the AgencY, which applicable ternis are incorporated herein by reference. Ptan agrees to provide Provider with a description ofthe applicable terms upon request. 5.5 Mental Heatth lnformation. Provider agrees to maintain the confrdentiality of mental heaith information by cooperating with and irnplementing poticies which allow release of mental heatth information only as allowed by lowa Code §228. 5.6 Substance Abuse tnformation. Provider shall protect and rnaintain the confidentiality of substance abuse inforrnation, allowing the release of substanCe abuse information onty in cornpliance with policies set forth in 42 CFR Part 2 and other applicabte Regulatory Requirements. 5.7 I -SMART Data. If Provider provides substance abuse services, Provider shalt report l -SMART data on all Medicaid Members receiving substance abuse services regardless of source of payment. IA Ancillary Hybrid Agreement 08-2015 21 5.8 DuaI EIiqibIeS. Provider agrees to provide Medically Necessary Covered Services to Members who are also eIigibIe for Medicare if the service is not covered by Medicare. Provider agreeS that Covered ServiceS provided under Ibis Agreemeflt are delivered without charge to Menibers who are duafly eligible for Medicare and Medicaid. 0 tui ftj'2 5.9 Medical Records. In addition to the Plan Access to and Requests for Provider Records Section of the Agreemertt Provider silalt comply with AmerigroUP's poticies and procedures for maintaifling rnedical records content and documentatiOn in compliance with the provisions of towa Admin. Code 441 Chapter 79.3 and all other applicable RegutatorY Requirements. Provider shail assure that its records document alt niedical services that the Medicaid Member receives in accordance with Regulatory Requiremeflts. Provider shall rnaintain Medicaid Members' medical records in a detaUed and comprehensiVe manner that conforms to good professional medical practice perniits effeotive professionat medical review and medical audit processes and facilitates an accurate systeni for follow-up treatment. Medical records must be Iegible, signed dated and rnaintained as required by RegulatorY Requirements. Provider agrees to provide a copy of a Medicaid Member's medical record upon reasonable request by the Medicaid Member at no charge. 5.10 Provider Availability. Provider shall be available to Medicaid Members twenty-four (24) hours-a-daY seven (7) days -a -Week and shall comply with appointnient standards established by the State Agency or Amerigroup as applicable. Provider shaU comply with corrective actions irnplernented by Anierigroup if Provider is identifled through an audit as failing to rneet these standards. 5.11 Cultural CompetenCV. Provider shall ensure that Medicaid Covered Services rendered to Medicaid Members, both clinical and non -clinical are accessible to all Medicaid Members, ineluding those with iniited Engtish proflcierioy or reading skills with diverse eultural and ethrilc backgrounds, the homeesS1 and Medicaid Menibers with physical and mental disabilities. Provider niust provide inforniatiOfl regarding treatment optionS in a culturaIIYCOniPetent manner including the option of no treatment. Provider must ensure that Medicaid MemberS with disabilities have effective communicatiOns with participants throughout the health system in making decisions regarding treatrnent options. 5.12 Backeround Checks. Providers shall compy with state requirements for employee backgroUnd checks and shall disolose any staif providing seMces who have ever had a founded child or dependent adult abuse report, or been convicted of a felony. Staff providing services shalt include anyone having contact with Medicaid Members or Medicaid Meniber data. Provider shall disclose any such report in a tirnely rrtanner in a written statenient to AmerigroUP within ten (10) days frorn the date of convictiofl, regardtess of appeal rights. 5.13 Nursinq Facilitv Providers. If Provider is a nursing faciFty Provider shall: 5.13.1 Promptly notify AmerigrouP of a Medicaid Member'S admission or request for admission to the nursing facility as soon as Provider has knowledge of such admission or request for admission; 5.13.2 Notify AmerigroLJP inirnediately if Provider is considering discharging a Member and agrees to consult with the Medicaid Mernbers care coordinator; 5.13.3 Notify the Medicaid Mernber and/or the Medicaid Membes representatiVe (if applicabte) in writing prior to discharge in accordanCe with RegulatOrY Requirements 5.13.4 Collect all applicable patient liabitity amounts frorn Medicaid Mernbers; 5.13.5 Notity AmerigrouP of any change in a Medicaid Menibers medical or functional condition that could impact the Medicaid Members level of care eligibitity for the currently authorized evet of nursing facility services - 5.13.6 Comply with federal Preadmissiofl Screening and Resident Review (PASRR) requirements to provide or arrange to provide specialized services and ati applicable lowa Law governing admission transfer and discharge policies; and 5.13.7 Provider agrees that if Provider is involuntarilY decertified by the State of towa or CMS, the Agreement and this Attachment will automaticatly be terminated in accordance with federal requirements. 22 IA AnelIlary Hybrid Agreement 08-2015 5.14 Home and Community Based Services (HCBS) Providers: If Provider is an HCBS Provider, Provider agrees: 5.14.1 To provide at least thirty (30) days advanoe notice to AmerigroUP when Provider 15 rio Ionger wifling or abte to provide services to a Medicaid Member and to cooperate with the Medicaid Mernbers care coordinator to facilitate a seamless transition to alternate providers; 5.14.2 In the event that a HCBS provider change is initiated for a Medicaid Member regardless of any other provision in the Agreerneflt Provider shall continue to provide Medicaid Covered Services to the Medicaid Member in accordance with the Medicaid Mernber's plan of care until the Medicaid Meniber has been transitioned to a new provider, as determined by AmerigroUP, or as otherwise directed by Amerigroup, which may exceed thirty (30) days from the date of notice to AmerigrOup 5.14.3 To immediately report any deviationS frorn a Medicaid Member's service schedule to the Medicaid Member'S care coordinatofl and 5.14.4 To compiy with all child arid dependent adult abuse reporting requirements. 5.15 If Provider isa hospital, Provider shall report adnuissiOn and discharge inforlTlation as directed by AmerigrouP in order to support the exchange of iriformation and coordinatiOn of care through the Iowa Health !nforrriation Network (IHIN). ARTtCLE VI TERMINATIOW 6.1 TerminatiOfl of Medicaid Participation Attaohment. Either party may terminate this Attachnleflt without cause by giving at Ieast one hundred and eighty (180) days prior written riotice of termination to the other party. 6.2 TerminatiOn of Governmeflt Contraot. If a Government Contract between Agency and AmerigrollP terminates or expires or ends for any reason or is modified to etiminate a Medicaid Progranl this Attachment shall have rio further or effeot with respect to the applicable Medicaid Program. 6.3 Effect of TerniinatiOn. Foliowing termination of this Attachmerlt the rernainder of the Agreernent shall continUe in full force and effect, if applicable. ARTIGLE Vil GENERAL PROVISIONS 7.1 RequlatOrv Amendment. otwithstandiflg the Arnendment Section in the Agreement, this Attachmeflt shaU be automatiCallY modified to conform to required changeS to Regulatory Requirements related to Medicaid Program(S) without the necessity of executing written amendments. 7.2 !nconsistencieS. n the event of an inconsistencY between terms and conditionS of this Attachment and the terms and conditions in the Agreemeflt the terms and conditions of this Attachrnent shall govern. Except as otherwise set forth herein, all other terms and conditions of the Agreement remain in full force and effect. 7.3 Subcontractor ReQuiremeflts. In addition to the Provider SubcontractOrS Section in the Agreement, Provider certifies that neither it nor its principals nor any of its subcontractorS are presently debarred suspended proposed for debarment declared ineligible, or voluntarity exduded from entering into this Attachmeflt by any Federal agency or by any department agency or political subdivision of the State. For purposeS of this Attachment, "principaV means an officer, director, owner partner key employee or other person with prirnary management or supervisory responsibilities or a person who has a critical infiuence or substantive control over Providers operationS (42 CFR 438.610). Provider agrees to comply with requirements set forth in 42 CFR 455.100 through 455.106 regarding disclosure by providers of ownership and controi inforrnation and disclosure of information on a providers owners' and other persons' conviction of criminal offenses against Medicare, Medicaid or Title XX services program cuisclosures») and wilt agree to provide required disclosures at the time of initia! contract, upon contract renewal and/or upon request by the ArnerigroUP. Provider further agrees to notify AmerigroUP within fourteen (14) days of any changes to the DisclosUres. 7.4 Survival of Attachment. Provider further agrees that: (1) the hold harmtess section shall survive the termination of this Attachment or disenroliment of the Medicaid Member; and (2) that provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and a Medicaid Meniber or persons acting on their behalf that relates to iiability for payment for Medicaid Covered Services provided under the terrns and conditions of this Attachment. IA Ancillary Hybrid Agreement 08-2015 23 PLAN COMPENSATION SCHEDULE ("PCS) ARTICLE 1 DEFINITIONS 'Ambulat�ry Payment Classification' ('APC) ar its successor means a grouping system developed for facility reimbursenlertt for Outpatient Services as established by CMS. 'Ambulatory Patient Group' (APG) means a fixed reimbursemertt to a facility for Outpatient ServiceS and which incorporates data regardirig the reason for the visit and patient data. "Amerigroup Iowa Medicaid Fee Schedule(sY' means AmerigroUP Rate(s) specified as ArnerigrOUP Iowa Medicaid Fee Schedule are based on the applicable Iowa Medicaid Fee Sebedule(s), which could be enhanced by additional Covered Services included in the Government Contract. IrAmerigroup Iowa Medicaid Rate" rneans AmerigroUp Rate specified as AmerigrOUp Iowa Medicaid Rate based on the appllcable towa Medicaid Rate, which could be enhanced by additional Covered Services included in the Government Contra�t. "Capitation" means the arnount of prepayment made by Amerigroup to a provider or management services organizatiOn on a per rnember per month basis for either speciflc setvices or the total cost of care for Covered Services Individual services billed shall not be reirnbursed separately. Case Rate" means the all-inelUsive AmerigrOlJp Rate for an entire adrnission or one outpatient encounter for Covered Services. lnd!vidual services billed shail not be reimbursed separately. "Chargemaster" or "Charge Master" or ItchargesI means facility's listing of faciFty charges for products, serviCeS and supplies. "CMS Outpatient ProspectiVe Payment System" (HOPPS) means a hospital outpatient prospectiVe paynient systern ("HOPPS") to reimburse for hospital Outpatient Services. "Coded Service ldentitier(S)" meafls a listing of descriptiVe terms and identifying codes, updated from time to time by CMS or other industry source, for reporting }-lealth Services on the CMS 1500 or CMS 1450/UB-04 claim form or its succesSOr as applicable based on the services provided. The required claim form will be listed in Article IV below.The codes inctude but are not Iimited to, American Medical AssociatiOn Current Procedural Terminology C'CPt-4'), CMS HealthCare ComiTiOn Procedure Coding Systern C'HCPCS"), International Classification of Diseases, gth Revision, Clinical ModificatiOn C'ICD-9- CM'), National Uniform BilUng Comrnittee ("RevenUe Code") and National Drug Code ("NDC") or their succeSSOrS. "Cost to Charge Ratio" C'CCR') n-teans the quotient of cost (total operating expenses minus other operating revenue) divided by charges (gross patient revenue) expressed as a decimal as deflned by RegulatOry ReqUiremeflts. "Diagnosis-related Group" ('DRG") rneans DiagnoSis Related Group or its successor as established by CMS or other grouper, inetuding but not Vmited to a state mandated grouper or other industry standard grouper. "DRG Rat&' means the all-inelusive dollar arnount which is multiplied by the appropriate DRG Weight to determine the AmerigrOuP Rate for Covered Services.. lndividual serviees reimburSed through the DRG Rate shall not be reirnbursed separately. "DRG Weight" rneans the weight applicable to the specific DRG methodology set forth in this PCS, including but not Iimited to, CMS DRG weights as published in the Federal Register, state agency weights, or other industry standard weights. "EIigible Charges" means charges billed by Provider subject to conditions and requirements which rnake the service eligible for reimbursemeflt. Eligibility for reirnbursement of the service is dependent upon application of the foliowing oonditions and requirements Member program ehgibility, Provider prograrn eligibiflty, benefit coverage, authorizatiori requirements provider manual uidelineS, Amerigroup administratiVe, clinical and reimbursement policies, and oode 24 IA Ancillarv Hybrid Agreernent 08-2015 ed1ing agic. The allowed arnount reimbursed for the eligthle oharge is based on the AmedgroUP Rate after application of Cost Shares and coordination of beneflts. Arnerigroup shall not remburse Provider for services or items Provider receives and/or provides free of charge. 'Emergency Condition' means a medical condftion mariifesting itself by acute symptoms of suthdent severity (including severe pain) such that a prudent layperson, with an averaoe knowledge of health and medicine, could reasonably expect the absence of immediate medical attention 10 result in serious jeopardy to the health of the individual, or in the case of a pregnant woman, the health of the woman or her unborn chilci; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. "EmergenoY Services" means those Covered Services furnished by a provider qualified to furnish emergency services, and which are needed to evaluate or treat an Emergency Condition. 'Encounter Data" means the information included on CIams submitted by Provider under capitated or risk -sharing arrartgements for Health Services rendered to Members "Encounter Rate" means the rate that is all inelusive of professional, technical and facility oharges including evaluation and management, pharniaceuticals, routine surgical and therapeutic procedures, and diagnostic testing (ineluding laboratory and radiology) capable of being performed on site "Fee Schedule(s)" means the cornplete isting of Amerigroup Rate(s) for speoific services that is payment for each unit of service allowed based on applicable Coded Service ldentifier(s) for Covered Services. 'Giobal Case Rate' means the all-iriolusive Amerigroup Rate which includes facility, professional and physician services for specific Coded Service Identifier(s) for Covered Services. Individual services billed shall not be reimbursed separately. "Iripatient Services" means Covered Services provided by faoflity to a Member who is admitted and treated as a registered inpatierit, is assigned a Iicensed bed within the facility, remains assigned to such bed and for whorn a roorn and board charge is made. "ObservatiOfl" means the services furnished on the facility's premises, including use of a bed and periodic monitoring by nursing or other staff, which are Medically Necessary to evaluate a Membes condition and determine if the Member requires an inpatient admission to the facility. Such determinatiofl shall be in cornpliance with Amerigroup Policies or Regulatoly RequiremefltS. "Outlier Rate" rneans the Amerigroup Rate of payment applied to an admissiofl which exceeds the outlier threshold as set forth in the PCS or in compliance with Amerigroup Policies or Regulatory Requirements. "Outpatient Services" means Covered Services provided by facility to a Mernber who is admitted and treated as a registered outpatient within facitity. "Patient Day" rneans each approved calendar day of care that a Member receives in the facility, to the extent such day of care is a Covered Service under the terms of the Member's Health Beneflt PIan, but excluding the day of discharge. "Percentage Rate" means the AmerigroUp Rate that is a percentage of Eligible Charges billed by Provider for Covered Services. "Per Diem Rate" means the AnierigrouP Rate that is the aIl-inclusive flxed payment for Covered Services rendered on a single date of service. ndividuat services bilied shall not be reimbursed separately. "Per Hour Rate" means the ArnerigroUp Rate that is payment based on an increment of tirne for Covered Services. "Per Unit Rate" means the Anierigroup Rate that is payment for each unit of service allowed based on applicable Coded Service Identifler(s) for Covered Services. - - "Per Visit Rate" means the Amerigroup Rate that is the all-indusive fixed payment for one encounter for Covered Services. ndividual services billed shall not be reimbursed separately. IA AnciIlary Hybrld Agreernent 08-2015 25 "Provder Charges' means the regular, uniform rate or price Provider determines and submits to Arnerigroup as charges for Health Services provided to Members. Such Provider Charges shall be no greater than the rate or price Provider submits to any person or other health care benefit payor for the sarne Health Services provided, regardless of whether Provider agrees with such person or other payor to accept a different rate or price as payment in full for such services. "Short Stay" nieans an inpatient hospital stay that is less than a specified number of calendar days in compliance with Amerigroup Policies or Regulatory Requrements. ARTICLE 11 GENERAL PROVISIONS Biflinci Form and Clams Reporflnu Requirements. Provider shall submit all Claims on a CMS 1500 or CMS 1450/UB-04 claim form or its successor as applicabe based on the services provided. The required claim form will be listed in Article IV below. Provider shall report all Health Services in accordance with the Coded Service ldentitier(s) reporting guidelines and instructions. Plan audits that result in identification of Health Services that are not reported in accordance with the Coded Service ldentifier(s) guidelines and instructions, will be subject to recovery through rernittance adjustment or other recovery action as may set forth in the provider manual(s). Clairn Submissions for Pharmaceuticals. Each Claim submitted for a pharmaceutical product must include standard Coded Service ldentifier(s), a National Drug Code CNDC") number of the covered medication, a description of the product and dosage and units administered. Unless otherwise required under Regulatory Fzequirernents, Plan shall not reimburse for any pharmaceuticals that are not administered [0 the Member andfor deemed contaminated and/ar considered waste. Codinq Updates. Coded Service ldentifier(s) used to define specific rates are updated frorn time to tirne to reflect new, deleted or replacement codes. Amerigroup shall use commercially reasonabl efforts to upclate all applicable Coded Service ldentifiers within sixty (60) days of release by CMS or other applicable authority. If an update is delayed beyond the sixty (60) days, Amerigroup shall notify Provider. If Provider biOs a revised code prior to the effective date of the revised code, the Caim will be rejected and Provider shall resubniit Claim with correct code. Claims processed prior to the implenientation of the revised codes shall not be reprocessed. In addition, Claims with codes which have been deleted will be rejected. Codinq Software. Updates to Amerigroup'S Claims processing filters, code editing software, any edits related thereto, as a result of changes in Coded Service Identifler(s) reporting guidelines and instructions, shall take place autoniatically and do not require any notice, diselosure or arnendment to Provider. Modifiers. All appropriate modifiers must be used in accordance with standard billing guidelines, if applicable. New/Expanded Service or NewfExpanded Technoloav. In accordance with the Change in Scope and Status provision of the Agreement, as of the Effective Date of this Agreernent any New/Expanded Service or NewlExpanded Technology (defined below) is not reimbursable under this Agreenient. Notwithstanding the foregoing, Provider may subnilt the foliowing documentation to Amerigroup at least sixty (60) days prior to the implementation of any New/Expanded Service or New/Expanded Technology for consideration as 8 reinibursable service: (1) a description of the New/Expanded Service or New/Expanded Technology; (2) Provider's proposed charge for the New/ Expanded Service or New/ Expanded Teohnology; (3) such other reasonable data and inforrnation required by Arnerigroup to evaluate the New/Expanded Service or New/Expanded Technology. In addition, Amerigroup niay also need to obtain approvai from applicable Agency prior to Anierigroup making determination that New/Expanded Service or New/Expanded Technology can be considered a reimbursable service. If Anierigroup agrees that the New/Expanded Service or New/ Expanded Technology may be reimbursable under this Agreement, then Amerigroup shall notify Provider, and both parties agree to negotiate in good faith, a new Amerigroup Rate for the NewlExpanded Service or New/Expanded Technology within sixty (60) days of Amerigroup's notice to Provider. If the parties are unable to reach an agreement on a new Amerigroup Rate for the New/Expanded Service or New/Expanded Technology before the end of the sixty (60) day period, then such New/Expanded Service or New/Expanded Technology shall not be reimbursed by Anierigroup, and the Payment in Full and Hold Harrnless provision of this Agreement shall apply. 26 A Ancillary Hybrid Agreenlent 08-2015 a) New/Expanded Service' shall be defined as a Health Service: (a) that Provider was riot provicl(ng lo Members as of Effective Oate of this Agreement arld; (b) for which there is not a specitic Arnerigroup Rate as set forth in this PCS. b) "New/Expanded Technology shall be defined as 5 technological advancement in the delivery of a Covered Service which results in 5 material increase to the cost of such service. New/ Expanded Technoogy shall not nelude a ne'w device or mplant that merely represents a new model or an improved model of a device or mpant used in conriection with a service provided by Provider as of the Effective Date of this Agreement Non -priced Codes for Covered Services. Arnerigroup reserves the rght to price non -priced codes for Covered Services, induding but not Iimited to, Not Otherwise Classified Codes ("NOC"), Not Otherwise Specified ("NOS"), Misceflaneous, and Individual Consideration Codes ("IC"). If a code for a Covered Service (1) does riot have a published dollar arnount on the then current applicable PIan, State or CMS Fee Schedule, (U) has a zero dollar amount Iisted, or (Hi) requires manual pricing, then such code shafl be reimbursed at a rate established by Amerigroup for such Covered Service. Arnerigroup may require the submission of medical records, invoices, or other dooumentation prior to the adjudication of such Claim(s). Notwithstariding the foregoing, any Covered Services not specified in this PCS or in the Fee Schedule(s) are not reimbursable. Services and Iterns Not Available. For any services and items not available from Provider, Provider shall utilize Participating Providers and shall refer and transfer Members to Participating Providers in accordance with Amerigroup Policies. Tax Assessment and Penalties. The Amerigroup Rates in this Agreement irielude all sales and use taxes and other taxes on Provider revenue, gross earnings, profits, income and other taxes, charges or assessrnents of any nature whatsoever (together with any related interest or pertalties) now or hereafter irnposed against or collectible by Provider with respect to Covered Services, unless otherwise required by Agency pursuant to Regulatory Rquirement. Neither Provider nor PIan shali add any amount to or deduct any amount from the Amerigroup Rates, whether on account of taxes, assessments, tax penaflies or tax exemptions. Udates to AmeriQrouD Rate(s Based on External Sources. Unless otherwise required by Regulatory RequirenientS, Arnerigroup shall use commercially reasonab!e efforts to update the Amerigroup Rate(s) based on any Agency, vendor or other entity (lIEernaI Sources') no later than sixty (60) days after Amerigropps receipt of the final ratelfee schedule change(s) from such External Sources, or on the effective date of such final rate/fee schedule change(s), whicheve is later. The effective date of such final rate/fee schedule changes shalt be the effective date of the change as published by External Sources. Exarnples include, but are not Iimited to, Medicare rate/fee schedules and state Medicaid rate/fee schedules. Claims processed prior to the irnplementation of the new Anierigroup Rate(s) in Arnerigroup's payment system shall not be reprocessed; however, if reprocessing of Claims is required by Regulatory Requirements, and such reprocessing could result in a poterttial under and/or over payment to a Provider, then PIan may reconcile the Claim adjustments to deterniine the reniaining amount Provider owes PIan, or that PIan owes to Provider. Any resultant overpayment recoveries (i.e. Provider owes PIan) shalt occur automatically without advance notification to Provider. Unless otherwise required by Regulatory RequirementS, Amerigroup will not be responsible for interest payments that may be the result of a late notification by External Sources to Amerigroup of rate/fee schedule changes. 27 IA Ancillary Hybrid Agreement 0S2015 ARTICLE 111 PROVIDER TYPE - ANCILLARY AMBULANCE SERVICES (Ground and Air AMB) Ambulance Provider (Grourtd AMO)' means locat ground transportation by a vehicle designed or air transportation by fixed wing or rotary wing equipped aircraft equipped, and used only to transport the sick and njured for the purpose of, or related to, medical freatment and operated according 10 state and local laws which control the ssuance of valid licenses or permits or be licensed when required by law. AUDIOLOGY SERVICES "Audiotogy ServiceC rneans those services which involve testing and evatuation of impaired hearing that cannot be improved by medication or surgical treatment; includes services related to hearing aid use and professional consultation DURABLE MEDICAL EQUIPMENT ("DME1 "Durable Medical Equipment" (DME) nieans a health care provider which provides medical anci surgical supplies which only serve a niedical purpose; rerital and/or purchase of durable medical equiprnent prescribed by a Participating Provider; or prosthetie appliances and orthotic devices for purchase, fltting, adjustment, repairs and replacement. HOME HEALTH AGENCY e'HHA") "Home Health Agency' ("HHA") means a health care provider which provides skilled nursing and other skilled services on a part time, episodic, or intermittent basis in the Member's residence, and is responsible for supervising the detivery of such services under a Plan of Care. "Plan of Care" means the program written by the Member's attending physician setting forth the diagnosis and the prescribed Covered Services for the Meniber. HOME INFUSION THERAPY ("HIT") "Home tnfusion Therapy Provider" C'HIT') means a health care provider that offers Members on an outpatient basis, treatment which involves intravenouS or subcutaneoUS Ireatments or injections. - INDEPENDENT LABORATORY ("LAB") "Independent Laboratory" ('LAB") means an eritity that provides Covered Services involvig the procurement, transportation, testing (which jncludes clinicat and anatomic/sUrgical pathology), reporting of specimens and consulting services provided by the LAB. ORTHOTICS "Orthotics" means devices prescribed by a Participating Provider that are rigid or semi-rigid which support, restore or protect body function and restrict or etiminate motion of a weak or diseased body part. PROSTHETICS "Prosthetics" means appliances prescribed by a Participating Provider that replace alt or part of a body organ (including contiguous tissue), or replace alt or part of the function of a pernianent!y inoperative, absent or malfunctioniflg body part. PHYSICALIOCCUPATIONAUSPEECH THERAPY rPT/OT/ST') "Physical Therapy" ("PT") means correctiVe rehabilltatiofl provided by licensed practitioners through the use of physical, chemical and other properties of heat, light, water, electricity, sound, massage and active, passive and resistive exercise. "occupational Therapy" ("OT) rneans the developrnnt of adaptive skills, increased performance capacity, and those factors that rnay inipede or restrict ability to function provided by ticensed practitioners. "Speech Therapy" ('ST") means the evaluation and treatment of disorders that result in impaired or ineffective communicatiOn provided by ticensed practitionerS. IA Ancillary Hybrid Agreenient 08-2015 28 ARTICLE IV SPECIEIC ANCiLLARY REIMBURSEMENT TERMS A. General Provisions 1. Any services not specified in the Rate Grids below are not reimbursable. B. Home Infusion Therapy Unless otherwise noted in this PCS, for Home nfusiort Therapy the Amerigroup Rate shall riclude, but Is not Iimited to the foliowing: professional services to order, prepare, compound, dispense, deliver, administer, or monitor any drug or substance used in Honie Infusiori Therapy. It shall also include, infusion pumps and supplies (e.g. pump, pole, tubing, electronic rrionitor, bandages, cotton, alcohol, intravenous start kits, filters and solutions), IV based solutions (e.g. 0.9% Nail, D5W, ete. indusive of additives), dressing kits, venous access device (e.g. PICC, mid!ine) and supplies, supplies related to infusion therapy, other skilled nursing services performed during the same infusion visit including but not Iimited to wound care, clinical rnonitoring, delivery/dispensing expenses, training and any additional professional services. Collection, delivery and reporting of the results af lab tests required to monitor response to therapy are also included. 2. Catheter maintenance, ineluding impIantabe port maintenance, is reinibursed at a Per Diem Day Rate. On the days the catheter is being used to provide other therapies, the catheter maintenance Per Diern Rate will not be paid. The nursing visit includes both catheter maintenance and implantable port maintenance and all necessary supplies. C. Durable Medical Equipment 1. Provider agrees to cornply with all of Anierigroup's Policies related to "rent to purchase" for DMEs. Original standard accessorieS are included in the rental or purchase price of the DME item and shall not be bilted separately by Provider nor reimbursed separately by Am&igroup. For patient owned equipment, replacement standard andlor custoniized accessories for DME shalt be billed separately by the Provider foliowing industry standard guidelines. 2. Purchase/rent to purchase items include DtvlEs that can be purchased outright or rented. Once the total amount reimbursed toward rentals and purchase meets the medical equipment's applicable Anierigroup Rate amount in effect for that date of service, it is considered purchased and becomes the property of the Member. 3. Amerigroup does not allow reimbursement for repair or replacement of rented or purchased items while under the warranty period designated by the applicable rnanufacturer. This charge will not be allowed on regular or rental DME Orthotics, Prosthetics and Medical Supplies ('DMEPOS') items (repair of a rental item included in the rental price and is not separately reimbursable). 4. Any exceptions to Amerigroup'S rent to purchase policy are referenced in the provider manual(s). IA Ancillary Hybrid Agreement 08-2015 29 1 00% of Amerigroup Iowa Medicaid Fee Schedule Ambu!ance Services Applicable CPT/HCPCS codes Per Service CMS 1500 Audiology Services Applicable CPT/HCPCS codes 1 00% of Amedgroup Iowa Medicaid Fee Schedule Per Service CMS 1500 :-- . Y MED1CA' 'Y4'-'4 -. 0 4 '- SMHEAITFANP Ij9MEi1FUS1Ot1 S]QES4RAWGThD -- sqtvire-D�siitition 4C1dd.$flvOP ''4enjflet ,,) M&t &bt�gt .- Ifltfr!st*jW?. Home Heaith Services Revenue Code with applicable CPT/HCPCS Code(s) 100% of Amerigroup Iowa Medicaid Fee Schedule Per Visit Rate CMS 1450 Ourable Medical Equiprnent Orthotics Prosthetics and Medical Supplies("DMEPOS") Revenue Code with applicable CPT/HCPCS codes 100% of the Amerigroup DMEPOS Fee Schedule Per Service CMS 1450 Drugs & Biologicals Revenue Code with applicable CPTJHCPCS/NDC code 100% of Medicare Part B Drug Average Sales Price ('ASP') Fee Schedule Per Service CMS 1450 IA Ancillary Hybrid Agreerneflt 08-2015 30 Lab Services Applicable CPT/HCPCS codes 1 00% ofAmerigroUp Iowa Medicaid Fee Schedule Per Service CMS 1500 31 IA Andilary Hybrid Agreement 08-2015 ::ZT ;. Yc : t rh Y L \_1 ‚ Sqrv�e " De$crutjon . T pded Servico' Qenfier "t- AmertgEoRp Rte r\:;' "ivethadoloy tc t L$fflhg hM4nent Therapy Services (Physical, Occupational, and Speech) Appflcable CPT/HCPCSINDG ccde .*. Applicable GPT/HCPCS codes 100% ofAmerigroup Iowa Medicaid Fee Schedule Por Service CMS 1500 31 IA Andilary Hybrid Agreement 08-2015 - GRID 'C'' ; SeThe9#SO'i)PtiOI -k l t t C �opd Ser* •O Atnerugreup Rite - f 1Methodologf -: -.' Durable Medical Equipment Orthotics, Prcsthetics and Medical SUppIIesCDMEPOS") Applicable CPT/HCPCS codes l00% ofthe Arnerigroup DMEPOS Fee Schedule Per Service CMS 1500 Drugs & Biologicals Appflcable CPT/HCPCSINDG ccde 100% of Medicare Part 8 Drug Average Sales Price (ASP") Fee Schedule PerService CMS 1500 31 IA Andilary Hybrid Agreement 08-2015 Amerigroup An Anthem Campany p rovi d ers .a me rigro u p .com PROVIDER/FACIUTY AND LONG-TERM SERVICES AND SUPPORTS PROVIDER APPLICATION Legal bushiess name: 0+ (jJAFerIo� Doirtg businea as: (if applicabl9) (Ji ±c(JDo flte .so Co tact person: krArn IWACJC Tax ID 1: ,1'9c Ernail: rnchr c r/oo-(A i)/Z2 Tax ID 2: Medicaid 1: (J�Oi Medicaid 2: Medicare 1: () 1 Medicare 2: Long-term care vendor number: EACILITY/ANCILLARV: AmbuIance (8) _Ambulatory surgery center (8) _Audiology servces (12) _Birthing center (13) DiaIysis (31) _Dietician/nutritioflal services (33) Durable medical equlpnientand supplies (36) _Early childhood intervention (37) _FamiIy planning services (41) Federaily qualified health center (293) FetaI monitoring serjices (45) _Genetic services (50) __.Fleinophilia center (52) jlonm health agency (64) _Home infusion therapy(65) Rospice care - outpatient (67) _Hospice facility (68) Hospital (69) Imaging facility (71) Inpatient rnental health/substance abuse facility (74) Inpatient rehab hospital (75) _lntensive family intervention (819) _Interpreter service (77) Laboratory (78) _Meth. maintenance clinic (84) _Nursing honie (98) _Occupational therapy services (105) _Organ transplant facility (111) _Orthotics and prosthetics (112) Outpatient mental health/substance abuse facility (115) _Outpatient rehab center (115) _Physical therapy services (148) _Psychiatric hospital (153) _Radiology—mobile unit (163) _Radiology facility (165) _flesidential treatment center (Ml-I/SA)(212) Respite care (159) _Rural health cllnic (172) _Skilled nursing facility (173) _Sleep disorder clinic (175) .Speech therapy services (177) _Sub acute/intermediate care facility (180) Trauma center (201) _Urgent care center (202) Waik-in clinlc (CCCs)(206) IAPEC-0006-15 Fac/Anc/LTC Application Page 1 August 2015 LONG-TERM CARE/HOME COMMUNITY BASED SERVICES/WAIVER Adult companion services (214) ._Ccre (911) Adult foster home (4) _Escort attendant (215) _Adult day activity/heafth servkes (27) Area Agency on Aging _Assistive Services/Technology (721/722) Attendant Care (901) _Centers for Independent Living (591) Chore services (21) CommunityTransitional Svcs (945) Consumer Directed Services (211) Financial assessment/risk reduction services (46) _Habilitation (1067) Home delivered meals (63) _jlonie health agency _Home Health Aide (235) _Home infusion therapy (65) _Horneniaker (216) Kome modification/repair (66) PROGRAMS: _Hospice care - outpaUent (67) I-Iospice facility (68) lntermediate Care Facility/MR (384) Muslc therapy (87) Nursing home (98) Nurse registry (213) Personal assistant services (143) _Personal eniergeflCy respOnse systems (457) Pest control (145) Prevocatlonal Services Residential care/assisted living facility (168) Respite care (169) Respite care - in home (462) _Respite care—inpatient (456) Service Eacilitator/ Indep Support Broker(S825) _Supportive Employment (653) Supportive Living Services (629) .Transitional Living SkilI (682) _Vehicle Modification (713) Page 2 Practice location name: ii rro3 tj» 1fedco RE Address je 1: / 4J F4cf T'tr» h(e21k Address line 2: Cit : At( \nu State: ZIP: ho County: P\)Ack fltJ. Phone: Fax: gi-qr7 0 Primary contact perso Administrator (full name): Does provider hill from this address? E Ves No Does this office meet ADA accessibility requirements? • Yes 4 No Check all that apply: Handicap accessib!e: Services for disabled: Accessible by pub!ic transportation: / Lyf Buliding fl Text tetephone fl Bus Language [1 Restroom 11 Merital/physical impairment LJ Regional train Parking • American Sign LI Subway tqit IIVU Narne(billing name): IrvTrcr\ SO4±U)'\n Address line 1: {L*Lfl Address line 2: City: State: ZIP: Phone: /'&- L!2?// Page 2 Note: If you are a DME provider, please submit NPI and taxonomy code(s) for each bcation. It more space is neeaea, separate sheet with name, service address, tax ID/EIN, NPI number and taxonomy code(s). Page 3 Practice Iocation name: -c& 1 / Address line 1: L/35 t.3ct 5Eceeij Address line 2: City: State: 1 o ( ZIP: 5oo County: &ftd( Phone: \O - Fax: 31q -C1( '? Prjmary contact person: bPvrn !flArc t - Administrator (full name): Does provider bill from this address? • ¥es No Does this offlce meet ADA accessibility requirements? fl Yes . No Check all that apply: Handicap accessible: j[ Building j' Parking Services for disabled: Q/rext telephone 0 American Sign Accessible by public transportation: ], Bus fl Subway fl Restroom Language Mental/physical impairrnent train • Regional Name (billing name): 9 too r rc Address line 1: EPST (hrc FreSL Address line 2: City: State: ZIP: 5oo3 Phone: aHcH qq AW9U* Provider name: - 7) kTt MO L4& Service address: L(Ttt) E. 0 Tax ID/EIN: NPI number: Taxonorny code(s): 3L1i(Lo3DO L Provider name: Service address: Tax ID/EIN: NPI nuniber: Taxonomy code(s): Note: If you are a DME provider, please submit NPI and taxonomy code(s) for each bcation. It more space is neeaea, separate sheet with name, service address, tax ID/EIN, NPI number and taxonomy code(s). Page 3 Note: If you are a DME provider, please submit NPI and taxonomy code(s) for each Iocation. If more space is needed, please attach a separate sheet with name, service address, tax ID/EIN, NPI number and taxonomy code(s). Page 3 Practice Iocation name: &5�LC Address line 1: LPo Qc4 Address ine 2: City: State: ZIP: SoC7c .2. County: &ftcjC /14L3/( Phone: c1:4.4q) Fax: 3qcjL/3 c Prjmary contact person: kbPr ffl&ckc Adnhinistrator (full name): - Does provider bill from this address? [J Ves No Does this offlce meet ADA accessibility requiremertts? Yes • No Check all that apply: Handicap accessible: Buflding Services for disabled: U,/Text telephone Accessible by public transportation: Bus - Parking 1 J American Sign 9 subway Language LJ iestroom Mental/physkal mpairmertt Regional train • Narne (billing name): 2 Address Iirie 1: Address line 2: City: kec \ State: ZIP: 3�c) ?) Phone: Provider name: Servke acldress: Tax ID/EIN: NPI nuniber: Taxonomy code(s): Provider name: Service address: 3c frS Tax ID/EIN: NPI number: Taxonomy cocle(s): Note: If you are a DME provider, please submit NPI and taxonomy code(s) for each Iocation. If more space is needed, please attach a separate sheet with name, service address, tax ID/EIN, NPI number and taxonomy code(s). Page 3 Note: If you are a DME provicler, please submit NPI and taxonomy code(s) for each Iocation. If more space 15 needed, please attach a separate sheet with name, service address, tax ID/EIN, NPI number and taxonomy code(s). Page 3 Practice acation name: -- 3 Address line 1: '9d' L)DflAA Adclress line 2: City: UMtrtoo State: Coo - ZIP: 5oC1c3 County: &ii&k /-{ALJJ( Phone: ;°- t443 Fax: 3tq I3 1 Pr)mary contact person: hPrr fl1<Ar;dt Administrator (full name): Does provider bill from this address? fl Yes No Does this office meet ADA accessibility requirements? [1 Ves No Check all that apply: Haridicap accessible: BuiIding Services for disabled: Text telephone Accessible by pubflc transportafion: Bus 55?Parking Sign D Restroorn mpairment train • American Language • Mentai/physical LI Subway fl Regional & Name (bifling name): Uku ¼-- Address line 1: 0'-; L 1 Address line 2: City: State: ZIP: J) J Phone: V1,( 17/() Provider name: Service address: g5 Tax ID/EIN: NPI nuniber: Taxonomy code(s): Provider narne: Service address: ,- ) Tax D/EIN: NPI number: Taxonomy code(s): Note: If you are a DME provicler, please submit NPI and taxonomy code(s) for each Iocation. If more space 15 needed, please attach a separate sheet with name, service address, tax ID/EIN, NPI number and taxonomy code(s). Page 3 Note: If vou are a DME provider, pease submit NPI and taxonomy code(s) for each Iocation. If more space is needed, please attach a separate sheet with narne, service address, tax JD/HN, NPI nurnber and taxonomy code(s). Page 3 Practice Iocation name: WAkcoo Re,c tn%1 Y) Address ine 1: LDOD I1boCoe1n '4tr Address Une 2: 3 City: UMtr State: f ZIP: ScflCI County: &&iiR Phone: Fax: 3qqjLj3 1 Prjmary coritact person: &rbtt !YArd. Adrninistrator (full narne): - Does provder bill from this address? fl Yes No Does this offlce nieet ADA accessibility requirements? 6aYes [1 No Check all that apply: ,- Handicap accessible: Building f3ij Parking Services for disabed: Text telephone [J Anierican Sign Nrestroom mpairment train Language • Mental/physical Accessible by public transportation: Bus 5 Subway fl Regional t Name (biling narne): Lk\Rkel N Address line 1: LFr - 1 - tr Vk Address line 2: City: State: ZIP: yj3 Phone: C4 ; t Provider name: Service address: Q Tax D/EIN: NPI number: Taxonomy code(s): Provider name: Service address: ____ 1 Tax D/EIN: NPI number: Taxonomy code(s): Note: If vou are a DME provider, pease submit NPI and taxonomy code(s) for each Iocation. If more space is needed, please attach a separate sheet with narne, service address, tax JD/HN, NPI nurnber and taxonomy code(s). Page 3 Note: If you are a DME provider, please submit NPI and taxonomy code(s) for each ocation. If more spacc is needed, please attach a separate sheet with name, service address, tax IDJEIN, NPJ number and taxonomy code(s). Page 3 Practjce ocatjon name: Ur\00 kt eaLC hv n Address line 1: 3.33 nbaroLc t Address inc 2: City: Go State: t c_c P ZIP: Soc County: &rkR /-!4L3)( Phone: Fax: 3qL/3 1 Prjmary contact person: m&Ar;d Administrator (full name): Does provider bill from this address? [1 Ves No Does this offlce meet ADA accessibility requirements? • Ves No Check all that apply: Handicap accessible: 3J(Buildng j(Parkng fl Restroom Services for disabled: J Text te!ephone [1 American Sign Language fJ Mental/physicai mpairment Accessible by public transportation: Bus LI Subway J Regional train Name (billing name): LLt( OC) t \t L. Address inc 1: 2 Address inc 2: City: 1 )Mc State: ZP: 3 5 Phone: 31d1 H 1c) Provider name: Service address: - N Tax IDJEIN: NPI number: Taxonomy code(s): Provider name: Service address: 7 Tax ID/EIN: T7 NPI nurnber: Taxonorny code(s): Note: If you are a DME provider, please submit NPI and taxonomy code(s) for each ocation. If more spacc is needed, please attach a separate sheet with name, service address, tax IDJEIN, NPJ number and taxonomy code(s). Page 3 Page 4 state: / Date of Iicense: License number: DQQQ Expiration date: i oV6 State: Date af Iicense: License number: Expiration date: CLIA certificate number: Lot A. LI ABC Jj ACHC fl ACR 9 CARF 9 TJC U MSM J AMH' • MAASF fl BOC Int'l. 9 CABC • CAP 9 CCAC 9 CHAP • COA • DNV 9 HFAP 9 HA 9 IAC 9 NABP 9 NBAOS Date of next survey NOT ACCREDITED (Complete Section B betow.) Date af nitiaI accreditation: / / Dateoflastsurvey: / / B. Has provider had an onsite survey by CMS or state agency? If no, successful completion of a health plan onsite visit will be required heafth plan to schedule the visit. Nonaccredited providers n,ust provide a copy of their most recent months) along with your Corrective Action PIan (if deficiencies stating facility 15 Ifl substantial compliance with most recent survey above require an onsite visit before network status may be granted. survey rnay delay your ability to become a participating provider. Yes J No Date of Iast state survey: to coniplete credentialing. government agency survey (may were cited), OR attach the letter from 3r / QS / L5 You will be contacted by the not be older than 36 the government agency meet the requirements or complete the onsite standards. Facilities that don't Failure to provicle documentatlon Current carrier name: \3\Ctt Srvs1rOEC? Policy number: Z. P 1 ' fl 3j A Coverage type: Occurrenc&based fl Effective date: Expiration date: Per incident: $ Aggregate: $ 0O0O61 Current carrier name: D( Pohcy number: 2. \xP 1 2 30 £z,rz Coverage Type: [21 Occurrence -based 9 Claims -based Effective date: H \Cj Expiration date: Per incident: $ t ObC) 0;flr Aggregate: $ \C) O) 0o7) Page 4 WATERLO-02 JDLJFEL CERTIFICATE OF LIABILITY INSURANCE IJATE (MMIDDJYYYY) 9/4/2015 THIS CERTIFICATE IS ISSLJED AS A MATTER OF INEORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIEICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. mIS CERTIFICATE 0!' INSURANCE DOES NOT CONSTITIJTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTI-{ORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an AUDITIONAL INSURED, tho policy(ies) must be ondorsed. If SUBROGATION 15 WAIVED, subjoct to tho terms and conditions of the policy, certain policies may requiro an endorsement. A statenient on this certificate doos not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER PDCM Insurance 3927 UniversityAve. P.O. Box 2597 Waterloo, IA 50704 CONTACT NAME: (A(C No Ext):(319) 234-8888 tNo): (319) 2347702 E-MAIL AODRESS: pdcmpdcm.com INSURER(S)AEFOROINO COVERAGE NAIC # INSURERA:TraVelers 40282 INSUREO City of waterloo 715 Mulberry Waterloo, IA 50703 INSURERB:Safety National Casuatty Corp. 1! ZLPI5P3O53A INSURER C: 07/01/2016 INSIJRER 0: $ 1,000,000 INSIJRER E: $ 100,000 INSURER F: REVISION NUMBER: THIS 3 TO CERTIFY THAT THE POLIGIES OF INSURANCE LISTED BELOW HAVEBEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGY PERIOD NDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR GONDITION OF ANY CONTRPCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN 5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS 0!' SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS. INSR LTR TYPEOFINS(JRANCE AOOLSUBR INSD WVD 1 POLICYNUMBER POLICYEFF (MM!DDJYYYY) POLICYEXP (MMIDDIYYYY) LIMITS A X COMMERCIALOENERALLIABILITY 1! ZLPI5P3O53A 07101/2015 07/01/2016 EACHOCCIJRRENCE $ 1,000,000 $ 100,000 X 0CCUR MED EXP (Any orie person) $ PERSONAL&ADVJNJURY $ 1,000,000 GENERLAGGREGATE $ 2,000,000 GENLAGGREGATELIMITAPPLIESPER; oiicv OTHER: LOC pR0DIJCTS-COMPIDPAGG $ 2,000,000 $ A AUTOMOBILELIABILITY X ANYAUTO Lg/NED HIRED AUTOS ULED NON -OWNED AUTOS H8109157P459 1 07/01/2015 07/01/2016 aOMBiEDINOLELIMIT $ 1,000,000 BODILYINJIJRY(Perperson) $ 000ILY INJLJRY (Per acddent) $ PROPERTY DAMAGE (Per accdent) $ A x UMBRELLALIAB EXCESSLIAB OGGUR CLAIMS -MADE ZUP15P0553 07/01/2015 07/01/2016 EACHOCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 $ X RETENTIDN$ 10,000 B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ANYPROPRIET0RJPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? (Mandatory in NI-!) Iryes. deseribe under DESCRIPTION 0F0PERTI0NS below .,, NIA AGC4053449 07/01/2015 07/01/2016 PER STATUTE OTH- ER ELEACHACGIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLIGY LIMIT $ 1,000,000 A Professional -EMT ZLP15P3053A 07/01/2015 07/01/2016 Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS! LOCATIONS IVEHICLES (ACORD 101, Additional Remarka Schedule, rnay be attached [more space is requi ed) Amerigroup of Iowa, Inc. 5088 North Ampton Norfolk, VA 23502 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEF0RE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE P0LICY PROVISIONS. AUTHORIZED REPRESENTATIVE &4L! ett»* - ACORD 25(2014/01) © 1988-2014 AGORD CORPORATION. All rights reserved. Tho AGORD name and logo are registered marks ofACORD CREDEI'JTIALING QUESTIONS Does the facility/ancillary/long-terrn care have: 1. Evidence of all subcontractors' professional Ilability claims history? Ves fl No 71 2. Any disciplinary action taken against any business or professional Iicense held in this or any other state or surrendered a Iicense in this or any state? Yes fl No 3. Any history of loss or limitation of privileges or disciplinary activity? Yes fl No Please include an explanation on a separate sheet for any questions answered VES. A1TESTATION AND INFORMATION RELEASE AUTHORIZATION All information providecl in this or in connection with this application 15 complete and accurate to the best of my knowledge, and 1 shall immediately notify Arnerigroup of any changes thereto. 1 understand that this application does not entitle rne to participation in Amerigroup. By applying for appointment as an Amerigroup Participating Provider, 1 authorize the Plan, its niedical director and appropriate representatives to consult with administrators and members of other institutions where 1 have been associated, including past and present malpractice carriers who may have information bearing on my professional competence, character and ethical qualiflcations. 1 hereby further consent to the inspection by Amerigroup, its rnedical director and appropriate representatives, of all records and documents, excluding medical records of non-members of Amerigroup plans, that may be material to an evaluation of any professional qualifications and competence to carry out the requested duties, as well as niy moral and ethical qualifications for Participating Provider status with Amerigroup. 1 consent and agree that Amerigroup wil! cornplete a criminal history background check to determine if 1 or any Subcontracted Providers have any history of felony convictions, including adjudication withheld on a felony, plea or nolo contendere to a felony or entry into a pretrial for a felony. 1 agree to obtain any consents or approvals required for my Subcontracted Providers to undergo such background checks. 1 hereby release Amerigroup and its representatives from liability for their acts performed in good faith and without malice in connection with evaluating rny application, credentials and qualiflcations. 1 hereby release any individuals and organizations from any Iiability that provide information to Amerigroup or its staif in good faith and without malice concerning my professional cornpetence, ethics, character and other qualifications, and 1 hereby consent to the release of such information. By executing this application, 1 confirm that 1 am bound by the terms of the Ancillary Agreement between rne or my group and Amerigroup, as such terms may be applicable to me. 1 understand that as an applicant for participation in <merigroup, 1 have the right to review information obtained from primary verification sources duringthe credentialing process. 1 further understand that upon notification from Arrterigroup, 1 have the right to explain any information obtained that rnay Qary substantially from that provided by me and correct any erroneous information submitted by another party. This shall be accomplished by my subniission of a written explanation or by appearance before the credentialing Conimittee, if they so request. 1 further understand that 1 rnay appeal the Committee's decision either in writing or by appearance before the Credentialing Committee, ifthey so request. Owner/registered/authorized agent printed name: 1 Date: Oer/registered/authorized agent signature: Title:A7tC SSN/Date of birth: SSN:YS�/f / t*? Date of birth: 4Oiijg' /99,9 Page 5 Enclosures Please submit aU applicable documents from the list below with your compieted and signed apptication. Failure to provide this information wifl prohibit Amerigroup from completing your credentialing and/or cont,racting process. ii Copy of all federal, state and/or Iocal Iicenses required to operate as a health care facility (by !ocation) Copy of accreditation certificate or letter 1 Copy of most recent CMS or state survey, including your corrective action plan if deficiencies cited OR cover Ietter from CMS/state agency stating facility is in substantial compliance Copy of CLIA certificate for each location, as applicable Page 6 Waterloo Fire Rescue Station 6 3233 Ansborough Ave Water!oo, IA 50701 Amerigroup Disclosure Form for Provicfer Entities Directions: Please answer ALL questions. For ariy "Yes" response, please provide an explanation or listing as required. If you do not believe a question is applicable to you or your organization/entity, you should answer the question "NA". If you need additional space to respond to a question, please add a separate sheet: Include your Entity Name an each sheet, identif'? the question and header for the listing. One Disclosure Entity Form is required per TIN. NO QLJESTIONS SHOULD BE LEFT BLANK. Dates of birth and Social Security numbers (SSNs) must be provided for validation purposes, as outlined in 42 CFR 455.104 (b) (1) (ifl. 1. tdentifying information Provider entity name 3 t(QO Provider DBA naime (if different from Provider entity name) flA4tr\O0 nt Provider Federal tax D number LJ (hQ3)'t Provider NEl number Medicaid ID number Providertelephone number g Di . oo.1- Provider address: Must include at Ieast one street address. (Attach a separate sheet if needed). List all practice Iocatioris City State ZIP code Wtrko rtt j E rc-\ €crt .50103 3 LJ. Ab707 \o n 5fl -�,td -‚ 11. OWNERSHIP AND CONTROL INFORMATION Directions: The entity/organization must Iist afl Controllers, Owners, Agents, and Managing Employees on the Master List. For the purposes af this form these terms are defined as foliows: Controller: includes all Directors, Trustees and Offlcers ofa corporation or Partners in a Partnership. Ifthe entity isa non- proflt or not-for-profit entity, please respond "N/A" to the percentage of ownership question below, but still Iist aU Q Controllers. L4S ?\- *- cJ re5-rc' (.t'C fYLFE opc&4.Owner:- indudes any person or businas entity that owns 5 percent or more of the assets, stock or profits of the Provider Entity either directly or indirectly. N 6 Agent: includes any person or entity that has the authority to obligate the Provider to a Contract, mortgage or loan that rnay or may not be secured by the entity's assets. cVuc Managing Employee: includes anyone who has the authority to make material business decisions on behalf of the Provider Entity. Page 7 A. Master Iist (Use adclitional pages if needed utilizing the headers for the table) Full name Address (Street and/or P0 Box) City ST ZIP DOB SSN for individuals or Tax ID for business entifles Percent owner - ship Title 0 � Ae(t°° J4 qj y i!tI,O 5t r flc p16tn7 b ¼2 v'n u'( Ip 5Ot2 uV5-t j cPr Page 8 B. Specific questions 1) Is any person isted in the Master iist related to another person ori the Master iist as a spouse, parent, child or sibling? Yes [1 No If "Yes", please provide the foliowing information about the related persons. If "No", go to the next question. Full Nanie of Eirst-related Person Full Name ofSecond-related Person Type of relation 2) Does any person or entity Iisted in the Master Iist have an Ownership or Control interest in any other Provicler entity? - Ves J No If "Ves", please provide the foliowing information about the other Provider entity the person on the Masterlist has an interest in. If "No", go to the next question. Name of Other Provider Entity Address City State ZIP Tax D 3) Has any person or entity Iisted in the Master list been convicted ofa criminai offense related to that person or entity's involvernent in any program under Medicare, Medicaid, TRICARE or the CHIP services program since the inception ofthose progranis? Yes LI No If "Yes", ptease provide the foliowing information. If "No", go to the next question. Name on court Name on Court Records SSN SSN/D OB MatMatter of the Offenseter of Matter of the Offense Date of Date of the Conviction Exclusion period of the offense if you were Exclusion Period of the Offense, if excluded by the federal Office ofthe Inspector General (OIG) 4) Has any person or entity isted in the Master list ever been Debarred from participation in federal governnient contracts? Debarred means an individual is prohibited froni participation in Contracts paicl for by the federal government, whether or not those contracts are in the health care area. Ves LI No If "Ves", please provide the foltowing information. If "No", go to the next question. Date of Debarrnent Length of Debarnient Reason for Debarment Page 9 5) Has any person ar entity Iisted in the Master Iist ever been Excluded from participation in federal health care programs (Medicare, Medicaid, CHIP or TRICARE) in the past? Excluded nieans a provider or entity has been notified by the Department of Health and Human Services, Office of the lnspector General (HHS, OIG) that they are prohibited from participating as a provider in any federaily funded health care program. Ves fl No J(1 If "Ves", please provide the foliowing information. If "No", go to the next question. Full Name of Individual or Entity Beginrilng date of Exclusion or Termination End date of Exelusion ar Terrnination Reason for Exclusion or Terminatiori Date of CMP 6) Has any person or entity listed in the Master List ever been Terminated from a state's Medicaid or CHIP program for reasoris having to do with program integrity (fraud or abuse)? Terniinated means the Provider lost the right to hill a state's Medicaid and/or CHJP progrartis for a cause related to fraud or abuse. Ves No If "Ves", please provide the foHowing inforniation. If "No", go to the next question. Full Name of Provider State of Practice When Terminated Reason for Terrnination Date ofTermination 7) Has any person or entity listed in the Master List ever had CiviI Monetary Penalties ( 'CMP'2) assessed against them? A CMP isa type of fine assessed against a provider by a governrnental agency that manages a federal health care prograni. Ves [1 No If "Ves", please provide the foliowing information. If "No", go to the next question. Full Narne of Individual or Entity State of Practice when CMP Assessed Reason for CMP Amount of CMP Date of CMP 8) Has any person Iisted in the Master List obtained an Ownership lnterest in a Provder Entity: (1) As a result of a transfer of ownership from someone Who was about to be Excluded prTerminated from participation in a federal health care program, or was in fact Excluded or Terniinated from participatiori in a federal health care program, (2), where the original Owner is or was a member of the curreht Owner's lnimediate Family or meniber ofthe current Owner's Household at the time of the transfer of ownership? [lrnmediate Famuly is defined as a person's husband or wife; natural or adoptive parent; child or sibling; stepparent, stepchild, stepbrother or stepsister; father-, rnother-, daughter-, son-, brother- or sister-in-Iaw; grandparent or grandchild; or spouse of a grandparent or grandchild. Member of household means, with respect to a person, any individual with whom they are sharing a common abode as part of a single-farnily unit, including domestic employees and others who live together as a family unit. A renter or boarder is not considered a meniber of the household.] Ves fl No If "Yes", please provide the following information. If "No", go to the next question. Full Name of Original Owner SSN or TAX ID of Original Owner Place ofTransfer Date of Tra n sfe r Page 10 9) Does any person or entity Iisted in the Master List have a direct or indirect Ownership interest of at Ieast 5 percent in a Subcontractor ofthe Provider Entity? A Subcontractor isa person or company that the Provider Entity has contracted with to provide some of the Provider Entities' management functions (i.e, biiling agent, or provide medical services, i.e., a medical lab). Yes j No j3' if "Ves", piease Iist each Suhcontractor. If"F'Jo", go to Section 111. Fuji Name ofSubcontractor Address City State ZIP Tax ID SSN for individuals orTaxifl for business entities Percent of owner - ship Title 9a) For each Subcontractor Vsted in 9 above, piease provide the foliowing information about the individuals with an Ownership or Control !nterest in the Subcontractor. See the directions for Section 11 above for a definition af these terms. Attach a separate sheet if necessary. 1 Full Name Address (Street and/or P0 Box) City State ZIP D0B SSN for individuals orTaxifl for business entities Percent of owner - ship Title Page 11 9b) Is anyone isted in Oa related to any person in the Master List? ves No If "Ves", please provide the foliowing information about the related persons. If "No", go to Section 111. Fuli Nanie of First Related Person Full Name of Second Related Person Type of Relation 11!. Business transactions 1) Has the Provider Entity entered into any financial transaction(s) with any Subcorttractor totaling more than 525,000 or any1signiflcant business transactions with any (Subcontractor)? Yes D No If "Ves", ptease provide the foltowing information. If "No" go to next question. List the ownership of any Subcontractor with whorn this provicler has had one or more business transactions totaling more than 525,000 during the previous twetve-month period and any signiflcant business transactions between this Provider and any wholly owned supplier, or between the Provider and any Subcontractor during the past five year (period). Futi name Address City State ZIP 2) Does the Provider Entity wholly own a Supptier? Supplier means an individual, agency or organization froni which the Provider Entity purchases goods and services used in carryirig out its responsibitities under Fvledicaid (e.g., a cornn,e,rcIal Iaundry, a rnanufacturer of hospital beds or a pharmacy). ¥es No J3 If "Ves", please provide the foliowing information. If "No", go to next question. Name Address City State ZI P NPI TI N Page 12 IV. Signature The state or federal Medicaid agency may refuse to enter nto, renew or terminate an agreement with a Provider if it is determined that a Provider did not fully, accurately and truthfully make the disdosures required by this statement. Additionally, faise statements ar representations of the required disclosures may be prosecuted under applicabe federal or state laws. The signature below MUST be the written signature of an individual who can legaily bind this Provider. In compliance with 42 CFR 455.104(c), Provider shall cornplete this disciosure of ownership upon application for network participation andfor prior to execution of a provider agreement, at the time of recredentialing/reenrollnient, and within 35 days after any change in ownership by the Provider. In compliance with 42 CFR 455.1O5(b), Provider certifies that it will submit within 35 days of the date on a request by the Secretary or the Medicaid agency, full and complete subcontractor inforniation as outlined in section 111, Business Transactions above. Narne of Person (Printed) Signature of Person Title Date kgsr C (q s/44 Narne of Person Completing Form Phone Number of Person Completing Form ( ) (\ft 5 (q Page 13 HC3 P41 MerrdI Meese My Profile Logout HeIp lowa Department of Pubile Health Promoffny and profecting the health of!owans FOR REVIEW DIRECTORS ONSITESDUE::, Edit Onsite Review (Last upclated 6/23/2015) Print Version Service Name Physlcal Address Contact Name Dayunie Phone Review Date * Completion Date Responsible Person * Drug Box * Waterloo Fire Rescue 425 East 3rd Street Waterloo, IA 50703 Black Hawk County Barbara McBride 319-291-4460 6123t2015 (mm/dd/yyyy) (mm/dd/'y) REPORTS Back to Onsite Reviews ADMIN Barbra Mo Brid N/A OnsiteReview Questions 132.7(1)a. Resolution Time Resolved Date Notes 132.7(1)d. 132.8(1)b. 132.8(1)c. 132.8(1)c.(2). 132.8(1)c.(2). 132.8(1)d. 1328(1)?. 132.8(1)h. 1328(3)a. 132.8(3)b. 132.8(3)c. 1328(3)d(1). 132.8(3)d(2). 132.8(3)d(3). 1328(3)?. Deficient 3ODays Current, complete application on rile (System Registry) —'3cnt 5tP*_ (mm/dd/yyyy) No driver and co,nmunications training dates listed in the system registry for San Eastman, Travis Ihnen, Micha Moore, and Ben Smith. Steve Jorden's CPR shows expired, Compliant Compliant Compliant Coinpliant Comptiant Compliant Compliant Not Applieable Compliant Compliant Contpliant Compliant Cotnpliant Coinpliant Coinpliant - Read 641-132(147A) Ambulance(s) and personnel to maintain 24/7 Appropriate staffing Emergency driving policy Driver training: CPR/emergency driving & comm. Written contingency p!an Written transportation agreenient Criticat care transport: P/P5 levels only Patient care report for every patient - Protocols: current year, signed, changes filed Personnel function within SOP and lev& of service auth, Personnel rosters and files current MD required CEH on file RN/PA exceptions and MD required CEH on file Physician medical director 132.8(3)g. 132.8(3)h. 132.8(3)j. 132.8(3)m(l). 132.8(3)rn(2), 132.8(3)m(3). 132.8(3)o. 132.8(4)b. 132.8(4)c. 132.8(4)d,e. esoIution Time Resolved Date Notes 132.8(5). 132.8(5)a,(2,3). 132.8(5)b. 132.8(5)c. 132.8(5)d. 132.8(5)1. 132.8(6», 132.8(6)b. 132.8(6)c. 132.9(2)c. 132.9(2)g. 132.9(3). 132.0(4). 132.0(4). 132.9(4)a1b,c,d. 136.2(3)a. 136.2(3)b. Resolution Time Resolved Date Notes Compliant Compliant Compliant Compliant Compliaiit Compliant Compllant Conipliaat Coxnpliant Deficient 30 Days Appropriate staif responds - reasonable amount of time Written notiflcation (7 days)—change of dir/owner Written notification (7 days)—change ot rned direction CQI policy includes medical audits CQI policy includes skills conipetency CQI policy includes follow-up (loop-closure/resolution) Document an equipnient malntenance prograni Equip and supplies per physician approved protocol Rx and OTC drug training per protocols Pharniacy agreement and p and p per agreernent Nt 4 (mm/dd/yyyy) The pharmacy agreeinent that was available was incoxnplete. Complele it and send me a copy. Alsn update the dnig Iist inthe protocols so it matehes what the services is carrying and send me a copy of the list. Coinpliant Coinpliant Cothpliant Compliant Compliant Compliant Conipliant Not Applieable Not Applicable Not Applieable Cornpliant Compliant Cotnpliant Coinpliant Coinpliant Compliant Deficient 30 Days Document a preventative vehicle maintenance proqram Garage climate controlled, maintained, clean and safe Interior & exterior of vehicle and equip dean/disinfected Equipment properly secured Airway, electrical, mechanical equip clean/operational Proper disposal for soiled supplies Report (48 hrs): Fire, damage or theft of amb, equip, Rx Subniit (7 days): MVC rpt. - crash with PD, P1, or F Report (10 days): Provider termination CQI policy: nieasurable outcomes CQI poflcy: type/frequency of review, action plan and f/u Assistant(s) appointed in writing in CQT policy Randomly review written audits (medical director) Quarterly written audits: medical director or designee Written audits review pt. care, times, system resp, doc. Data collection method Data subrnitted (90 days) following the end of a quarter V' (mm/dd/yyyy) The service has not eotered the 1 st Quarter 2015 data into Fietd thidge. Enter 1 st quarter EMS data into Field Dridge and e-mail me when completed. 9/2/2015 Iowa FireBridge Fire Oepartmenls Data Exchange r Dispatch ] More Weloome, Erica Christlansen 1 Logout Waterloo Fre Departrnent * Waterloo Fire Departnient > Reports > Data Transfer Histo,y tiploaded Date UtlIIty Oeehboard ] ncidents Modules Date Transfer History = Completed = Con,pleted w/ Errors = Pending • = Incomplete Total Records Total Records Found in File * Iniported * User Imported File 1 Staif fjr Q4IC� Setup Status Data Quality Import Update 'Jalldation Report jj 08/31/15 09:08 AM NFIRS DMa 186 185 Kevin Lee augl6-30-2015.INC 13' 13' 08/31/15 09:04 AM NFIRS Data 110 110 Kevin Lee augl-15-2015.INC 13' 13' 13' I 08/10/15 09:06 AM NFIRS Data 142 136 Kevin Lee Ju1y29-aug8.INC 13' 8' [3' 07/29/15 10:11 AM NFIRS Data 145 144 Kevin Lee ju1y1628.INC 2' 13' 2' 07/29/15 10:07 AM NFIRS DMa 193 193 Kevin Lee julyl-15.INC 13' 13' 2' 07/17/15 04:47 PM XML 2.0 539 539 ESO ESO t'lEMSrSImport.xmI 13' 13' 13' j 07/07/15 10:41 AM XML2.O 594 594 ESO ESO WATERL0OJMAGETREND_20150101-201501312.XML 0' 13' 13' (: j 07/07/15 10:21 AFI XML2.O - 9 E50 850 WATERLO0JMAGETREND_201S0101-2015011.Xi4L,k\(1) 0 0 07/02/15 01:55 PM NRRS Data 2 2 Kevin Lee resub2.INC 13' 2' 13' 07/02/15 01:46 PM NFIRS Data 79 78 kevin Lee may24-31.IMC 13' 13' 13' 07/02/15 01:42 PM NFIRS Data 1 1 Itevin Les resub.INC 13' 13' 13' 07/02/1501:34 PM NFIRS Data 1 0 •Kevin Lee 1A07009062015.INC 0' 13' 13' 07/02/15 11:51 AM NFIRS Date 2 1 itevin Lee june resub.INC 13' 2' 13' [j] 07/02/15 11:39 AM NFIRS Oata 196 192 itevin Lee junel6-3OJNC 13' 13' 3' 07/02/15 11:34 AM NFJRS Oata 200 199 Kevin Lee junel-15.INC 13' 13' 13' Records 1-15 ef 326 NOTES 1)TotIsnay represenl more than one servire's meords if reere uian ene service was uploaded at he saee tlrne, 2)Total Racords Found In File accounl for all racords lhaI could be foundkead In (ram (he lmported dala file. 3)Tolal Records lmported Iridirates Ihe total number of mcoids lhat impoded and am availabia through Run History and Repertlng. ImageTrend Service aridge u5S © 2015 Imagelrend, Inc. Version 8.8.3.2 https://www.iowafirebridge.com/resource/intranewrepOrlS/default.Cftll?IaYOLItetrUe&PAjD= 1414 •l,l