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«QUALCARE AMENDMENT TO PROVIDER NETWORK PARTICIPATION AGREEMENT This AMENDMENT (the “Amendment”) amends that certain Provider Network ...»

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QUALCARE

AMENDMENT TO PROVIDER NETWORK

PARTICIPATION AGREEMENT

This AMENDMENT (the “Amendment”) amends that certain Provider Network

Participation Agreement (the “Agreement”) by and between QualCare and Group.

WHEREAS, QualCare and Group each agree to amend the Agreement in order to conform the Agreement to changes in applicable federal and state laws, rules and regulations, and to incorporate other administrative changes to the Agreement.

NOW, THEREFORE, in consideration of the premises and the mutual promises, covenants and conditions herein contained and for other good and valuable consideration, the

receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows:

I. DEFINITIONS. All defined terms not specifically defined in this Amendment shall have the meanings set forth in the Agreement.

II. AMENDMENTS.

A. The second WHEREAS paragraph of the Agreement is hereby deleted in its

entirety and amended as follows:

WHEREAS, Group is a health care professional or facility that is duly licensed, certified, or otherwise authorized to practice his/her profession in the applicable jurisdiction where Covered Services will be furnished hereunder; and

B. Article 1 of the Agreement is hereby amended to include the following:

"Adverse Benefit Determination" means a denial, reduction or termination of, or a failure to make payment (in whole or in part) for, a benefit, including a denial, reduction or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because the Carrier determines the item or service to be experimental or investigational, cosmetic, dental rather than medical, excluded as a pre-existing condition or because the Carrier has rescinded the coverage.

C. The following definitions in Article 1 of the Agreement are hereby deleted in their

entirety and amended as follows:

“Carrier” means an insurance company authorized to transact the business of insurance in New Jersey and doing health insurance business in accordance with N.J.S.A. 17B:17-1 et seq., a hospital service corporation authorized to transact business in accordance with N.J.S.A. 17:48-1, et seq., a medical service corporation authorized to transact business in accordance with N.J.S.A.

BE:4642433.2/QUA064-226303 17:48A-1, et seq., a health service corporation authorized to transact business in accordance with N.J.S.A. 17:48E-1, et seq., or a health maintenance organization authorized to transact business pursuant to N.J.S.A. 26:2J-1, et seq.

“Clean Claim” means the claim is for a service or supply covered by the Health Benefits Plan that has been delivered to the proper billing address and has no defect or impropriety, including any lack of required substantiating documentation, or particular circumstance requiring special treatment that otherwise prevents timely payment being made on the claim. Providers shall be entitled to reimbursement on “Clean Claims” if: (a) The health care provider is eligible at the date of service; (b) The Member who received the health care service was covered on the date of service; (c) The claim is for a service or supply covered under the Health Benefits Plan; (d) The claim is submitted with all the information requested by the Payor on the claim form or in other instructions that were distributed in advance to the health care provider or Member in accordance with the provisions of section 4 of P.L.2005, c.352 (C.17B:30-51); and (e) The Payor has no reason to believe that the claim has been submitted fraudulently.

“Covered Services” means, with respect to Health Benefits Plans, Medically Necessary services or supplies provided to a Member under the applicable Health Benefits Plan for which the Payor is obligated to pay benefits or provide services.

“Health Benefits Plan” or “Plan” means a policy or contract for the payment of benefits for hospital and medical expenses or the provision of hospital and medical services delivered or issued for delivery in New Jersey by an applicable Payor.

“Material Change” means any change or amendment taken by QualCare or Payor, as applicable, that could reasonably be expected to have a material adverse impact on either the aggregate level of reimbursement to Participating Provider or the administrative expenses incurred by Participating Provider in complying with such change or amendment.

“Participating Hospital” means a general acute care facility licensed by the Commissioner of Health pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), including rehabilitation, psychiatric and long-term acute facilities, that has entered into an agreement with QualCare to provide Covered Services to Members.

“Participating Physician” means a physician licensed pursuant to Title 45 of the New Jersey Revised Statutes, who has entered into an agreement with QualCare to provide Covered Services to Members, and who has privileges to admit patients to the acute care facilities of at least one Participating Hospital, if necessary or required.





“Participating Provider” means a Participating Hospital, Participating Physician and/or another health care provider that, under a contract with QualCare, has agreed to provide Covered Services or supplies to Members for a predetermined fee or set of fees.

“Payor” means a Carrier, third party administrator, or self-funded plan that is contractually obligated under the applicable Health Benefits Plan to make payment on behalf of Members with respect to Covered Services.

-2BE:4642433.2/QUA064-226303 “Provider” means any physician, other health care professional, hospital, health care facility, or any other person or entity who is licensed, certified, or otherwise authorized to provide health care or other services within the scope of his/her/its license, certification, or authorization in the state or jurisdiction in which the services are furnished.

“Urgently Needed Services” means services for a non-life-threatening condition that requires care by a provider within twenty-four (24) hours.

D. Article 3.2.1 of the Agreement is hereby deleted in its entirety and amended as

follows:

is duly licensed, certified, or authorized to practice his/her profession without restriction or limitation within the applicable jurisdiction where Covered Services will be furnished hereunder;

and E. Article 3.2 of the Agreement is hereby amended to include the following new

Article 3.2.12:

has identified on the signature page all tax identification number(s) under which Participating Provider will submit claims for Covered Services rendered on behalf of Members hereunder.

F. Article 4.5 of the Agreement is hereby deleted in its entirety and amended as

follows:

Member Identification Cards; Verification. QualCare shall assist Payor in providing each of its Members with an identification card that indicates his/her enrollment in Payor’s Health Benefits Plan. This identification card shall include the QualCare logo, a description of the network to be accessed, the applicable telephone number(s) for eligibility, benefits and UM questions, the Payor identification number, and other information as may be required by the applicable Payor.

G. Article 4.7 of the Agreement is hereby deleted in its entirety and amended as

follows:

No Liability for Covered Services. QualCare shall not be obligated to perform or be liable for the performance of any Covered Services required to be performed by Participating Provider pursuant to any Payor Agreement. QualCare shall not be liable for any payment of any claims for furnishing Covered Services to Members, and QualCare shall not be an insurer, guarantor, or underwriter of the responsibility or liability of any Payor to provide benefits pursuant to any Health Benefits Plan.

H. Article 5.11 of the Agreement is hereby deleted in its entirety and amended as

follows:

Notice of Changes. Participating Provider shall provide QualCare with at least thirty (30) days advanced written notice, or otherwise use its/his/her best efforts to provide such written notice, in the event of any change in the Participating Provider’s status, including without limitation changes to Participating Provider’s tax identification number(s), and/or changes or limitations on new patients, office hours, office locations, and scope of services.

-3BE:4642433.2/QUA064-226303 I. Article 6.1 of the Agreement is hereby deleted in its entirety and amended as

follows:

Establishment. QualCare or Payor, as applicable, or its representative shall establish UM and QM programs to review and monitor the quality, Medical Necessity, and appropriateness of Covered Services furnished by Participating Provider on an inpatient and outpatient basis. To the extent that QualCare is responsible for establishing UM or QM programs, QualCare shall establish appropriate medical committees to assure effective utilization and quality of care for Members and a multidisciplinary committee for continuous quality improvement (CQI) to monitor the quality of the UM program. Such committees will assist QualCare in the development, implementation, administration, and monitoring of QualCare’s UM and QM programs, as applicable.

J. Article 6.3.2.a of the Agreement is hereby deleted in its entirety and amended as

follows:

Adverse Benefit Determinations of the UM and QM committee may be used to deny or reduce payment for those Covered Services provided to Members. A Member may not be billed for the amount of any such payment that is so denied. Reimbursement will not be denied retroactively for a Covered Service provided to a Member where Participating Provider relied upon the written or oral Authorization of QualCare or Payor, as applicable, prior to providing services to the Member, except in cases of misrepresentation or fraud, or in cases of Member ineligibility under the applicable Plan.

K. Article 6.3.2.b of the Agreement is hereby deleted in its entirety and amended as

follows:

Adverse Benefit Determinations made under the UM and QM programs are for purposes of determining whether services are Covered Services under the terms and conditions of the applicable Health Benefits Plan and the extent to which benefit payments will be made. Unless otherwise expressly set forth below, Adverse Benefit Determinations shall be made as required by the exigencies of the situation – within seventy two (72) hours of receipt of a claim for Urgently Needed Services, within fifteen (15) days of receipt of a claim for all other nonUrgently Needed Services, such as pre-authorizations, and within thirty (30) days of receipt of a post-service claim. Adverse Benefit Determinations shall be provided within two (2) business days. Such Adverse Benefit Determinations shall in no way affect the responsibility of Participating Provider to provide appropriate services to Members.

L. Articles 6.4.1, 6.4.1.a, and 6.4.1.b of the Agreement are hereby deleted in their

entirety and amended as follows:

Participating Provider, acting on behalf of the Member with the Member’s consent, may appeal any Adverse Benefit Determination resulting in a denial, termination, or limitation of services or the payment of benefits therefor under the applicable internal appeal processes of Carrier.

a. For group and individual Plans, under a stage 1 internal appeal, Participating Provider, acting on behalf of the Member with the Member’s consent, shall have the right to speak, regarding an Adverse Benefit Determination, with the Carrier’s medical

-4BE:4642433.2/QUA064-226303 director, or the medical director’s designee who rendered the Adverse Benefit Determination.

Stage 1 appeals shall be concluded as required by the exigencies of the situation – within seventy-two (72) hours of receipt of the stage 1 appeal for any Urgently Needed Services, Emergency services, admissions, availability of care, continued stay and health care services for which the Member received Emergency services but has not been discharged from a facility, or within ten (10) calendar days in the case of all other stage 1 appeals. As applicable, at the conclusion of a stage 1 internal appeal, Carrier shall include a written explanation of the right to a further internal or external appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed.

b. For group Plans, under a stage 2 internal appeal, Participating Provider, acting on behalf of the Member with the Member’s consent, shall have the right to pursue his/her/its appeal before a panel of physicians and/or other providers selected by Carrier who have not been involved in Adverse Benefit Determination at issue. Stage 2 appeals shall be concluded as required by the exigencies of the situation – within seventy-two (72) hours of receipt of the stage 2 appeal for any Urgently Needed Services, Emergency services, admissions, availability of care, continued stay and health care services for which the Member received Emergency services but has not been discharged from a facility, or within twenty (20) business days in the case of all other stage 2 appeals. As applicable, at the conclusion of a stage 2 internal appeal, Carrier shall include a written explanation of the right to a further external appeal, including the applicable time limits, if any, for making the appeal, and to whom the appeal should be addressed.

M. Article 6.4.2 of the Agreement is hereby deleted in its entirety and amended as

follows:



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