HomeMy WebLinkAboutGrant Related - GRIS (007)DocuSign Envelope ID- C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
K20-110
PROFILE SHEET
W9/LEGAL BUSINESS NAME
County of Grant
FEDERAL TAX ID #
916001319
PRIMARY PHYSICAL
ADDRESS LINE 1
322 Fortuyn Rd
PRIMARY PHYSICAL CITY
Grand Coulee
PREAVURY PHYSICAL STATE
Washington
PRIMARY PHYSICAL ZIP
99133
PRIMARY CONTACT
PERSON
J Doe2386
PRIMARY PHONE/
AITTHORIZATION FAX
5097659239 , 5097654124
PRIMARY EMAIL
sshenvood@co.grant.wa.us
BILLING ADDRESS LINE 1
PG Box 1057
BILLING CITY
:NOSES LAKE
BILLING STATE
Washington
BILLING ZIP
98837
BILLING CONTACT PERSON
J Doe2386
BILLING PHONE/FAX
5097659239 1/5097654124
BILLING EMAIL
sshenvoodCaco.grant.wa.us
003WA75397 Page 1
DocuSign Envelope ID: C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
PROFESSIONAL SERVICES AGREEMENT
PARTIES
Regence BlueShield, a Washington Nonprofit Corporation, ("Network Subcontractor"), and
County of Grant, on behalf of itself and the hospital, ancillary providers, and individual
providers to be credentialed under this Agreement hereto (collectively "Provider"). Network
Subcontractor and Provider are referred to individually herein as a Party and collectively as the
Parties.
EFFECTIVE DATE
This Agreement (the "Agreement") shall be effective on the date last signed on the signature
page (the "Effective Date").
RECITALS
A. Network Subcontractor has subcontracted with TriWest Healthcare Alliance Corp.
("TriWest") to establish a provider network for TriWest in conjunction with TriWest-
administered health care programs.
B. Provider is a duly licensed and/or certified, and in good standing with, the state in which they
operate, and desires to participate in Network Subcontractor's network for TriWest-
administered health care programs.
Therefore, the Parties agree as follows:
AGREEMENT
L DEFINITIONS
Authorization Preauthorization or Prior Authorization — Approval for requested services,
procedures or admission that is required to be obtained prior to services being rendered.
Beneficiary — Any person eligible to receive Covered Services under the rules, regulations,
policies and instructions of an applicable health care Program.
Clean Claim — A claim that contains all the required data elements necessary for adjudication
without requesting supplemental information from the submitter.
Copayments - Deductibles, copayments and/or cost sharing amounts payable by a
Beneficiary pursuant to the rules, regulations, policies and instructions of an applicable
health care Program.
Covered Services - Services, items and supplies for which benefits are available in
accordance with the rules, regulations, policies and instructions of an applicable health care
Program.
Electronic Data Interchange (EDI) - The transfer of claims data in a standard electronic
format.
Medically Necessary (Medical Necessity) - The appropriate and necessary treatment of the
patient's condition, illness or injury emphasizing accepted standards of medical practice and
applicable policy over cost or resource considerations.
Network Provider Provider - A provider who has contracted to render Covered Services
under an applicable health care Program and any professional provider employed by the
003WA75397 Page 2
DocuSign Envelope ID_ C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
contracting provider or billing for services under the contracting provider's Tax
Identification Number (TIN).
E=m — Any health care prograin administered by TriWest that is made part of this
Agreement through the methods described in Section V of this Agreement.
Provider Handbook — A Program -specific set of comprehensive written guidelines,
instructions, tyles. policies and procedures as established and published by TriWest for
participating Providers, as may be amended from time to time by TriWest in accordance with
the provisions of this Agreement.
Reimbursement Rates - The rates set forth in Exhibit(s) applicable to a TriWest-administered
health care program, which shall not exceed the amount payable by the health care program.
TriWest - TriWest Healthcare Alliance Corp. and. as applicable, its subcontractors.
IL TERM; TERVI1VATlOAT
A. Term - This Agreement shall commence upon the Effective Date and continue for an
initial two year term. Thereafter, both Parties agree that the term of this Agreement shall
automatically be extended for one-year periods unless terminated by either Party as
permitted by this Agreement.
B. Individual Provider Term — This Agreement shall become effective as to an Individual
Provider's participation in the Program upon Individual Provider being fully credentialed
by TriWest, but no sooner than the Effective Date.
C. Termination without Cause - Either Party may terminate this Agreement at any time
without cause upon at least ninety (90) days' prior written notice to the other Party.
Participation of any individual Provider credentialed under this Agreement shall be
automatically terminated on the date of disaffiliation of the individual Provider from
Provider. Provider shall give TriWest at least ninety (90) days' prior written notice of the
individual Provider's disaffiliation with Provider. An individual Provider terminating its
participation shall not terminate this Agreement for the remaining Providers credentialed
under this Agreement.
D. Immediate Termination — Network Subcontractor shall have the right to immediately
terminate this Agreement or a Provider's participation in a TriWest-administered
Program upon written notice to Provider upon the occurrence of any of the events listed
in the applicable Provider Handbook, including but not limited to loss of state or federal
license, substandard liability insurance, non-compliance/falsification on credentialing
application, or Provider is arrested. on felony charges. Termination of an individual
Provider pursuant to this Section II.D. will not terminate this Agreement for the
remaining Providers credentialed under this Agreement.
E. Material Breach - Either Party may terminate this Agreement for any material breach of
this Agreement by the other Party, but only if that breach is not cured within thirty (30)
days after written notice to the breaching Party.
F. After termination of this Agreement, Provider shall notify any Beneficiaries that Provider
is no longer a Network Provider and Provider shall cooperate with TriWest to ensure a
smooth transition for Beneficiaries from Provider to another Network Provider.
G. Services Upon Termination - Upon termination of this Agreement. Provider shall
continue to provide Covered Services for specific conditions for which a Beneficiary was
003WA75397 Page 3
DocuSign Envelope ID: C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
under a Provider's care at the time of such termination so long as the Beneficiary retains
eligibility, until the earlier of (1) completion of such services or (2) the assumption of
such treatment by another Provider. Compensation for continued services authorized by
TriWest shall be reimbursed at the amount allowed by the applicable health care
Program's policy and Federal law.
III. PRO 'IDER'S RESPONSIBILITIES
A. Provider agrees to treat Beneficiaries according to the terms and conditions of this
Agreement and the terms and conditions set forth in the applicable Provider Handbook,
as amended from time to time, and in accordance with all applicable laws, rules and
regulations pertaining to the applicable program. Provider shall accept the terms of
reimbursement and Reimbursement Rates set forth in the applicable exhibit as payment i
full for Covered Services. This paragraph shall survive the termination of this Agreement.
B. Provider agrees to be bound by, and comply with, the Provider Handbook applicable to
each Program under which Provider provides Covered Services to a Beneficiary. The
Provider Handbook can be found on the TriWest Provider Portal. The Provider
Handbook may be amended from time to time by TriWest, provided that TriWest or
Network Subcontractor will provide electronic or written notice to Provider of any
material changes to a Provider Handbook no fewer than thirty (30) days prior to the
effective date of any change. Such notice may be provided through a posting by TriWest
or its designee on the TriWest Provider Portal or by any other method reasonably
calculated to make the Provider aware of the amendment.
C. Provider shall collect applicable Copayments from Beneficiaries. Provider may not bill
Beneficiaries for any service that is not a Covered Service or disallowed.. Except for
applicable Copayments, Provider agrees that in no event (including, but not limited to,
nonpayment, or breach of this Agreement by TriWest or Network Subcontractor, or
TriWest's or Network Subcontractor's insolvency) shall Provider bill or collect for
Covered Services from a Beneficiary. This provision shall survive termination of this
Agreement. Provider shall not require payment from a Beneficiary for any excluded or
excludable service and/or non -Covered Service that the Beneficiary received unless the
Beneficiary has been properly informed that the services are excludable and/or not
Covered Services and has agreed in advance of receiving the services, in writing, to pay
for such services. The writing must be specific as to the details of the excluded or non -
Covered Service. General agreements to pay, such as those signed by the Beneficiary at
the time of service, are not sufficient to establish that the Beneficiary knew specific
services were excluded or excludable or that the Beneficiary agreed to pay. This
provision shall survive termination of this Agreement.
D. All claims shall be submitted electronically pursuant to the claims submission rules and
procedures found in the applicable Provider Handbook.
E. Provider shall comply with all applicable federal, state and local laws, including but not
limited to, confidentiality and security of Beneficiary medical records. Health Insurance
Portability and Accountability Act (HIPAA), Americans with Disabilities Act,
discrimination, and handicap accessibility. Furthermore, Provider warrants and certifies
that Provider is in compliance with all federal, state and local laws applicable to
Provider's business of providing health care services. Provider shall also comply with all
regulations, rules, policies and procedures of the applicable Program, including any
003WA75397 Page 4
DocuSign Envelope ID: C5732FC0-B56B-4EFO-AOB9-E9ED6FDD3B78
materials published by the applicable health care Program and/or TriWest, including but
not limited to the applicable Provider Handbook.
F. Provider must comply with all credentialing requirements of the applicable Program,
which are located in the applicable Provider Handbook.
G. Immediately upon learning of any actions, policies, determinations or internal or external
developments that may have a direct impact on any Provider's ability to perform its
obligations under this Agreement, Provider shall notify TriWest in writing pursuant to the
provisions set forth in the applicable Provider Handbook.
H. Provider agrees that TriWest and its designee, including without limitation, Network
Subcontractor, shall have access. upon demand and at reasonable times, to the books,
records and papers of Provider relating to the health care services provided to
Beneficiaries under an applicable Program, to the costs thereof, and to Copayments
received by Provider from Beneficiaries for Covered Services. TriWest and its designee
shall have the right to inspect, at reasonable times, Provider's facilities upon five (5)
days' prior notice to Provider. Provider will provide adequate space to TriWest and its
designee for the conduct of on-site inspections and reviews and shall cooperate in the
conduct of such on-site inspections and reviews. Provider will photocopy and deliver to
TriWest or its designee all information required for off-site review by TriWest of
Provider's performance under this Agreement within thirty (30) days of a request by
TriWest. This section shall survive termination of this Agreement.
I. Provider shall maintain applicable licensure. Medicare certification, and be able to
provide evidence of full accreditation by The Joint Commission or other accreditation
organization approved by TriWest. Provider shall be responsible for ensuring its directly
employed or contracted professional maintain applicable state license(s) that are free of
any sanctions or restrictions.
J. If Provider enters into any subcontracts with any subcontractors whereby such
subcontractor assumes any of Provider's duties, responsibilities, or other obligations
under this Agreement, Provider assumes full responsibility for credentialing, licensure,
and professional liability insurance of said subcontractor and shall ensure that any such
subcontracts require subcontractors to comply with the terms and conditions of this
Agreement.
IV PAYMENT TO PROVIDER
A. TriWest will make best efforts to process Clean Claims within thirty (30) days of receipt
and will make payment directly to Provider for Covered Services rendered by Provider to
Beneficiaries in accordance with the terms of the Reimbursement Exhibit. Provider
understands and agrees that neither Network Subcontractor nor TriWest is the insurer,
guarantor or underwriter of the payment of benefits to Provider for the Programs, and
agrees that Network Subcontractor shall not be responsible for payment of any claims
submitted by Provider for Covered Services to Beneficiaries.
B. All services must be authorized, Medically Necessary and provided at an appropriate
level of care. Provider must comply with applicable TriWest utilization review/payment
management programs and procedures. TriWest may utilize a standard industry code
review system in adjudicating claims and determining appropriate levels of coding.
003WA75397 Page 5
DocuSign Envelope ID_ C5732FCo-B56B-4EFQ-AOB9-E9ED6FDD3B78
C. Provider understands and agrees that there may be payment adjustments, including
retroactive adjustments, through the remittance or return of underpayments,
overpayments, recoupments and adjustments for retroactive terminations or denials of
coverage and claims payment determinations.
V. PAR TICIPA TION IN TRI WEST PR0GRA _VIS
A. Provider agrees to participate in all Programs that TriW'est currently administers and in
the future will administer. This Agreement will apply to Provider's participation in, and
provision of Covered Services to a Beneficiary under, all such Programs. Provider fiuther
agrees that Provider's participation is governed by the Terms and Conditions applicable
to each Program, which will be delivered at signing or at the time a Program is later
added to this Agreement pursuant to Section V, paragraph C of this Agreement, and by
the Provider Handbook for that program.
B. Provider's participation in Programs currently administered by TrAVest shall be effective
upon the Effective Date set forth above.
C. Additional Programs may be added to this Agreement upon at least thirty (30) days' prior
written notice to Provider. Provider's participation in each additional Program will
become effective upon the effective date set forth in the written notice provided to
Provider unless Provider gives written notice to Network Subcontractor of Provider's
rejection of the new Program prior to the effective date.
U. GENERAL PROVISIONS
A. Modifications
Any modification of this Agreement, including any of its Addenda, proposed by Network
Subcontractor shall be effective thirty (30) days after Network Subcontractor has given
written notice to Provider of the modification and Provider has not notified Network
Subcontractor in writing of Provider's rejection of the requested modification within that
timeframe.
Modifications that are required because of legislative, regulatory or legal requirements,
including without limitation any and all changes made to reimbursement or policies under
a government program do not require the consent of Provider and will be effective
immediately on the effective date thereof.
B. Applicable Law; Jurisdiction; Venue
This Agreement is governed by the laws in the State in which the Provider is located and
applicable federal law. In the event of a conflict between State and federal law, federal
law shall control.
C. Assignment
Except as permitted in this Agreement, neither Party may assign or transfer any right,
benefit. obligation or duty under the terms of this Agreement to any third party without
the prior written consent of the other Party and TriWest as the third party beneficiary,
003WA75397 Page 6
DocuSign Envelope ID_ C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
except that Network Subcontractor may assign all or any part of this Agreement or any
responsibilities hereunder to TriWest.
D. Network Subcontractor's Relationship to Provider
Provider further acknowledges and agrees that he/she/it has not entered into this
Agreement based upon representations by any person, entity or organization other than
Network Subcontractor and that no person, entity or organization other than Network
Subcontractor shall be held accountable or liable to Provider for any of Network
Subcontractor's obligations to Provider created under this Agreement. This paragraph
shall not create any additional obligations whatsoever on the part of Network-
Subcontractor
etworkSubcontractor other than those obligations created under other provisions of this
Agreement.
E. Dispute Resolution
1. In the event of any dispute arising under this Agreement, including without limitation
if Provider believes that TriWest incorrectly denied, paid, or processed all or part of a
claim and desires to obtain a review of the determination, Provider shall, within
ninety (90) days of initial determination:
a. submit a written request for review to TriWest; and
b. include in the written request the items of concern regarding TriWest's
determination and all additional information (including medical information)
supporting Provider's belief that the denial was incorrect.
On the basis of the information supplied with the request for review, together with
any other information available to it, TriWest will review its prior determination.
Provider will be notified in writing of TriWest's decision and the reasons for the
determination within sixty (60) days of TriWest's receipt of the request for review.
If Provider still believes that TriWest's determination is incorrect and/or has
information that was not previously available for review when submitted to TriWest,
Provider shall direct a second request for review in writing to TriWest within sixty
(60) days of receipt of the prior determination.
If Provider fails to submit any request for review within the timeframes set forth
above.. Provider shall be deemed to have waived its right to any remedies and to
pursue the matter further. Without limiting the foregoing, in such instance. Provider
may neither initiate a demand for arbitration pursuant to Section VI.E.3 of this
Agreement nor pursue additional payment from the Beneficiary.
2. In the event that a dispute is not or cannot be resolved through the review process
described above, each Party shall designate a member of its senior management to
meet in an attempt to resolve the dispute.
3. The Parties agree that any disputes that cannot be resolved by the review process and
senior management meeting shall be settled by final and binding arbitration.
Arbitration shall be conducted under the Commercial Arbitration Rules of the
American Arbitration Association. There will be a single arbitrator who shall be a
retired federal judge. The arbitration decision shall be binding on both parties and
shall be confidential. The arbitrator shall be bound by applicable law and shall issue
written findings of fact and conclusions of law. The arbitrator shall have no authority
003WA75397 Page 7
DocuSign Envelope ID: C5732FC0-B56B-4EFO-AOB9-E9ED6FDD3B78
to conduct or issue a decision with respect to any class arbitration or other claim
brought by Provider on behalf of the general public under a statue or regulation that
allows an individual to sue on behalf of the Attorney General or other federal. state or
municipal actor, or in any other representative capacity. The arbitrator shall have no
authority to award damages or provide a remedy that would not be available to such
prevailing party in a court of law nor shall the arbitrator have the authority to award
punitive damages. The cost of the arbitration shall be shared equally by the parties;
provided that each party shall be responsible for its own attorneys` fees and costs.
4. A demand for arbitration pursuant to Section VI.E.3 must be filed within six (5)
months of the date of the written decision rendered of the second request for review
described in Section VI.E.1, notwithstanding any communication between the parties
that may take place, or payment(s) that may be subsequently made related to the lack
of action or alleged breach that is the subject of the dispute. Should the aggrieved
party fail to file a demand for arbitration of the dispute within the timeframes set forth
herein, the aggrieved party shall have no right to pursue any remedy with respect to
such alleged breach, including, without limitation, initiation of any arbitration or civil
action in state or federal court, and if the aggrieved party is Provider, Provider shall
have no right to pursue payment of any disputed amounts from any Beneficiaries.
5. In the event the dispute resolution process is initiated as set forth above, any interest
charges that would be applicable to claims payments will not accrue while resolution
of the dispute is pending.
b. In the event that a judgment upon award in arbitration is not timely satisfied, such
judgment may be entered in any court of competent jurisdiction, or application may
be made to such court for a judicial acceptance of the award and enforcement, as the
law of the state having jurisdiction may require or allow. Notwithstanding the
foregoing, in the event a dispute is resolved pursuant to this Section VI.E., including
without limitation any resolution due to a waiver of Provider's rights to further pursue
a dispute, the subject of the dispute and its resolution shall be confidential.
F. Entire Agreement
This Agreement, including all attachments and Exhibits referenced in this Agreement, the
applicable Provider Handbook as amended by TriWest from time to time in accordance
with this Agreement, and the Terms &: Conditions applicable to each Program are
incorporated herein by reference, and constitute the entire understanding of the Parties
and supersede all prior agreements between the Parties with respect to the same subject
matter.
G. Mutual Indemnification
Provider shall hold harmless and indemnify and defend Network Subcontractor and
TriWest for, from, and against any Provider -related claims, losses, damages, liabilities,
costs, expenses or obligations arising out of or resulting from any Provider's wrongful or
negligent conduct in the performance of this Agreement including, but not limited to, the
provision of health care services by any Provider. Network Subcontractor shall hold
harmless and indemnify and defend Provider for, from, and against any losses, damages,
liabilities, costs, expenses or obligations arising out of or resulting from Network
Subcontractor's wrongful or negligent conduct in the performance of this Agreement.
H. Relationship of the Parties
003WA75397 Page 8
DocuSign Envelope ID: C5732Fr-O-B56B-4EFO-AOB9-E9ED6FDD3B78
The relationship of the Parties is not and shall not be construed or interpreted to be a
partnership. joint venture or agency. The relationship between the Parties is an
independent contractor relationship.
I. Release
Provider acknowledges that a number of functions under this agreement will be
performed by TriWest as set forth in this Agreement, including. but not limited to, claims
adjudication and payment. and utilization review. Provider agrees to this delegation of
functions to TriWest and further agrees that Network Subcontractor shall not be liable for
payments under this agreement or for negligent or intentional wrongdoing or breach of
this Agreement by TriWest. TriWest shall be solely liable for its actions and inactions
and for all payments due to Provider under this Agreement.
J. Third Party Beneficiary
TriWest shall be a third -party beneficiary of this Agreement and shall be entitled to
enforce Provider's obligations under this Agreement, and. Provider shall be entitled to
enforce TriWest's obligations under this Agreement. Except as expressly set forth in this
Section VI.J, nothing in this Agreement, express or implied, is intended to confer any
rights, remedies, claims, or interests upon a person not a party to this Agreement.
K. Waiver
There shall be no waiver of any term, provision or condition of this Agreement unless in
writing and signed by both Parties.
L. Severability
If any provision of this Agreement is deemed illegal, unenforceable or in conflict with
any law of a federal, state or local goverment having jurisdiction over this Agreement,
the validity of the remaining sections shall not be affected. This includes, without
limitation, a change in law or government program policy that is inconsistent with any
provision of this Agreement. In addition Network Subcontractor shall replace the illegal,
unenforceable or invalid provision(s) with a new provision(s) that, being valid, legal and
enforceable comes closest to the intention of the Parties concerning the illegal,
unenforceable or invalid provision(s). Network Subcontractor shall deliver to Provider, in
writing, replacement language to effectuate the new provision(s). The replacement
language shall specify its effective date and shall take effect without signatures of the
Parties.
M. No Oral Modifications.
Except as set forth in Sections III.B, V, and VI.A above. this Agreement and any of its
Addenda may be modified or amended only by written agreement executed by all Parties
to this Agreement.
N. Construction
The Parties to this Agreement have both had an equal opportunity to review, discuss and
negotiate the language and terms of this Agreement and therefore both Parties
acknowledge and agree that there shall not be any presumption to construe ambiguous or
disputed language against the drafter.
O. Confidentiality
003WA75397 Page 9
DocuSign Envelope ID= C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
Provider, Network Subcontractor and TriWest each agree to keep strictly confidential all
reimbursement rates and payment methodologies set forth in this Agreement and its
Addenda, except that this provision does not preclude disclosure by TriWest to
Beneficiaries of the method of compensation used by TriWest nor disclosure by Provider,
Network Subcontractor or TriWest to government agencies as may be required by law or
regulation. Provider, Network Subcontractor and TriWest agree that nothing in this
Agreement shall be construed as a limitation of (i) Provider's rights or obligations to
discuss with the Beneficiaries matters pertaining to the Beneficiaries' health regardless of
coverage options or (ii) TriWest's rights or obligations with respect to subcontractors.
Except as provided in this Section VI.O, any other release of the reimbursement rates set
forth in this Agreement and its Addenda by Provider, Network Subcontractor or TriWest
shall require the written permission of the others.
P. No Inducement to Refer
Nothing contained in this Agreement will require either Party or any physician of a Party
to admit or refer any patients to the other Party's facilities. The Parties enter into this
Agreement with the intent of conducting their relationship in full compliance with
applicable federal, state and local law, including the Medicare/Medicaid Anti -Fraud and
Abuse Amendments and the Physician Ownership and Referral Act (commonly known as
the Stark Lain). Notwithstanding any unanticipated effect of any of the provisions herein,
neither Party will intentionally conduct itself under the terms of this Agreement in a
manner to constitute a violation of these provisions.
Q. Eligibility for Participation in Government Programs
Each Party represents that neither it, nor any of its management or any other employees
or independent contractors who will have any involvement in the services or products
supplied under this Agreement, have been excluded from participation in any government
healthcare program, debarred from or under any other federal program (including but not
limited to debarment under the Generic Drug Enforcement Act), or convicted of any
offense in 42 U.S.C. Section 1320a-7, and that it, its employees, and independent
contractors are not otherwise ineligible for participation in federal healthcare programs.
Further, each Party represents that it is not aware of any such pending action(s)
(including criminal action) against it or its employees or independent contractors. Each
Party shall notify the other Party immediately upon becoming aware of any pending or
final action in any of these areas.
R. Time Limited
This Agreement is not an offer and will not be binding until fully executed by the Parties
and accepted by TriWest. This Agreement should be returned to TriWest within one
hundred eighty (180) days of Provider's receipt, or Provider should reach out to TriWest
to determine whether this Agreement remains valid.
S. Authority on Behalf of Providers
Provider represents and warrants that it is duly authorized to negotiate and enter into this
Agreement on behalf of each of the Providers identified in Exhibit 1.
Signature appears on last page
003WA75397 Page 10
DocuSign Envelope ID: C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
Each person signing this Agreement certifies that he/she has the appropriate authority to bind the
respective Party. Intending to be legally bound, the Parties have executed this Agreement as of
its Effective Date.
Network Subcontractor
Regence BlueShield, Washington
La
Signature
Signatory Name:Melissa Powell
Signatory Title:Vice President
Date:
Whose main address is:
1800 Ninth Avenue
Seattle
WA98101
Fax:
Accepted by TriWest:
TriWest Healthcare Alliance Corp.
Signature Date
Frank E. Maguire, M.D.
Chief Network Officer
Whose main address is:
P.O. Box 42049
Phoenix,
AZ 85053
Fax # (866) 867-7925
003WA75397
Provider
County of Grant
By:
Signature
Cindy Carter, Chair
Signatory Name and I Itle (Printed)
Date: 7 - -7 - c)-oa-o
Tax Id Number: 916001319
Whose main address is:
322 Fortuyn Rd
Grand Coulee
WA 99133
Fax: 5097654124
Page 1 I
DocuSign Envelope ID: C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
COMMUNITY CARE NETWORK
TERMS AND CONDITIONS
These Community Care Network Terms and Conditions ("T & C") are hereby incorporated by
this reference into the Professional Services Agreement ("Agreement") by and between County
of Grant ("Provider") and Regence BlueShield, a Washington Nonprofit Corporation,
("Network Subcontractor"). as if fully set forth therein and is hereby effective
. All defined terms used herein will have the same meanings set forth in the
Agreement. Provider shall provide VA Beneficiaries (defined below) with the services described
herein ("Services').
PURPOSE: The purpose of these T & C is to include Provider in a network to provide health
care services to Department of Veterans Affairs (VA) Beneficiaries under the Community Care
Network ("CCN") program and to establish the terms of participation in the CCN program.
All of the terms of the Agreement remain in full force and effect and will apply to Provider's
participation in the CCN program; provided that, in the event of a conflict between the terms of
these T & C and the terms of the Agreement, the terms of these T & C shall govern.
In addition to the terms and conditions of the Agreement, the following terms and conditions are
applicable to the CCN program.
1. DEFINITIONS: For purposes of these T & C, the following definitions shall apply:
CCN Covered Services — Services, items and supplies for which benefits are available to
VA Beneficiaries in accordance with the rules, regulations, polices and instructions of
Veterans Administration and the Veterans Health Administration.
Prior Authorization — A required process through which VA reviews and approves certain
medical services to ensure the medical necessity and appropriateness of care prior to
services being rendered within a specified timeframe from a non -VA provider or
additional resources in the community. This type of process requires a Prior
Authorization be obtained "prior to" the specified service.
Emergency Care —Medical care required within twenty-four hours or less that is essential
to evaluate and stabilize conditions of an Emergency/Emergent Need that if not provided
may result in unacceptable morbidity/pain if there is significant delay in evaluation or
treatment.
Emergency/Emergent Need — Conditions of one's health that may result in the loss of
life. limb. vision, or result in unacceptable morbidly/pain when there is significant delay
in evaluation or treatment.
TriWest Provider Handbook(Provider Handbook) — The set of comprehensive written
guidelines, instructions, rules, policies and procedures for the CCN program, as
established and published by TriWest for participating providers, and as may be amended
from time to time by TriWest in accordance with the provisions of this Agreement.
Urgent Care — The medical services defined in 38 C.F.R. § 17.4600(b)(5) provided in an
outpatient setting to treat acute or chronic illness or injury.
003WA75397C01 Page 1
DocuSign Envelope ID: C5732FC4-B56B-4EFO-AOB9-E9ED6FDD3B78
Veterans Health Administration (VA) — The division of the Department of Veterans
Affairs that provides health care services and administers health care benefits for eligible
Beneficiaries.
VA Beneficiary - Any person eligible to receive CCN Covered Services under the rules,
regulations, policies and instructions of the VA.
2. Provider shall comply with all applicable laws, rules, regulations, and requirements,
including all VA and TriWest .rules, regulations, requirements, policies, and procedures,
including the terms and conditions in the Provider Handbook, as amended from time to
time, and shall treat VA Beneficiaries pursuant to the terms and conditions of both these
T & C and the Agreement as applicable, and in accordance with the above referenced
laws, rules, regulations, and requirements.
3. Provider shall provide and maintain policies of general and professional liability
(malpractice) coverage in accordance with the terms and conditions set forth in the
TriWest Provider Handbook.
4. Provider will use best efforts to complete training provided by VA or TriWest as
specified in the Provider Handbook.
5. Provider understands and agrees that VA and TriWest have no obligation under the terms
of this Agreement or the T & C to refer VA Beneficiaries to Provider for services.
6. Provider shall accept the terms of reimbursement and the Reimbursement Rates set forth
in Exhibit 1 to these T & C as payment in full for the provision of CCN Covered Services
to VA Beneficiaries. With the exception of covered Urgent and Emergent Care, Provider
will be reimbursed only for services rendered to VA Beneficiaries that have a Prior
Authorization by VA. In no event will Provider be paid for such services more than the
amount payable by VA. All services must be Medically Necessary. Prior Authorization
is not a guarantee of payment of a claim.
7. Provider will comply with the policies and procedures of the Provider Handbook for
coverage and reimbursement for Urgent and Emergency Care, handling VA Beneficiary
Other Health Insurance (OHI), VA Beneficiary co -pays and the influenza vaccine.
Emergency Care Providers must notify VA, via secure email, secure fax or EDI, within
seventy-two (72) hours of the Veteran self -presenting to their facility for care. If a
Veteran has a Prior Authorization for care and during treatment it is determined the
Veteran is experiencing an emergency, the treating Provider must seek emergency
treatment immediately and notify VA immediately.
8. Provider will cooperate with TriWest's efforts to detect and prevent any activity that may
constitute a compliance concern including fraud, waste, or abuse, following standards set
by federal and state law and regulation. Claims that constitute fraud, waste or abuse will
be denied.
9. Provider shall not bill VA Beneficiaries for any CCN Covered Services, including but not
limited to VA Beneficiaries not appearing (e.g. "no show") for their appointment and
treatments that were set up but never started, or any other administrative or service fees.
Provider may collect payment from VA Beneficiaries for non -CCN Covered Services or
003WA75397C01 Page 2
DocuSign Envelope ID_ C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
services that were not Medically Necessary when Provider has entered into a written
agreement with the VA Beneficiary in advance that notifies the VA Beneficiary of the
services to be billed and of their payment responsibilities for those services in accordance
with federal law and the Agreement.
10. Provider shall submit claims for CCN Covered Services on behalf of VA Beneficiaries in
accordance with the claims submission rules and procedures as outlined in the Triwest
Provider Handbook. Provider shall use best efforts to submit claims within thirty (30)
days after the provision of the CCN Covered Services. No payment shall be made for a
Clean Claim that is (i) submitted more than one hundred and eighty (180) days after the
provision of the CCN Covered Services; or (ii) for services provided to VA Beneficiaries
without a Prior Authorization by VA; or (iii) for services for VA Beneficiaries for which
required medical reports have not been timely received by VA. Referring Provider will
comply with Provider Handbook policies and procedures for referrals to ancillary
providers.
11. In the event Provider believes that TriWest incorrectly denied, paid, or processed all or
part of a claim and desires to obtain a review of the determination. Provider shall, within
ninety (90) days of initial determination, submit a written request for review to Triwest.
The request must be in writing and includes the items of concern regarding Triwest's
determination and all additional information (including medical information) supporting
Provider's belief that the denial or other Triwest determination was incorrect. All other
dispute provisions specified in the Agreement remain in full force and effect.
12. Medical documentation, which includes both outpatient and inpatient records, must be
returned in accordance with the policies and procedures set forth in the Triwest Provider
Handbook.
13. Provider shall provide a VA Beneficiary with a copy of his or her medical record at no
charge, to include narrative summary and other documentation of care, within ten (10)
business days of the request.
14. Provider shall provide copies of medical records to Triwest within ten (10) business days
of Triwest's request, to permit Triwest to conduct peer review, quality assurance and
utilization review. Triwest will not pay, and Provider agrees to waive, any costs
associated with the aforementioned submission of medical documentation, including but
not limited to any copying or handling fees. Triwest will accept secure electronic
medical records in a HIPAA compliant encrypted format.
15. Provider shall notify NetSub of any change in address, professional affiliation, tax
identification number, licensure status, and/or staff privileges. Provider shall use best
efforts to notify NetSub at least sixty (60) days prior to the date of the change, or at the
earliest opportunity. If advance notification is not possible, Provider shall notify NetSub
no later than fourteen (14) days after the effective date of the change.
16. Provider shall use best efforts to comply with the VA Beneficiary access standards
specified in the Provider Handbook.
003WA75397C01 Page 3
DocuSign Envelope ID= C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
17. Provider shall not advertise the award of the Agreement or these T & C in its commercial
advertising in such a manner as to state or imply that the Department of Veterans Affairs
endorses a product, project or commercial line of endeavor.
18. TERMINATION: The T & C and Provider's participation in the CCN program may be
terminated immediately upon Provider's failure to meet CCN program participation
requirements. Either Party may terminate Provider's participation in the CCN program
without cause upon ninety (90) calendar days' notice by any Party.
19. SURVIVABILITY: The obligations of Sections 2 and 8 of these T & C shall survive the
termination of these T & C and the Agreement.
If any provision of these T & C is deemed illegal, unenforceable or in conflict with any law of a
federal, state or local government having jurisdiction over these T & C, the validity of the
remaining sections of these T & C and of the Agreement shall not be affected.
No Signature Required
003WA75397C01 Page 4
DocuSign Envelope ID_ C5732FC0-B56B-4EFO-AOB9-E9ED6FDD3B78
Exhibit 1 to the CCN Terms and Conditions
Reimbursement Rates
PROVIDER NAME: See Exhibit 2
TIN: See Exhibit 2
Provider acknowledges that this Exhibit 1 to the T & C sets forth the exclusive reimbursement it
will receive for the provision of CCN Covered Services to VA Beneficiaries except for
applicable Copayments.
Provider acknowledges that TriWest, as the third party administrator for CCN Program, is not
the insurer, guarantor, or underwriter of the payment of Covered Service for VA Beneficiaries'
benefits to the Provider. The services and payments made under this T & C shall be subject to all
applicable federal laws and VA rules and regulations. In no event will Provider be paid more
than the amount payable by VA. As federal law or regulation requires change in VA
reimbursement or the methodology to compute any VA payments, this Exhibit is automatically
updated to comply with said change. There will be no separate additional payment for services
provided in any Health Professional Shortage Area (HPSA).
The terms of the T & C, specifically including this Exhibit, are applicable for all care that
requires a Prior Authorization for VA Beneficiaries billed under the TIN(s) listed in Exhibit 2.
PROFESSIOVTAL SERVICES
Provider agrees to accept one hundred percent (100%) of the current applicable Medicare
Payment Methodology, as updated from time to time, for the locale cohere the service is
provided.
If a billed medical procedure or service is not payable under Medicare or is payable under
Medicare but does not have established pricing at the national or local level, payment will be
based upon the below hierarchy in order from first to last:
VA Fee Schedule
Billed Charges (inclusive of any agreed discount)
Provider agrees to accept a twenty-five percent (25%) discount off Provider's billed charge.
1NF'LUENZA VACCINE
For the administration of the influenza vaccine Provider agrees to accept thirty dollars ($30) as
the Reimbursement Rate.
003 WA75397C01 Page 5
DocuSign Envelope ID: C5732FCO-B56B-4EFO-AOB9-E9ED6FDD3B78
Exhibit 2 to the CCN Terms and Conditions
ProWder Listing
Provider Name Tax ID Number
County of Grant 910001319
003WA75397C0I Page 6