Exhibit 10.24
MOLINA HEALTHCARE OF CALIFORNIA

HOSPITAL SERVICES AGREEMENT

      This Hospital Services Agreement (“Agreement”) is entered by and between
Molina Healthcare of California, a California corporation (“Health Plan”), and
Pacific Hospital of Long Beach.

RECITALS

  A.   Health Plan arranges for the provision of certain health care services to
Members pursuant to contracts with various government sponsored health programs.
Health Plan intends to participate in additional government sponsored health
programs and offer other health products as the opportunities become available.
    B.   Health Plan arranges for the provision of certain health care services
to Members by entering into provider service agreements with individual
physicians, groups of physicians, individual practice associations, hospitals,
clinics, ancillary health providers, and other health providers.     C.  
Provider is licensed to render hospital inpatient and outpatient services and
desires to provide such services to Health Plan’s Members in connection with
Health Plan’s contractual obligations to provide and/or arrange for Health Care
Services for Health Plan’s Members.

      Now, therefore, in consideration of the promises, covenants and warranties
stated herein, Health Plan and Provider agree as follows:

ARTICLE ONE — DEFINITIONS

1.1   Provider means the health care professional(s), or entity(ies) identified
in Attachment A to this Agreement.   1.2   Capitalized words or phrases in this
Agreement shall have the meaning set forth in Attachment B.

ARTICLE TWO — PROVIDER OBLIGATIONS

2.1   Serving as a Panel Provider. Provider shall provide hospital inpatient
and/or outpatient services to Members for the products specified in Attachment
C. Provider agrees that its facility information may be used in Health Plan’s
provider directories, promotional materials, advertising and other informational
material

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 1 of 40

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      made available to the public and Members. Facility Information includes,
but is not limited to, name, address, telephone number, hours of operation, and
services. Provider shall promptly notify Health Plan of any changes in this
practice information.

2.2   Standards for Provision of Care.

  a.   Provision of Covered Services. Provider shall provide Covered Services to
Members, within the scope of Provider’s license, in accordance with this
Agreement, Health Plan’s policies and procedures, the terms and conditions of
the Health Plan product which covers the Member, and the requirements of any
applicable government sponsored program.     b.   Standard of Care. Provider
shall provide Covered Services to Members at a level of care and competence that
equals or exceeds the generally accepted and professionally recognized standard
of practice at the time of treatment, all applicable rules and/or standards of
professional conduct, and any controlling governmental licensing requirements.  
  c.   Facilities, Equipment, and Personnel. Provider’s facilities, equipment,
personnel and administrative services shall be at a level and quality as
necessary to perform Provider’s duties and responsibilities under this Agreement
and to meet all applicable legal requirements, including the accessibility
requirements of the Americans with Disabilities Act.     d.   Prior
Authorization. Provider shall verify eligibility of Members prior to rendering
services. Prior to admitting any Member as an inpatient or outpatient, Provider
shall obtain the prior authorization of Health Plan in accordance with Health
Plan’s Provider Manual unless the situation is one involving the delivery of
Emergency Services. For Emergency Services that result in an admission, Provider
shall notify Health Plan or its agent within twenty-four (24) hours of admission
and shall request authorization from Health Plan prior to the provision of any
post-stabilization care. For non-emergent services, regardless of whether prior
authorization was received, Provider shall cooperate and participate in Health
Plan’s notification procedures described in the Provider Manual for all
inpatient admissions (acute, rehabilitation, mental health and SNF) including
admissions resulting from an outpatient visit, and Provider shall notify Health
Plan of any admission within twenty-four (24) hours of admission.     e.  
Contracted Providers. Except in the case of Emergency Services or upon prior
authorization of Health Plan, Provider shall use only those health
professionals, hospitals, laboratories, skilled nursing and other facilities and
providers which have contracted with Health Plan (“Participating Providers”).

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

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  f.   Prescriptions. Except with respect to prescriptions and pharmaceuticals
ordered for in-patient hospital services, Provider shall abide by Health Plan’s
drug formularies and prescription policies, including those regarding the
prescription of generic or lowest cost alternative brand name pharmaceuticals.
Provider shall obtain prior authorization from Health Plan if Provider believes
a generic equivalent or formulary drug should not be dispensed. Provider
acknowledges the authority of Health Plan contracting pharmacists to substitute
generics for brand name pharmaceuticals unless counter indicated on the
prescription by the Provider.     g.   Availability of Services. Provider shall
make Covered Services available twenty-four (24) hours a day, seven (7) days a
week. Provider shall meet the applicable standards for timely access to care and
services, taking into account the urgency of the need for the services.     h.  
Hospital Services are those Plan benefits to include short term inpatient or
outpatient general hospital services including room with customary furnishings
and equipment, meals (including special diets as medically necessary), general
nursing care, use of operating room and related facilities, intensive care unit
and services, emergency services, drugs, including drugs to be dispensed at time
of emergency room visit in amount sufficient to last until such time Member can
reasonably be expected to fill a prescription, medications, biological,
anesthesia and oxygen services, ambulatory care services, diagnostic laboratory
and x-ray services, special duty nursing as medically necessary, physical
therapy, respiratory therapy, administration of blood and blood products, and
diagnostic, therapeutic and rehabilitative services as appropriate, and
coordinated discharge planning including the planning of such continuing care as
may be necessary, both medically and as a means of preventing possible early
re-hospitalization.

2.3   Standards for Hospital Providers.

  a.   Hospital Providers. Provider shall have a sufficient number of Hospital
Providers to provide Covered Services and meet the needs of Health Plan and its
Members as determined by Health Plan’s Quality Improvement Program and in
accordance with state and federal law. Provider shall be responsible for the
Covered Services provided by Hospital Providers.     b.   Contract with Hospital
Providers. Provider’s contract with its Hospital Providers shall be in writing
and shall bind Hospital Providers to the terms and conditions of this Agreement
including, but not limited to, terms relating to licensure, insurance and
billing of Members for Covered Services.     c.   Hospital Provider Information.
Upon request, Provider shall provide Health Plan with a complete list of its
Hospital Providers, together with the

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 3 of 40

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      provider specific information required by Health Plan for credentialing
and for administration of its health programs.

  d.   Restriction, Suspension or Termination of Hospital Provider(s). Provider
shall immediately restrict, suspend or terminate Hospital Providers(s) from
providing Covered Services to Members in the following circumstances: (i) the
Hospital Provider(s) ceases to meet the licensing/certification requirements or
other professional standards as specified in this Article; or (ii) Health Plan
or Provider reasonably determine that there are serious deficiencies in the
quality of care of the applicable Hospital Provider(s) which affects or could
adversely affect the health or safety of Members.     e.   Staffing Privileges.
Provider agrees to use its best efforts to arrange staff privileges or other
appropriate access for Health Plan’s contracted providers, Health Plan’s medical
directors and hospitalist providers who are qualified medical or osteopathic
physicians, provided they meet the reasonable standard of practice and
credentialing standards established by Provider’s medical staff and the bylaws,
rules and regulations of Provider.     f.   Notification. Provider shall notify
Health Plan within five (5) business days of becoming aware of any of its
Hospital Provider(s) who cease to meet the licensing/certification requirements
or other professional standards as described in this Agreement. Provider will
notify Health Plan within five (5) business days should any disciplinary or
other action of any kind be initiated against any Health Plan contracted
provider, medical director or hospitalist provider which could result in any
suspension, reduction or modification of his/her hospital privileges. Provider’s
notification to Health Plan shall state Provider’s actions taken against the
Hospital Provider or Health Plan provider. If Provider fails to act as required
by this Article with respect to any of its Hospital Provider(s) or Health Plan
reasonably determines and provides documentation to Provider that there are
serious deficiencies in the professional competence, conduct, or quality of care
of the Hospital Provider which could adversely affect the health and safety of
Members, Health Plan shall have the right to prohibit such Hospital Provider(s)
from continuing to provide Covered Services to Members.

2.4   Nondiscrimination.

  a.   Enrollment. Provider shall not differentiate or discriminate in providing
Covered Services to Members because of race, color, religion, national origin,
ancestry, age, sex, marital status, sexual orientation, physical, sensory or
mental handicap, socioeconomic status, or participation in publicly financed
programs of health care services. Provider shall render Covered Services to
Members in the same location, in the same manner, in accordance with the

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 4 of 40

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      same standards, and within the same time availability regardless of payor.

  b.   Employment. Provider shall not differentiate or discriminate against any
employee or applicant for employment, with respect to their hire, tenure, terms,
conditions or privileges of employment, or any matter directly or indirectly
related to employment, because of race, color, religion, national origin,
ancestry, age, sex, height, weight, marital status, physical, sensory or mental
disability unrelated to the individual’s ability to perform the duties of the
particular job or position.

2.5   Recordkeeping.

  a.   Maintaining Member Medical Record. Provider shall maintain a medical
record for each Member to whom Provider renders health care services. Provider
shall open each Member’s medical record upon the Member’s first encounter with
Provider. The Member’s medical record shall contain all information required by
state and federal law, generally accepted and prevailing professional practice,
applicable government sponsored health programs, and all Health Plan policies
and procedures. Provider shall retain all such records for at least ten
(10) years.     b.   Confidentiality of Member Health Information. Provider
shall comply with all applicable state and federal laws, Health Plan’s policies
and procedures, government sponsored program requirements regarding privacy and
confidentiality of Members’ health information and medical records, including
mental health records. Provider shall not disclose or use Member names,
addresses, social security numbers, identities, other personal information,
treatment modalities, or medical records without obtaining appropriate
authorization to do so. This provision shall not affect or limit Provider’s
obligation to make available medical records, encounter data and information
concerning Member care to Health Plan, any authorized state or federal agency,
or other Providers of health care upon authorized referral.     c.   HIPAA. To
the extent Provider is considered a covered entity under the Health Insurance
Portability and Accountability Act (“HIPAA”), Provider shall comply with all
provisions of HIPAA including, but not limited to, provisions addressing
privacy, security, and confidentiality.     d.   National Provider
Identification (“NPI”). In accordance with applicable statutes and regulations
of the Health Insurance Portability and Accountability Act (HIPAA) of 1996,
Provider shall comply with the Standard Unique Identifier for Health Care
Provider regulations promulgated under HIPAA (45 CFR Section 162.402, et seq.)
and use only the NPI to identify HIPAA covered health care providers in standard
transactions. Provider shall obtain an NPI from the National Plan and Provider
Enumeration System (“NPPES”)

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 5 of 40

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      for itself or for any subpart of the Provider. Provider shall make best
efforts to report its NPI and any subparts to Health Plan. Provider shall report
any changes in its NPI or subparts to Health Plan within thirty (30) days of the
change. Provider shall use its NPI to identify itself on all claims and
encounters (both electronic and paper formats) submitted to Health Plan.

  e.   Delivery of Patient Care Information. Provider shall promptly deliver to
Health Plan, upon request and/or as may be required by state or federal law,
Health Plan’s policies and procedures, applicable government sponsored health
programs, Health Plan’s contracts with the government agencies, or third party
payers, any information, statistical data, encounter data, or patient treatment
information pertaining to Members served by Provider, including but not limited
to, any and all information requested by Health Plan in conjunction with
utilization review and management, grievances, peer review, HEDIS Studies,
Health Plan’s Quality Improvement Program, or claims payment. Provider shall
further provide direct access at reasonable times to said patient care
information as requested by Health Plan or as required by any governmental
agency or any appropriate state and federal authority having jurisdiction over
Health Plan. Health Plan shall have the right to withhold compensation from
Provider in the event that Provider fails or refuses to promptly provide any
such information to Health Plan.     f.   Member Access to Health Information.
Provider shall give Health Plan and Members access to Members’ health
information including, but not limited to, medical records and billing records,
in accordance with the requirements of state and federal law, applicable
government sponsored health programs, and Health Plan’s policies and procedures.

2.6   Program Participation.

  a.   Participation in Grievance Program. Provider shall participate in Health
Plan’s Grievance Program and shall cooperate with Health Plan in identifying,
processing, and promptly resolving all Member complaints, grievances, or
inquiries.     b.   Participation in Quality Improvement Program. Provider shall
participate in Health Plan’s Quality Improvement Program and shall cooperate
with Health Plan in conducting peer review and audits of care rendered by
Provider.     c.   Participation in Utilization Review and Management Program.
Provider shall participate in and comply with Health Plan’s Utilization Review
and Management Program, including all policies and procedures regarding prior
authorizations, and shall cooperate with Health Plan in audits to identify,

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 6 of 40

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      confirm, and/or assess utilization levels of Covered Services.

  d.   Participation in Credentialing. Provider shall participate in Health
Plan’s credentialing and re-credentialing process and shall satisfy, throughout
the term of this Agreement, all credentialing and re-credentialing criteria
established by the Health Plan. Provider shall immediately notify Health Plan of
any change in the information submitted or relied upon by Provider to achieve
credentialed status. If Provider’s credentialed status is revoked, suspended or
limited by Health Plan, Health Plan may at its discretion terminate this
Agreement and/or move Members to another hospital.     e.   Provider Manual.
Provider shall comply and render Covered Services in accordance with the
contents, instructions and procedures set forth in Health Plan’s Provider
Manual, which may be amended from time to time. Health Plan’s Provider Manual is
incorporated in this Agreement by this reference.     f.   Health
Education/Training. Provider shall participate in and cooperate with Health
Plan’s Provider education and training efforts as well as Member education and
efforts. Provider shall also comply with all Health Plan health education,
cultural and linguistic standards, policies, and procedures, and such standards,
policies, and procedures as may be necessary for Health Plan to comply with its
contracts with employers, the state, or federal government. Provider shall
promptly deliver to medical staff, all informational, promotional, educational,
or instructional materials prepared by Health Plan regarding any aspect of
providing Covered Services to Members.

2.7   Promotional Activities. At the request of Health Plan, Provider shall
(a) display Health Plan promotional materials in its offices and facilities as
practical, and (b) shall cooperate with and participate in all reasonable Health
Plan’s marketing efforts. Provider shall not use Health Plan’s name in any
advertising or promotional materials without the prior written permission of
Health Plan.   2.8   Licensure and Standing.

  a.   Licensure. Provider warrants and represents that it is appropriately
licensed as a general acute care hospital to render health care services.
Provider shall provide evidence of licensure to Health Plan upon request.
Provider shall maintain its licensure in good standing, free of disciplinary
action, and in unrestricted status throughout the term of this Agreement.
Provider shall immediately notify Health Plan of any change in Provider’s
licensure status, including any disciplinary action taken or proposed by any
licensing agency responsible for oversight of Provider.     b.   Unrestricted
Status. Provider warrants and represents that it has not been convicted of
crimes as specified in Section 1128 of the Social Security Act

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 7 of 40

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      (42 U.S.C. 1320a-7), excluded from participation in the Medicare or
Medicaid program, assessed a civil penalty under the provisions of Section 1128,
entered into a contractual relationship with an entity convicted of a crime
specified in Section 1128, or taken any other action that would prohibit it from
participation in Medicaid and/or state health care programs.

  c.   Malpractice and Other Actions. Provider shall give immediate notice to
Health Plan of: (a) any malpractice claim asserted against it by a Member, any
payment made by or on behalf of Provider in settlement or compromise of such a
claim, or any payment made by or on behalf of Provider pursuant to a judgment
rendered upon such a claim; (b) any criminal investigations or proceedings
against Provider; (c) any convictions of Provider for crimes involving moral
turpitude or felonies; and (d) any civil claim asserted against Provider that
may jeopardize Provider’s financial soundness.     d.   Liability Insurance.
Provider shall maintain premises and professional liability insurance in
coverage amounts appropriate for the size and nature of Provider’s facility and
the nature of Provider’s health care activities. If the coverage is claims made
or reporting, Provider agrees to purchase similar “tail” coverage upon
termination of the Provider’s present or subsequent policy. Provider shall
deliver copies of such insurance policies to Health Plan within five business
days of a written request by Health Plan.

2.9   Claims Payment

  a.   Submitting Claims. Provider shall promptly submit to Health Plan claims
for Covered Services rendered to Members. All claims shall be submitted in a
form acceptable to and approved by Health Plan, and shall include any and all
medical records pertaining to the claim if requested by Health Plan or otherwise
required by Health Plan’s policies and procedures. Except as otherwise provided
by law or provided by government sponsored program requirements, any claims that
are not submitted by Provider to Health Plan within ninety (90) days of
providing the Covered Services that are the subject of the claim shall not be
eligible for payment, and Provider hereby waives any right to payment therefor.
    b.   Compensation. Health Plan shall pay Provider for Clean Claims for
Covered Services provided to Members, including Emergency Services, in
accordance with applicable law and regulations and in accordance with the
compensation schedule set forth in Attachment D. Provider shall accept such
payment, applicable co-payments, deductibles, and coordination of benefits
collections as payment in full for services provided under this Agreement.
Provider shall not balance bill Members for any Covered Services.

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 8 of 40

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  c.   Co-payments and Deductibles. Provider is responsible for collection of
co- payments and deductibles, if any.     d.   Coordination of Benefits. Health
Plan is a secondary payer in any situation where there is another payer as
primary carrier. Provider shall make reasonable inquiry of Members to learn
whether Member has health insurance or health benefits other than from Health
Plan or is entitled to payment by a third party under any other insurance or
plan of any type, and Provider shall immediately notify Health Plan of said
entitlement. In the event that coordination of benefits occurs, Provider shall
be compensated in an amount equal to the allowable Clean Claim less the amount
paid by other health plans, insurance carriers and payers, not to exceed the
amount specified in Attachment D.     e.   Payments which are the Responsibility
of a Capitated Provider. Provider agrees that if Provider is or becomes a party
to a subcontract or other agreement with a provider contracted with Health Plan,
who receives a global capitation from Health Plan for both professional and
facility services and is responsible for arranging for Covered Services through
subcontract arrangements (“Capitated Provider”), that Provider shall look solely
to the Capitated Provider, and not Health Plan, for payment of Covered Services
provided to Members that are covered by Health Plan’s agreements with such
Capitated Providers.

2.10   Claims Review.

  a.   Emergency Room. For admissions through the Emergency Room in which there
is: (a) a direct admission to Provider’s intensive care units for the provision
of Emergency Services, (b) a direct transfer to Provider’s operating room for
the provision of Emergency Services, or (c) an authorization by Health Plan or
its agents for the provision of post-stabilization care, Health Plan will not
retrospectively deny payment for the day of admission. For all other services,
including those admissions through the Emergency Room that resulted in a one
(1) day admission, Health Plan reserves the right to retrospectively review such
claims to determine if such services were Medically Necessary and may deny
payment for any such services which do not constitute Covered Services.
Notwithstanding the foregoing, Provider is not required to obtain authorization
from Health Plan prior to the provision of Emergency Services and care necessary
to stabilize a Member’s emergency medical condition. Health Plan will not
retrospectively deny payment for any services rendered by Provider in good faith
pursuant to the prior authorization of Health Plan.     b.   Authorized
Services. Health Plan is responsible for the authorization of medical services
provided to Members. If Provider has obtained concurrent or

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 9 of 40

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      prior authorization for a Covered Service provided to a Member, Health
Plan will not retrospectively deny payment for such authorized Covered Service,
unless Provider’s claim and/or medical record for such services do not support
the specific services and/or level of care authorized by Health Plan. Health
Plan shall conduct medical management throughout the course of treatment.
Provider acknowledges that initial and subsequent authorizations shall be
obtained as necessary.

  c.   Reporting Requirements. Provider’s failure to comply with Health Plan’s
requirements regarding Provider’s identification and reporting of institutional
and outpatient services, admissions, and/or related services to Health Plan or
to obtain authorization as required may result in non-payment to Provider for
all days and charges until the day that notification is received and services
are authorized.     d.   Offset. In the event that Health Plan determines that a
claim has been overpaid or paid in duplicate, or that funds were paid which were
not provided for under this Agreement, Provider shall make repayment to Health
Plan within thirty (30) working days of written notification by Health Plan of
the overpayment, duplicate payment, or other excess payment. In addition to any
other contractual or legal remedy, Health Plan may recover the amounts owed by
way of offset or recoupment from current or future amounts due Provider by
giving Provider not less than thirty (30) working days notice in which to
exercise Provider’s appeal rights under this Agreement. As a material condition
to Health Plan’s obligations under this Agreement, Provider agrees that the
offset and recoupment rights set forth herein shall be deemed to be and to
constitute rights of offset and recoupment authorized in state and federal law
or in equity to the maximum extent legally permissible, and that such rights
shall not be subject to any requirement of prior or other approval from any
court or other governmental authority that may now or hereafter have
jurisdiction over Health Plan and/or Provider.     e.   Claims Review and Audit.
Provider acknowledges Health Plan’s right to review Provider’s claims prior to
payment for appropriateness in accordance with industry standard billing rules,
including, but not limited to, current UB manual and editor, current CPT and
HCPCS coding, CMS billing rules, CMS bundling/unbundling rules, National Correct
Coding Initiatives (NCCI) Edits, CMS multiple procedure billing rules, and FDA
definitions and determinations of designated implantable devices and/or
implantable orthopedic devices. Provider acknowledges Health Plan’s right to
conduct such review and audit on a line-by-line basis or on such other basis as
Health Plan deems appropriate, and Health Plan’s right to exclude inappropriate
line items to adjust payment and reimburse Provider at the revised allowable
level. Provider also acknowledges Health Plan’s right to conduct utilization
reviews to determine medical necessity and to conduct post-payment billing
audits.

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 10 of 40

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      Provider shall cooperate with Health Plan’s audits of claims and payments
by providing access at reasonable times to requested claims information, all
supporting medical records, Provider’s charging policies, and other related
data. Health Plan shall use established industry claims adjudication and/or
clinical practices, state and federal guidelines, and/or Health Plan’s policies
and data to determine the appropriateness of the billing, coding and payment.

2.11   Compliance with Applicable Law. Provider shall comply with all applicable
state and federal laws governing the delivery of Covered Services to Members
including, but not limited to, title VI of the Civil Rights Act of 1964; title
IX of the Education Amendments of 1972 (regarding education programs and
activities); the Age Discrimination Act of 1975; the Rehabilitation act of 1973;
the Balanced Budget Act of 1997; and the Americans with Disabilities Act:

  a.   Provider acknowledges that this Agreement and all Covered Services
rendered pursuant to this Agreement are subject to state licensing statutes and
regulations set forth in Attachment E.     b.   Provider acknowledges that all
Covered Services rendered in conjunction with the state Medicaid program are
subject to the additional provisions set forth in Attachment F, the effect of
which provisions is limited solely to activities and Covered Services related to
the state Medicaid program.     c.   Provider acknowledges that all Covered
Services rendered in conjunction with the Medicare program are subject to the
Medicare provisions set forth in Attachment H, the effect of which provisions is
limited solely to activities and Covered Services related to the Medicare
program.

2.12   Provider Non-solicitation Obligations. Provider shall not unilaterally
assign or transfer patients served under this Agreement to another hospital
without the prior written approval of Health Plan. Nor shall Provider solicit or
encourage Members to select another health plan for the primary purpose of
securing financial gain for Provider. Nothing in this provision is intended to
limit Provider’s ability to fully inform Members of all available health care
treatment options or modalities.   2.13   Fraud and Abuse Reporting. Provider
shall report to Health Plan’s compliance officer all cases of suspected fraud
and/or abuse, as defined in Title 42, of the Code of Federal Regulations,
Section 455.2, where there is reason to believe that an incident of fraud and/or
abuse has occurred, by subcontractors, Members, providers, or employees within
ten (10) state working days of the date when Provider first becomes aware of, or
is on notice of, such activity. Provider shall establish policies and procedures
for identifying, investigating, and taking appropriate corrective action against
fraud and/or abuse in the provision of health care services under the Medicaid
program. Upon the request of Health Plan and/or the state, Provider shall
consult with the appropriate state agency prior to

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 11 of 40

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    and during the course of any such investigations.

2.14   Advance Directive. Provider shall document all patient records with
respect to the existence of an Advance Directive in compliance with the Patient
Self- Determination Act (Section 4751 of the Omnibus Reconciliation Act of
1990), as amended, and other appropriate laws.   2.15   Reciprocity Agreements.
Provider shall cooperate with Health Plan’s Participating Providers and
affiliates of Health Plan and agrees to provide Covered Services to Members
enrolled in various government sponsored health programs and other health
products, and various government sponsored health programs and other health
products of affiliates, and to assure reciprocity of health care services.
Without limiting the foregoing, if any Member receives services or treatment
constituting Covered Services from Provider and a capitated Participating
Provider is financially responsible for such services, such Participating
Provider shall be solely responsible for compensating Provider for any Covered
Services provided by the Provider in accordance with the applicable Payments
which are the Responsibility of a Capitated Provider provisions of this
Agreement. Payment by the Participating Provider shall be at; (i) the rates
agreed by the Participating Provider and Provider, or (ii) if there is no
applicable agreement, at the lesser of Provider’s billed charges or an amount
equivalent to one hundred percent (100%) of the governing rates provided by
applicable State and Federal Law specific to the Member’s enrolled benefit plan
(i.e. Medicaid, Medicare, etc) in place at the time services are rendered, or
(iii) at the election of the Participating Provider, at the rates set forth in
this Agreement. Provider agrees that the applicable provisions of the
Compensation section of this Agreement shall continue to be binding upon
Provider, especially in that Provider shall not balance bill Members for any
Covered Services. Provider shall comply with the procedures established by
Health Plan or its affiliates and this Agreement for reimbursement of such
services or treatment. Provider shall not encourage Members to receive Covered
Services from non-Participating Providers. Breach of this section shall
constitute breach of a material term of the Agreement and will give rise to
cause for termination of this Agreement pursuant to the applicable Termination
with Cause provisions of this Agreement. Provider shall abide by all provisions
of this Agreement relating to non-billing of Members with respect to all
services and treatment subject to this reciprocity arrangement.

ARTICLE THREE — HEALTH PLAN’S OBLIGATIONS

3.1   Compensation. Health Plan shall pay Provider in accordance with the terms
and conditions of this Agreement and the compensation schedule set forth in
Attachment D.   3.2   Member Eligibility Determination. Health Plan shall
maintain data on Member eligibility and enrollment. Health Plan shall promptly
verify Member

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 12 of 40

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    eligibility at the request of Provider.

3.3   Prior Authorization Review. Health Plan shall timely respond to requests
for prior authorization and/or determination of Covered Services.   3.4  
Medical Necessity Determination. Health Plan’s determination with regard to
Medically Necessary services and scope of Covered Services, including
determinations of level of care and length of stay benefits available under the
Member’s health program shall govern. The primary concern with respect to all
medical determination shall be in the interest of the Member.   3.5   Provider
Directory. Health Plan will provide Members with access to Health Plan’s
Provider Directory, updated from time to time, identifying the professional
status, specialty, office address, and telephone number of Health Plan
contracted providers.   3.6   Provider Services. Health Plan will maintain a
Provider Manual describing Health Plan’s policies and procedures, Covered
Services, limitations and exclusions, and coordination of benefits information.
Health Plan will maintain a Provider Services Department available to educate
Provider regarding Health Plan’s policies and procedures.   3.7   Medical
Director. Health Plan will employ a physician as medical director who shall be
responsible for the management of both the; (i) medical, and
(ii) medically-related scientific and technical, aspects of Health Plan.

ARTICLE FOUR — TERM AND TERMINATION

4.1   Term. This Agreement shall commence on the effective date indicated by
Health Plan on the signature page of this Agreement (“Effective Date”) and shall
continue in effect for one year; thereafter, it shall automatically renew for
successive one year terms unless and until terminated by either party in
accordance with the provisions of this Agreement or in accordance with
applicable provisions set forth in the attachments.   4.2   Termination without
Cause. This Agreement may be terminated without cause by either party on at
least one hundred and twenty (120) days written notice to the other party.   4.3
  Termination with Cause. In the event of a breach of any material provision of
this Agreement, the party claiming the breach will give the other party written
notice of termination setting forth the facts underlying its claim(s) that the
other party has breached the Agreement. The party receiving the notice of
termination shall have thirty (30) days from the date of receipt of such notice
to remedy or cure the claimed breach to the satisfaction of the other party.
During this thirty

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 13 of 40

--------------------------------------------------------------------------------

 

    (30) day period, the parties agree to meet as reasonably necessary and to
confer in good faith in an attempt to resolve the claimed breach. If the party
receiving the notice of termination has not remedied or cured the breach within
such thirty (30) day period, the party who provided the notice of termination
shall have the right to immediately terminate this Agreement.

4.4   Immediate Termination. Notwithstanding any other provision of this
Agreement, Health Plan may immediately terminate this Agreement and transfer
Member(s) to another provider by giving notice to Provider in the event of any
of the following:

  a.   Provider’s license or certificate to render health care services is
limited, suspended or revoked, or disciplinary proceedings are commenced against
Provider by the state licensing authority;     b.   Provider fails to maintain
insurance required by this Agreement;     c.   Provider loses credentialed
status;     d.   Provider becomes insolvent or files a petition to declare
bankruptcy or for reorganization under the bankruptcy laws of the United States,
or a trustee in bankruptcy or receiver for Provider is appointed by appropriate
authority;     e.   Health Plan determines that Provider’s facility and/or
equipment is insufficient to render Covered Services to Members;     f.  
Provider is excluded from participation in Medicare and state health care
programs pursuant to Section 1128 of the Social Security Act or otherwise is
terminated as a provider by any state or federal health care program;     g.  
Provider engages in fraud or deception, or knowingly permits fraud or deception
by another in connection with Provider’s obligations under this Agreement;    
h.   Health Plan determines that health care services are not being properly
provided, or arranged for, and that such failure poses a threat to Members’
health and safety.

ARTICLE FIVE — GENERAL PROVISIONS

5.1   Indemnification. Each party shall indemnify and hold harmless the other
party and its officers, directors, shareholders, employees, agents, and
representatives from any and all liabilities, losses, damages, claims, and
expenses of any kind, including costs and attorneys’ fees, which result from the
duties and obligations of the indemnifying party and/or its officers, directors,
shareholders, employees,

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 14 of 40

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    agents, and representatives under this Agreement.

5.2   Relationship of the Parties. Nothing contained in this Agreement is
intended to create, nor shall it be construed to create, any relationship
between the parties other than that of independent parties contracting with each
other solely for the purpose of effectuating the provisions of this Agreement.
This Agreement is not intended to create a relationship of agency,
representation, joint venture, or employment between the parties. Nothing herein
contained shall prevent any of the parties from entering into similar
arrangements with other parties. Each of the parties shall maintain separate and
independent management and shall be responsible for its own operations. Nothing
contained in this Agreement is intended to create, nor shall be construed to
create, any right in any third party, including but not limited to Health Plan’s
Members. Nor shall any third party have any right to enforce the terms of this
Agreement.   5.3   Entire Agreement. This Agreement, together with Attachments
and incorporated documents or materials, contains the entire agreement between
Health Plan and Provider relating to the rights granted and obligations imposed
by this Agreement. The contract between the state and the Health Plan is
incorporated herein by reference and shall be the guiding and controlling
document when interpreting the terms of this Agreement. Any prior agreements,
promises, negotiations, or representations, either oral or written, relating to
the subject matter of this Agreement are of no force or effect.   5.4  
Severability. If any term, provision, covenant, or condition of this Agreement
is held by a court of competent jurisdiction to be invalid, void, or
unenforceable, the remaining provisions shall remain in full force and effect
and shall in no way be affected, impaired, or invalidated as a result of such
decision.   5.5   Non-exclusivity. This Agreement shall not be construed to be
an exclusive Agreement between Health Plan and Provider. Nor shall it be deemed
to be an Agreement requiring Health Plan to refer Members to Provider for health
care services.   5.6   Amendment. Health Plan may, without Provider’s consent,
amend this Agreement to maintain consistency and/or compliance with any state or
federal law, policy, directive, or government sponsored program requirement upon
forty-five (45) business days’ notice to Provider unless a shorter timeframe is
necessary for compliance. Health Plan may otherwise materially amend this
Agreement only after forty-five (45) business days prior written notice to
Provider and only if mutually agreed to by the parties as evidenced by the
amendment being executed by each party hereto.   5.7   Assignment. Provider may
not assign, transfer, subcontract or delegate, in whole or in part, any rights,
duties, or obligations under this Agreement without

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 15 of 40

--------------------------------------------------------------------------------

 

    the prior written consent of Health Plan. Subject to the foregoing, this
Agreement is binding upon, and inures to the benefit of the Health Plan and
Provider and their respective successors in interest and assigns. Neither the
acquisition of Health Plan nor a change of its legal name shall be deemed an
assignment.

5.8   Arbitration. Any claim or controversy arising out of or in connection with
this Agreement shall be resolved, to the extent possible, within forty-five
(45) days through informal meetings and discussions held in good faith between
appropriate representatives of the parties. Any remaining claim or controversy
shall be settled by binding arbitration administered by the American Arbitration
Association (“AAA”) in accordance with its Commercial Arbitration Rules then in
effect by a single arbitrator in Long Beach, CA; provided, however, that binding
arbitration shall not be utilized to adjudicate matters that primarily involve
review of Provider’s professional competence or professional conduct, and shall
not be available as a mechanism for appeal of any determinations made as to such
matters. If possible, the arbitrator shall be an attorney with at least fifteen
(15) years of experience, including at least five (5) years of experience in
managed health care. The parties shall conduct a mandatory settlement conference
at the initiation of arbitration, to be administered by AAA. The arbitrator
shall have no authority to provide a remedy or award damages 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. Each party shall bear its own
costs and expenses, including its own attorneys’ fees, and shall bear an equal
share of the arbitrator’s and administrative fees of arbitration. The parties
agree to accept any decision by the arbitrator as a final determination of the
matter in dispute, and judgment on the award rendered by the arbitrator may be
entered in any court having jurisdiction. Arbitration must be initiated within
one year of the earlier of the date the claim or controversy arose, was
discovered, or should have been discovered with reasonable diligence; otherwise
it shall be deemed waived. The use of binding arbitration shall not preclude a
request for equitable and injunctive relief made to a court of appropriate
jurisdiction.   5.9   Attachments. Each of the Attachments identified below is
hereby made a part of this Agreement       Attachment A — Provider
Identification Sheet
Attachment B — Definitions
Attachment C — Products/Programs
Attachment D — Compensation Schedule
Attachment E — Licensing Provisions
Attachment F — Medicaid Program Provisions
Attachment G — Acknowledgment of Receipt of Provider Manual
Attachment H — Medicare Program Provisions
Attachment I — Disclosure Form
Attachment J — Certificate of Ownership

HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 16 of 40

--------------------------------------------------------------------------------

 

5.10   Notice. All notices required or permitted by this Agreement shall be in
writing and may be delivered in person or may be sent by registered or certified
mail or U.S. Postal Service Express Mail, with postage prepaid, or by Federal
Express or other overnight courier that guarantees next day delivery, or by
facsimile transmission, and shall be deemed sufficiently given if served in the
manner specified in this Section. The addresses below shall be the particular
party’s address for delivery or mailing of notice purposes:

If to Health Plan:
Molina Healthcare of California
200 Oceangate, Suite 100, Long Beach, California, 90802
Attention: President/CEO
If to Provider:
Pacific Hospital of Long Beach

                    
Attention: Michael D Drobot, CEO

    The parties may change the names and addresses noted above through written
notice in compliance with this Section. Any notice sent by registered or
certified mail, return receipt requested, shall be deemed given on the date of
delivery shown on the receipt card, or if no delivery date is shown, the
postmark date. Notices delivered by U.S. Postal Service Express mail, Federal
Express or overnight courier that guarantees next day delivery shall be deemed
given twenty-four (24) hours after delivery of the notice to the United States
Postal Service, Federal Express or overnight courier. If any notice is
transmitted by facsimile transmission or similar means, the notice shall be
deemed served or delivered upon telephone confirmation of receipt of the
transmission, provided a copy is also delivered via delivery or mail.

*** THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK ***
HSA — Hospital Services Agreement

         
Molina ECMS ref# 729
      Provider or authorized
MHC v122706 / MHI v091707
      representative’s initials:
Pacific Hospital of Long Beach
       

Page 17 of 40

--------------------------------------------------------------------------------

 

SIGNATURE AUTHORIZATION
     IN WITNESS WHEREOF, the parties hereto have agreed to and executed this
Agreement by their officers thereunto duly authorized as of the Effective Date
set forth by Health Plan below. The individual signing below on behalf of
Provider acknowledges, warrants, and represents that said individual has the
authority and proper authorization to execute this Agreement on behalf of
Provider and its constituent providers, if any, and does so freely with the
intent to fully bind Provider, and its constituent providers, if any, to the
provisions of this Agreement.

     
Pacific Hospital of Long Beach
  Molina Healthcare of California

             
Provider
      Molina    
Signature:
  /s/ M. Drobot   Signature:   /s/ Lisa Rubino
 
           
Signatory Name
  M. Drobot   Signatory Name   Lisa Rubino
(Printed):
      (Printed):    
 
           
Signatory Title
      Signatory Title   President
(Printed):
  CEO   (Printed):    
 
           
Signature Date:
  4/16/09   Signature Date:   4/30/09  
 
      Effective Date:   (To be completed by Health Plan)
 
           

      HSA — Hospital Services Agreement

 
   
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 18 of 40

 

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ATTACHMENT A
Provider Identification Sheet
Mark applicable category(ies) below. For those Providers representing multiple
health care professional(s) or entity(ies), please check all the categories that
apply.

             
 
 
  Primary Care Physician    
 
   
 
           
 
 
  Specialist: type    
 
   
 
                     
 
   

     
 
 
  Group/IPA (a list of constituent members with their License and DEA numbers is
attached and incorporated herein)

             
 X
 
  Hospital    
 
   

             
 
 
  Ancillary Provider: type    
 
   
 
           
 
 
  Pharmacy    
 
   
 
           
 
 
  Other: type    
 
   

Please enter “N/A” for the following if not applicable or not available:

         
Provider Name
  Pacific Hospital of Long Beach   Billing Address:
Telephone No.
  562-997-2500   P O Box 77417, Los Angeles, CA, 90084
Facsimile No.
       
Email Address
       
Tax I.D. No.
    Physical Address (if different than above):
License No.
       
NPI (or UPIN if NPI
  NPI: 1861407637    
not yet designated)
  UPIN:    
DEA No.
       

(Use continuation pages if multiple providers under common ownership will submit
bills under this Agreement)
I, the undersigned, am authorized to and do hereby verify the accuracy of the
foregoing Provider information.

         
 
  Provider    
 
  Signature:   /s/ M. Drobot
 
       
 
  Signatory Name   M. Drobot
 
  (Printed):    
 
       
 
  Signatory Title   CEO
 
  (Printed):    
 
       
 
  Signature Date:   4/16/09

      HSA — Hospital Services Agreement

 
   
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 19 of 40

 

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ATTACHMENT A
Provider Identification Sheet (Continuation Page)
Use one or more continuation pages as necessary when multiple providers under
common ownership (the Provider is signing on behalf of all of them) are expected
to bill Health Plan under more than one TIN and/or billing address. Please enter
“N/A” for the following if not applicable or not available:

         
Provider Name
      Billing Address:
Telephone No.
      Street
Facsimile No.
      City
Email Address
      State, Zip          ,
Tax I.D. No.
      Physical Address:
License No.
      Street
NPI (or UPIN if NPI
not yet designated)
  NPI:
UPIN:   City
DEA No.
      State, Zip          ,
 
       
Provider Name
      Billing Address:
Telephone No.
      Street
Facsimile No.
      City
Email Address
      State, Zip          ,
Tax I.D. No.
      Physical Address:
License No.
      Street
NPI (or UPIN if NPI
not yet designated)
  NPI:
UPIN:   City
DEA No.
      State, Zip          ,
 
       
Provider Name
      Billing Address:
Telephone No.
      Street
Facsimile No.
      City
Email Address
      State, Zip          ,
Tax I.D. No.
      Physical Address:
License No.
      Street
NPI (or UPIN if NPI
not yet designated)
  NPI:
UPIN:   City
DEA No.
      State, Zip          ,  
Provider Name
      Billing Address:
Telephone No.
      Street
Facsimile No.
      City
Email Address
      State, Zip          ,
Tax I.D. No.
      Physical Address:
License No.
      Street
NPI (or UPIN if NPI
not yet designated)
  NPI:
UPIN:   City
DEA No.
      State, Zip          ,

      HSA — Hospital Services Agreement

 
   
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 20 of 40

 

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ATTACHMENT B
Definitions

1.   Advance Directive is a Member’s written instructions, recognized under
state law, relating to the provision of health care when the Member is not
competent to make a health care decision as determined under state law. Examples
of Advance Directives are living wills and durable powers of attorney for health
care.   2.   Agreement means this Provider Services Agreement, all Attachments,
and incorporated documents or materials.   3.   Claim means an invoice for
services rendered to a Member by Provider, submitted in a format approved by
Health Plan, and with all service and encounter information required by Health
Plan.   4.   Clean Claim means a claim for Covered Services that has no defect,
impropriety, lack of any required substantiating documentation, or particular
circumstance requiring special treatment that prevents timely payment from being
made on the claim.   5.   CMS means the Centers for Medicare and Medicaid
Services, an administrative agency of the United States Government, responsible
for administering the Medicare program.   6.   CMS Agreement means the Medicare
Advantage contract between Health Plan and CMS.   7.   Covered Services means
those health care services that are Medically Necessary, are within the normal
scope of practice and licensure of Provider, and are benefits of the Health Plan
product or a Health Plan affiliate’s product which covers the Member.   8.  
Emergency Services are Covered Services necessary to evaluate or stabilize a
medical or psychiatric condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) so as to cause a prudent layperson,
who possesses an average knowledge of health and medicine, to reasonably expect
the absence of immediate medical attention to result in: (a) placement of the
Member’s health (or the health of the Member’s unborn child) in serious
jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction
of any bodily organ or part. For Health Plan’s Medicaid / Medi-Cal members,
Emergency Services also includes any services defined as emergency services
under 42 C.F.R. §438.114.   9.   Grievance Program means the procedures
established by Health Plan to timely address Enrollee and Provider complaints or
grievances.

      HSA — Hospital Services Agreement

 
   
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 21 of 40

 

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10.   Health Plan means Molina Healthcare of California   11.   HEDIS Studies
means Health Employer Data and Information Set.   12.   IPA means Independent
Practice Association.   13.   Medically Necessary means those medical services
and supplies which are provided in accordance with professionally recognized
standards of practice which are determined to be: (a) appropriate and necessary
for the symptoms, diagnosis or treatment of the Member’s medical condition;
(b) provided for the diagnosis and direct care and treatment of such condition;
(c) not furnished primarily for the convenience of the Member, the Member’s
family, the treating provider, or other provider; (d) furnished at the most
appropriate level which can be provided consistent with generally accepted
medical standards of care; and (e) consistent with Health Plan policy.   14.  
Medicare means the Hospital Insurance Plan (Part A) and the Supplementary
Medical Insurance Plan (Part B) provided under Title XVIII of the Social
Security Act, as amended.   15.   Medicare Advantage means the managed care
program established by the Medicare Modernization Act of 2003 to serve
Medicare-eligible beneficiaries. Medicare Advantage plans generally cover Part A
and Part B services and may also include Part D services.   16.   Medicare
Advantage Special Needs Plan (MA-SNP) means the managed care program established
by the Medicare Modernization Act of 2003 which allows health plans to create
specialized plans for beneficiaries who are eligible for Medicare and Medicaid.
  17.   Member(s) means a person(s) enrolled in one of Health Plan’s benefit
products or a Health Plan affiliate’s benefit product and who is eligible to
received Covered Services.   18.   Provider means the person(s) and/or entity
identified in Attachment A to this Agreement. Where Provider is a Group/IPA or
Hospital, Provider means and includes all constituent physicians, allied health
professionals and staff persons who provide health care services to Members by
and/or through the Group/IPA or Hospital. All of said persons are bound by the
terms of this Agreement.   19.   Provider Manual means the compilation of Health
Plan policies, procedures, standards and specimen documents, as may be
unilaterally amended or modified from time to time by Health Plan or mutually
amended or modified from time to time by the parties, that have been compiled by
Health Plan for the use and instruction of Provider, and to which Provider must
adhere.

      HSA — Hospital Services Agreement

 
   
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 22 of 40

 

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20.   Quality Improvement Program means the policies, procedures and systems
developed by Health Plan for monitoring, assessing and improving the
accessibility, quality and continuity of care provided to Members.   21.  
Utilization Review and Management Program means the policies, procedures and
systems developed by Health Plan for monitoring the utilization of Covered
Services by Members, including but not limited to under-utilization and
over-utilization.   22.   Utilization Management Reduction Amount means that
amount by which payments otherwise owing to Provider are reduced in the event
that Provider is de-delegated responsibility for utilization management.

      HSA — Hospital Services Agreement

 
   
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 23 of 40

 

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ATTACHMENT C
Products/Programs

    Provider hereby elects to participate as a panel provider for each of the
following Health Plan products as offered and applicable.

             
 
 
    1.     Medi-Cal Primary Care Case Manager
 
           
 
 
    2.     Medi-Cal Prepaid Health Plan
 
           
 
 
    3.     Medi-Cal Geographic Managed Care
 
           
 X
 
    4.     Medi-Cal Two-Plan Model
 
           
 X
 
    5.     Healthy Families
 
           
 X
 
    6.     Medicare Advantage (Molina Medicare Options)
 
           
 X
 
    7.     MA-SNP (Molina Medicare Options Plus)
 
           
 
 
    8.     Other Products — Provider agrees that Health Plan may from time to
time add additional products for which provider agrees to participate as a
contracted provider

     Health Plan shall maintain any applicable benefit and Covered Services
descriptions in its Provider Manual.

      HSA — Hospital Services Agreement

 
   
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 24 of 40

 

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ATTACHMENT D
Compensation Schedule
Pacific Hospital of Long Beach
Medi-Cal & Healthy Families
Molina shall pay Provider on a fee for service basis at the lesser of:
(i) Provider’s billed charges; or (ii) in accordance with the fee schedule set
forth below for all Covered Services provided to a Member, which are authorized,
by Molina or its designee for Molina Healthcare’s Managed Medi-Cal & Healthy
Family Members, less any applicable Member co-payments, deductibles,
co-insurance, or amounts paid or to be paid by other liable third parties, if
any.

          SERVICE   APPLICABLE CODES     DESCRIPTION   (if designated)   PAYMENT
RATES
Medical/Surgical
  UB: 100, 101, 110, 111, 112, 117, 119, 120, 121, 127, 129, 130, 131, 132, 137,
139, 140, 141, 142, 147, 149, 150, 151, 152, 157, 159, 160, 164, 169,   $1,200
Per Diem
 
       
DOU
  UB: 206, 214   $1,200 Per Diem
 
       
ICU/CCU
  UB: 200, 201, 202, 207, 208, 209, 210, 211, 213, 219   $1,300 Per Diem
 
       
OB Vaginal Delivery
2 days
  DRG’s 767, 768, 774, 775 includes One well baby defined by UB codes 170 or 171
Additional baby is Reimbursed at Boarder Baby Rate   $2,400 Case Rate
 
       
OB C-Section 3 days
  DRG-765, 766 includes one well baby defined by
UB codes 170-or 171   $3,600 Case Rate
 
       
Outpatient Diagnostic Services/Emergency Room Procedures
  UB: 300-319, UB: 320-359, UB: 610-619; UB: 730-749, UB: 450-459, UB: 351, 352,
359   105% of Medi-Cal
 
       
Outpatient Surgery
  UB: 360, 361, 369, 490, 499, 500   100% of applicable APC. Multiple procedures
shall be reimbursed according to the Medicare guidelines.
 
       
Partial Psych Care
  UB: 114, 124, 134, 154, 513   $600.00 Case Rate
 
       
Exclusions
  UB: 274, 275, 276, 278   The following items with a cost greater than $500.00
are excluded from the rates above and shall be reimbursed at a rate of Hospital
Cost plus 5%: Implantable devices (including non-reusable orthopedic
instrumentations, spinal cages, alugraphs, putty, pacemakers, leads, orthotics
and prosthetics.

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 25 of 40

--------------------------------------------------------------------------------

 

ATTACHMENT D-1
Compensation Schedule
Pacific Hospital of Long Beach
Molina Medicare Options (MMO) &
Molina Medicare Options Plus (MMOP)
Molina shall pay Provider on a fee for service basis at the lesser of:
(i) Provider’s billed charges; or (ii) in accordance with the fee schedule set
forth below for all Covered Services provided to a Member, which are authorized,
by Molina or its designee for Molina Healthcare’s Managed Molina Medicare
Options & Molina Medicare Options Plus Members, less any applicable Member
co-payments, deductibles, co-insurance, or amounts paid or to be paid by other
liable third parties, if any.
INPATIENT SERVICES:
Inpatient Services with Codable Medicare DRGs:

•   Health Plan agrees to reimburse Provider one hundred percent (100%) of the
prevailing Medicare Inpatient Prospective Payment System (DRG) in effect at the
time of service. Such Medicare DRG reimbursement will include DME, IME, DSH,
Capital, and all other Medicare payments, including outliers.   •   This
reimbursement methodology is not intended to imply any governance or regulations
set forth by Centers of Medicare and Medicaid Services (CMS), but is used to
describe the type of mathematical reimbursement formula agreed upon by Provider
and Health Plan.   •   Provider uses its Fiscal Intermediary to administer their
Medicare program. The Fiscal Intermediary calculates and updates factors used in
the calculation of the Medicare reimbursement formulas, which will be adopted
for use in this Agreement. Any change in the reimbursement formula factors,
including, but not limited to, changes in DRG definitions to comply with
industry mandated standards, will be applicable to the reimbursement set forth
in this Agreement, effective concurrently with the effective date of updates to
the Inpatient PPS PC Pricer.

OUTPATIENT SERVICES

•   Health Plan agrees to reimburse Provider at one hundred percent (100%) of
the prevailing Medicare Ambulatory Payment Classification (APC) in effect at the
time services are rendered.

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 26 of 40

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ARTICLE FIVE — NOTATIONS

6.1   Capitalized terms utilized in this Attachment, which are not otherwise
defined in this Attachment, if any, shall have the same meaning set forth in the
definitions to this Agreement.

6.2   Unless otherwise set forth above, the stipulated Hospital Provider payment
rates shall apply to all Professional Clean Claims submitted by Hospital
Providers.

4/16/09
HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 27 of 40

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ATTACHMENT E
REQUIRED PROVISIONS
(Health Care Service Plans)
The following provisions are required by (i) federal statutes and regulations
applicable to Health Plan, or (ii) state statutes and regulations applicable to
health care service plans. Any purported modifications to these provisions
inconsistent with such statutes, regulations, and agreements shall be null and
void.
DMHC Provisions

1.   In the event that Health Plan fails to pay Provider for Covered Services,
the Member or subscriber shall not be liable to Provider for any sums owed by
Health Plan. Provider shall not collect or attempt to collect from a Member or
subscriber any sums owed to Provider by the Health Plan. Provider may not and
will not maintain any action at law against a Member or subscriber to collect
sums owed to the Provider by Health Plan. (Health and Safety Code section 1379)

2.   To the extent that any of Health Plan’s quality of care review functions or
systems are administered by Provider, Provider shall deliver to Health Plan any
information requested in order to monitor or require compliance with Health
Plan’s quality of care review system. (Rule 1300.51, J-5)

3.   Provider is responsible for coordinating the provision of health care
services to Members who select Provider if Provider is a primary care physician.
(Rule 1300.67.1(a))

4.   Provider shall maintain Member medical records in a readily available
manner that permits sharing within Health Plan of all pertinent information
relating to the health care of Members. (Rule 1300.67.1(c))

5.   Provider shall maintain reasonable hours of operation and make reasonable
provisions for after-hour services. (Rule 1300.67.2(b))

6.   To the extent Provider has any role in rendering emergency health care
services, Provider shall make such emergency health care services available and
accessible twenty-four (24) hours a day, seven days a week. (Rule 1300.67.2(c))

7.   Provider shall participate in Plan’s system for monitoring and evaluating
accessibility of care including but not limited to waiting times and appointment
availability, and addressing problems that may develop. Provider shall timely
notify Health Plan of any changes to address or inability to maintain Health
Plan’s access standards. (Rule 1300.67(f))

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 28 of 40

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8.   Health Plan is subject to the requirements of the Knox-Keene Health Care
Service Plan Act of 1975, as amended (Chapter 2.2 of Division 2 of the Health
and Safety Code), and the Regulations promulgated hereunder (subchapter 5.5 of
Chapter 3 of Title 28 of the California Code of Regulations). Any provision of
the aforementioned statutes or regulation that is required to be in this
Agreement shall bind the Health Plan whether or not expressly set forth in this
Agreement. (Rule 1300.67.4(a)(9))

9.   Upon the termination of this Agreement, Health Plan shall be liable for
Covered Services rendered by Provider (other than for copayments as defined in
subdivision (g) of Section 1345 of the Health and Safety Code) to a subscriber
or Member who retains eligibility under the applicable plan contract or by
operation of law under the care of Provider at the time of termination of the
Agreement until the services being rendered to the subscriber or Member by
Provider are completed, unless the Health Plan makes reasonable and medically
appropriate provision for the assumption of services by a contracting provider.
(Health and Safety Code section 1373.96) (Rule 1300.67.4(a)(10))

10.   Any written communications to Members that concern a termination of this
agreement shall comply with the notification requirements set forth in Health
and Safety Code section 1373.65(f)

11.   Provider shall maintain all records and provide all information to the
Health Plan or the DMHC as may be necessary for compliance by the Health Plan
with the provisions of the Knox-Keene Health Care Service Plan Act of 1975, as
amended and any regulations promulgated thereunder. To the extent feasible, all
such records shall be located in this state. Provider shall retain such records
for at least two years: this obligation shall not terminate upon termination of
the Agreement, whether by rescission or otherwise. (Health and Safety Code
section 1381) (Rule 1300.67.8(b))

12.   Provider shall afford Health Plan and the DMHC access at reasonable times
upon demand to the books, records and papers of Provider relating to health
services provided to Members and subscribers, to the cost thereof, to payments
received by Provider from Members and subscribers of the Health Plan (or from
others on their behalf), and, unless Provider is compensated on a
fee-for-services basis, to the financial condition of Provider. Provider shall
promptly deliver to Health Plan, any financial information requested by Health
Plan for the purpose of determining Provider’s ability to bear capitation or
other applicable forms of risk sharing compensation. (Rule 1300.67.8(c))

13.   Provider shall not and is hereby prohibited from demanding surcharges from
Members for Covered Services. Should Health Plan receive notice of any such
surcharges by Provider, Health Plan may take any action it deems appropriate
including but not limited to demanding repayment by Provider to Members of any
surcharges, terminating this Agreement, repaying surcharges to Members and

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 29 of 40

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  offsetting the cost of the same against any amounts otherwise owing to
Provider. (Rule 1300.67.8(d))   14.   Upon Health Plan’s request, provider shall
report all co-payments paid by Members to provider. (Health and Safety Code
section 1385)

15.   To the extent that any of Health Plan’s quality assurance functions are
delegated to Provider, Provider shall promptly deliver to Health Plan all
information requested for the purpose of monitoring and evaluating Provider’s
performance of those quality assurance functions. (Rule 1300.70)

16.   Provider may utilize Health Plan’s Provider Dispute Resolution Process by
phoning or writing the Provider Services Department, Molina Medical Centers,
Third Floor, One Golden Shore Drive, Long Beach, CA 90802 (800) 526-8196, ext.
1249. The Provider Dispute Resolution Process, however, does not and cannot
serve as an appeal process from any fair hearing proceeding held pursuant to
Health and Safety Code Section 809, et. seq. Please see the Provider Manual for
more information regarding the dispute resolution process. (Health and Safety
Code Section 1367(h).) (Rule 1300.71.38)

17.   Provider shall display in each reception and waiting area a notice
informing Members how to contact their health plan, file a complaint with their
plan, obtain assistance from the DMHC, and seek an independent medical review.
(Rule 1300.67.8(f))

18.   Provider shall provide grievance forms and assist Members in filing
grievances. Provider shall cooperate with Health Plan in responding to Member
grievances and requests for independent medical reviews. (Rule 1300.68(b))

19.   In the event a Member seeks and obtains a recovery from a third party or a
third party’s insurer for injuries caused to that Member, and only to the extent
permitted by the Member’s evidence of coverage and by California law, Provider
may have the right to assert a third party lien for and to recover from the
Member the reasonable value of Covered Services provided to the Member by
Provider for the injuries caused by the third party. Health Plan shall similarly
have the right to assert a lien for and recover for payments made by Health Plan
for such injuries. Provider shall cooperate with Health Plan in identifying such
third party liability claims and in providing such information. Pursuit and
recovery of under third party liens shall be conducted in accordance with
California Civil Code section 3040.

20.   The Provider Manual may be unilaterally amended or modified by Health Plan
to maintain consistency and/or compliance with any state or federal law, policy,
directive, or government sponsored program requirement upon forty-five
(45) business days’ notice to Provider unless a shorter timeframe is necessary
for compliance. Health Plan may otherwise materially amend the Provider Manual
only after
forty-five (45) business days prior written notice to Provider and only if

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 30 of 40

--------------------------------------------------------------------------------

 

    mutually agreed to by the parties as evidenced by the amendment being
executed by each party.   21.   Notwithstanding any other provision in this
Agreement, if Health Plan or Health Plan’s capitated provider is not the primary
payer under coordination of benefits, Provider may submit claims to Health Plan
or Health Plan’s capitated provider within ninety (90) days from the date of
payment or date of contest, denial or notice from the primary payer. Except as
otherwise provided by law or provided by government sponsored program
requirements, any claims that are not submitted by Provider to Health Plan
within ninety (90) days from the date of payment or date of contest, denial or
notice from the primary payer shall not be eligible for payment, and Provider
hereby waives any right to payment therefore.

22.   Notwithstanding any other provision in this Agreement, if Health Plan or
Health Plan’s capitated provider denies a claim because it was filed beyond the
claim filing deadline, Health Plan will, upon Provider’s submission of a
provider dispute pursuant to Title 28, California Code of Regulations, section
1300.71.38 and the demonstration of good cause for the delay, accept, and
adjudicate the claim according to California Health & Safety Code section 1371
or 1371.35, which ever is applicable, and the California Code of Regulations.

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 31 of 40

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ATTACHMENT F
DHCS Provisions
     The following provisions apply exclusively to Covered Services provided and
activities engaged in pursuant to Medicaid Program:

1.   All Medicaid covered services are set forth in Attachment C and the
Provider Manual as set forth in this Agreement. (Rule 53250(c)(1))   2.   This
Agreement shall be governed by and construed in accordance with all laws,
regulations and contractual obligations incumbent upon the Health Plan. (Rule
53250(c)(2))   3.   This Agreement shall become effective upon approval by the
Department of Health Care Services (“DHCS”) in writing, or by operation of law
where the DHCS has acknowledged receipt of this Agreement and has failed to
approve or disapprove the Agreement within 60 days of receipt.
(Rule 53250(c)(3))   4.   Amendments to this Agreement shall be submitted to the
DHCS, for prior approval, at least thirty (30) days before the effective date of
any proposed changes governing compensation, services or term. Proposed changes
which are neither approved nor disapproved by the DHCS, shall become effective
by operation of law thirty (30) days after the DHCS has acknowledged receipt, or
upon the date specified in the Amendment, whichever is later. (Rule 53250(c)(3))
  5.   Provider agrees to submit all reports required and requested by Health
Plan, in a form acceptable to Health Plan. (Rule 53250(c)(5))   6.   Provider
shall make all of its books and records, pertaining to the goods and services
furnished under the terms of this Agreement, available for inspection,
examination or copying:

  a.   By the DHCS, the United States Department of Health and Human Services,
the DMHC, and the Department of Justice;     b.   At all reasonable times, at
Provider’s place of business or at such other mutually agreeable location in
California;     c.   In a form maintained in accordance with the general
standards applicable to such book or record keeping;     d.   For a term of at
least five years from the close of the fiscal year in which the date of service
occurred, in which the record or data was created or applied, and for which the
financial record was created;

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 32 of 40

--------------------------------------------------------------------------------

 

  e.   Including all encounter data for a period of at least five years. (Rule
53250(e)(1))

7.   Provider agrees to notify the DHCS in the event that this Agreement is
amended or terminated. Notice to the DHCS shall be considered given when
properly addressed and deposited in the United States Postal Service as First
Class Registered Mail, postage attached.
(Rule 53250(e)(4))   8.   Provider shall maintain and make available to the
DHCS, upon request, copies of all subcontracts and shall ensure that all
subcontracts are in writing and require that subcontractors:

  a.   Make all applicable books and records available at all reasonable times
for inspection, examining or copying by the DHCS, the U.S. Department of Health
and Human Services, the DMHC, and the Department of Justice;     b.   Retain
such books and records for a term of at least five years from the fiscal year in
which the date of service occurred, in which the record or data was created or
applied, and for which the financial record was created. (Rule 53250(e)(3))

9.   Provider agrees that any assignment or delegation of this Agreement shall
be void unless prior written approval is obtained from the DHCS in those
instances where prior approval by the DHCS is required. (Rule 53250(e)(5))   10.
  Provider agrees to hold harmless both the State of California and Health Plan
members in the event that Health Plan cannot or will not pay for services
performed by Provider pursuant to this Agreement. (Rule 53250(e)(6))   11.  
Provider shall assist Health Plan in the transfer of care in the event Health
Plan’s Two-Plan Model Contract with the DHCS expires or terminates. Providers
shall assist Health Plan in the transfer and care in the event this Agreement
expires or terminates for any reason.   12.   Provider shall not attempt
recovery in circumstances involving casualty insurance, tort liability or
workers’ compensation. Provider shall report to the DHCS within ten (10) days
after discovery any circumstances which may result in casualty insurance
payments, tort liability payments, or workers’ compensation award.
(Rule 53222(b))   13.   Provider shall disclose the names of the officers and
owners of Provider, stockholders owning more than ten percent (10%) of the stock
issued by Provider, if any, and major creditors holding more than five percent
(5%) of the dept of Provider. For that purpose, Provider shall use the
Disclosure Form made available by Health Plan. (W&I Code section 14452(a))

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 33 of 40

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14.   Provider acknowledges that Health Plan bears significant risk by assuming
financial responsibility for all in-patient hospitalization expenditures,
including expenditures for services connected with the period of
hospitalization. (Rule 53251(c) & (e))   15.   Non-Discrimination Clause. During
the performance of this Agreement, Provider and Provider’s subcontractors will
not unlawfully discriminate, harass, or allow harassment, against any employee
or applicant for employment because of sex, race, color, ancestry, religious
creed, national origin, physical disability (including HIV and AIDS), mental
disability, medical condition (including cancer), age (over 40), marital status,
and denial of family care leave. Provider and Provider’s subcontractors will
ensure the evaluation and treatment of their employees and applicants for
employment are free from discrimination and harassment. Provider and Provider’s
subcontractors will comply with the provisions of the Fair Employment and
Housing Act (Government Code, Section 12900, et. seq.) and the applicable
regulations promulgated thereunder (California Code of Regulations, Title 2,
Section 7285.0, et seq.). The applicable regulations of the Fair Employment and
Housing Commission implementing Government Code Section 12990(a-f), set forth in
Chapter 5 of Division 4 of Title 2 of the California Code of Regulations are
incorporated into this Agreement by reference and made a part hereof as if set
forth in full. Provider and Provider’s subcontractors as the case may require
will give notice of their obligations under this clause to labor organizations
with which they have a collective bargaining or other agreement.   16.  
Provider agrees to arrange for the provision of interpreter services for Members
at all provider sites.   17.   Nothing in this Agreement shall be interpreted in
any manner to terminate or diminish Health Plan’s independent obligations to the
State of California under one or more of its contracts with the Department of
Health Services.

Upon request by DHCS, Provider shall timely gather, preserve and provide to
DSHS, in the form and manner specified by DHCS, any information specified by
DHCS, subject to lawful privileges, in Provider’s possession, related to
threatened or pending litigation by or against DHCS. If Provider asserts that
any requested documents are covered by a privilege, Provider shall: (1) identify
such privileged documents with sufficient particularity to reasonably identify
the document while retaining the privilege; and (2) state the privilege being
claimed that supports withholding production of the document. Such request shall
include, but is not limited to, a response to a request for documents submitted
by any party in any litigation by or against DHCS. Provider acknowledges that
time may be of the essence in responding to such request. Provider shall use all
reasonable efforts to immediately notify DHCS and Health Plan of any subpoenas,
document production requests, or requests for records, received by Provider
related to Health Plan’s contract with DHCS. Provider shall be reimbursed by
DHCS for the services necessary to comply with this requirement under the
reimbursement terms
HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 34 of 40

--------------------------------------------------------------------------------

 

specified in Health Plan’s contract with DHCS.
HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 35 of 40

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ATTACHMENT G
Acknowledgement of Receipt of Provider Manual
Provider hereby acknowledges receipt of Health Plan’s Provider Manual.
Date of receipt: 4|16|09
Initials of authorized
representative of Provider: /s/ Michael D. Drobot
HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials: _______
Pacific Hospital of Long Beach
   

Page 36 of 40

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ATTACHMENT H
Medicare Program Provisions
The following provisions apply to all services rendered in conjunction with
Health Plan’s Medicare Programs as set forth in Attachment C to this Agreement.
The Agreement shall be automatically modified to conform to subsequent
amendments to Medicare standards. Any purported modification to the Agreement
inconsistent with Medicare standards is not effective. In the event of any
inconsistency between the terms of this Attachment and the terms of the
Agreement, the terms of this Attachment shall control.

1.   Right to Audit. Provider shall make all of its “Relevant Records” available
for inspection, examination and copying by all federal and state agencies with
regulatory authority over the subject matter of this Agreement. Provider shall
permit such inspection at Provider’s place of business and at all reasonable
times. “Relevant Records” shall mean all books and records of Provider related
directly or indirectly to the goods and services furnished under the terms of
this Agreement. Provider shall maintain such Relevant Records for the period of
time required by applicable federal and state statutes, but in no event less
than ten (10) years. This provision shall survive termination of the Agreement.
(42 CFR 422.504(e)(2), 422.504(e)(3), 422.504(e)(4), and 422.504(i)(2)(ii)).  
2.   Confidentiality. Provider shall comply with the confidentiality and
enrollee record accuracy requirements set forth in 42 CFR 422.118. (42 CFR
422.504(a)(13)).   3.   Hold Harmless. Provider agrees that under no
circumstance shall a subscriber or enrollee be liable to the Provider for any
sums owed by Health Plan to the Provider. (42 CFR 422.504(g)(1)(i).   4.  
Delegation. If Provider is delegated any of the activities or functions of
Health Plan as required in the CMS Agreement, Provider agrees to comply with all
applicable contractual provisions in the same manner as if Provider had executed
such contract with CMS directly. The activities or functions delegated to
Provider are set forth in the Agreement. In the event CMS or Health Plan
determines, in its sole discretion, that Provider has not performed the
delegated activities or functions satisfactorily, the delegated activities shall
be revoked upon not less than five (5) days prior written notice. Health Plan
shall monitor the performance of such delegated activities on an ongoing basis,
and Provider shall cooperate with all reasonable requests made by Health Plan in
order to accomplish such monitoring. If Provider is delegated credentialing
activities, Provider’s credentialing process will be reviewed and approved by
Health Plan, and such credentialing process will be audited by Health Plan on an
ongoing basis; further, Provider agrees that its credentialing process will
comply with all applicable NCQA standards. Health Plan retains the right to
approve, suspend, or

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 37 of 40

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    terminate any credentialing delegation arrangement. (42 CFR
422.504(i)(3)(iii), 422.504(i)(4)) and 422.504(i)(5).   5.   Medicare Claims
Payment. Health Plan and Provider agree that Health Plan shall pay all Clean
Claims within sixty (60) days of the date such claim is delivered by Provider to
Health Plan and Health Plan determines such claim is complete/clean. Any claims
that are not submitted to Health Plan within six (6) months of providing the
Covered Services that are the subject of the claim shall not be eligible for
payment, and Provider hereby waives any right to payment therefore. Health Plan
reserves the right to deny any claims that are not in accordance with the
Medicare Claims Processing Manual and Medicare rules for billing. Health Plan
shall pay interest on Clean Claims that are not paid within sixty (60) days for
the period beginning on the day after the required payment date and ending on
the date on which payment is made. Interest shall be computed at the rate of
interest provided under 41 U.S.C. §611. (42 CFR 422.520(b)).   6.   Reporting.
Provider shall comply with the reporting requirements set forth in 42 CFR
422.516 and 42 CFR 422.257. (42 CFR 504(a)(8)).   7.   Accountability. Provider
acknowledges and agrees that Health Plan is accountable to CMS for overseeing
any functions or responsibilities delegated to Provider. (42 CFR
422.504(i)(3)(ii)(A)).   8.   Medicare Compliance. Provider shall comply with
all applicable Medicare laws, regulations, and CMS instructions.
(42 CFR 422.504(i)(4)(v)).   9.   Benefit Continuation. Notwithstanding the
termination of the Provider Agreement, Provider shall not abandon any Medicare
patients, and shall continue to see and treat those patients requiring ongoing
medical care (including, but not limited to, patients that are hospitalized on
the termination date of the Provider Agreement) on the same terms and conditions
as prior to termination, and shall continue to see and treat such ongoing
patients until such time as such patients may be transitioned to another
appropriate medical provider (or, if applicable, such patients are discharged
from the hospital). (42 CFR 422.504(g)(2)(I), 422.504(g)(2)(ii), and
422.504(g)(3)).

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 38 of 40

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ATTACHMENT I
DISCLOSURE FORM
(Welfare and Institutions Code Section 14452 (a))
HealthSmart Pacific, Inc., dba
Name of Subcontractor Pacific Hospital of Long Beach
The undersigned hereby certifies that the following information regarding
Pacific Hospital of Long Beach (the “Organization”) is true and correct as of
the date set forth below.

1.   Officers/Directors General Partners: Please see attachment   2.  
Co-Owner(s):   3.   Stockholders owning more than ten percent (10%) of the stock
of the Organization:       Abraws Healthcare, Inc.   4.   Major creditors
holding more than five percent (5%) of Organization’s debt:       East West
Bank, Future Opportunities, LLC   5.   Form of Organization (Corporation,
Partnership, Sole Proprietorship, Individual):       Corporation   6.   If not
already disclosed above, is Organization, either directly or indirectly, related
to or affiliated with the Contracting Health Plan? Explain:       Yes. Faustino
Bernadette

             
Date: 4/11/09
  By:   /s/ M. Drobot    
 
           
 
  Print Name:   M. Drobot    
 
  Title:   CEO    

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MHC v122706 / MHI v091707
  representative’s initials:                     
Pacific Hospital of Long Beach
   

Page 39 of 40

 

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HealthSmart Pacific, Inc. dba
Pacific Hospital of Long Beach
Officers/Directors/General Partners:

     
Chairman of the Board
  Faustino Bernadett, M.D.
Chief Executive Officer
  Michael D. Drobot
President
  Clark Todd
Treasurer
  G. William Hammer
Secretary
  Michael J. Tichon

1

--------------------------------------------------------------------------------

 

ATTACHMENT J
CERTIFICATE OF OWNERSHIP
I, Mr. Drobot, an authorized representative of Pacific Hospital of Long Beach,
do certify that, to the best of my knowledge, the individuals or entities listed
below have a five percent or more ownership, direct or indirect, or control
interest in the aforementioned entity as defined under 42 U.S. C. Section 1320 a
3 (2). This form is to be submitted annually to the organization contracting
with the Managed Risk Medical Insurance Board for the Healthy Families Program
and/or Access to Infants and Mothers Program.

                      Employer     Social Security   Name of Individual/Entity  
Identification Number     Number  
/s/ Tino Bernadett
             
 
           
 
               
 
           
 
               
 
           
 
               
 
           
 
               
 
           

o   No one is listed because there are no individuals or entities with a five
(5%) percent or more interest   o   No one is listed because the plan is under
government ownership.   o   No one is listed because the provider of services is
a non-profit, public benefit corporation for which there are no outside
controlling interests.

     
/s/ Michael D. Drobot               CEO
  4/16/09
 
   
Signature of Authorized Representative and Title
  Date

HSA — Hospital Services Agreement

     
Molina ECMS ref# 729
  Provider or authorized
MCH v122706 / MHI v091707
  representative’s initials:
Pacific Hospital of Long Beach
   

Page 40 of 40