Exhibit 10.58

 

 

SETTLEMENT AGREEMENT

 

dated as of

 

July 11, 2005

 

by and among

 

WELLPOINT, INC.,

 

THE REPRESENTATIVE PLAINTIFFS,

 

THE SIGNATORY MEDICAL SOCIETIES,

 

AND CLASS COUNSEL

 

 

 

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SETTLEMENT AGREEMENT

 

This Agreement is made and entered into as of the date set forth on the
signature pages hereto by and among the Representative Plaintiffs in the Actions
(on behalf of themselves and each of the Class Members who have not validly and
timely requested to Opt-Out of this Agreement), by and through Class Counsel,
Company and those medical societies identified on the signature pages hereto
(such medical societies are herein collectively referred to as the “Signatory
Medical Societies”) (the Representative Plaintiffs, the Class Members who have
not validly and timely requested to Opt-Out of this Agreement, Company and the
Signatory Medical Societies are herein collectively referred to as the
“Parties”). The Parties intend this Agreement to resolve, discharge and settle
the Released Claims, fully, finally and forever according to the terms and
conditions set forth below.

 

W I T N E S S E T H:

 

WHEREAS, by Order filed June 13, 2000, the United States District Court for the
Southern District of Florida (the “Court”) assigned each action that has been
assigned MDL Docket No. 1334 to one of two tracks: a “Subscriber Track” and a
“Provider Track”;

 

WHEREAS, the Provider Track includes all actions under MDL Docket No. 1334
brought by health care providers or by representatives of said providers;

 

WHEREAS, by Order filed October 23, 2000, the Judicial Panel on Multidistrict
Litigation transferred and consolidated the Provider Track actions for pretrial
purposes before the Court;

 

WHEREAS, on September 19, 2002, certain Representative Plaintiffs in Shane I
filed Plaintiffs’ Second Amended Consolidated Class Action Complaint, and, on
September 26, 2002, the Court issued its Order Granting Provider Track Class
Certification in Shane I;

 

WHEREAS, on September 1, 2004, certain Representative Plaintiffs in Shane II
filed Plaintiffs’ Amended Class Action Complaint;

 

WHEREAS, on November 9, 2004, certain Representative Plaintiffs in Thomas filed
Plaintiffs’ Third Amended Class Action Complaint;

 

WHEREAS, Company denies the material factual allegations and legal claims
asserted in the Complaints, including without limitation any and all charges of
wrongdoing or liability arising out of any of the conduct, statements, acts or
omissions alleged, or that could have been alleged, in the Complaints including
without limitation the allegations that the Representative Plaintiffs and/or
other Class Members have suffered damages; that Company improperly manipulated
claim procedures or capitation payments or any other payments; that Company paid
at incorrect rates or improperly applied reimbursement policies; that Company
fraudulently misrepresented the criteria for insurance coverage determination,
treatment decisions, claims payments and adequacy of capitation payments; that
Company conspired with or aided and abetted wrongful conduct of any other
person; and that the Representative Plaintiffs and/or other Class Members were
harmed by the conduct alleged in the Complaints;

 

WHEREAS, Company has asserted a number of defenses to the claims set forth in
the Complaints that Company believes are meritorious; nonetheless, Company has a
desire to make more transparent, simplify and otherwise improve the systems
through which it conducts business with Representative Plaintiffs and has
concluded that further conduct of the Actions would be protracted and expensive
and that it is desirable that the Actions be fully and finally settled in the
manner and upon the terms and conditions set forth in this Agreement;

 

WHEREAS, the Representative Plaintiffs believe that the claims asserted in the
Actions have merit; nonetheless Representative Plaintiffs and Class Counsel
recognize and acknowledge the expense and length of continued proceedings that
would be necessary to prosecute the Actions against Company through trial and
appeals;

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WHEREAS, Representative Plaintiffs and Class Counsel also have taken into
account the uncertain outcome and the risk of any class action, especially in
complex actions such as the Actions, as well as the difficulties and delays
inherent in such Actions, and Counsel for the Representative Plaintiffs believe
that the settlement set forth in this Agreement confers substantial benefits
upon the Representative Plaintiffs and the other Class Members;

 

WHEREAS, based on their evaluation of all of these factors, and recognizing that
Company’s compliance with the terms of this Agreement is beneficial to Class
Members and that such compliance does not and shall not violate any legal right
of Class Members, the Representative Plaintiffs and Class Counsel have
determined that this Agreement is in the best interests of themselves and the
other Class Members;

 

WHEREAS, the Signatory Medical Societies have determined that it is in their
best interests to obtain the benefits afforded to such Signatory Medical
Societies by the applicable provisions of this Agreement, and, in exchange
therefor, to make the commitments and agreements contained herein, including
without limitation those contained in § 13;

 

NOW, THEREFORE, IT IS HEREBY STIPULATED AND AGREED by and among the Parties
that, subject to the approval of the Court, the Actions and the Released Claims
shall be finally and fully resolved, compromised, discharged and settled under
the following terms and conditions:

 

1. Definitions.

 

As used in this Agreement and all exhibits to this Agreement, the following
terms have the meaning specified.

 

1.1 “Actions” means Shane I, Shane II, and Thomas.

 

1.2 “Active Physician” means a Class Member who is a Physician and who is not a
Retired Physician as of the Preliminary Approval Date.

 

1.3 “Active Physician Amount” shall have the meaning assigned to that term in
§ 8.3(b) of this Agreement.

 

1.4 “Adverse Determination” shall have the meaning assigned to that term in
§ 7.11(b)(i) of this Agreement.

 

1.5 “Affiliate” or “Affiliates” means with respect to any Person, any other
Person controlling, controlled by or under common control with such first
Person. The term “control” (including without limitation, with correlative
meaning, the terms “controlled by” “under common control with”), as used with
respect to any Person, means the possession, directly or indirectly, of the
power to direct or cause the direction of the management and Policies of such
Person, whether through the ownership of voting securities or otherwise.

 

1.6 “Agreement” means this Settlement Agreement, inclusive of all exhibits
hereto.

 

1.7 “AMA” means the American Medical Association.

 

1.8 “Attorney’s Fees” means the funds for attorney’s fees and expenses that may
be awarded by the Court to Class Counsel.

 

1.9 “Bar Order” means an order of the Court barring the assertion of claims
against the Released Parties for contribution, indemnity or other similar claims
by other Persons in the form included as part of the Final Order and Judgment.

 

1.10 “Base Amount” shall have the meaning assigned to that term in § 8.3(d) of
this Agreement.

 

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1.11 “BCBSA” means the Blue Cross Blue Shield Association.

 

1.12 “Billing Dispute” shall have the meaning assigned to that term in § 7.10(a)
of this Agreement.

 

1.13 “Billing Dispute External Review Board” shall have the meaning assigned to
that term in § 7.10(a) of this Agreement.

 

1.14 “BlueCard Program” means the program governed by BCBSA that requires Blue
Cross and/or Blue Shield Plans to use certain policies, procedures and/or
technology to service Blue Cross and/or Blue Shield members located outside of a
Blue Cross and/or Blue Shield Plan’s service area.

 

1.15 “Blue Cross and/or Blue Shield Plan Plan Members” means a Plan Member of a
Subsidiary that is a Blue Cross and/or Blue Shield licensee.

 

1.16 “Capitation” means the payment by Company to Physicians, Physician Groups
or Physician Organizations of a per member per month amount (including but not
limited to percentage of premium) by which Company transfers to the provider the
financial risk for those Covered Services as set forth in the contract between
Company and the provider.

 

1.17 “CCI” or the “Correct Coding Initiative” means CMS’s published list of
edits and adjustments that are made to health care providers’ claims submitted
for services or supplies provided to patients insured under the federal Medicare
program and/or under other federal insurance programs.

 

1.18 “Certification” shall mean the document Company files pursuant to § 7.34.

 

1.19 “Claim Form” means a document in substantially the form attached hereto as
Exhibit A.

 

1.20 [This section intentionally left blank.]

 

1.21 “Class” means any and all Physicians, Physicians Groups and Physician
Organizations who provided Covered Services to any Plan Member or any individual
enrolled in or covered by a plan offered or administered by any Person named as
a defendant in the Complaints or by any of their respective current or former
Subsidiaries or Affiliates, in each case from August 4, 1990 through the
Preliminary Approval Date.

 

1.22 “Class Counsel” means those persons identified in § 5 as Class Counsel.

 

1.23 “Class Member” means any Person who is a member of the Class.

 

1.24 “Clinical Information” means clinical, operative or other medical records
and reports kept in the ordinary course of a Physician’s, Physician Group’s or
Physician Organization’s business, and, where applicable, requested statements
of Medical Necessity.

 

1.25 “CMS” means the Centers for Medicare and Medicaid Services (formerly known
as Health Care Financing Administration).

 

1.26 “CMS-1500” means the health care provider claim form number 1500 created by
CMS, as such form exists on the date of this Agreement and as it may be amended,
modified or superseded thereafter during the term of this Agreement.

 

1.27 “Company” means WellPoint, Inc. and each of its Subsidiaries.

 

1.28 “Complaints” means the initial complaint and any and all subsequent
complaints filed in the Actions.

 

1.29 “Complete Claim” means, except as provided in the last sentence of
§ 7.18(a), a claim for Covered Services that (a) is timely received by Company,
(b) has a corresponding referral (whether in paper or electronic format), if
required for the applicable claim, (c) meets all the requirements of § 7.17(b),
(d) (i) when submitted

 

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via paper has all the elements of the CMS-1500 (or successor standard) forms or
(ii) when submitted via an electronic transaction, uses only permitted standard
code sets (e.g., CPT®-4, ICD-9, HCPCS) and has all the elements of the standard
electronic formats, as required by applicable Federal authority and state
regulatory authority, (e) is a claim for which Company is the primary payor or
Company’s responsibility as a secondary payor has been established, (f) contains
no defect or error that would affect the adjudication of the claim, (g) includes
supporting documentation consistent with this Agreement sufficient for Company
to make a payment determination, and (h) is under a Plan for which all
applicable premiums have been paid.

 

1.30 “Compliance Dispute” means any claim that Company has failed to carry out
any of its obligations under § 7 of this Agreement (with the exception of §
7.29(f)); provided, however, that none of the following shall be deemed a
Compliance Dispute: (A) a Released Claim, (B) a Retained Claim, (C) a Billing
Dispute; (D) a claim for which the Adverse Determination Review Process is
available.

 

1.31 “Compliance Dispute Claim Form” means a document in substantially the same
form as Exhibit B, attached hereto.

 

1.32 “Compliance Dispute Facilitator” means the person who, pursuant to §
12.1(a) of this Agreement, shall screen Compliance Disputes.

 

1.33 “Compliance Dispute Review Officer” means the person chosen pursuant to §
12.1(b) of this Agreement and charged with the administration of Certifications
and Compliance Disputes under this Agreement.

 

1.34 “Conclusion Date” shall have the meaning assigned to that term in the
preamble to § 7 of this Agreement.

 

1.35 “Court” shall have the meaning assigned to that term in the recitals of
this Agreement.

 

1.36 “Covered Services” means a health care benefit that is within the coverage
described in the Plan Documents applicable to an eligible Company Plan Member.

 

1.37 “CPT®,” “CPT® Codes,” and “CPT Coding” mean medical nomenclature published
by the AMA containing a systematic listing and coding of procedures and services
provided to patients by physicians and certain non-physician health
professionals. When used herein, “CPT®” and “CPT® Codes” refer to such medical
nomenclature as it exists as of the date of this Agreement and as it may be
amended, modified or superseded thereafter during the term of this Agreement.

 

1.38 “Credentialing Committee” means any committee maintained by Company which
has decision-making authority regarding credentialing and re-credentialing of
individual Physicians as Participating Physicians with Company.

 

1.39 “Delegated Entity,” (1) as the term applies to arrangements in California
with respect to which Company is operating as a Blue Cross and/or Blue Shield
licensee, means (i) a risk-bearing organization, organized delivery system,
limited or specialized licensed health plan or other risk-bearing entity as
defined by California law, or (ii) a full service licensed health plan where it
is reasonably necessary because Company does not have reasonable capacity to
provide or administer coverage in those geographic areas or specialty services;
and (2) as the term applies otherwise, means an entity that is not an Affiliate
of Company to the extent that such entity (i) maintains its own contracts with
Physicians separate from any contracts between Company and Physicians, and,
(ii) by agreement with Company, (A) agrees to provide Plan Members with access
to such Physicians pursuant to terms of such agreements; and (B) performs some
or all of the functions with respect to Plans which otherwise would be performed
by Company, including without limitation claims adjudication, utilization
review, utilizations management and Physician credentialing.

 

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1.40 “Downcoding” shall have the meaning assigned to that term in § 7.19 of this
Agreement.

 

1.41 “Edit” means a practice or procedure pursuant to which one or more
adjustments are made to CPT® Codes or HCPCS Level II Codes included in a claim
that result in (a) payment being made based on some, but not all, of the CPT®
Codes or HCPCS Level II Codes included in the claim, (b) payment being made
based on different CPT® Codes or HCPCS Level II Codes than those included in the
claim, (c) payment for one or more of the CPT® Codes or HCPCS Level II Codes
included in the claim being reduced by application of Multiple Procedure Logic,
(d) payment for one or more of the CPT® Codes or HCPCS Level II Codes being
denied, or (e) any combination of the above.

 

1.42 “Effective Date” shall have the meaning assigned to that term in § 14.4 of
this Agreement.

 

1.43 “Effective Period” shall have the meaning assigned to that term in the
preamble to § 7 of this Agreement.

 

1.44 “Enrollment” or “Enrollment Date” shall mean the date upon which a Plan
Member becomes eligible to receive Covered Services.

 

1.45 “EOB” means an Explanation of Benefit or any comparable form or statement
communicating to a Plan Member the results of Company’s adjudication of claim(s)
with respect to or on behalf of such Plan Member.

 

1.46 “ERISA” means the Employment Retirement Income Security Act of 1974, as
amended, and the rules and regulations promulgated thereunder.

 

1.47 “Execution Date” means the later of (i) the date on which the signature of
Company has been delivered to Class Counsel; and (ii) the date on which the
signatures of all Representative Plaintiffs, Signatory Medical Societies and
Class Counsel have been delivered to Company.

 

1.48 “External Review” shall have the meaning assigned to that term in
§ 7.11(e)(i) of this Agreement.

 

1.49 “FDA” means the Food and Drug Administration.

 

1.50 “Federal Employee Program” means the federal government nationwide service
benefit plan administered pursuant to a contract between BCBSA and the Office of
Personnel Management.

 

1.51 “Final Order and Judgment” means the order and form of judgment approving
this Agreement and dismissing Company with prejudice, in each case in the forms
attached hereto as Exhibits C1-4.

 

1.52 “Final Order Date” means the date on which the Court enters the Final Order
and Judgment.

 

1.53 “First Alternate” shall have the meaning assigned to that term in § 12.1(b)
of this Agreement.

 

1.54 “Foundation” shall have the meaning assigned to that term in § 8.1 of this
Agreement.

 

1.55 “Force Majeure” shall have the meaning assigned to that term in § 7.32 of
this Agreement.

 

1.56 “Fully-Insured Plan” means a Plan as to which Company assumes all or a
majority of healthcare cost and/or utilization risk.

 

1.57 “HCPCS Level II Codes” means alphanumeric codes used to identify those
codes not included in CPT® and that are commonly referred to as Healthcare
Common Procedure Coding System Level II Codes.

 

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1.58 “HealthLink” means HealthLink, Inc. and any of its Subsidiaries and
Affiliates.

 

1.59 “HIPAA” means the Health Insurance Portability and Accountability Act of
1996.

 

1.60 “Implementation Date” shall have the meaning assigned to that term in the
preamble to § 7 of this Agreement.

 

1.61 “Independent Review Organization” shall have the meaning assigned to that
term in § 7.11(e)(i) of this Agreement.

 

1.62 “Interest Rate” means a 4.75% rate of return without compounding.

 

1.63 “Internal Compliance Officer” shall have the meaning assigned to that term
in § 12.7.

 

1.64 “Individually Negotiated Contract” means a contract pursuant to which the
parties to the contract, as a result of negotiation, agreed to one or more
substantial modifications to the terms of Company’s applicable standard form
agreement to individually suit, in whole or in part, the needs of a
Participating Physician, Physician Group or Physician Organization (including
but not limited to higher or customized rates and/or other customized payment
methodologies).

 

1.65 “Mailed Notice” means the form of the notice attached hereto as Exhibit D.

 

1.66 “Medical Necessity” and “Medically Necessary” shall have the meaning
assigned to that term in § 7.16(a) of this Agreement.

 

1.67 “Multiple Procedure Logic” means the practices or procedures used by
Company to reduce the allowable amount for one or more of the CPT® Codes or
HCPCS Level II Codes included in a claim as a result of multiple surgical
procedures or services having been performed on the same patient on the same
date of service.

 

1.68 “Non-Participating” means, with respect to a Physician, Physician Group, or
Physician Organization, a Physician, Physician Group, or Physician Organization
that is not a Participating Physician, Physician Group, or Physician
Organization.

 

1.69 “Non-Released Litigation” shall have the meaning assigned to that term in
§ 13.3(c) of this Agreement.

 

1.70 “Notice Date” shall have the meaning assigned to that term in § 6.1 of this
Agreement.

 

1.71 “Objection Date” shall have the meaning assigned to that term in § 6 of
this Agreement.

 

1.72 “Opt Out” shall have the meaning assigned to that term in § 6.1 of this
Agreement.

 

1.73 “Opt Out Deadline” shall have the meaning assigned to that term in § 6.1 of
this Agreement.

 

1.74 “Overpayment” means, with respect to a claim submitted by or on behalf of a
Physician, Physician Group or Physician Organization, any erroneous or excess
payment that Company makes for any reason, including, but not limited to,
(i) payment at an incorrect rate, (ii) duplicate payments for the same Physician
Service, (iii) payment with respect to an individual who was not a Plan Member
on the date the Physician provided the Physician Service(s) that are the subject
of such payment, and (iv) payment for any non-Covered Service.

 

1.75 “Participating Physician” means a Physician who has entered into a valid
written contract with Company (or who has agreed pursuant to an arrangement with
a Physician Group, Physician Organization or

 

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other entity which has a valid written contract with Company) to provide Covered
Services to Plan Members and, where applicable, who meets Company’s
credentialing requirements, during the effective period of such a contract. The
fact that a Physician has entered into an agreement with a rental network
(§ 7.29(p)(ii)) does not make that Physician a Participating Physician.

 

1.76 “Participating Psychiatrist” means a Psychiatrist who is a Participating
Physician.

 

1.77 “Parties” shall have meaning assigned to that term in the preamble of this
Agreement.

 

1.78 “Person” or “Persons” means all persons and entities (including without
limitation natural persons, firms, corporations, limited liability companies,
joint ventures, joint stock companies, unincorporated organizations, agencies,
bodies, governments, political subdivisions, governmental agencies and
authorities, associations, partnerships, limited liability partnerships, trusts,
and their predecessors, successors, administrators, executors, heirs and
assigns).

 

1.79 “Petitioner” shall have the meaning assigned to that term in § 12.2 of this
Agreement.

 

1.80 “Physician” means an individual duly licensed by a state licensing board as
a Medical Doctor or as a Doctor of Osteopathy and shall include both
Participating Physicians and Non-Participating Physicians.

 

1.81 “Physician Advisory Committee” shall have the meaning assigned to that term
in § 7.9(a) of this Agreement.

 

1.82 “Physician Group” means two or more Physicians, and those claiming by or
through them, who practice under a single taxpayer identification number.

 

1.83 “Physician Organization” means any association, partnership, corporation or
other form of organization (including without limitation independent practice
associations and physician hospital organizations), that arranges for care to be
provided to Plan Members by Physicians organized under multiple taxpayer
identification numbers.

 

1.84 “Physician Services” means Covered Services that a Physician provides to a
Plan Member, as specified in applicable agreements with Company or otherwise.

 

1.85 “Physician Specialty Society” means a United States medical specialty
society that represents diplomats certified by a board recognized by the
American Board of Medical Specialties.

 

1.86 “Plan” means a benefit plan through which a Plan Member obtains health care
benefits set forth in pertinent Plan Documents.

 

1.87 “Plan Documents” means the documents defining the health care benefits
available to a Plan Member, including the Plan Member’s Summary Plan
Description, Certificate of Coverage or other applicable coverage document, and
the terms and conditions under which such benefits are available under the Plan.

 

1.88 “Plan Member” means an individual enrolled in or covered by a Plan offered
and administered by Company.

 

1.89 “Post-Service Appeal” shall have the meaning assigned to that term in §
7.11(c)(ii)(A) of this Agreement.

 

1.90 “Precertification” means approval by the Company that the service or supply
is Medically Necessary and/or not experimental or investigational.

 

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1.91 “Preliminary Approval Date” means the date the Preliminary Approval Order
is entered by the Court.

 

1.92 “Preliminary Approval Hearing” shall have the meaning assigned to that term
in § 4 of this Agreement.

 

1.93 “Preliminary Approval Order” means the preliminary approval order as
attached hereto at Exhibit E.

 

1.94 “Pre-Service Appeal” shall have the meaning assigned to that term in §
7.11(c)(i) of this Agreement.

 

1.95 “Product Network” means a network of Participating Physicians who, pursuant
to contracts with Company, provide Covered Services to Plan Members for one or
more products or types of products offered by Company (e.g., HMO, PPO, POS,
Indemnity) in exchange for a specified type of compensation (e.g.,
fee-for-service, capitation).

 

1.96 “Provider Track” shall have the meaning assigned to that term in the
recitals of this Agreement.

 

1.97 “Provider Website” means the secure (password protected) online resources
for Participating Physicians to obtain information about Company, its products
and policies and other information described in more detail in this Agreement.

 

1.98 “Prudent Buyer Plan Participating Physician Agreement” means the standard
form agreement between Blue Cross of California and its Participating
Physicians, Physician Groups, and Physician Organizations to provide Covered
Services for its preferred provider organization products.

 

1.99 “Psychiatrist” means a Physician who is duly licensed by a state licensing
board to provide mental health services and shall include without limitation
both Participating Physicians and Non-Participating Physicians.

 

1.100 “Public Website” means the online resources for the public to obtain
information about Company, its products and policies and other information.

 

1.101 “Published Notice” means the form of notice attached hereto as Exhibit F.

 

1.102 “Qualified Reviewer” shall have the meaning assigned to that term in §
7.11(c)(ii)(A) of this Agreement.

 

1.103 “Released Parties” shall have the meaning assigned to that term in §
13.1(a) of this Agreement.

 

1.104 “Released Rights” or “Released Claims” shall have the meaning assigned to
that term in § 13.1(c) of this Agreement.

 

1.105 “Releasing Parties” shall have the meaning assigned to that term in §
13.1(a) of this Agreement.

 

1.106 “Remittance Advice” means the form sent by Company to health care
providers explaining Company’s computation of benefits and payment amounts on a
claim. The Remittance Advice is sometimes referred to as an “Explanation of
Payment” form or “EOP.”

 

1.107 “Representative Plaintiffs” means collectively Glenn Kelly, M.D., Leonard
Klay, M.D., Charles B. Shane, M.D., Jeffrey Book, D.O., Andres Taleisnik, M.D.,
Julio Taleisnik, M.D., Roger Wilson, M.D., Thomas Backer, M.D., Martin Moran,
M.D., H. Robert Harrison, M.D., Lance R. Goodman, M.D., Stephen R. Levinson,
M.D., K. Laugel, M.D., Kevin J. Lynch, M.D., Kenneth A. Thomas, M.D., Manual
Porth, M.D., John West, M.D., Mark Vrana, M.D., Jonathan D. Winner, M.D.,
William Robert Smith, Jr., M.D., and Andres Melendez-Dedos, M.D.

 

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1.108 “Retained Claims” shall have the meaning assigned to that term in § 13.6
of this Agreement.

 

1.109 “Retired Physician” means a Class Member who, subsequent to August 4,
1990, has become an inactive Physician, has retired from the practice of, or has
otherwise ceased to practice, medicine or has died as of the date of Preliminary
Approval.

 

1.110 “Reversion Amount” shall have the meaning assigned to that term in § 8.4
of this Agreement.

 

1.111 “Second Alternate” shall have the meaning assigned to that term in §
12.1(b) of this Agreement.

 

1.112 “Self-Insured Plan” means any Plan other than a Fully Insured Plan.

 

1.113 “Senior Management” shall have the meaning assigned to that term in § 12.7
of this Agreement.

 

1.114 “Settlement Administrator” shall have the meaning assigned to that term in
§ 8.3 of this Agreement.

 

1.115 “Settlement Amount” shall have the meaning assigned to that term in § 8.2
of this Agreement.

 

1.116 “Settlement Fund” shall have the meaning assigned to that term in § 8.2 of
this Agreement.

 

1.117 “Settlement Hearing Date” shall have the meaning assigned to that term in
§ 6.2 of this Agreement.

 

1.118 “Signatory Medical Societies” shall have the meaning assigned to that term
in the preamble of this Agreement.

 

1.119 “Significant Edit” means an Edit that Company reasonably believes, based
on its experience with submitted claims, will cause, on the initial review of
submitted claims, the denial of or reduction in payment for a particular CPT®
Code or HCPCS Level II Code more than two-hundred and fifty (250) times per year
in any state in which Company operates.

 

1.120 “Shane I” means Shane v. Humana Inc., et al., Master File No.
00-1334-MD-MORENO.

 

1.121 “Shane II” means Shane v. Humana Inc., et al.¸ Case
No. 04-21589-CIV-MORENO.

 

1.122 “Subscriber Track” shall have the meaning assigned to that term in the
recitals to this Agreement.

 

1.123 “Subsidiary” or “Subsidiaries” shall mean any entity of which securities
or other ownership interests having ordinary voting power to elect a majority of
the board of directors or other persons performing similar functions are, as of
Preliminary Approval, or were prior thereto, directly or indirectly owned by
Company, but only so long as such securities or other ownership interests having
ordinary voting power to elect a majority of the board of directors or other
persons performing similar functions are, directly or indirectly, held by
Company.

 

1.124 “Tag-Along Actions” shall have the meaning assigned to such term in § 15.1
of this Agreement.

 

1.125 “Termination Date” shall have the meaning assigned to that term in § 14.6
of this Agreement.

 

1.126 “Thomas” means Thomas v. Blue Cross and Blue Shield Assoc., et al., Case
No. 03-21296-CIV-MORENO/KLEIN.

 

1.127 “Transition Period” shall have the meaning assigned to that term in §
7.13(b) of this Agreement.

 

2. The Actions and Class Covered by This Agreement

 

This Agreement sets forth the terms of an agreement with respect to the Actions
between Company and all Class Members who have not validly and timely requested
to Opt-Out of this Agreement. This Agreement relates only to the Actions and
other Provider Track actions assigned MDL Docket No. 1334, unless otherwise
specified herein.

 

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3. Commitment to Support and Communications with Class Members

 

The Parties agree that it is in their best interests to consummate this
Agreement and all the terms and conditions contained herein and to cooperate
with each other and to take all actions reasonably necessary to obtain Court
approval of this Agreement and entry of the orders of the Court that are
required to implement its provisions. They also agree to support this Agreement
in accordance with and subject to the provisions of this Agreement.

 

Class Counsel and Plaintiffs shall make every reasonable effort to encourage
putative Class Members to participate and not to Opt Out. In addition, Class
Counsel shall make all reasonable efforts to enforce the Compliance Dispute
resolution provisions of this Agreement set forth in § 12. Plaintiffs, Class
Counsel and Company agree that Company may communicate with putative Class
Members regarding the provisions of this Agreement, so long as such
communications are not inconsistent with the Mailed Notice or other agreed upon
communications concerning the Agreement. Company will not discourage the filing
of any claims allowed under § 8.3 of this Agreement or advise Class Members with
respect to the category or categories of such claims that the Class Members
should or should not file under this Agreement. Company will refer to the
Settlement Administrator or to Class Counsel any inquiries from Class Members
about such claims to be filed under this Agreement.

 

4. Preliminary Approval of Settlement

 

Pursuant to Rule 23(e) of the Federal Rules of Civil Procedure, the Parties
shall submit this Agreement, together with the exhibits attached hereto, to the
Court at a hearing (the “Preliminary Approval Hearing”) for, among other things,
its conditional certification of a settlement class, preliminary approval of the
Agreement, the Mailed Notice, the Published Notice and the Claim Form and shall
apply to the Court for an Order of Preliminary Approval and Conditional Class
Certification, substantially in the form of Exhibit E (“Preliminary Approval
Order”).

 

5. Notice to Class Members; Notice to Parties Pursuant to This Agreement

 

After the Court has entered the Preliminary Approval Order and approved the
Mailed Notice, the Published Notice and the Claim Form, notice to Class Members
shall be disseminated in such form as the Court shall direct; provided that the
forms of notice are substantially similar to the Mailed Notice and the Published
Notice. A copy of the Claim Form shall be included with the copy of the Mailed
Notice that is disseminated to Physicians, Physician Groups, and Physician
Organizations. The Mailed Notice shall request and require that any Class Member
who has assigned a claim covered by this Agreement to another Person, in whole
or in part, to deliver the Mailed Notice to such Person.

 

Class Counsel and Company shall be jointly responsible for identifying names and
addresses of Class Members and shall cooperate with each other and the
Settlement Administrator to make such identifications and determinations.

 

Company shall pay the reasonable cost of notice to Class Members, including
without limitation first class mail costs for the mailing of the Mailed Notice,
substantially in the same form as Exhibit D. Payment by Company of the cost of
the Mailed Notice shall be non-refundable and shall be in addition to the other
agreements made herein. Company shall pay for the cost to publish the Published
Notice no more than three times in the legal notices section in the national
editions of THE WALL STREET JOURNAL and USA TODAY. If publication in one or more
of said publications on the foregoing schedule is determined not to be
practicable, then either Class Counsel or Company may apply to the Court for
alternative notice by publication. Company shall also publish the Published
Notice on the Public Website, and, to the extent feasible, shall also publish
notice in a nationwide periodical addressing issues of concern to physicians
such as The Journal of the American Medical Association or The American Medical
News. Company shall maintain the Public Website notices at Company’s cost
through at least the Objection Date.

 

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All notices to any Party (including without limitation any designations made by
Class Counsel pursuant to this Agreement) required under this Agreement shall be
sent by first class U.S. Mail, by hand delivery, or by facsimile, to the
recipients designated in this Agreement. Timeliness of all submissions and
notices shall be measured by the date of receipt, unless the addressee refuses
or delays receipt. The Persons designated to receive notices under this
Agreement are as follows, unless notification of any change to such designation
is given to each other Party hereto pursuant to this § 5:

 

Representative Plaintiffs and Signatory Medical Societies: Notice to be given to
Class Counsel on behalf of Representative Plaintiffs and Signatory Medical
Societies.

 

Class Counsel:

 

Archie C. Lamb, Jr.

Law Offices of Archie C. Lamb, LLC

2017 Second Avenue North

Birmingham, AL 35203

 

Aaron S. Podhurst

Barry L. Meadow

Podhurst Orseck, PA

25 W. Flagler Street, Suite 800

Miami, FL 33130-1780

 

Nicholas B. Roth

Eyster Key Tubb Weaver & Roth, LLP

402 East Moulton Street, SE

Eyster Building

Decatur, AL 35601

 

Mark Gray

GRAY WHITE & WEISS

1200 PNC Plaza

500 West Jefferson

Louisville, KY 40202

 

Robert Foote

FOOTE & MEYERS

416 S. 2nd Street

Geneva, IL 60134

 

James B. Tilghman

STEWART TILGHMAN FOX & BIANCHI

1 SE 3rd Avenue, Ste 3000

Miami, FL 33131-1764

 

Dennis G. Pantazis

WIGGINS CHILDS QUINN & PANTAZIS

1400 SouthTrust Tower

420 North 20th Street

Birmingham, AL 35203

 

Harley S. Tropin

Janet L. Humphreys

Adam M. Moskowitz

Kozyak Tropin & Throckmorton, PA

200 S. Biscayne Boulevard, Suite 2800

Miami, FL 33131-2335

 

Edith M. Kallas

Joseph P. Guglielmo

Milberg Weiss Bershad & Schulman

One Pennsylvania Plaza

New York, NY 10119

 

Joe R. Whatley, Jr.

Charlene P. Ford

Othni J. Lathram

Whatley Drake, LLC

2323 Second Avenue North

Birmingham, AL 35203-3807

 

J. Mark White

WHITE ANDREWS ARNOLD & DOWD

2025 3rd Avenue North, Ste 600

Birmingham, AL 35203

 

Guido Saveri

R. Alexander Saveri

Cadio Zirpoli

SAVERI & SAVERI

111 Pine Street, Ste 1700

San Francisco, CA 94111-5619

 

Kenneth S. Canfield

Ralph Knowles

DOFFERMYRE SHIELDS CANFIELD KNOWLES

& DEVINE

1355 Peachtree St., Ste 1600

Atlanta, GA 30309

 

11

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Company:

 

Craig A. Hoover

HOGAN & HARTSON LLP

555 Thirteenth Street, NW

Washington, DC 20004

 

With copies to:

 

Angela F. Braly, Esq.

WellPoint, Inc.

120 Monument Circle

Indianapolis, IN 46204

 

Raymond L. Umstead, Esq.

WellPoint, Inc.

120 Monument Circle

Indianapolis, IN 46204

 

Elliot K. Gordon, Esq.

WellPoint, Inc.

1 WellPoint Way

Thousand Oaks, CA 91362

 

James E. Hartley, Jr.

DRUBNER HARTLEY & O’CONNOR

500 Chase Parkway, 4th Fl.

Waterbury, CT 06708

 

Stan Blumenfeld

O’MELVENY & MYERS LLP

400 South Hope Street

Los Angeles, CA 90071-2899

 

In the event that any Party receives a notice from any other Party (in
accordance with the provisions of § 5 of this Agreement and as required by any
other provision of this Agreement), for which there is a written acknowledgement
of receipt, and such receiving Party does not respond to such notice within
thirty (30) days of receipt thereof, such receiving Party shall be deemed to
have accepted any proposal made by the notifying Party in such notice and shall
be deemed to have waived any rights under this Agreement with respect to the
matter that is the subject of such notice.

 

6. Procedure for Final Approval; Limited Waiver

 

Following the dissemination of notice as described in § 5, Representative
Plaintiffs, Class Counsel and Company shall seek the Court’s final approval of
this Agreement. Class Members shall have until the Objection Date to file, in
the manner specified in the Mailed Notice, any objection or other response to
this Agreement. The Parties agree to urge the Court to set the Objection Date
for the date that is 60 days after the Notice Date (the “Objection Date”).

 

6.1 Opt-Out Timing and Rights

 

The Parties will jointly request of the Court that the Mailed Notice and the
Published Notice be disseminated no later than 30 days after the Preliminary
Approval Date (the “Notice Date”).

 

The Mailed Notice and the Published Notice shall provide that Class Members may
request exclusion from the Class by providing notice, in the manner specified in
the Notice, on or before a date set by the Court as the Opt-Out Deadline.
Representative Plaintiffs, Class Counsel and Company agree to urge the Court to
set the Opt-Out Deadline for the date that is 60 days after the Notice Date (the
“Opt-Out Deadline”).

 

Class Members have the right to exclude themselves (“Opt-Out”) from this
Agreement and from the Class by timely submitting to the Clerk of the Court a
request to Opt-Out and otherwise complying with the agreed upon Opt-Out
procedure approved by the Court. Class Members who so timely request to Opt-Out

 

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shall be excluded from this Agreement and from the Class. Any Class Member who
does not submit a request to Opt-Out by the Opt-Out Deadline or who does not
otherwise comply with the agreed upon Opt-Out procedure approved by the Court
shall be bound by the terms of this Agreement and the Final Order and Judgment.
Any Class Member who does not Opt-Out of this Agreement shall be deemed to have
taken all actions necessary to withdraw and revoke the assignment to any Person
of any claim against Company.

 

Any Class Member who timely submits a request to Opt-Out shall have until the
Settlement Hearing Date to deliver to Class Counsel and the Settlement
Administrator a written revocation of such Class Member’s request to Opt-Out.
Class Counsel shall timely apprise the Court of such revocations.

 

Within ten (10) days after the Opt-Out Deadline, the Settlement Administrator
shall furnish Company with a complete list in machine-readable form of all
Opt-Out requests filed by the Opt-Out Deadline and not timely revoked. Company
shall pay costs of obtaining a copy of the Opt-Out requests.

 

Notwithstanding any other provisions in this Agreement, after reviewing said
list and/or copies of Opt-Out requests and revocations, Company reserves the
right, in its sole and absolute discretion, to terminate this Agreement by
delivering a notice of termination to Class Counsel, with a copy to the Court,
prior to the commencement of the Settlement Hearing if Company determines that
Opt-Out requests have been filed (i) relating to more than 25,000 individual
Physicians who are Class Members or (ii) representing Class Members who, in the
aggregate, received at least five percent (5%) of the total dollar payments that
Company made to Class Members in calendar year 2004.

 

6.2 Setting the Settlement Hearing Date and Settlement Hearing Proceedings

 

Representative Plaintiffs, the Signatory Medical Societies, Class Counsel and
Company agree to urge the Court to hold the Settlement Hearing on the date that
is 105 days after the Notice Date (the “Settlement Hearing Date”) and to work
together to identify and submit any evidence that may be required by the Court
to satisfy the burden of proof for obtaining approval of this Agreement and the
orders of the Court that are necessary to effectuate the provisions of this
Agreement, including without limitation the Final Order and Judgment and the
orders contained therein. At the Settlement Hearing, the Representative
Plaintiffs, the Signatory Medical Societies, Class Counsel and Company shall
present evidence necessary and appropriate to obtain the Court’s approval of
this Agreement, the Final Order and Judgment and the orders contained therein
(including without limitation the Bar Order), and shall meet and confer prior to
the Settlement Hearing to coordinate their presentation to the Court in support
of Court approval thereof.

 

7. Settlement Consideration: Business Practice Initiatives

 

The settlement consideration to the Class Members who have not validly and
timely requested to Opt-Out of this Agreement includes, among other things,
initiatives and other commitments with respect to Company’s business practices.
The Parties agree that the business practice initiatives and other commitments
set forth below, which absent this Agreement Company would be under no
obligation to undertake, constitute substantial value, and will enhance and
facilitate the delivery of Physician Services by Class Members who have not
validly and timely requested to Opt-Out of the Agreement. Company investigated
and began to implement certain of the business practice initiatives described in
or contemplated by this § 7 after the Actions began and/or while the Parties
were engaged in discussions to resolve the Actions. Such initial and partial
implementation, which shows the Parties’ good faith desire to resolve the
Actions, were undertaken to form part of the consideration of the settlement.
Company shall have the unilateral and unrestricted right to block access to
and/or not apply any or all of the business practice initiatives described in or
contemplated by this § 7 to such Class Members, if any, who Opt Out of the
Agreement. Without in any way qualifying or limiting the foregoing, Company
(a) is informed that it is not uncommon for some members of a class action to
opt out for a variety of reasons independent of, among other things, the
substantive allegations in the complaint or the terms of a proposed settlement,
and (b) states its present intention to exercise, in whole or in part, the right
referred to in the immediately preceding sentence to Class Members who Opt-Out.

 

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Company covenants and agrees that, during the period from and after the
Execution Date and until the Preliminary Approval Date, it shall not effect any
material changes in the business practices that are the subject of the Complaint
and governed by the provisions of this Agreement, except changes to such
business practices that are contemplated by or otherwise consistent with this
Agreement.

 

Company shall be obligated to commence implementing each commitment set forth in
this § 7 from and after the date set forth on Exhibit G attached hereto across
from the relevant section number on such Exhibit (the “Implementation Date”) and
shall continue implementing each such commitment until the Termination Date,
except as modified by § 14.6 (the earliest of such dates, the “Conclusion
Date”). With respect to each commitment set forth in this § 7, the “Effective
Period” for such commitment shall be the period of time beginning on the
Implementation Date shown on Exhibit G and continuing through the Conclusion
Date for such commitment. Notwithstanding anything to the contrary contained
herein, with respect to each commitment set forth in this § 7, from and after
the Conclusion Date for such commitment, Company shall be under no obligation
whatsoever to continue to implement such commitment, except as provided in
§ 14.6.

 

7.1 Automated Adjudication of Claims

 

Company, recognizing the desirability of making investments to improve its
business relationships with Physicians providing health care services and
supplies to Plan Members through, inter alia, efficiency in the processing of
claims, has made substantial investments and will continue to make investments
in its claims systems and processes until the Conclusion Date in an effort to
improve the overall efficiency of the claim adjudication process.

 

7.2 Increased Internet and Clearinghouse Functionality

 

Company has made substantial investments, and will continue to make investments,
to enhance the ability of Physicians, via the internet or clearinghouses, to
register referrals, pre-certify procedures, submit claims for Covered Services,
check Plan Member eligibility for Covered Services (based upon current
information supplied by or relating to Plan sponsors or other group customers),
and to check the status of claims for Covered Services. Company shall allow any
Participating Physician, at the physician’s election, to engage in any
electronic transaction for which a standard transaction has been established by
the HIPAA Standard Transactions and Code Sets Rule.

 

7.3 Availability of Fee Schedules and Scheduled Payment Dates

 

Company shall develop and implement a plan not later than twelve (12) months
after the Final Order Date reasonably designed to permit a Participating
Physician, Physician Group, or Physician Organization that, in each case, has
entered into a written contract directly with Company, to the extent the
Participating Physician, Physician Group or Physician Organization is
compensated on a non-capitated basis, to view, by CD-ROM or electronically (at
Company’s option), on a confidential basis, complete fee information showing the
applicable fee schedule amounts for such Participating Physician, Physician
Group, or Physician Organization pursuant to that Participating Physician’s,
Physician Group’s, or Physician Organization’s direct written agreement with
Company. A Participating Physician, Physician Group or Physician Organization
may elect to receive a hard copy of the fee schedule in lieu of the foregoing.
The fee schedule information will be provided by the fee-for-service dollar
amount allowable for each CPT® Code for those CPT® Codes that a Participating
Physician, Physician Group, or Physician Organization in the same specialty
typically uses in providing Covered Services. A Participating Physician,
Physician Group or Physician Organization may request and Company will provide
the fee-for-service dollar amount allowable for other CPT® Codes that a
Participating Physician, Physician Group or Physician Organization actually
bills Company. Compensation to Participating Physicians compensated on a
non-capitated basis shall be based on a maximum allowable amount, which equals
the lesser of the Participating Physician’s actual billed charge or the
applicable fee schedule amount. Commencing with the Final Order Date and
continuing until implementation of the initiative described above, Company, upon
written request from a Participating

 

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Physician, Physician Group, or Physician Organization that, in each case, has
entered into a written contract directly with Company, will provide, by hard
copy, the fee schedule for up to one hundred (100) CPT® Codes customarily and
routinely used by such Participating Physician, Physician Group, or Physician
Organization, as specified by such Participating Physician, Physician Group, or
Physician Organization. Company shall be obligated to honor only two such
requests made annually by such Participating Physician, Physician Group, or
Physician Organization. Company will attempt to include provisions in its
agreements with Delegated Entities that require comparable disclosure. Company
will not require a Participating Physician, Physician Group, or Physician
Organization to provide Company with billing rates as a precondition to Company
providing fee information pursuant to this section.

 

7.4 Investments in Initiatives to Improve Provider Relations

 

Since the inception of these Actions and through the Termination Date, Company
has and will expend significant amounts of money and other resources to improve
its relations with those providing health care services and supplies to Plan
Members, including but not limited to the initiatives described in §§ 7.1, 7.2,
7.3, 7.7, 7.23 and 7.24 of this Agreement.

 

7.5 Reduced Precertification Requirements

 

Company has reduced and will continue to attempt to limit the number of services
and supplies requiring Precertification and has standardized the services and
supplies for which Precertification is required within each market, line of
business (e.g., group, individual, etc.) or product for its Fully-Insured and
Self-Insured Plans. Company will continue to review its Precertification
requirements for further opportunities to reduce the number of services and
supplies requiring precertification. Company may continue to require
Precertification for services and supplies and may alter or amend the number of
services and supplies requiring Precertification in response to changes in
market conditions, medical technology, and utilization patterns. Company shall
post to its Provider Website not later than three (3) months after the Final
Order Date those services or supplies for which Precertification is routinely
required for its products, and Company shall update such posting to the extent
the services or supplies for which precertification is routinely required
changes. Notwithstanding the above, Company’s Self-Insured Plan customers may
specify services or supplies for which Precertification is required that differ
from or are in addition to the services or supplies for which Company routinely
requires Precertification for its Fully-Insured Plans, and such Self-Insured
Plans may contract with a different entity to provide Precertification services.
Company will propose to its Self-Insured Plan customers that they utilize
Company’s standard list of services or supplies for which Precertification is
required. With a Self-Insured Plan’s approval, Company will post such
Self-Insured Plan’s customized Precertification requirements to Company’s
Provider Website.

 

7.6 Greater Notice of Policy and Procedure Changes

 

Company shall, if it intends to make a material adverse change(s) in the terms
of contracts (including policies and procedures incorporated by reference
therein) with Participating Physicians, Physician Groups, or Physician
Organizations, give at least ninety (90) days written notice to each
Participating Physician, Physician Group, or Physician Organization affected
thereby with whom Company has directly contracted (except to the extent that a
shorter notice period is required to comply with changes in applicable law),
which notice shall reasonably apprise the Participating Physician, Physician
Group, or Physician Organization of such change(s), and the change(s) shall
become effective at the conclusion of the notice period. If a Participating
Physician, Physician Group, or Physician Organization objects to the change(s)
that is subject to the notice, the Participating Physician, Physician Group, or
Physician Organization must, within thirty (30) days of the date of the notice
(which shall be the date the notice is sent by United States mail, by facsimile,
or, if Company offers it, electronically at the option of the Physician,
Physician Group, or Physician Organization), give written notice to terminate
his, her, or its contract with Company, which termination shall be effective at
the end of the notice period of the material adverse change unless, within
sixty-five (65) days of the date of the original notice of change(s), Company
gives written notice to the

 

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objecting Participating Physician, Physician Group, or Physician Organization
that it will not implement, as to the objecting Participating Physician,
Physician Group, or Physician Organization, the material adverse change(s) to
which the Participating Physician, Physician Group, or Physician Organization
objected. The continuation of care provisions in § 7.13(c) shall apply to any
contract termination pursuant to this § 7.6.

 

7.7 Initiatives to Reduce Claim Resubmissions

 

Company has implemented a series of initiatives designed to increase the
percentage of claim issues resolved on initial review and thereby reduce the
percentage of resubmitted claims. Such initiatives include, but are not limited
to, implementation of or improvement in virtual processor technologies that
analyze pended claims and identify and adjudicate those pended claims that can
be decided without further review by Company personnel, implementation of
additional automated processes for completing otherwise incomplete claims in
order to avoid rejection of such claims, implementation of changes in processes
and work flows, enhancement of capabilities to better identify duplicate claims
and avoid unnecessary rejections, implementation of improvements in Company’s
communications with Physicians regarding Company’s billing requirements, and
analysis of the reasons claims are rejected or pended and appropriate responsive
action, all of which are designed to improve Company’s ability to resolve issues
arising from defective or missing information on claims. Company agrees to
continue these or comparable business practices during the Effective Period.

 

7.8 Disclosure of and Commitments Concerning Claims Payment Practices

 

(a) Company recognizes the benefit of greater standardization in its claims
systems and, to that end, Company expects to consolidate its claims systems in
certain of its multistate regions, which will result in greater consistency with
respect to its automated “bundling” and other claims payment rules within those
regions.

 

(b) Company agrees that, except for Medicaid, State Childrens’ Health Insurance
Programs, and other similar government programs for low-income persons and/or
members of state-established high risk pools, (i) its automated “bundling” and
other claims payment rules shall be consistent in all material respects, within
each state in which Company operates as a Blue Cross and/or Blue Shield
licensee, for claims submitted by or on behalf of Company’s Blue Cross and/or
Blue Shield Plan Plan Members; provided, however, that this obligation shall not
apply to claims processed on Company’s Virginia claims system known as AMYSIS,
which currently is used solely to process HMO claims for the Virginia Plan, or
to claims processed on Company’s Wisconsin claims system known as FACTS, which
currently is used solely to process some ASO claims; and (ii) UniCare’s and
HealthLink’s respective automated “bundling” and other claims payment rules
shall, with respect to each such entity, be consistent in all material respects
within each state in which each entity applies such rules.

 

(c) In furtherance of the objectives set forth in (a) above and as part of the
transition, the parties agree that there will be interim transition periods
during which Company is unable to comply fully with the obligations in (b) as a
result of the consolidation of systems. Such inability to comply shall not be
deemed a violation of this Agreement.

 

(d) Company agrees to disclose its Significant Edits on the Provider Website by
not later than six (6) months after the Final Order Date, or as soon thereafter
as practicable. Company agrees to update its disclosure of Significant Edits
once per calendar year to reflect changes in Company’s Significant Edits and
Company’s experience with submitted claims; provided that Company shall promptly
disclose newly-adopted Significant Edits.

 

(i) Not later than six (6) months after the Final Order Date or as soon
thereafter as practicable, Company shall publish on the Provider Website, for
each commercially available claims editing software product then in use by
Company, a list identifying each customized Edit added to the standard claims
editing software product at Company’s request.

 

16

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(ii) Not later than the Final Order Date, Company shall not routinely require
submission of Clinical Information, before or after payment of claims, in
connection with Company’s adjudication of a Physician’s claims for payment,
except as to claims for unlisted codes, claims to which a modifier 22 is
appended, and other limited categories of claims as to which Company determines
that routine review of Clinical Information is appropriate; provided that
Company shall disclose any such categories on the Public Website and the
Provider Website. Notwithstanding the foregoing, Company may require submission
of Clinical Information in connection with Company’s adjudication of a
Physician’s claims for payment for the purpose of investigating fraudulent or
abusive (whether intentional or unintentional) billing practices, but only so
long as, and only during such times as, Company has a reasonable basis for
believing that such investigation is warranted. A Physician may contest,
pursuant to § 7.10(c), any requirement that the Physician submit Clinical
Information in connection with Company’s adjudication of the Physician’s claims
for payment for the purpose of investigating fraudulent or abusive (whether
intentional or unintentional) billing practices. Nothing in this § 7.8(d)(ii) is
intended or shall be construed to limit Company’s right to require submission of
Clinical Information when such requirement is not in connection with Company’s
adjudication of a Physician’s claims for payment or is otherwise permitted by
this Agreement, including but not limited to the right to require submission of
Clinical Information for Precertification purposes consistent with § 7.5.

 

(iii) Not later than six (6) months after the Final Order Date, Company shall
publish on the Provider Website those limited code combinations as to which it
has determined that particular services or procedures, relative to modifiers 25
and 59, are not appropriately reported together with those modifiers and
Company’s application of the rule differs from CPT® Codes, guidelines and
conventions; provided that no such determination shall be inconsistent with the
undertakings set forth in this Agreement.

 

(e) Company shall promptly update the disclosures required by § 7.8(d)(i),
(d)(ii) and (d)(iii) when changes are made to the policies, procedures, or
determinations referenced therein.

 

7.9 Physician Advisory Committee

 

(a) Prior to the later to occur of (i) three months after the Final Order Date
and (ii) selection of the members of the Physician Advisory Committee in
accordance with § 7.9(b) of this Agreement, Company shall take all actions
reasonably necessary on its part to establish a Physician Advisory Committee
(“Physician Advisory Committee”) to discuss regional or national issues arising
from or related to the relationships and interactions between and among
Physicians, their patients, and the Company. These issues may include, but are
not limited to: (a) improvement of health care and clinical quality;
(b) improvement of communications, relations and cooperation between Physicians
and the Company; and/or (c) matters of a clinical or administrative nature that
impact the interaction between Physicians and the Company. The Physician
Advisory Committee shall meet at least once every six months during the
Effective Period. All communications to the Physician Advisory Committee by
Participating Physicians and/or Non-Participating Physicians shall be
accomplished through members of the Physician Advisory Committee who shall
represent the interests of such Participating and/or Non-Participating
Physicians and whose contact information shall be posted on the Provider
Website.

 

(b) The Physician Advisory Committee shall include twelve (12) members, one of
whom shall be Company’s Chief Medical Officer or his designee, who shall serve
as chairperson of the Physician Advisory Committee.

 

Except as otherwise provided in this § 7.9(b), the remaining members of the
Physician Advisory Committee shall be Participating Physicians.

 

Company shall select three (3) members in addition to its Chief Medical Officer
not later than 60 days after the Preliminary Approval Date. The Representative
Plaintiffs shall select four (4) members not later than 60 days after the
Preliminary Approval Date. The members selected by the

 

17

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Representative Plaintiffs shall include at least one board-certified primary
care Participating Physician, at least one board-certified specialist
Participating Physician, and at least one Participating Physician who occupies a
leadership position with a specialty medical society, state or local medical
society, or large free-standing or hospital based group physician practice.
Those eight (8) members shall select the remaining four (4) members not later
than 120 days after the Preliminary Approval Date. The eight (8) members
selected by the Company and the Representative Plaintiffs shall have the option
to cause one of such remaining four (4) members to be a Non-Participating
Physician.

 

The Company and the Representative Plaintiffs shall strive to select Physicians:
(a) from diverse geographic regions and (b) who are committed to the Physician
Advisory Committee functioning as a constructive and collaborative body. If any
member discontinues serving on the Physician Advisory Committee, that member’s
position shall be filled in the same manner as the member was originally
selected.

 

The names of the members of the Physician Advisory Committee and the dates of
the Physician Advisory Committee meetings shall be posted on the Provider
Website.

 

(c) Any motion for the Physician Advisory Committee to consider an issue must be
proposed by the chairperson or any other voting member of the Physician Advisory
Committee. The issue shall be heard only if, at a meeting at which a quorum
exists, a majority of the voting members of the Physician Advisory Committee
present vote in favor of hearing the issue.

 

For purposes of this subparagraph (c), “quorum” shall mean seven (7) or more
voting members of the Physician Advisory Committee of which at least two
(2) members were selected by the Representative Plaintiffs, two (2) members were
selected by the Company, and two (2) members were selected by the members
selected by the Company and Representative Plaintiffs.

 

Upon a majority vote of the voting members of the Physician Advisory Committee,
the Physician Advisory Committee may make recommendations to the Company,
provided that such recommendations are within the Physician Advisory Committee’s
purview as described in § 7.9(a).

 

Company shall consider whether the implementation of any recommendation of the
Physician Advisory Committee is: (a) reasonable considering the opportunities
and constraints of the current health care financing/administration marketplace;
(b) consistent with the best interests of Company’s Participating Physicians,
Plan Members, customers, shareholders and other constituents; and (c) in
furtherance of scientifically and clinically sound medical care. If Company
decides not to accept a recommendation of the Physician Advisory Committee,
Company shall communicate that decision in writing to the Committee with an
explanation of Company’s reasons, and Company shall also disclose the
recommendation and response on the Provider Website. Company agrees to post on
the Provider Website a listing of all Physician Advisory Committee
recommendations made to Company and Company’s responses to such recommendations.

 

(d) Each member of the Physician Advisory Committee shall agree to maintain and
treat as confidential any proprietary information reasonably designated as such
by the Company. No member of the Physician Advisory Committee shall serve as a
member of an advisory or similar committee established by any other managed care
company or health insurer, but this provision is not meant to exclude Physicians
who serve on credentialing or similar committees for other companies.

 

(e) Company shall develop and implement reasonable payment provisions for the
expenses of members of the Physician Advisory Committee, including without
limitation a reasonable per diem to be set by the Company. Such payment
provisions shall be consistent with Company’s typical payment provisions for
Physicians serving on its existing regional organizations of this type.

 

7.10 New Dispute Resolution Process for Physician Billing Disputes

 

(a) Not later than four (4) months after the Final Order Date, Company shall
take all actions necessary on its part to arrange for the establishment of an
independent Billing Dispute External Review Board or

 

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Boards (the “Billing Dispute External Review Board”) for resolving disputes with
Physicians and Physician Groups concerning (i) application of Company’s coding
and payment rules and methodologies for fee-for-service claims (including
without limitation any bundling, Downcoding, application of a CPT® modifier,
and/or other reassignment of a code by Company) to patient-specific factual
situations, including without limitation the appropriate payment when two or
more CPT® Codes are billed together, or whether a payment-enhancing modifier is
appropriate, (ii) whether Company has complied with the provisions of this
Agreement, including without limitation § 7.8(d)(ii), in requiring that a
Physician submit records, either prior to or after payment, in connection with
Company’s adjudication of such Physician’s claims for payments or (iii) any
Retained Claims, so long as such Retained Claims are submitted by the Physician
to the Billing Dispute External Review Board prior to the later to occur of
(x) 90 days after the Final Order Date or (y) 30 days after exhaustion of
Company’s internal appeals process. Each such matter shall be a “Billing
Dispute.” The Billing Dispute External Review Board(s) shall not have
jurisdiction over any other disputes, including without limitation those
disputes that fall within the scope of the External Review process set forth in
§ 7.11 of this Agreement, Compliance Disputes and disputes concerning the scope
of Covered Services; nor shall such Board(s) have jurisdiction or authority to
revise or establish any reimbursement policy of the Company or any Plan or any
policy regarding requests for submission of Clinical Information. Nothing
contained in this § 7.10 is intended, or shall be construed, to supercede, alter
or limit the rights or remedies otherwise available to any Plan Member under
§ 502(a) of ERISA or to supercede in any respect the claims procedures for Plan
Members of § 503 of ERISA, or required by applicable state or federal law or
regulation. In the case of a state or federally-required external review process
for billing disputes that is different than the process herein set forth, only
the state or federally-required program shall be utilized for disputes subject
to the state or federally-required process.

 

(b) Any Physician or Physician Group may submit Billing Disputes to the Billing
Dispute External Review Board upon payment of a filing fee calculated as set
forth in § 7.10(h) and in accordance with the provisions of § 7.10(b)(3), after
the Physician or Physician Group exhausts Company’s internal appeals process,
when the amount in dispute (either a single claim for Covered Services or
multiple claims involving similar issues) exceeds $500. Billing disputes may be
submitted only by individual Physicians and Physician Groups. Company shall post
a description of its provider internal appeals process on the Provider Website.

 

(1) Notwithstanding the foregoing, a Physician or Physician Group may submit a
Billing Dispute if less than $500 is at issue and if such Physician or Physician
Group intends to submit additional Billing Disputes during the one (1) year
period following the submission of the original Billing Dispute which involve
issues that are similar to those of the original Billing Dispute, in which event
the Billing Dispute External Review Board will, at the request of such Physician
or Physician Group, defer consideration of such Billing Dispute while the
Physician or Physician Group accumulates such additional Billing Disputes. In
the event that a Billing Dispute is deferred pursuant to the preceding sentence
and, as of the Conclusion Date, the Physician or Physician Group has not
accumulated the requisite amount of Billing Disputes and Company has chosen not
to continue the Billing Dispute process following the Conclusion Date, then any
rights the Physician or Physician Group had as to such Billing Disputes,
including rights to arbitration, shall be tolled from the date the Billing
Dispute was submitted to the Billing Dispute External Review Board through and
including the Conclusion Date.

 

(2) In any event, a Physician or Physician Group will have one (1) year from the
date he, she or it submits the original Billing Dispute and notifies the Billing
Dispute External Review Board that consideration of such Billing Dispute should
be deferred to submit additional Billing Disputes involving issues that are
similar to those of the original Billing Dispute and amounts in dispute that in
aggregate exceed $500. In the event such additional Billing Disputes are not so
submitted pursuant to the preceding sentence, the Billing Dispute External
Review Board shall dismiss the original Billing Dispute and any such additional
Billing Disputes.

 

(3) The Physician or Physician Group must exhaust Company’s internal appeals
process before submitting a Billing Dispute to the Billing Dispute External
Review Board; provided that a Physician

 

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or Physician Group shall be deemed to have satisfied this requirement if Company
does not communicate notice of a decision resulting from such internal appeals
process within 30 days of receipt of all documentation reasonably needed to
decide the internal appeal. In the event Company and a Physician or Physician
Group disagree as to whether the requirements of the preceding sentence have
been satisfied, such disagreement shall be resolved by the Billing Dispute
External Review Board. Except as otherwise provided in § 7.10(b)(2), all Billing
Disputes must be submitted to the Billing Dispute External Review Board no more
than 90 days after a Physician or Physician Group exhausts Company’s internal
appeals process and the Billing Dispute External Review Board shall not hear or
decide any Billing Dispute submitted more than 90 days after Company’s internal
appeals process has been exhausted. Company shall supply appropriate
documentation to the Billing Dispute External Review Board not later than 30
days after request by the Billing Dispute External Review Board, which request
shall not be made, if Billing Disputes are submitted pursuant to § 7.10(b)(2),
until Billing Disputes have been submitted involving amounts in dispute that in
aggregate exceed $500.

 

(4) Except to the extent otherwise specified in this § 7.10(b), procedures for
review by the Billing Dispute External Review Board, including without
limitation the documentation to be supplied to the reviewers or review
organizations and a prohibition on ex parte communications between any party and
the Billing Dispute External Review Board, shall be set by agreement between the
Company and Class Counsel, or their designee, with input from the Billing
Dispute External Review Board. Such procedures shall provide that (x) a
Physician or Physician Group submitting a Billing Dispute to the Billing Dispute
External Review shall state in the documents submitted to the Billing Dispute
External Review Board the amount in dispute, and (y) that the Billing Dispute
External Review Board shall not be permitted to issue an award that exceeds the
greater of the amount stated by such Physician or Physician Group in the
documents submitted to the Billing Dispute External Review Board to be in
dispute or the amount payable under the terms of the applicable contract (or in
the case of Non-Participating Physicians, the amount payable under the
applicable Plan).

 

(c) Any Physician who contests the appropriateness of Company’s requirement that
such Physician submit records, either prior to or after payment, in connection
with Company’s adjudication of such Physician’s claims for payments may elect
not to utilize the internal review process and request that the Billing Dispute
External Review Board grant expedited review of the Company’s requirement, if
the Physician demonstrates to the Billing Dispute External Review Board that
Company’s requirement has a significant adverse economic effect on the Physician
which justifies expedited review. In the event that the Billing Dispute External
Review Board determines that such Physician has not so demonstrated the Billing
Dispute External Review Board shall dismiss such claim without prejudice,
pending the exhaustion by such Physician of Company’s internal appeals process.

 

(d) Company and Class Counsel, or their designee, shall select the
organization(s) that shall constitute the Billing Dispute External Review Board
or Boards. If Company and Class Counsel, or their designee, cannot agree on
members of the Billing Dispute External Review Board or Boards within 120 days
of the Preliminary Approval Date, the matter shall be deemed a Compliance
Dispute and referred to the Compliance Dispute Review Officer. Billing Disputes
shall be stayed and any time limitations shall be tolled pending resolution of
such Compliance Dispute. With respect to Billing Disputes brought by Physicians,
the members of the Billing Dispute External Review Board or Boards shall be
bound by the terms of the applicable Plan, any applicable agreement between the
Physician and Company, and the provisions of this Agreement. If the dispute
cannot be resolved by reference to the foregoing documents, then the Billing
Dispute External Review Board(s) shall resolve Billing Disputes by determining,
first, whether the billing was coded and submitted properly based on generally
accepted medical coding standards, including but not limited to CPT® Coding and
CCI/CMS guidelines, and second, whether applicable Company reimbursement
policies were properly applied, including those reimbursement policies required
or permitted under this Agreement, including without limitation reimbursement
policies posted by the Company pursuant to § 7.8(d).

 

20

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(e) Company’s contract(s) with the Billing Dispute External Review Board or with
members of the Billing Dispute External Review Board shall require decisions to
be rendered not later than 30 days after receipt of the documents necessary for
the review and to provide notice of such decision to the parties promptly
thereafter.

 

(f) In the event that the Billing Dispute External Review Board issues a
decision requiring payment by Company, Company shall make such payment within
fifteen days after Company receives notice of such decision.

 

(g) Any decision by the Billing Dispute External Review Board shall be binding
on Company and the Physician or Physician Group. For Retained Claims, all
Billing Disputes shall be directed not to the Court nor to any other state
court, federal court, arbitration panel (except as hereinafter provided) or any
other binding or non-binding dispute resolution mechanism but instead shall be
submitted to final and binding resolution before the Billing Dispute External
Review Board so long as such Billing Dispute arises after the establishment of
the Billing Dispute External Review Board pursuant to § 7.10(d). Retained Claims
as defined in § 13.6 shall not be barred as untimely so long as they are
submitted within thirty (30) days of the establishment of the Billing Dispute
External Review Board.

 

(h) For any Billing Dispute that a Physician submits to the Billing Dispute
External Review Board, the Physician submitting such Billing Dispute shall pay
to Company a filing calculated as follows: (i) if the amount in dispute is
$1,000 or less, the filing fee shall be $50 or (ii) if the amount in dispute
exceeds $1,000, the filing fee shall be equal to $50, plus 5% of the amount by
which the amount in dispute exceeds $1,000, but in no event shall the fee be
greater than 50% of the cost of the review. The Company shall refund the
applicable filing fee paid by a Physician who submits a Billing Dispute to the
Billing Dispute External Review Board in the event the Physician is the
prevailing party with respect to such Billing Dispute.

 

(i) The determination made with respect to any Billing Dispute pursuant to this
section shall not act as precedent as to any other Billing Dispute under this
section.

 

7.11 Determinations Related to Medical Necessity or the Experimental or
Investigational Nature of Any Proposed Health Care Service or Supply

 

(a) Initial Determinations

 

A Physician designated by Company shall be responsible for making the initial
determination for Company whether proposed health care services or supplies are
Medically Necessary or experimental or investigational in nature. A nurse or
other health care professional, acting for a medical director, may approve any
proposed health care service or supply as being Medically Necessary, but only a
Physician designated by Company may deny any such service or supply as being not
Medically Necessary or experimental or investigational in nature.

 

(b) Plan Member Internal Appeal and External Review Process

 

(i) Company currently maintains and will continue to maintain an internal appeal
and external review process permitting Plan Members to seek internal and
independent external review of any determination made by Company that certain
services are not covered services because they are not Medically Necessary or
are experimental or investigational in nature (“Adverse Determination”) where
Company both makes the Adverse Determination and administers the Plan Member
appeals and external review processes.

 

(ii) As set forth in this § 7.11, Company will establish and maintain an
internal appeal and external review process for Physicians with respect to
Adverse Determinations to the extent Company both makes the Adverse
Determination and administers the Plan Member appeals and/or external review
processes.

 

(iii) Except where any applicable law or regulation requires a different
definition, Company shall use the definition of Medical Necessity set forth in §
7.16 (a) of this Agreement in the internal appeal

 

21

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and external review processes set forth in this § 7.11. Provided, however, that
nothing in this Agreement shall: (a) limit or prevent Company from denying
coverage on the grounds that services are experimental or investigational; or
(b) alter or restrict Company’s rights under contracts with Participating
Physicians to restrict or prohibit them from billing a Plan Member for services
determined to be not Medically Necessary or experimental or investigational.
Company agrees that a Participating Physician may bill a Plan Member for
services determined to be not Medically Necessary or experimental or
investigational when the Participating Physician provides the Plan Member with
advance written notice that (a) identifies the proposed services, (b) informs
that Plan Member that such services may be deemed by Company to be not Medically
Necessary or experimental or investigational, and (c) provides an estimate of
the cost to the Plan Member for such services and the Plan Member agrees in
writing in advance of receiving such services to assume financial responsibility
for such services.

 

(iv) In applying experimental and investigational exclusions in a Plan to either
proposed health care services or as part of a Post-Service Appeal to the
Company, Company shall consider credible scientific evidence published in
peer-reviewed medical literature generally recognized by the relevant medical
community, Physician Specialty Society recommendations, the views of Physicians
practicing in relevant clinical areas, the individual clinical circumstances of
the particular Plan Member, the views of the treating Physician and any other
relevant factors.

 

(c) Physician Internal Appeals of Adverse Determinations.

 

(i) Pre-Service Appeals.

 

Physicians shall have the right to file an appeal of an Adverse Determination
prior to rendering the service (“Pre-Service Appeals”), if they are appealing on
the Plan Member’s behalf. For urgent Pre-Service Appeals, the Physician shall be
automatically deemed the authorized representative of the Plan Member. For all
other Pre-Service Appeals, authorization must be obtained from the Plan Member
in writing. Pre-Service Appeals filed by Physicians on behalf of a Plan Member
will be handled by Company under the appeal process available to the Plan Member
based on the terms of the Plan Member’s health benefit plan and the applicable
state and federal laws and regulations.

 

(ii) Post-Service Appeals

 

(A) With respect to an appeal of an Adverse Determination made after the service
has been rendered (“Post-Service Appeals”), Company shall adopt a one level
internal appeal process for Physicians. That process shall ensure that only a
Physician in the same specialty as the Physician who treated the condition
(hereinafter “Qualified Reviewer”), other than the Physician that made the
initial Adverse Determination, may deny the appeal of the Physician who treated
the condition. A nurse or other health care professional employed by Company may
review the internal appeal and may grant but not deny the appeal. If the nurse
or other healthcare professional does not grant the appeal, then a Qualified
Reviewer, designated by Company, other than the one that made the initial
Adverse Determination, shall review and decide the internal appeal in accordance
with applicable Company health care clinical guidelines.

 

(B) For purposes of this section, “same specialty” shall mean a Physician with
similar credentials and licensure as those who typically treat the condition or
health problem in question in the appeal or a Physician who has experience
treating the same problems as those in question in the appeal, in addition to
experience treating similar complications of those problems.

 

(C) Prior to requesting internal Post-Service Appeal, Physician shall use best
efforts to first seek written authorization to proceed as the Plan Member’s
representative. If Physician obtains the Plan Member’s consent to proceed on
their behalf, then Physician’s appeal rights are those of the Plan Member and
Physician is bound by the decision rendered in the Plan Member’s appeal process.
If the Post-Service appeal or external review decision is favorable to the

 

22

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Non-Participating Physician, then payment by Company will be subject to the
terms, conditions and limitations of the applicable health benefit plan.
However, payment will be issued directly to the Non-Participating Physician.

 

(d) Timeframes for Physician Internal Appeals of Adverse Determinations

 

All internal Post-Service Appeals filed by Physicians shall be adjudicated
within the time limits established under regulations issued by the Department of
Labor regardless of whether ERISA applies.

 

(e) Adverse Determination External Review Process for Physicians

 

(i) If the Company upholds its initial Adverse Determination through the
internal Post-Service Appeals process and the cost of the service at issue
exceeds the threshold amount, if any, the Plan Member would need to satisfy in
order to seek external review under the terms of the applicable health benefit
plan, Company shall make available to Physician the option to seek external
review of the Adverse Determination through an independent review organization
(“Independent Review Organization”) identified by Company (“External Review”).
The Physician shall have the option to submit a written request for External
Review within sixty (60) days from the date of the internal Post-Service Appeal
denial decision by Company. Election to pursue External Review under this § 7.11
is at the option of the Physician, who may instead choose any other remedy
available as a matter of law or contract.

 

(ii) External Review is not available for a Physician before Physician has
exhausted the internal Post-Service Appeal process unless both the Company and
the Physician agree to forego the internal Post-Service Appeal and proceed
directly to External Review or Company cannot provide a Qualified Reviewer for
internal appeal.

 

(iii) Physicians seeking External Review shall pay a filing fee of $50; provided
that if the matter involves services or supplies for which Company requires
pre-certification then the filing fee shall be the lesser of (i) $250 and
(ii) the sum of $50 and the amount by which the amount in dispute exceeds
$1,000, towards the cost of the External review for each External Review
requested. Payment must be submitted along with the External Review request;
provided, however, that Physician shall be entitled to a refund of such payment
in the event that the Physician prevails in the External Review process.

 

(iv) Any decision issued pursuant to an External Review process, regardless of
whether such External Review process is initiated and pursued by a Plan Member
or a Physician, shall be binding upon both the Physician and the Company.

 

(v) Company will contract with the Independent Review Organization to conduct a
de novo review of the case. For coverage issues other than a determination of
Medical Necessity, the Plan Member’s health benefit Plan Documents will control.
In the event an External Review process is initiated, Company shall promptly,
but in any event no later than ten (10) business days following receipt of the
request, submit documentation pertaining to the appeal to an Independent Review
Organization. Company shall require that the Independent Review Organization
provide a decision within thirty (30) days of Company’s submission of all
necessary information. The external reviewer designated to conduct the review by
the Independent Review Organization shall be of the same specialty (but not
necessarily the same sub-specialty) as the appealing Physician.

 

(vi) The Independent Review Organization’s compensation shall not be tied to the
outcome of the reviews performed. Likewise, the selection process among
qualified Independent Review Organizations will not create any incentives for
Independent Review Organizations to make decisions in a biased manner.

 

(vii) In the case of a state-required external review process that is available
to Physicians without the Plan Member’s consent and that is different than the
process herein set forth, only the state-required program shall be utilized
where applicable, consistent with § 7.11(b)(iii).

 

23

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(viii) Notwithstanding the preceding provisions of this § 7.11 and in addition
to any requirements contained above, Physicians may not initiate an internal
Post-Service Appeal or External Review of any denied service if:

 

(A) The Plan Member (or his or her representative) or the Physician (either
independently where Company is required to accept an independent physician
appeal by state law or as the Plan Member’s representative) filed a Pre-Service
Appeal pertaining to the same denied service; or

 

(B) The Plan Member (or his or her representative) is currently seeking or has
sought review related to the same denied service. In the event both Plan Member
(or his or her representative) and Physician seek review of the same denied
service, the Plan Member’s review shall go forward and the Physician’s request
for review will be dismissed; or

 

(C) As to External Review only, the Plan Member is covered under a Self-Insured
Plan and the Plan sponsor has not agreed by contract to participate in Company’s
External Review program set forth in this § 7.11(e); or

 

(D) The Plan Member (or his or her representative) has filed suit under § 502(a)
of ERISA or other suit for the denial of health care services or supplies
regarding an Adverse Determination. In that event, or if such a suit is
subsequently initiated, the Plan Member’s lawsuit shall go forward and the
Physician’s claims shall be dismissed and may not be brought by or on behalf of
the Physician in any forum; provided that such dismissal shall be without
prejudice to any Physician seeking to establish that the rights sought to be
vindicated in such lawsuit belong to such Physician and not to such Plan Member.

 

(E) Nothing contained in this § 7.11 is intended, or shall be construed, to
supersede, alter or limit the rights or remedies otherwise available to any
Person under § 502(a) of ERISA or to supersede in any respect the claims
procedures under § 503 of ERISA.

 

(f) Precedential Effect

 

The determination made with respect to any Adverse Determination pursuant to any
internal appeal and External Review process referenced in this § 7.11 shall not
act as precedent as to any other Medical Necessity or experimental or
investigational determination under this § 7.11.

 

7.12 [This section intentionally left blank.]

 

7.13 Participating in Company’s Network

 

(a) Credentialing of Physicians

 

Company will allow Physicians to submit credentialing applications (including,
as relevant, licensure and hospital privileges or other required information)
and will begin to process such applications prior to the time that the Physician
formally changes or commences employment or changes location, provided that the
Physician must represent that he or she has new employment or intends to move to
a new location. Company shall complete primary source verification and notify
the Physician as to whether he or she is credentialed within ninety (90) days of
receiving a Physician’s completed application to be a Participating Physician
unless in spite of Company’s best efforts and because of a failure of a third
party to provide necessary documentation, Company cannot obtain the necessary
information to make a decision within ninety (90) days. In such event, Company
shall make every effort to obtain such information as soon as possible. Company
commits that the Credentialing Committee for each market shall meet at least
once every forty-five (45) days to consider credentialing applications for which
primary source verification has been completed. If a Physician is already
credentialed by Company but changes employment or changes location, Company will
only require the submission of such additional information, if any, as is
necessary to continue the Physician’s credentials based upon the changed
employment or location.

 

24

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(b) All Products Clauses

 

Company agrees that it shall not require a Participating Physician to
participate in a capitated fee arrangement in order to participate in Product
Networks in which such Participating Physician is compensated on a fee for
service basis. Company further agrees that it shall not require a Participating
Physician to participate in its Medicare Advantage or Medicaid Product Networks
in order to participate in its commercial Product Networks. Except where a
Participating Physician (or Physician Group comprised of Participating
Physicians or Physician Organization) has agreed in an Individually Negotiated
Contract to participate in more than one Product Network for a specified period
of time (in which case the terms of such Individually Negotiated Contract shall
govern), if a Participating Physician (or Physician Group comprised of
Participating Physicians or Physician Organization) either (a) chooses not to
participate in all Company Product Networks or (b) terminates participation in
some Company Product Networks, then the reimbursement levels (e.g.,
fee-for-service maximum allowable amount, capitation rate or other reimbursement
methodology) offered to or applied by Company to such Participating Physician
(or Physician Group or Physician Organization) for the Product Network(s) in
which such Physician (or Physician Group or Physician Organization) continues to
participate shall not be lower than Company’s standard reimbursement levels
(e.g., fee-for-service maximum allowable amount, capitation rate or other
reimbursement methodology) in that geographic market. Notwithstanding the
foregoing, Company may offer a higher reimbursement level (e.g., fee-for-service
maximum allowable amount, capitation rate or other reimbursement methodology) or
other incentive to any Participating Physician (or Physician Group or Physician
Organization) who elects to participate (or elects to continue participation) in
more than one of Company’s Product Networks. Nothing in this paragraph shall
obligate Company to pay more than the lesser of the Physician’s billed charges
or the Company’s applicable fee-for-service amount.

 

Within sixty (60) days of the Effective Date, Company shall provide notice to
all Participating Physicians or Physician Groups in its standard Prudent Buyer
Plan Participating Physician Agreement that the Physician or Physician Group
may, within sixty (60) days from the mailing of the notice, opt out of any
obligation under the Agreement to provide medical services for work-related
injuries or illnesses. Such an election to opt out shall take effect twelve
(12) months after the end of the opt out period (“Transition Period”), and
Physicians or Physician Groups that elect to opt out shall not be required after
the Transition Period to provide medical services for work-related injuries or
illnesses as a condition of being a Participating Physician or Physician Group
under the standard Prudent Buyer Plan Participating Physician Agreement. Any
Physician or Physician Group that enters into the standard Prudent Buyer
Participating Physician Agreement following the date the Company mails out the
opt-out notice described above shall be given the right, at the time of
execution of such Agreement, to elect not to provide medical services under such
Agreement for work-related injuries or illnesses. Any Physician or Physician
Group that opts-out or elects not to provide such medical services and Company
are free to negotiate an agreement under which such Physician or Physician Group
provides medical services for work-related injuries or illnesses. The foregoing
opt-out right shall not extend to any Physician or Physician Group with any
other contract, or addendum to the Standard Prudent Buyer Plan Participating
Physician Agreement, that specifically relates to the provision of medical
services for work-related injuries and illnesses. Company further agrees that
Physicians or Physician Groups that do not accept or treat patients for
work-related injuries or illnesses shall not be required to provide such
services. Company does not now and will not require Physicians, Physician
Groups, or Physician Organizations who have contracted under the standard
Prudent Buyer Participating Physician Agreement to provide medical services for
work-related injuries or illnesses, and who are in a patient’s medical provider
network, to refer such patient to another Physician, Physician Group, or
Physician Organization that provides the same services for work-related injuries
or illnesses under the standard Prudent Buyer Participating Physician Agreement
or other Company Participating Physician Agreement on the basis that such other
Physician, Physician Group, or Physician Organization is compensated at a lower
rate. Nothing in this § 7.13(b) shall limit Company’s right to establish medical

 

25

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provider networks and/or determine which Physicians, Physician Groups, or
Physician Organizations are included in a medical provider network.

 

(c) Termination Without Cause

 

Unless an Individually Negotiated Contract between Company and a Participating
Physician, Physician Group, or Physician Organization specifies a different
period of notice, or specifies that the contract may not be terminated except
for cause during a defined period of time, either party to a contract between
Company and a Participating Physician, Physician Group, or Physician
Organization shall have the right to terminate the contract without cause upon
at least one hundred and twenty (120) calendar days written notice to the other
party.

 

In the event of a contract termination by either party, the following
obligations shall apply with respect to the continuation of care for those
patients of a Participating Physician, Physician Group, or Physician
Organization who are entitled to continuation of care as reasonably defined
under the Participating Physician’s, Physician Group’s, or Physician
Organization’s contract with Company or under applicable law. In the case of a
continuation of care situation as defined in the preceding sentence, the
Participating Physician, Physician Group, or Physician Organization shall
continue to render necessary care to the Plan Member consistent with contractual
or legal obligations; provided that, if, upon notice from the Physician,
Physician Group, Physician Organization, or Plan Member that a Plan Member is in
a continuation of care situation, Company does not use due diligence to make
alternative care available to the Plan Member within 90 days after receipt of
such notice, then for continuation of care services provided after termination,
Company shall pay to the Physician, Physician Group, or Physician Organization
the standard rates paid to Non-Participating Physicians for that geographical
area. Other than as specified in this § 7.13(c), the contractual provisions
applicable to continuation of care shall apply.

 

Notwithstanding the foregoing obligations, Company’s obligations under this
§ 7.13(c) shall not apply to the extent that other Participating Physicians,
Physician Groups, or Physician Organizations are not available to replace the
terminating Physician, Physician Group, or Physician Organization due to
(i) geographic or travel-time barriers; or (ii) contractual provisions between
the terminating Physician, Physician Group, or Physician Organization and a
facility at which Plan Member receives care that limits or precludes other
Participating Physicians, Physician Groups, or Physician Organizations from
rendering replacement services to Plan Members (e.g., an exclusive services
agreement between the terminating Physician, Physician Group, or Physician
Organization and a facility where Plan Member receives services).

 

(d) Rights of Class Members to Refuse to Accept Additional Patients

 

Company will not prevent individual Participating Physicians from closing their
practices to all new patients from all third party payors with whom they
contract.

 

7.14 Fee Schedule Changes

 

(a) Notices Regarding Fee Schedules

 

Company agrees to establish and operate one or more standard fee schedules of
fee for service payments to Participating Physicians for each geographic market
in which Company maintains a Product Network. Company also agrees, effective
January 1 of the year following the Effective Date, not to reduce the fees set
forth in such fee schedules more than once per calendar year except as otherwise
provided in this § 7.14(a). Company further agrees that it shall give notice of
any such reductions in fees as a material adverse change subject to the
provisions of § 7.6 hereof; provided, however, that to the extent a fee schedule
is directly tied to the CMS fee schedules or state Medicaid fee schedules
currently in effect, it shall adjust automatically to reflect applicable interim
and annual revisions made by CMS or the state Medicaid agency without notice to
the Physician. If an annual revision made by CMS or a state Medicaid agency
results in a reduction in the fees in a fee schedule

 

26

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that is directly tied to the CMS fee schedules or state Medicaid fee schedules,
a Participating Physician shall have the right to terminate his or her contract
with Company by giving Company written notice of termination within thirty
(30) days of the date on which CMS or the state Medicaid agency published notice
of the annual revision, which termination shall be effective ninety (90) days
after the date that such notice was published. Notwithstanding the foregoing,
Company may increase or reduce the fees set forth in such fee schedules by
updating its fee schedules at any time (i) to reflect changes in market prices
for vaccines, injectibles, pharmaceuticals, durable medical supplies, other
goods, and non-Physician services, (ii) to add payment rates for newly-adopted
CPT® Codes, (iii) to add payment rates for new technologies and new uses of
established technologies that Company concludes are eligible for payment, and
(iv) to reflect applicable interim revisions made by CMS. Nothing contained in
this § 7.14(a) shall prevent Company from maintaining, altering or expanding the
use of Capitation or other compensation methodologies. The requirements in this
§ 7.14(a) shall not apply to Individually Negotiated Contracts to the extent
those requirements are inconsistent with the terms relating to reductions in fee
schedules or termination in such contracts.

 

(b) Payment Rules for Injectibles, DME, Administration of Vaccines, and Review
of New Technologies

 

Company agrees to pay a fee for the administration of vaccines and injectibles
by a Physician. Company also agrees to pay for the vaccines and injectibles
themselves. Company shall pay for newly recommended vaccines as of the effective
date of a recommendation made by any of the following: the U.S. Preventive
Services Task Force, the American Academy of Pediatrics, and the Advisory
Committee on Immunization Practices. Other than as specified in the preceding
sentence with respect to newly recommended vaccines, if a Physician Specialty
Society recommends as an appropriate standard of care a new technology or
treatment, or a new use for an established technology or treatment, Company
shall evaluate such recommendation and issue a coverage statement not later than
one hundred twenty (120) days after Company learns of such Physician Specialty
Society recommendation. With respect to capitated primary care Participating
Physicians, Company shall continue to pay separate fees (in addition to
contractually agreed-upon Capitation payments) for vaccines administered
pursuant to the schedules recommended by the U.S. Preventive Services Task
Force, the American Academy of Pediatrics, or the Advisory Committee on
Immunization Practices, unless Company and the capitated Participating
Physicians have entered into an Individually Negotiated Contract that includes
payment for such vaccines and their administration in the Capitation amount.

 

(c) Usual, Reasonable, and Customary Appeals

 

At least until the Termination Date, if a Non-Participating Physician initiates
a dispute using Company’s internal dispute resolution procedures over how
Company has determined the usual, reasonable and customary amount for a given
health care service or supply, and, consequently, over how Company has computed
the amount payable for that health care service or supply, Company shall
disclose to the Non-Participating Physician initiating the dispute the general
methodology, including the percentile of included charge data on which the
maximum allowable amount is based, and source of data used by Company to
determine the usual, reasonable and customary amount for that service or supply.

 

(d) Usual, Reasonable and Customary Determinations

 

Company agrees that, to the extent it uses Physician charge data to determine
the usual, reasonable and customary amount to be paid for services performed by
Non-Participating Physicians, it will not use any internal claims database that
(i) systematically under-reports the number of claims paid for procedures in the
geographic area used by Company to determine such amount; (ii) eliminates or
excludes the highest charges for paid claims for any procedures in the
geographic area used by Company to determine such fees, provided, however, that
such charges may be excluded if Company excludes an equivalent number or
percentage of the lowest charges for such procedures, or reasonably determines
that any such charges are the result of erroneous data; (iii) includes charges
for procedures

 

27

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performed in a geographic area other than the one used by Company to determine
such amount, provided, however, that such charges may be considered where
Company determines there is an insufficient number of charges in the relevant
geographic area to reasonably determine a usual, reasonable and customary
amount; (iv) calculates the usual, reasonable and customary amount based upon
fees paid under a discounted fee schedule rather than billed charges; and
(v) lacks quality controls sufficient to reasonably test the validity of the
data included in the database.

 

7.15 [This section intentionally left blank.]

 

7.16 Application of Clinical Judgment to Patient-Specific and Policy Issues

 

(a) Patient-specific Issues Involving Clinical Judgment.

 

Medical Necessity Definition

 

Except where any applicable law or regulation requires a different definition,
Company shall apply as to its current agreements and include in its future
agreements with Participating Physicians the following definition of “Medically
Necessary” or comparable term in each such agreement: “Medically Necessary” or
“Medical Necessity” shall mean health care services that a Physician, exercising
prudent clinical judgment, would provide to a patient for the purpose of
preventing, evaluating, diagnosing or treating an illness, injury, disease or
its symptoms, and that are (a) in accordance with generally accepted standards
of medical practice; (b) clinically appropriate, in terms of type, frequency,
extent, site and duration, and considered effective for the patient’s illness,
injury or disease; and (c) not primarily for the convenience of the patient,
physician, or other health care provider, and not more costly than an
alternative service or sequence of services at least as likely to produce
equivalent therapeutic or diagnostic results as to the diagnosis or treatment of
that patient’s illness, injury or disease. For these purposes, “generally
accepted standards of medical practice” means standards that are based on
credible scientific evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community, Physician Specialty
Society recommendations and the views of Physicians practicing in relevant
clinical areas and any other relevant factors.

 

Adverse Determination Denial Rate

 

For the calendar year beginning after the Final Order Date, and thereafter
during the Effective Period, Company shall make an annual, aggregate disclosure
of the number of Adverse Determinations sent to external review for final
determination for the preceding calendar year and the percentage of such Adverse
Determinations that are upheld or reversed. Company shall make this disclosure
by means of the Provider Website or other comparable electronic medium.

 

(b) Policy Issues Involving Clinical Judgment.

 

In formulating and adopting medical policies with respect to Covered Services,
Company shall rely on credible scientific evidence published in peer-reviewed
medical literature generally recognized by the relevant medical community, and
shall continue to make such policies readily available to Plan Members and
Participating Physicians via the Public Website or by other electronic means. In
formulating and adopting such policies, Company shall take into account national
Physician Specialty Society recommendations and the views of prudent Physicians
practicing in relevant clinical areas and any other clinically relevant factors.
Promptly after adoption, Company shall file a copy of each new policy or
guideline with the Physicians’ Advisory Committee.

 

  (c) Future Consideration by Company of an Administrative Exemption Program.

 

Company shall consider the feasibility and desirability of exempting certain
Participating Physicians from certain administrative requirements based on
criteria such as the Participating Physician’s delivery of quality and cost
effective medical care and accuracy and appropriateness of claims submissions.
Company shall not be obliged to implement any such exemption process during the
term hereof, and this § 7.16(c) is not intended and shall not be construed to
limit Company’s ability

 

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to implement any such program on a pilot or experimental basis, base exemptions
on any Company determined basis, or otherwise to implement one or more programs
in only some markets.

 

7.17 Billing and Payment

 

(a) Time Period for Submission of Bills for Services Rendered

 

Company shall not contest the timeliness of bills for Covered Services provided
under a Fully-Insured Plan if such bills are received by Company within 180 days
after the later of: (i) the date of service and (ii) the date of the Physician’s
receipt of the EOB from the primary payor, when Company is the secondary payor.
Company shall propose to Self-Insured Plan sponsors that they adopt the 180 day
time period referenced in the preceding sentence, in the event that a
Self-Insured Plan has a more restrictive time period. Company shall extend the
180 day time period for a reasonable period, on a case by case basis, in the
event that a Physician provides notice to Company, along with appropriate
evidence, of circumstances reasonably beyond the Physician’s control that
resulted in the delayed submission. Company shall determine such circumstances
and the reasonableness of the submission date. Nothing in this § 7.17(a) shall
limit Company’s ability to provide incentives for prompt submission of bills.

 

(b) Claims Submission

 

Company agrees to accept from Participating Physicians and Non-Participating
Physicians properly completed paper claims submitted on Form CMS-1500 or the
equivalent. Company also agrees to accept electronic claims populated with
similar information in HIPAA-compliant format using HIPAA-compliant code sets,
subject to Company’s reasonable requirements pertaining to the exchange of
electronic transactions. If a Physician elects not to be compliant with the
portions of HIPAA relating to the electronic submission of claims, Company shall
not require such Physician to use electronic transactions or otherwise require
such Physician to become compliant with HIPAA. Instead, Company will maintain
reasonable non-electronic systems to serve the information needs of such
Physicians. Notwithstanding the above, Company may continue to require
submission of Clinical Information and other additional information in
connection with its review of specific claims and as contemplated elsewhere in
this Agreement, including without limitation §§ 7.5 and 7.8(d)(ii); provided,
however, that nothing in this sentence is intended or shall be construed to
alter or limit any restrictions set forth elsewhere in this Agreement concerning
Company’s ability to make requests for Clinical Information in connection with
adjudication of claims. Company shall disclose on the Provider Website and the
Public Website its policies and procedures regarding the appropriate format for
claims submissions and requests for Clinical Information.

 

7.18 Timelines for Processing and Payment of Complete Claims

 

(a) Beginning not later than nine (9) months after the Final Order Date, Company
shall mail a check or make an electronic funds transfer in payment for Complete
Claims for Covered Services within thirty (30) calendar days following the later
of Company’s receipt of such claim or the date on which Company is in receipt of
all information needed and in a format required for such claim to constitute a
Complete Claim, including without limitation all documentation reasonably needed
by Company to determine that such claim does not contain any material defect or
error. Beginning one year following the Effective Date, Company shall mail a
check or make an electronic funds transfer in payment for Complete Claims for
Covered Services that are submitted electronically by Physicians within fifteen
(15) calendar days following the later of Company’s receipt of such claim or the
date on which Company is in receipt of all information needed and in a format
required for such claim to constitute a Complete Claim, including without
limitation all documentation reasonably needed by Company to determine that such
claim does not contain any material defect or error. If payment for Complete
Claims for Covered Services is not made within the time periods specified in
this § 7.18(a), Company shall pay interest pursuant to §§ 7.18(b) or (c), as
applicable. With respect to any claims for Covered Services governed by the laws
of a state that provides a definition or other

 

29

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similar provision for determining whether a claim is a Complete Claim, Company
shall determine whether a claim is a Complete Claim, for both Fully-Insured
Plans and Self-Insured Plans, using the description set forth in such state’s
laws or regulations.

 

(b) With respect to any claims for Covered Services governed by the laws of a
state that requires interest to be computed and paid on claims for Covered
Services, Company shall compute and pay interest using the time periods
specified in § 7.18(a) on claims for Covered Services under both Fully-Insured
Plans and Self-Insured Plans using the interest calculation methodology and
interest rates set forth in such state’s laws or regulations.

 

(c) With respect to any claims for Covered Services governed by the laws of a
state that does not require interest to be computed and paid on claims for
Covered Services, Company shall compute and pay interest on claims for Covered
Services under both Fully-Insured Plans and Self-Insured Plans using the
methodology set forth in this § 7.18(c). For each Complete Claim with respect to
which Company mails a check or makes an electronic funds transfer later than the
applicable period specified in § 7.18(a), Company shall pay simple interest at
six percent (6%) per annum on the balance due on each such claim computed from
the sixteenth (16th) or the thirty-first (31st) day (as appropriate based on the
circumstances described in § 7.18(a) above) following the later of Company’s
receipt of such a claim or the date on which Company is in receipt of all
information needed and in a format required for such a claim to constitute a
Complete Claim, up to but excluding the date on which Company mails the check
(or makes the electronic funds transfer) for payment of such Complete Claim.
Interest paid pursuant to this § 7.18(c) shall, at Company’s election, either be
included in the claim payment check or wire transfer or be remitted periodically
(but at least quarterly) in a separate check or wire transfer along with a
report detailing the claims for which interest is being paid.

 

(d) Company shall have no obligation to make any interest payment pursuant to
§ 7.18(b) or (c) above (i) with respect to any Complete Claim if, within 30 days
of the submission of an original claim, a duplicate claim is submitted while
adjudication of the original claim is still in process; (ii) to any
Participating Physician who balance bills a Plan Member in violation of such
Participating Physician’s agreement(s) with Company; (iii) with respect to any
time period during which a Force Majeure, as defined in § 7.32 of this
Agreement, prevents adjudication of claims; or (iv) where payment is made to a
Plan Member.

 

(e) Company shall affix to or on paper claims for Covered Services the date such
claims are received by Company. Company shall send an electronic acknowledgement
of claims for Covered Services submitted electronically identifying the date
such claims are received by Company. If Company determines that there is any
defect or error in a claim that prevents the claim from entering Company’s
adjudication system, it shall so notify the Physician within ten (10) days of
receipt of such claim. Nothing contained in this § 7.18 is intended or shall be
construed to alter Company’s ability to request Clinical Information consistent
with the provisions of § 7.8(d)(ii) or any other provision of this Agreement.

 

(f) Notwithstanding anything in the Agreement to the contrary, the requirements
of § 7.18 shall not apply to (i) claims for Covered Services that are processed
under the BCBSA BlueCard Program or any similar national account delivery
program governed by the BCBSA (including but not limited to NASCO-to-NASCO
arrangements) in which Company participates but is not solely responsible for
the processing and payment of the claim, (ii) claims for Covered Services under
a program offered or sponsored by any state or federal governmental entity other
than in its capacity as an employer, and (iii) claims for Covered Services under
the HealthLink program.

 

7.19 No Automatic Downcoding of Evaluation and Management Claims

 

As of the Final Order Date, Company shall not automatically reassign or reduce
the code level of evaluation and management codes billed for Covered Services
(“Downcoding”), except that Company may reassign a new patient visit code to an
established patient visit code based solely on CPT® Codes, guidelines and
conventions. Notwithstanding the foregoing sentence, Company shall continue to
have the right to deny, pend or adjust such claims for Covered Services on other
bases and shall have the right to reassign or reduce

 

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the code level for selected claims for Covered Services (or claims for Covered
Services submitted by selected Physicians or Physician Groups or Physician
Organizations) based on a review of the information in the Clinical Information
at the time the service was rendered for the particular claims or a review of
information derived from Company’s fraud or abuse billing detection programs
that create a reasonable belief of fraudulent or abusive (whether intentional or
unintentional) billing practices; provided that the decision to reassign or
reduce is based primarily on a review of Clinical Information.

 

7.20 Bundling and Other Computerized Claim Editing

 

Company agrees to take actions necessary on Company’s part to cause the
claim-editing software program it uses to continue to produce editing results
consistent with the standards set forth in this § 7.20 and, if Company has
actual knowledge of non-conformity with such standards, to take reasonable
actions necessary on its part to promptly modify such software to any extent
necessary to conform to such standards; provided that nothing in this paragraph
is intended or shall be construed to require Company to pay for anything other
than Covered Services for Plan Members, to make payment at any particular rates,
to limit Company’s right to deny, pend or adjust claims based on a reasonable
belief of fraudulent or abusive (whether intentional or unintentional) billing
practices (so long as the Physician has been given the opportunity to provide
Clinical Information and Company has reviewed any Clinical Information so
provided before denying or adjusting the claims). For purposes of this § 7.20
only, if any change to CPT® affects Company’s obligations hereunder, Company
will promptly develop plans to cause its Physician payment practices to be
consistent with the commitments set forth in this § 7.20. Except as set forth
below, the obligations set forth below in this § 7.20 shall take effect on the
date set forth in Exhibit G. The parties agree that all references to the AMA
CPT® book and to CPT® Codes in this § 7.20 refer to the AMA CPT® book and the
CPT® Codes listed in the AMA CPT® book in effect at the time the services were
provided.

 

(a) Company will process and separately reimburse those codes listed in the AMA
CPT® book as modifier 51 exempt CPT® Codes without reducing payment under
Company’s Multiple Procedure Logic, provided that the AMA CPT® book provides
that such services are appropriately reported together.

 

(b) Company will process and separately reimburse codes listed in the AMA CPT®
book as add-on billing codes without reducing payment under Company’s Multiple
Procedure Logic; provided that the AMA CPT® book provides that such add-on CPT®
Codes are appropriately billed with proper primary procedure codes.

 

(c)    (i) Company shall not require a Physician to submit Clinical Information
of their patient encounters solely because the Physician seeks payment for both
surgical procedures and CPT® evaluation and management services for the same
patient on the same date of service, provided that the correct CPT® evaluation
and management code, surgical code and modifier (e.g., CPT® modifiers 25 or 57)
are included on the initial claim submission.

 

(ii) If a bill contains a CPT® Code for an evaluation and management service
appended with a CPT® modifier 25 and a CPT® Code for performance of a
non-evaluation and management service procedure code, both codes shall be
recognized and separately eligible for payment, unless the Clinical Information
indicates that use of the CPT® modifier 25 was inappropriate or Company has
disclosed pursuant to § 7.8(d)(iii) the limited number of finite code
combinations that are not appropriately reported together. Payment shall only be
made for one evaluation and management service for any single day unless payment
for more than one is appropriate pursuant to AMA CPT® Codes, guidelines and
conventions and is supported by appropriate diagnoses in the Clinical
Information.

 

(iii) Company will remove from its claim review and payment systems those Edits
that generally deny payment for CPT® evaluation and management codes with a CPT®
modifier 25 appended when submitted with surgical or other procedure codes for
the same patient on the same date of service except for a limited number of
exceptions, consistent with § 7.20(c)(ii) above, which will be disclosed on
Company’s Provider Website.

 

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(iv) Nothing in this Agreement shall (i) prohibit Company from requiring use of
the appropriate CPT® Code modifiers, according to CPT® Codes, guidelines and
conventions, for evaluation and management billing codes (e.g., CPT® modifiers
25 or 57) on their original claim forms, or (ii) preclude Company from requiring
Participating Physicians and Non-Participating Physicians (to the extent the
audit is limited to claims submitted under an assignment of benefits) to submit
to an audit of their submitted claims (including claims for surgical procedures
and evaluation and management services on the same date of service submitted
with the appropriate modifier), and to provide their Clinical Information in
connection with such an audit.

 

(d) A CPT® Code for supervision and interpretation or radiologic guidance (e.g.,
fluoroscopic, ultrasound or mammographic) shall be separately recognized and
eligible for payment to the extent that the associated procedure code is
recognized and eligible for payment; provided that, (i) the associated procedure
code does not include supervision and interpretation or radiologic guidance
according to AMA CPT® Codes, guidelines and conventions and (ii) for each such
procedure (e.g., review of x-ray or biopsy analysis or ultrasound guidance),
Company shall not be required to pay for supervision or interpretation or
radiologic guidance by more than one qualified health care professional.

 

(e) With respect to indented codes, Company shall not reassign any CPT® Code
into any other CPT® Code or deem a code ineligible for payment based solely on
the format of the published CPT® descriptions.

 

(f) CPT® Codes submitted with a modifier 59 attached will be eligible for
payment to the extent they follow the AMA CPT® book and they designate a
distinct or independent procedure performed on the same day by the same
Physician, but only to the extent that: (1) although such procedures or services
are not normally reported together they are appropriately reported together
under the particular presenting circumstances; and (2) it would not be more
appropriate to append any other CPT® recognized modifier to such codes.

 

(g) No global periods for surgical procedures shall be longer than the period
then designated by CMS; provided that this limitation shall not restrict Company
from establishing a global period for surgical procedures (except where CMS has
determined a global period is not appropriate or has identified a global period
not associated with a specific number of days).

 

(h) Company shall not automatically change a Code to one reflecting a reduced
intensity of the service when such CPT® Code is one among or across a series
that includes without limitation codes that differentiate among simple,
intermediate and complex, complete or limited, and/or size.

 

(i) Not later than six (6) months after the Final Order Date, or as soon
thereafter as is reasonably practicable, Company shall update its claims editing
software at least once each year to (A) cause its claim processing systems to
recognize any new CPT® Codes or any reclassifications of existing CPT® Codes as
modifier 51 exempt since the previous annual update, and (B) cause its claim
processing personnel to recognize any additions to HCPCS Level II Codes
promulgated by CMS since the prior annual update. As to both clauses (A) and
(B) above, Company shall not be obligated to take any action prior to the
effective date of the additions or reclassifications. Nothing in this
subparagraph shall be interpreted to require Company to recognize any such new
or reclassified CPT® Codes or HCPCS Level II Codes as Covered Services under any
Plan Member’s Plan, and nothing in this subparagraph shall be interpreted to
require that the updates contemplated in (A) and (B) be completed at the same
time; provided that (A) and (B) are each completed once each year.

 

(j) Nothing contained in this § 7.20 shall be construed to limit Company’s
recognition of CPT® modifiers to those CPT® modifiers specifically addressed in
this § 7.20.

 

7.21 EOB and Remittance Advice Content

 

(a) Not later than six (6) months after the Final Order Date or as soon
thereafter as practicable, Company’s EOB forms shall contain at least the
following information: (i) the name of and a number identifying the Plan Member,
(ii) the date of service, (iii) the amount of payment for services provided,

 

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(iv) any adjustment to the invoice submitted, and (v) a generic explanation of
any adjustment to the invoice submitted. Each such EOB form, or documents
provided by Company to a Plan Member along with each such EOB form, also shall
specify an address and phone number for questions regarding the claim described
on such EOB form. EOB contents must include the total amount originally billed
by the Physician. Consistent with the desire that Plan Members receive accurate
communications that do not disparage Non-Participating Physicians, each such EOB
form shall indicate the amount, if any, for which the Physician may bill the
Plan Member and shall state “Physician may bill you” such amount, if any, or
contain substantially similar language, and shall not characterize disallowed
amounts, if any, as unreasonable. Not later than six (6) months after the Final
Order Date or as soon thereafter as practicable, the physician Remittance Advice
or similar forms that Company sends to Physicians communicating the results of
claims adjudications shall contain at least: (i) the name of and a number
identifying the Plan Member, (ii) the date of service, (iii) the amount of
payment per line item, (iv) the procedure code(s), (v) the amount of payment,
(vi) any adjustment to the invoice submitted, (vii) a generic explanation of any
adjustment of the invoice submitted that complies with HIPAA requirements, and
(viii) any adjustment or change in any code on a line-by-line basis. Each such
Physician Remittance Advice or similar form, or documents provided by Company to
the Physician along with each such Physician Remittance Advice or similar form,
also shall specify an address and phone number for questions by the Physician
regarding the claim described on such Physician Remittance Advice or similar
form. This paragraph is not intended and shall not be construed to limit
Company’s right to replace Physician Remittance Advice or similar forms with
electronic Remittance Advices or the equivalent, to the extent such electronic
Remittance Advices or the equivalent provide similar information so long as
Company complies with § 7.17(b).

 

(b) Physicians, Class Counsel, and Company agree that this Agreement is not
intended to alter or change rights of a Non-Participating Physician to balance
bill or bill the Plan Member at rates and on terms that are agreed to between
the Non-Participating Physician and the Plan Member.

 

7.22 Overpayment Recovery Procedures

 

As of the Final Order Date, Company shall initiate or continue to take actions
reasonably designed to reduce Overpayments. Such actions may include, without
limitation, system enhancements to identify duplicate invoices prior to payment
and construction and maintenance of one or more common physician databases for
use in connection with payment of physician invoices. Company shall publish on
the Public Website and the Provider Website an address and procedures for
Physicians to return Overpayments. In addition, other than for recovery of
duplicate payments, Company shall initiate Overpayment recovery efforts by
providing Physicians with at least thirty (30) days written notice before
engaging in additional Overpayment recovery efforts. Such notice shall include
(i) the patient’s name, (ii) the service date, (iii) the payment amount received
by Physician, and (iv) a reasonably specific explanation of the proposed
adjustment (including, without limitation, procedure code where appropriate).
Company shall not initiate Overpayment recovery efforts more than eighteen
(18) months after the payment was received by Physician; provided, however, that
no time limit shall apply to the initiation of Overpayment recovery efforts
(a) based on a reasonable belief of fraud or other intentional misconduct,
(b) required by a Self-Insured Plan, or (c) required by a state or federal
government program. Notwithstanding the above, in the event that a Physician
asserts a claim of underpayment, Company may defend or set off such claim based
on Overpayments going back in time as far as the claimed underpayment. If a
Physician requests an appeal within thirty (30) days of receipt of a request for
repayment of an Overpayment, Company shall not require such Physician to repay
the alleged Overpayment before such appeal is concluded.

 

7.23 Efforts to Improve Accuracy of Information about Eligibility of Plan
Members

 

Commencing on the Final Order Date, Company shall initiate or continue to take
actions reasonably designed to reduce Overpayments and claim denials resulting
from inaccurate information about the eligibility of Plan Members. Such actions
include, without limitation:

 

a. Working collaboratively with large third party administrators who handle
customer eligibility to develop systems for collecting and transmitting
eligibility information on a timely and accurate basis.

 

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b. Developing scorecards for large third party administrators to track the
timeliness of the information they deliver to Company.

 

c. Working collaboratively with large third party administrators to develop
systems that extract Plan Member termination information directly from a payroll
system.

 

d. Working collaboratively with plan sponsors and other group customers to
increase (i) the percentage of customers transmitting eligibility information to
Company in an electronic format and (ii) the frequency of the transmissions of
eligibility files from the customer to Company.

 

e. Developing employee metrics for Company’s internal eligibility personnel to
measure performance and reward behaviors that reduce the impact of retroactive
termination of Plan Members on claims payments. Such performance measures may
include, without limitation: (i) the timely delivery of reports to third party
eligibility administrators/plan sponsors relating to terminated Plan Members;
(ii) timely follow-up with such third party eligibility administrators/plan
sponsors on such reports to verify the Plan Member’s termination; and
(iii) timely error correction.

 

f. Contacting large group customers prior to their contract renewal date to
determine to the extent practicable whether the customer intends to terminate or
renew coverage.

 

g. Offering Physicians, and encouraging the use of, the ability to verify
eligibility electronically.

 

h. Enhancing responses to eligibility inquiries to include co-pay and deductible
information.

 

i. Offering employers, and encouraging the use of, electronic maintenance
capabilities to facilitate updating of eligibility information.

 

It is understood that the foregoing activities may be effected by the Company in
discrete geographic regions or portions of the Company’s business, with a view
to evaluating their effectiveness in achieving the desired objectives. Company
may reduce, discontinue, or expand such activities commensurate with their
demonstrated effectiveness.

 

7.24 Responses to Physician Inquiries

 

Company has taken actions and expended significant amounts of money and other
resources reasonably designed to improve the speed, accuracy and efficiency of
responses to Physician inquiries and concerns. Such actions and expenditures
include investments in new technology, enhanced employee training, departmental
restructuring and re-designed work processes. Company shall continue with these
and other efforts, where appropriate, to further improve the speed, accuracy and
efficiency of responses to Physician inquiries and concerns, and shall make
expenditures reasonably needed to achieve these goals.

 

7.25 Effect of Company Confirmation of Patient Procedure/Medical Necessity

 

Company agrees that if Company certifies that a proposed service is medically
necessary for a particular Plan Member, Company shall not subsequently revoke
that medical necessity determination absent evidence of fraud, evidence that the
information submitted was materially erroneous or incomplete, or evidence of
material change in the Plan Member’s health condition between the date that the
certification was provided and the date of the service that makes the proposed
service no longer medically necessary for such Plan Member. In the event that
Company certifies the medical necessity of a course of treatment limited by
number, time period or otherwise, then a request for services beyond the
certified course of treatment shall be deemed to be a new request and Company’s
denial of such request shall not be deemed to be inconsistent with the preceding
sentence.

 

7.26 Electronic Connectivity

 

The Provider Website shall operate at times and with a degree of reliability
comparable to that for Company’s other websites.

 

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7.27 Information about Physicians Provided by Company

 

Information currently posted on the Public Website about individual Physicians
or contained in printed materials prepared by Company is derived from data
supplied by those Physicians and from applicable agreements between Company and
Participating Physicians or their Physician Groups or Physician Organizations.
Upon written notice of an inaccuracy sent to Company (pursuant to the direction
as to how to give such notice that will be posted on the Provider Website), if
Company does not dispute that there is an inaccuracy Company shall take steps
reasonably necessary to ensure that the Public Website is updated within twenty
(20) business days after receipt of such notice and that written materials are
revised before the next edition of such materials is printed (to the extent
there is sufficient time to make such revisions before the next printing) to
reflect any corrections in the Physician information to make it accurate. Upon
written notice that a Physician is incorrectly listed as a Participating
Physician on the Public Website or in printed materials prepared by Company
(pursuant to the direction as to how to give such notice that will be posted on
the Provider Website), if Company does not dispute that there is an inaccuracy
Company shall take steps reasonably necessary to delete any such erroneous
reference from the Public Website within twenty (20) business days after receipt
of such notice and from any written materials before the next edition of such
materials is printed (to the extent there is sufficient time to make such
revisions before the next printing), and Company shall make corresponding
changes in systems affecting the level of payments and generation of EOBs within
twenty (20) business days after receipt of such notice. If Company disputes that
there is an inaccuracy, it will so notify the Physician within the same time
periods specified above, including the basis on which it disputes that there is
an inaccuracy.

 

7.28 Capitation and Physician Organization Specific Issues

 

(a) Capitation Reporting

 

Not later than 120 days after the Final Order Date, Company agrees to provide
monthly reports to Participating Physicians, Physician Groups, or Physician
Organizations that receive Capitation. These monthly reports will include
membership information to allow reconciliation by Participating Physicians,
Physician Groups, and Physician Organizations, as applicable, of per member per
month Capitation payments, including Plan Member identification number or the
equivalent, name, age, gender, monthly Capitation amount, primary care
Physician, Enrollment Date, and, in the monthly report following an applicable
change (e.g., selection of new primary care Physician) a report of such change,
as well as an explanation of any deductions. Nothing in this Agreement shall
prohibit the continuation or subsequent negotiation of different reporting
requirements in an Individually Negotiated Contract.

 

(b) Payments for Plan Members under Capitation Who Do Not Select Primary Care
Physician at Time of Enrollment

 

For a Plan Member who is enrolled in a Plan requiring selection of a
Participating Physician, Physician Group or Physician Organization receiving
Capitation, if a newly enrolled Plan Member does not make such selection upon
Enrollment or within thirty (30) calendar days after the Enrollment Date, then
within forty-five (45) calendar days after the Enrollment Date Company shall
assign the Plan Member to a Participating Physician, Physician Group or
Physician Organization randomly related to the Plan Member’s home address zip
code or on the basis of another reasonable method developed by Company. Company
shall pay Capitation to the assigned Participating Physician, Physician Group or
Physician Organization in accordance with the applicable terms of such
Participating Physician, Physician Group or Physician Organization’s agreement
with Company, from the effective date of Enrollment. The Plan Member shall have
the right thereafter to designate a Participating Physician, Physician Group or
Physician Organization or to select a new Participating Physician, Physician
Group or Physician Organization at any time in accordance with such Plan
Member’s Plan, and Company shall pay Capitation to such Participating Physician,
Physician Group or Physician Organization from the effective date of such
designation or selection in accordance with the

 

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applicable terms of such Participating Physician, Physician Group or Physician
Organization’s agreement with Company. Nothing herein shall require Company to
pay Capitation on behalf of a Plan Member to more than one Participating
Physician, Physician Group or Physician Organization for the same services
during the same period of time.

 

(c) Company agrees that it shall not apply withholds or risk pools to Capitation
arrangements except pursuant to Individually Negotiated Contracts.

 

7.29 Miscellaneous

 

(a) Gag Clauses

 

Company does not and shall not include in its contracts with Participating
Physicians any provision limiting the free, open and unrestricted exchange of
information between Participating Physicians and Plan Members regarding the
nature of the Plan Member’s medical conditions or treatment and provider options
and the relative risks and benefits and costs to the Plan Member of such
options, whether or not such treatment is covered under the Plan Member’s Plan,
and any right to appeal any adverse decision by Company regarding coverage of
treatment that has been recommended or rendered. Company agrees not to penalize
or sanction Participating Physicians in any way for engaging in any free, open
and unrestricted communication with a Plan Member with respect to the foregoing
subjects or for advocating for any service on behalf of a Plan Member.

 

(b) Ownership of Clinical Information

 

Company agrees that it does not own Clinical Information kept by Physicians;
however, nothing in this provision or this Agreement is intended to or should be
construed to convey to a Physician any property interest in (a) Company’s data
or intellectual property, (b) products or services offered or provided by
Company now or in the future, or (c) any business, systems or information
management process that incorporates any such medical records or related data
obtained by Company from such Physicians or any reports or data resulting from
any such data or processes; provided, however, that nothing in this provision is
intended or should be construed to limit or expand Company’s right to request
and receive Clinical Information from Physicians.

 

(c) Arbitration

 

(i) With respect to any arbitration proceeding between Company and a
Participating Physician who practices individually or in a Physician Group of
less than six Physicians, Company agrees that it shall refund any applicable
filing fees or arbitrators’ fees paid by such Physician in the event the
Physician is the prevailing party with respect to such arbitration proceeding;
provided, however, that this paragraph shall not apply with respect to any
arbitration proceeding in which the Participating Physician purports to
represent any Physician outside of his or her Physician Group.

 

(ii) Company agrees not to include language in any agreement with a Physician,
Physician Group, or Physician Organization (A) requiring that any arbitration
panel have multiple members, (B) preventing the recovery of any statutory or
otherwise legally available damages or other relief in an arbitration
proceeding, (C) restricting the statutory or otherwise legally available scope
or standard of review, (D) completely prohibiting discovery; (E) shortening any
statute of limitations, or (F) requiring that any arbitration proceeding occur
more than 50 miles from the principal office of the Physician, Physician Group,
or Physician Organization.

 

(d) Impact of this Agreement on Standard Form Agreements and Individually
Negotiated Contracts.

 

(i) Company’s future standard form agreements with Participating Physicians
shall not be inconsistent with the commitments and undertakings Company makes in
this Agreement. To the extent that Company’s existing standard form agreements
with Participating Physicians contain provisions inconsistent with the terms
hereof, Company shall administer such agreements consistent with the terms set
forth in this Agreement.

 

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(ii) Where Company and a Participating Physician, Physician Group or Physician
Organization have an Individually Negotiated Contract, this Agreement shall not
modify or nullify the inconsistent terms of such Individually Negotiated
Contract unless the Participating Physician, Physician Group or Physician
Organization notifies Company in writing no later than sixty (60) days after
notice of Preliminary Approval, specifically setting forth the terms it seeks to
have modified or nullified by this Agreement; provided, however, that (1) with
respect to Company’s use of Edits, Company shall administer Individually
Negotiated Contracts consistent with the terms set forth in this Agreement and
(2) the Agreement shall not modify or nullify the terms of Individually
Negotiated Contracts with respect to those terms the Agreement expressly states
either are unaffected by the Agreement or are controlled by Individually
Negotiated Contracts.

 

(iii) With respect to Individually Negotiated Contracts executed after the
Preliminary Approval Date of this Agreement, Company may agree with individual
Participating Physicians, Physician Groups or Physician Organizations on terms
that deviate from the terms of this Agreement relating to higher or customized
rates, length of term of the contract, and/or other customized payment
methodologies or as otherwise permitted under §§ 7.13(b), 7.13(c), 7.14(a),
7.14(b), 7.28(a), and 7.28(c). In addition, Company may agree with individual
Participating Physicians, Physician Groups or Physician Organizations on terms
that deviate from any other terms of this Agreement upon request of such
individual Participating Physicians, Physician Groups or Physician
Organizations.

 

(e) Impact of this Agreement on Covered Services

 

Notwithstanding anything to the contrary contained in this Agreement, nothing
contained in this Agreement shall supercede or otherwise alter the scope of
Covered Services of any Plan or require Company or any Plan to pay for services
that are not Covered Services. In determining whether services provided to a
Plan Member are Covered Services under a Self-Insured Plan, Company shall apply
the definition of “Medically Necessary” (or any comparable term) contained in
§ 7.16(a) except with respect to the limited number of large Self-Insured Plans
that require that a different definition of “Medically Necessary” (or any
comparable term) be applied. With respect to such Self-Insured Plans, Company
shall recommend that the definition of “Medically Necessary” (or any comparable
term) contained in § 7.16(a) apply.

 

(f) Privacy of Records

 

Company shall safeguard the confidentiality of Plan Member Clinical Information
in accordance with HIPAA, state and other federal law and any other applicable
legal requirements. This undertaking shall not be the subject of a Compliance
Dispute, provided, however, that Physicians may resort to remedial measures, if
any, provided by HIPAA and state and other federal law and regulations to
protect Physicians’ interests in the confidentiality of Plan Member Clinical
Information.

 

(g) Pharmacy Risk Pools

 

Company shall not require the use of pharmacy risk pools. A “pharmacy risk pool”
is an arrangement whereby amounts payable to a Participating Physician can be
reduced due to pharmacy utilization by Plan Members.

 

(h) Ability of Physicians to Obtain “Stop Loss” Coverage from Insurers Other
than Company

 

Company shall not restrict Physicians from purchasing stop loss coverage from
insurers other than Company.

 

  (i) Pharmacy Provisions

 

Company shall disclose to Plan Members whether that Plan Member’s health plan
uses a formulary and, if so, explain what a formulary is, how Company determines
which prescription medications are included in the formulary, and how often
Company reviews the formulary list. When Company provides pharmacy coverage,
Company shall make formulary information available to Plan

 

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Members. Company shall maintain the process, as reasonably amended, for covering
medications not included in the formulary when medically necessary that is in
place on the Execution Date. Company will continue to provide coverage for
off-label uses of pharmaceuticals that have been approved by the FDA (but not
approved for the prescribed use) provided that the drug is not contraindicated
by the FDA for the off-label use prescribed, and that the drug has been proven
safe, effective and accepted for the treatment of the specific medical condition
for which the drug has been prescribed, as evidenced by supporting documentation
in any one of the following (1) the American Hospital Formulary Service Drug
Information or the United States Pharmacopeia Drug Information; or (2) results
of controlled clinical studies published in at least two peer-reviewed national
professional medical journals. Company shall retain the right to pre-certify
coverage of specific medications for non-approved use. Company’s disclosure
concerning pre-certification and potential restrictions on non-approved use of
prescription medications shall be similar in substance to disclosure concerning
formularies, as described above.

 

(j) Restrictive Endorsements

 

Where Company’s reimbursement of a Physician for services performed by that
Physician is a partial payment of allowable charges, a Physician may negotiate a
check with a “Payment in Full” or other restrictive endorsement without waiving
the right to pursue a remedy available under this Agreement.

 

(k) Scope of Company’s Responsibilities

 

(i) The obligations undertaken by Company under § 7 of this Agreement shall be
applicable only to those functions or activities performed directly by Company,
its employees, and third parties (other than Delegated Entities) performing
functions or activities on Company’s behalf. Company shall make a good faith
effort to include in contracts entered into with Delegated Entities subsequent
to the Final Order Date terms that are substantially equivalent to the terms of
this Agreement; provided that Company shall not be liable under this Agreement
in the event any Delegated Entity acts in a manner inconsistent with the terms
of this Agreement.

 

(ii) The provisions of this Agreement shall apply to HealthLink only to the
extent that Company has final decision-making authority with respect to the
activity that is the subject of the applicable commitment under the Agreement.

 

(iii) The provisions of this Agreement shall apply to Company’s activities in
connection with the BlueCard Program or any similar national account delivery
program governed by the BCBSA (including but not limited to NASCO-to-NASCO
arrangements) only to the extent that the Company is solely responsible for the
activity, under any such program, that is the subject of the applicable
commitment under the Agreement.

 

(iv) Company represents that it has reasonably investigated and has not
identified any provision in § 7 of this Agreement that would cause Company to be
in violation of any BCBSA requirements, rules or regulations. Company agrees
that it will not encourage or support any change in BCBSA requirements, rules or
regulations that would conflict with Company’s obligations under this Agreement.
If Company becomes aware of any BCBSA requirement, rule or regulation that it
must comply with but that is in conflict with any term of this Agreement, it
will provide notice to the Plaintiffs and meet and confer with Plaintiffs’
counsel in an attempt to reach agreement as to the action to be taken, if any,
to resolve the conflict. If, as a result of an agreement with Plaintiffs in
Thomas, the BCBSA validly enacts a requirement, rule or regulation relating to
business practice changes within the BlueCard Program or any similar national
account delivery program governed by BCBSA (including but not limited to
NASCO-to-NASCO arrangements), Company agrees to comply with such requirement,
rule or regulation. Company shall not be required to take or refrain from taking
any action pursuant to this Agreement that it believes would cause Company to be
in violation of any BCBSA requirements, rules, or regulations and will provide
the basis for such belief.

 

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If Company believes it is unable to comply with any provision of this Agreement
based on any BCBSA requirement, rule or regulation and provides a declaration
stating the basis for such belief and the meet and confer process does not
result in an agreement acceptable to Plaintiffs’ counsel, then Plaintiffs’
counsel may bring a proceeding before the Compliance Dispute Resolution Officer
and the Compliance Dispute Resolution Officer shall have the jurisdiction to
determine whether there is a comparable remedy to replace the one that Company
believes it is unable to comply with and if so, to order that Company comply
with such comparable provision for the remainder of the Effective Period. If
Company believes it is unable to comply with the comparable replacement
provision based on any BCBSA requirement, rule or regulation and provides a
declaration stating the basis for such belief, then the parties will repeat the
process set forth herein to obtain another comparable replacement provision.

 

(v) To the extent any settlement(s) of Thomas, as to some or all Thomas
defendants, specifically imposes on, in the aggregate, ten (10) or more Blue
Cross and/or Blue Shield licensees or plans who are defendants in the Thomas
action a lesser obligation than that specifically set forth in § 7 regarding
(1) programs offered or sponsored by any state or federal governmental entity
other than in its capacity as an employer or (2) the obligations set forth in §
7.19 or § 7.20, Company may comply only with such lesser obligation.

 

(l) Copies of Contracts

 

Company shall provide a copy of its contract with a particular Participating
Physician (including without limitation a contract with a Physician Organization
or a Physician Group in which such Participating Physician participates) to such
Participating Physician, upon receipt by Company of a written request by such
Participating Physician to provide such copy, except in circumstances where
Company is restricted from providing a Participating Physician with a copy of
Company’s contract with a Physician Organization or Physician Group specifically
because of terms contained in that contract. Company will not require that a
restriction as described in the previous sentence be included in its contracts
with Physician Organizations or Physician Groups.

 

(m) State and Federal Laws and Regulations

 

Nothing contained in § 7 of this Agreement is intended to or shall, in any way,
reduce, eliminate, or supersede any Party’s obligation to comply with applicable
provisions of relevant state and federal law and regulations. To the extent
state or federal law or regulation imposes, with respect to a specific
obligation created by § 7, a greater obligation than that specifically set forth
in § 7, Company shall comply with said law or regulation. The Compliance Dispute
resolution procedures contained in § 12 shall apply with respect to any alleged
breach of an obligation created by the preceding sentence. Nothing in this
§ 7.29(m) is intended to give rise to or should be construed as giving rise to
any private right of action for any violation of any federal or state law or
regulation (whether under a breach of contract theory or any other theory) where
federal or state law or regulation does not allow a Physician a right of action
for such violation. The Compliance Dispute Review Officer shall not take any
action inconsistent with any ruling, determination or directive by any court or
regulatory agency. Any action taken by the Compliance Dispute Review Officer
that is inconsistent with any subsequent ruling, determination or directive by
any court or regulatory agency shall not be binding on Company as of the
effective date of such subsequent ruling, determination or directive.

 

(n) Ability of Company to Modify Means of Disclosure

 

Company may alter the method or means by which it makes any disclosure or
otherwise transmits information as described in, and required by, this
Agreement, so long as Company reasonably believes, expects and intends that the
newly-adopted means or method of disclosure or transmission is as effective or
more effective than the means or method set forth in this Agreement.

 

(o) Limitations on Obligations of Non-Participating Physicians

 

No affirmative obligation that § 7 imposes on Physicians shall apply to any
Non-Participating Physician unless and until, and then only to the extent that,
such Non-Participating Physician pursues

 

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with Company a claim for payment on the Non-Participating Physician’s own behalf
or such Non-Participating Physician pursues benefits under this Agreement, in
which case any affirmative obligations that § 7 imposes on Physicians shall
apply to such Non-Participating Physician with respect to such claim or such
benefits.

 

(p) Limitation on Rental Networks

 

(i) Limitation on Renting the Company’s Networks—Disclosures Regarding Networks

 

Company agrees that it shall disclose on the applicable Provider Websites the
identities of those entities to which it provides access to its network of
Participating Physicians and for which (i) Company does not adjudicate claims or
(ii) Company adjudicates claims but does not provide the EOB or Remittance
Advice. The foregoing shall not apply to (A) the BlueCard Program or any similar
national account delivery program governed by BCBSA, (B) arrangements between or
among the Company’s subsidiaries, and (C) HealthLink or any other Subsidiary
whose primary function is the rental of physician networks.

 

(ii) Limitation on Use of Rental Networks or Discounted Fee Schedules

 

Company agrees that, whenever it pays a Non-Participating Physician based upon a
fee schedule established by another entity, (1) Company shall, upon request by
such Non-Participating Physician, provide the name, address and telephone number
of such entity and (2) Company shall disclose on each EOB or Remittance Advice,
the identity of such entity in sufficient detail for the Physician to identify
it; provided, however, that such obligation shall not apply to the BlueCard
program or any similar national account delivery program governed by the BCBSA
or where the identity of such entity is contained on a Plan Member’s
identification card. In addition to the foregoing, Company agrees that it shall
endeavor to include in contracts entered into with such entities following the
Effective Date, an obligation on the part of such entities to furnish
Non-Participating Physicians a copy, upon request, of the signed agreement
showing that the Non-Participating Physician agreed to be bound by that entity’s
fee schedule with respect to services provided to a Plan Member.

 

The Parties are precluded from using anything in this § 7.29(p) in connection
with efforts to obtain legislative or regulatory changes, including but not
limited to the subject of this section, the content of this section, or the
relief in this section. The parties are free to pursue, support, or oppose any
proposed legislative or regulatory changes related to the subject matter of this
section.

 

(q) Effect of Assignment of Benefits

 

The existence, submission, and/or acceptance of an assignment of benefits
authorization in favor of a Non-Participating Physician shall not preclude the
Non-Participating Physician from collecting from the Plan Member the difference
between the Non-Participating Physician’s full fee and the payment (if any)
received by the Non-Participating Physician from the Company.

 

7.30 Compliance with Applicable Law and Requirements of Government Contracts

 

The obligations undertaken in § 7 herein shall be fulfilled by Company to the
extent permissible under applicable laws and regulations, the terms and
conditions of current and future government contracts, and applicable
governmental directives. If, and during such time as, Company is unable to
fulfill an obligation under § 7 to the extent contemplated by this Agreement
because to do so would require governmental approval or action, Company shall
perform such obligation to the extent permissible under applicable laws and
regulations, the terms and conditions of current and future government
contracts, and applicable governmental directives, and Company shall continue to
fulfill its other obligations under § 7 to the extent permitted under applicable
laws and regulations, the terms and conditions of current and future government
contracts, and applicable governmental directives. To the extent that any
governmental approval is required for any Party to fulfill an obligation under §
7, such Party shall make all reasonable efforts to obtain any necessary
approvals from the appropriate governmental entities. For any obligation under §
7 that cannot be

 

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undertaken without governmental approval, the Effective Date as to that
obligation shall be delayed until such approval is granted. Nothing in this § 7
shall apply to Company’s role as a carrier providing administrative services for
the Medicare Part B program or to the Federal Employee Program. Notwithstanding
the above, if as a result of an agreement with plaintiffs in Thomas the BCBSA
makes commitments with respect to the Federal Employee Program that apply to
Blue Cross and/or Blue Shield licensees, Company agrees to comply with such
commitments on the same terms, conditions, and time frames as are applicable to
other Blue Cross and/or Blue Shield licensees.

 

7.31 Estimated Value of § 7 Initiatives

 

Since the inception of these Actions and through the Termination Date, Company
will have spent over $250,000,000.00 in order to implement and carry out the
initiatives described in §§ 7.1, 7.2, 7.3, 7.7, 7.23, and 7.24 of this
Agreement. Taking into account these expenditures and the other commitments
regarding Company’s business practices set forth in § 7 of this Agreement, the
Parties estimate that the approximate aggregate value of the initiatives and
other commitments regarding Company’s business practices set forth in § 7 of
this Agreement is in excess of the amount stated above.

 

7.32 Force Majeure

 

Company shall not be liable for any delay or non-performance of its obligations
under this § 7 arising from any act of God, governmental act, act of terrorism,
war, fire, flood, earthquake or other natural disaster, explosion or civil
commotion. The performance of Company’s obligations under this § 7, to the
extent affected by the delay, shall be suspended for the period during which the
cause, or Company’s substantial inability to perform arising from the cause,
persists.

 

  7.33 Managed Care Issues Relating to Mental Health and Substance Abuse

 

a. Except where any applicable law or regulation requires a different
definition, Company shall apply as to its current agreements and include in its
future agreements with Participating Physicians the definition of Medical
Necessity in § 7.16(a) with respect to mental health services, including
treatment for psychiatric illness and substance abuse, subject to the terms and
conditions of the Plan Member’s Plan; provided that in determining the clinical
appropriateness of care, the following minimum standards relevant to mental
health care must be met:

 

(i) There is a diagnosis as defined by standard diagnostic nomenclatures (DSM IV
or its equivalent in ICD-9-CM) and an individualized treatment plan appropriate
for the Plan Member’s illness or condition; and

 

(ii) There is a reasonable expectation that the Plan Member’s illness,
condition, or level of functioning will be stabilized, improved, or maintained
through ambulatory care, through treatment known to be effective for the Plan
Member’s illness; custodial care is not typically a Covered Service; and

 

(iii) The mental health services are not primarily for the avoidance of
incarceration of the Plan Member.

 

b. Company agrees that Participating Psychiatrists will be listed in Company’s
provider directory, via the hard-copy directory, via the Company’s Public
Website, via a “hot link” on Company’s Public Website, or otherwise. If a
primary care Physician referral is required, Company will allow its primary care
Participating Physicians to make referrals to Company’s Participating
Psychiatrists, provided that any such referral is subject to the same referral
requirements that apply to referrals to other Participating Physicians. Nothing
in the preceding sentence shall be construed to remove or change any applicable
Plan Member or Physician Precertification requirements.

 

c. Company agrees that, where a Psychiatrist has not entered into a different
agreement with Company or the hospital or other mental health care facility
where the services are rendered, and where Company has

 

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not entered into a different agreement with such hospital or mental health care
facility, Company will separately consider and pay for Medically Necessary
Covered Services provided to a Plan Member by the Psychiatrist, in accordance
with the terms and conditions of the Member’s Plan.

 

d. Company adheres to applicable state “prudent layperson” laws which require
payment of benefits for mental health services in the event of an emergency
under prudent layperson standards. An emergency department Physician can make a
decision regarding admission or physical or chemical restraints. Company agrees
that, where a Physician has not entered into a different agreement with Company
or the hospital or other mental health care facility where the services are
rendered, and where Company has not entered into a different agreement with such
hospital or mental health care facility, in the event of an emergency, Company
will pay for Medically Necessary emergency care mental health Covered Services
provided by Physicians in accordance with applicable prudent layperson
standards, the definition of Medical Necessity in § 7.16(a), and the terms and
conditions of the Plan Member’s Plan, and Company will pay for Medically
Necessary mental health Covered Services provided by Physicians resulting from
the admission in accordance with the definition of Medical Necessity in §
7.16(a) and the terms and conditions of the Plan Member’s Plan.

 

e. Company will post on its Provider Website an authorization form that
Physicians providing mental health services to Plan Members may print or
download to obtain Plan Member consent for release of Clinical Information to
Company.

 

7.34 Annual Compliance Reporting

 

Company shall file annually a Certification that Company is in compliance with
its obligations under § 7. If Company is not in compliance, Company shall
identify how Company is not in compliance. In addition, Company shall file
annually and within thirty (30) days after the Termination Date, a Certification
containing or attaching the following information relating to the following
sections of this Agreement:

 

7.5    Company’s standard pre-certification lists 7.6    A list of the dates on
which Company mailed notices of material adverse changes to Participating
Physicians 7.7    A summary of the initiatives Company implemented or employed
to reduce claim resubmissions 7.8(b)    A summary of the efforts made by Company
to cause its automated “bundling” and other claims payment rules to be
consistent within each state 7.8(d)    A list of Company’s Significant Edits
7.8(d)(i)    A list of each customized Edit added to any standard claims editing
software product at Company’s request 7.8(d)(ii)    A list of categories of
claims as to which Company has determined that routine review of Clinical
Information is appropriate 7.8(d)(iii)    A list of any circumstances as to
which Company has determined that particular services or procedures, relative to
modifiers 25 and 59, are not appropriately reported together with those
modifiers 7.9(b)    A list of the dates of meetings of the Physician Advisory
Committee and of the members of the Physician Advisory Committee 7.9(c)    A
summary of any recommendations made to Company by the Physician Advisory
Committee and Company’s response 7.10(b)(4)    The procedures for review
developed by the Billing Dispute External Review Board 7.10(g)    A summary of
any decisions issued by the Billing Dispute External Review Board

 

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7.14(a)    A list of the dates of any annual revisions to Company’s standard fee
schedules 7.14(b)    A list of the dates on which Company issued coverage
statements with respect to any new technology or treatment or new use for an
established technology or treatment recommended by a Physician Specialty Society
7.16(a)    The number of Adverse Medical Necessity Determinations sent to
external review for final determination for the preceding calendar year and the
percentage of such Adverse Medical Necessity Determinations that are upheld or
reversed. 7.17(b)    A summary of Company’s policies and procedures regarding
the appropriate format for claims submissions and requests for Clinical
Information 7.21(a)    Copies of the forms of Company’s standard EOB form and
Physician Remittance Advice 7.22    Copies of the forms of written notice
provided to Physicians before initiating Overpayment recovery efforts 7.23    A
summary of the actions initiated or continued to be taken by Company to improve
accuracy of information about eligibility of Plan Members 7.24    A summary of
the actions initiated or continued to be taken by Company to further improve the
speed, accuracy and efficiency of responses to Physicians’ inquiries and
concerns 7.26    A list of the dates (if any) that the Provider Website was
substantially inoperable during the Effective Period 7.28(a)    Copies of the
forms of the standard monthly reports provided by Company to Participating
Physicians, Physician Groups, or Physician Organizations that receive Capitation
7.31    The approximate aggregate amount spent by Company during the year
preceding the Certification in order to implement and carry out the initiatives
described in §§ 7.1, 7.2, 7.3, 7.7, 7.23, and 7.24 of the Agreement and, to the
extent practicable, a breakdown of such expenditures by category

 

8. Other Settlement Consideration

 

In addition to the business initiatives set forth in § 7 of this Agreement, the
settlement consideration shall include a contribution by Company to a charitable
Foundation, as described in more detail in § 8.1, and a settlement fund for
payment of claims to Class Members, which will be established and operated in
accordance with the provisions of §§ 8.2 through 8.4.

 

8.1 Foundation

 

No later than ten (10) days after the Effective Date, Company shall contribute
$5,000,000.00 to the Physicians’ Foundation for Health Systems Innovations, Inc.
Additional funding shall be provided to the Foundation by the Settlement Fund in
accordance with §§ 8.3 and 8.4 of this Agreement.

 

8.2 Settlement Fund

 

By no later than ten (10) days after Preliminary Approval, Company shall cause
to be established an account for the administration of settlement payments to
Class Members (the “Settlement Fund”), which account shall be governed by the
terms of an escrow agreement to be entered into between Company and the escrow
agent that is retained by Company to manage such account. No later than ten
(10) days after the Effective Date, Company shall cause to be contributed to the
Settlement Fund the amount of $135,000,000.00 (the “Settlement Amount”), by wire
transfer in immediately available funds. Such payment shall be treated as a
payment to a Qualified or Designated Settlement Fund under I.R.C. § 468B and the
regulations or proposed regulations promulgated thereunder (including without
limitation Treasury Reg. § 1.468B-1-5 or any successor regulation).

 

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8.3 Responsibilities of the Settlement Administrator

 

The settlement administrator that is selected and retained by Company (the
“Settlement Administrator”), under the joint supervision of Company and Class
Counsel or their designees, and subject to the supervision, direction and
approval of the Court, shall be responsible for the administration of the
Settlement Fund. The responsibilities of the Settlement Administrator shall
expressly include without limitation: (a) the determination of the eligibility
of any Class Member to receive payment from the Settlement Fund and the amount
of payment to be made to each Class Member, in accordance with the provisions of
§ 8.3 of this Agreement; (b) the determination as to whether the election of any
Class Member to transfer a settlement payment to the Foundation has been
authorized by such Class Member, in accordance with the provisions of § 8.3 of
this Agreement; (c) the administration of an appropriate procedure for the
adjudication of disputes that may arise with respect to the eligibility of a
Class Member to receive a payment from the Settlement Fund or the amount of the
payment authorized to be made by the Settlement Fund to any Class Member under
the provisions of this Agreement; (d) the filing of any tax returns necessary to
report any income earned by the Settlement Fund and the payment from the
Settlement Fund, as and when legally required, of any tax payments (including
interest and penalties) due on income earned by the Settlement Fund and to
request refunds, when and if appropriate, with any such tax refunds that are
issued to become part of the Settlement Fund; and (e) the compliance by the
Settlement Fund with any other applicable law. The fees and expenses of the
Settlement Administrator shall be paid by Company; provided that neither Company
nor Class Counsel shall be responsible for any other costs, expenses or
liabilities of the Settlement Fund.

 

(a) The portion of the Settlement Fund that will be available in the aggregate
to satisfy claims by Retired Physicians (the “Retired Physician Amount”) shall
be equal to the Settlement Amount multiplied by two times the quotient derived
by dividing the number of Retired Physicians who file valid Proofs of Claim by
the total number of Class Members. Each Retired Physician who files a valid
Claim Form shall be entitled to receive a payment from the Settlement Fund equal
to the Retired Physician Amount divided by the total number of Retired Physician
valid Proofs of Claim.

 

(b) The amount remaining in the Settlement Fund after subtracting the Retired
Physician Amount will be available in the aggregate to satisfy claims by Class
Members other than Retired Physicians (the “Active Physician Amount”).

 

(c) Each Active Physician who files a valid Claim Form shall be entitled to
receive payment from the Settlement Fund in an amount to be determined according
to whether the Active Physician’s gross receipts for providing Covered Services
to Company Plan Members during the three calendar year period of 2002, 2003 and
2004 were (x) less than $5,000, (y) at least $5,000 but less than $50,000, or
(z) $50,000 or greater. For purposes of this determination, amounts received
include amounts paid by Company or by Delegated Entities for providing Covered
Services to Company Plan Members. The Settlement Administrator shall determine
the category for each Active Physician based upon the certification in the Claim
Form and/or such independent verification, if any, that the Settlement
Administrator may undertake in its sole discretion.

 

(d) The Settlement Administrator shall determine the total number of Active
Physicians who fall within each of the three categories set forth in § 8.3(c)
and determine the total number of distribution shares (each a “Base Amount”)
necessary to make distributions according to the following formula: The Active
Physician Amount shall be allocated among Active Physicians who file valid
Proofs of Claim such that each such Active Physician who falls within §
8.3(c)(x) shall be entitled to receive a single Base Amount, each such Active
Physician who falls within § 8.3(c)(y) shall be entitled to receive five times
the Base Amount and each such Active Physician who falls within § 8.3(c)(z)
shall be entitled to receive ten times the Base Amount. A Class Member who files
an otherwise valid Claim Form but does not certify whether they are a Retired or
Active Physician or specify a category of gross receipts for Covered Services to
Company Plan Members, shall be deemed to be entitled to a single Base Amount,
and the Settlement Administrator has no obligation to pursue additional
information about the Class Member’s status or amount of receipts.

 

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(e) The Settlement Administrator shall establish procedures to permit an Active
Physician to establish, through the submission of billing records or similar
information, that he or she should fall into a category entitled to a higher
payment from the Settlement Fund based on aggregate payments received for
providing Covered Services to Company Plan Members over any other consecutive
three-year period from January 1, 1996 through December 31, 2004.

 

(f) The Settlement Administrator shall determine the total number of Retired
Physicians filing valid Claim Forms and divide that number into the Retired
Physician Amount to determine the amount to distribute to each Retired
Physician. The Settlement Administrator shall determine the total number of
Active Physicians filing valid Claim Forms, calculate the total number of Base
Amounts to be distributed for Active Physicians as set forth in § 8.3(d) above,
and divide that number into the Active Physician Amount to determine the dollar
value of each Base Amount to be distributed to each Active Physician according
to the number of Base Amounts to which they are entitled under § 8.3(d). The
result for each category shall determine the amount to be distributed to
eligible Class Members submitting a valid Claim Form for each category.

 

(g) Each Class Member who files a valid Claim Form may elect either to receive
the payment from the Settlement Fund or to direct that such amount be
contributed on his, her or its behalf to the Foundation or to another foundation
established by a Signatory Medical Society which is approved by Class Counsel
and Company and set forth on the list of available foundations attached to the
Claim Form.

 

(h) An eligible Class Member must submit a timely claim form (the “Claim Form”)
to the Settlement Administrator using the Claim Form attached as Exhibit A
hereto and in accordance with the instructions included in the Mailed Notice and
in the Claim Forms in order for such Class Member to have a valid right to
receive payment from the Settlement Fund. Promptly after receipt of all timely
Claim Forms, the Settlement Administrator shall calculate the amount that is
payable to, or on behalf of, each Class Member (or to the Foundation) pursuant
to the provisions of § 8.3. Reasonably promptly upon completion by the
Settlement Administrator of the calculations of the amounts that are payable,
the Settlement Administrator shall cause the Settlement Fund to disburse payment
to Class Members in each Category who or which submitted valid Claim Forms in
accordance with § 8.3 or to the Foundation as directed by such Class Members.
Any Class Member submitting a Claim Form shall, through the act of submitting
that Claim Form, be subject to the jurisdiction of the Court for any related
proceedings. Physician Groups and Physician Organizations shall be allowed to
file Claim Forms on behalf of Physicians employed by or otherwise working with
them at the time that the claims are made, without the necessity of individual
signatures from the individual Physicians, but only if the Physician does not
submit an individual claim on his/her own behalf.

 

8.4 Reversion to Foundation of Unclaimed Amounts

 

At a reasonable time determined by the Settlement Administrator not less than
120 days after all payments have been disbursed to Class Members or to the
Foundation, at the direction of Class Members, in each case pursuant to § 8.3 of
this Agreement, the Settlement Administrator shall determine the amount of
unclaimed funds remaining in the Settlement Fund (e.g., uncashed checks),
including interest earned on such funds after the payments have been disbursed
but excluding taxes owed (the “Reversion Amount”). The Settlement Administrator
shall provide written notice of the Reversion Amount to Company and Class
Counsel and, no later than twenty (20) business days after providing such
written notice, the Settlement Administrator shall cause the Settlement Fund to
remit the Reversion Amount to the Foundation by wire transfer. Following the
Settlement Administrator’s determination of the Reversion Amount, stop payment
orders may be placed on all unclaimed funds, and no Class Member shall have any
claim on the Settlement Fund or the Parties or their counsel or the Settlement
Administrator thereafter.

 

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8.5 Timing of Payments and Interest

 

Company’s payments pursuant to §§ 8.1 and 8.2 shall be made no later than ten
(10) days after the Effective Date. The amount of each payment due shall be
increased by the amount of interest accrued on each payment at the Interest Rate
from the Preliminary Approval Date to the Effective Date, with no compounding.

 

8.6 Other Settlement Administration Provisions

 

(a) The Company’s payment of the Settlement Amount plus accrued interest into
the escrow administered by the Settlement Administrator shall be treated as a
payment to a Qualified or Designated Settlement Fund under I.R.C. § 468B and the
regulations or proposed regulations promulgated thereunder (including without
limitation Treasury Reg. § 1.468B-1-5 or any successor regulation).

 

(b) The Parties, Class Counsel and Company’s counsel shall not have any
responsibility for, interest in, or liability whatsoever with respect to the
investment of or distribution of the Settlement Fund. Parties, Class Counsel and
Company’s counsel shall not have any responsibility for, interest in, or
liability whatsoever with respect to the determination, administration,
calculation, or payment of Proofs of Claim from the Settlement Fund (except as
specifically described in this Agreement) or any losses incurred in connection
therewith.

 

(c) The escrow agent(s) with whom the Settlement Fund is deposited shall invest
the monies in those funds solely in interest bearing investments which the
escrow agent(s) consider(s) to involve no substantial risk to payment of
principal at maturity.

 

(d) No Person shall have any cause of action against the Plaintiffs, Class
Counsel, the Settlement Administrator, Company, the Released Persons, or
Company’s counsel, including any counsel representing Company in connection with
these Actions, based on the administration or implementation of the Agreement or
orders of the Court or based on the distribution of monies under the Agreement.
In such circumstances, the sole remedy (other than those provided pursuant to
the terms of the Agreement) is application to this Court for enforcement of the
Agreement or order pursuant to § 12.

 

(e) The Settlement Administrator shall make appropriate reports under Internal
Revenue Code § 1099 with respect to all payments it makes to Class Members under
this Agreement. The Settlement Administrator shall file any tax returns
necessary with respect to any income earned by the Settlement Fund and shall
pay, as and when legally required to do so, any tax payments (including interest
and penalties) due on income earned by such Fund, and shall request refunds,
when and if appropriate, and shall apply any such refunds that are issued to the
Settlement Fund to become a part thereof (or, if refunds are received after
distribution, to the Foundation).

 

(f) If a Class Member submits a Claim Form requesting compensation under the
wrong compensation category (e.g., a request under the Retired Physician Amount
which should have been submitted as a request under the Active Physician
Amount), the Settlement Administrator may at its sole discretion review the
Claim Form under the provisions set forth herein for the correct settlement
category unless the documentation submitted with said Claim Form is insufficient
under those provisions.

 

(g) If the Final Order and Judgment is set aside or reversed in whole or in part
for any reason (except for a matter found to be severable under § 13.8(c)), then
at such time as the time for any appeal from the final order of set aside or
reversal has elapsed (including without limitation any extension of time for the
filing of any appeal that may result by operation of law or order of the Court)
with no notice of appeal having been filed, all funds in the Settlement Fund,
including interest accrued thereon, shall be released forthwith to Company.

 

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9. Attorneys’ Fees, and Representative Plaintiffs’ Fees

 

9.1 Company Shall Pay Attorneys’ Fees

 

Class Counsel intend to apply to the Court for an award of Attorneys’ Fees in an
amount not to exceed $58,000,000.00, which application Company agrees not to
oppose. Company shall pay such Attorneys’ Fees in the amount awarded by the
Court up to but not exceeding such unopposed amount in accordance with § 9.3 of
this Agreement. If the Court awards Attorneys’ Fees in excess of $58,000,000.00,
Class Counsel, on behalf of themselves and the Class, hereby covenant and agree
to waive, release and forever discharge the amount of any such excess award and
to make no effort of any kind or description ever to collect same. The
Attorneys’ Fees agreed to be paid pursuant to this provision are in addition to
and separate from all other consideration and remedies paid to and available to
the Class Members who have not validly and timely requested to Opt-Out of this
Agreement. Company shall not be obligated to pay any attorneys’ fees or expenses
incurred by or on behalf of any Releasing Party in connection with the Action,
other than the payment of Attorneys’ Fees in accordance with this § 9.1.

 

9.2 Company Shall Pay Representative Plaintiffs’ Fees

 

In addition to Attorney’s Fees, Class Counsel intends to apply to the Court for
an award of fees for each Representative Plaintiff in the amount of $7,500.00,
which application Company agrees not to oppose. Company shall pay such fees to
Representative Plaintiffs in the amount awarded by the Court up to but not
exceeding such unopposed amount in accordance with § 9.3. If the Court awards
fees to Representative Plaintiffs in excess of $7,500.00 each, Representative
Plaintiffs, on behalf of themselves and the Class, hereby covenant and agree to
waive, release and forever discharge the amount of any such excess award and to
make no effort of any kind or description ever to collect same. The fees to
Representative Plaintiffs agreed to be paid pursuant to this § 9.2 are in
addition to the other consideration afforded the Class Members who have not
validly and timely requested to Opt-Out of this Agreement. Company shall support
the award of fees to Representative Plaintiffs up to $7,500.00 as reasonable and
appropriate and shall not to object to such request nor appeal an award up to
the amounts specified above. Such amounts are the only consideration and fees
that Released Persons shall be obligated to give Class Counsel or Representative
Plaintiffs as a result of prosecuting and settling these Actions, other than the
additional express agreements made herein.

 

9.3 Timing of Fee Payments

 

Company’s payments pursuant to §§ 9.1 and 9.2 shall be made no later than ten
(10) days after the Effective Date. The amount of each payment due shall be
increased by the amount of interest accrued on each payment at the Interest Rate
from the Preliminary Approval Date to the Effective Date, with no compounding.

 

10. Application to Fully Funded and Self Funded Plans

 

This Agreement applies to Company’s conduct with respect to both Fully-Insured
Plans and Self-Funded Plans, except as otherwise specified in this Agreement or
provided by applicable law.

 

11. Limited Liability

 

The Billing Dispute External Review Board or Boards (and its members and agents,
if any), the Compliance Dispute Facilitator (and his agents, if any), the
Internal Compliance Officer (and his agents, if any) and the Compliance Dispute
Review Officer (and his agents, if any) do not owe a fiduciary duty to the Class
Members, the Representative Plaintiffs, or Company. The Parties shall ask the
Court to grant the Billing Dispute External Review Board, the Compliance Dispute
Facilitator (and his agents, if any), the Internal Compliance Officer (and his
agents, if any) and the Compliance Dispute Review Officer (and his agents, if
any) limited immunity from liability to the effect that the above-mentioned (and
their members and agents, if any) shall be liable only for willful misconduct
and gross negligence.

 

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12. Compliance Disputes Arising Under This Agreement

 

12.1 Jurisdiction

 

(a) Compliance Dispute Facilitator.

 

All Compliance Disputes shall be directed not to the Court nor to any other
state court, federal court, arbitration panel or any other binding or
non-binding dispute resolution mechanism but to the Compliance Dispute
Facilitator to be designated by Class Counsel. Company shall publish on the
Public Website the name and address of the Compliance Dispute Facilitator. The
proposed Final Order and Judgment shall provide that no state or federal court
or dispute resolution body of any kind shall have jurisdiction over any
enforcement of § 7 of this Agreement at any time, including without limitation
through any form of review or appeal, except to the extent otherwise provided in
this Agreement.

 

(b) Compliance Dispute Review Officer.

 

Pursuant to §§ 12.3 and 12.6, and subject to §§ 12.4 and 12.5, the Compliance
Dispute Facilitator shall refer Compliance Disputes that satisfy the
requirements of § 12.3(b) to the Compliance Dispute Review Officer for
resolution. The Compliance Dispute Review Officer shall be appointed by mutual
agreement of Company and Class Counsel within 30 days of the Preliminary
Approval Date, or such later date as may be mutually agreed by Company and Class
Counsel. If the Compliance Dispute Review Officer is no longer able to serve in
such role for any reason, then a replacement shall be chosen by mutual agreement
of Class Counsel, or their designee, and Company. If Class Counsel, or their
designee, and Company cannot mutually agree on such replacement Compliance
Dispute Review Officer, such replacement Compliance Dispute Review Officer shall
be a Person to be agreed upon by Company and Class Counsel prior to the
Effective Date (the “First Alternate”). If the First Alternate is unable or
unwilling to serve in such role for any reason, then such replacement Compliance
Dispute Review Officer shall be a Person to be agreed upon by Company and Class
Counsel prior to the Effective Date (the “Second Alternate”). If the Second
Alternate is unable or unwilling to serve in such role for any reason, then such
Compliance Dispute Review Officer shall be a Person to be agreed upon by Company
and Class Counsel prior to the Effective Date.

 

(c) Fees and Costs.

 

Company shall pay the reasonable hourly fees and costs of the Compliance Dispute
Facilitator and the Compliance Dispute Review Officer for services on compliance
disputes with Company. If the parties are unable to reach agreement regarding
the fees and costs of the Compliance Dispute Facilitator and the Compliance
Dispute Review Officer, either party may apply to the Court for relief relating
exclusively to this § 12.1(c).

 

12.2 Who May Petition the Compliance Dispute Facilitator

 

The following may petition the Compliance Dispute Facilitator (each a
“Petitioner”):

 

(a) any Class Member who has not validly and timely requested to Opt-Out of this
Agreement and who contends that Company has materially failed to perform
specific obligations under § 7 of this Agreement, and that such Class Member is
adversely affected by Company’s failure to comply with such specific obligations
under § 7; and

 

(b) any Signatory Medical Society.

 

(c) Nothing in subsections (a) and (b) of this § 12.2 is intended or shall be
construed to limit the remedies that the Compliance Dispute Review Officer may
order pursuant to § 12.6(f) herein.

 

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12.3 Procedure for Submission, and Requirements, of Compliance Disputes

 

(a) Compliance Dispute Claim Form

 

Before the Compliance Dispute Facilitator may consider a Compliance Dispute, a
Petitioner must submit a properly completed Compliance Dispute Claim Form,
attached hereto as Exhibit C and approved by the Court, to the Compliance
Dispute Facilitator, who shall promptly provide a copy of such Compliance
Dispute Form to Company The Compliance Dispute Claim Form may include supporting
documentation or affidavit testimony. The Compliance Dispute Claim Form attached
hereto as Exhibit C shall be made available by the Compliance Dispute
Facilitator to Class Members upon request.

 

(b) Qualifying Submissions

 

When the Compliance Dispute Facilitator is petitioned pursuant to § 12.2(a) or
(b) of this Agreement, in order for the Compliance Dispute Facilitator to refer
the Compliance Dispute to the Compliance Dispute Review Officer, the Compliance
Dispute Facilitator must determine that:

 

(1) the Petitioner has satisfied the requirements of § 12.2;

 

(2) the Petitioner has submitted a properly completed submission not later than
ninety (90) days after such Compliance Dispute arose or after the petitioner
reasonably became aware of the Dispute, whichever is later; and

 

(3) in the Compliance Dispute Facilitator’s judgment, the Petitioner’s
Compliance Dispute

 

(a) is not frivolous,

 

(b) cannot be easily resolved by the Compliance Dispute Facilitator without the
intervention of the Compliance Dispute Review Officer, and

 

(c) is not properly the subject of a proceeding pursuant to §§ 7.10 or 7.11 of
this Agreement.

 

If the Compliance Dispute Facilitator determines that the Petitioner’s
Compliance Dispute is properly the subject of an alternative dispute resolution
proceeding pursuant to §§ 7.10 or 7.11 of this Agreement, the Compliance Dispute
Facilitator shall expressly inform the Petitioner of the External Review
procedures available to such Petitioner.

 

12.4 Rejection of Frivolous Claims

 

The Compliance Dispute Facilitator may reject as frivolous, and the Compliance
Dispute Review Officer shall not hear, any Compliance Dispute that the
Compliance Dispute Facilitator determines in his or her sole and absolute
discretion to be frivolous, filed for nuisance purposes, or otherwise without
merit on its face. The Compliance Dispute Facilitator may issue a written
explanation or a written order of the grounds for denial of Petitioner’s
Compliance Dispute. Petitioner shall have no right to appeal the Compliance
Dispute Facilitator’s decision.

 

12.5 Dispute Resolution Without Referral to Compliance Dispute Review Officer

 

If in the Compliance Dispute Facilitator’s judgment Petitioner’s Compliance
Dispute can be resolved using available resources without the invocation of the
Compliance Dispute Review Officer’s authority, the Compliance Dispute
Facilitator shall refer the Petitioner to the appropriate resources or otherwise
assist in the resolution of Petitioner’s Dispute. All Parties agree that dispute
resolution without invocation of the Compliance Dispute Review Officer’s
authority is preferable, and all Parties further agree to assist the Compliance
Dispute Facilitator in these efforts.

 

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12.6 Procedure for Compliance Dispute Review Officer Determination of Compliance
Disputes

 

(a) Optional Initial Negotiation and Mediation.

 

In the event the Compliance Dispute Facilitator has determined pursuant to
§§ 12.2 – 12.5 that the Compliance Dispute Review Officer should resolve a
particular Compliance Dispute, the Compliance Dispute Facilitator shall notify
the Compliance Dispute Review Officer, Petitioner and Company of such
determination and the basis therefor. Unless the Petitioner specifies otherwise,
the Compliance Dispute Facilitator shall serve as the Petitioner’s
representative in the Compliance Dispute process thereafter with respect to such
Compliance Dispute. If the Petitioner, the Facilitator and the Company agree,
the Compliance Dispute Review Officer shall then direct the Petitioner and
Company to convene negotiations at a time and place agreeable to both so that
they may reach agreement on whether a breach of Company’s obligations under § 7
of this Agreement has occurred and, if so, what remedy, if any, should be
implemented. At these negotiations, the Compliance Dispute Review Officer shall,
if requested by both Petitioner and Company, serve as a non-binding mediator. If
the Petitioner and Company cannot resolve the Compliance Dispute within 90 days
of the date of the determination and notification by the Compliance Dispute
Facilitator that the Compliance Dispute Review Officer should resolve the
Compliance Dispute, then they shall so inform the Compliance Dispute Review
Officer.

 

(b) Memoranda to Compliance Dispute Review Officer.

 

If the Compliance Dispute Review Officer has been notified pursuant to § 12.6(a)
that no agreement has been reached through negotiation or if the parties have
not agreed to participate in the optional initial negotiations and mediation
under § 12.6(a), the Compliance Dispute Review Officer shall request written
memoranda from the Petitioner and Company as to the merits of the Compliance
Dispute and appropriate remedies for such Compliance Dispute. The Petitioner
shall have 15 days from the date of the Compliance Dispute Review Officer’s
request to submit its memorandum and appropriate supporting exhibits, and
Company shall respond within 15 days after Company’s receipt of Petitioner’s
memorandum and accompanying exhibits. Requests for extensions of time for the
submission of such materials must be submitted to the Compliance Dispute Review
Officer no less than five (5) days before the date the memoranda and supporting
exhibits in question are due and shall be granted only for good cause shown. The
filing of such a request shall toll the time for submitting a memorandum and
supporting exhibits until such time as the request for extension has been
granted or denied.

 

(c) Oral Argument Concerning Compliance Dispute.

 

Petitioner or Company may, at the time of submission of the memoranda described
in § 12.6(b), request oral argument before the Compliance Dispute Review Officer
on the subject of the Compliance Dispute and appropriate remedies, if any. If
either the Petitioner or Company so requests, the Compliance Dispute Review
Officer shall hear such argument at a time and place convenient to the
Compliance Dispute Review Officer, the Petitioner, and Company, and shall accept
and consider any evidence relevant to the Compliance Dispute introduced at the
hearing.

 

(d) Decisions by the Compliance Dispute Review Officer.

 

In resolving a Compliance Dispute, the Compliance Dispute Review Officer shall
decide, based on the written submissions, oral argument and any other relevant
evidence that the Compliance Dispute Review Officer in his or her sole
discretion deems necessary, (i) whether the Compliance Dispute Facilitator
properly determined pursuant to §§ 12.3 and 12.4 that the Compliance Dispute
should be heard by the Compliance Dispute Review Officer and, if so,
(ii) whether Company has failed to comply with its obligations under § 7 of this
Agreement, and if so, direct what actions are to be taken by Company to obtain
compliance. In no event shall the Compliance Dispute Review Officer direct that
Company spend amounts or take actions above or below Company’s obligations under
§ 7 of this Agreement for any violations of this Agreement, including without
limitation any systemic violation under § 12.6(f). The Compliance Dispute Review
Officer must base his or her decision solely on the

 

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evidence received with respect to the Compliance Dispute and not on anything
outside the record, and must, at the time he or she announces his or her
decision, issue a written opinion setting forth the basis of the decision.

 

(e) Rehearing by the Compliance Dispute Review Officer.

 

After the Compliance Dispute Review Officer has issued a written opinion in
accordance with § 12.6(d), the Petitioner or Company, or both, may petition the
Compliance Dispute Review Officer within ten (10) days from receipt of the
decision, in writing, for rehearing on the question of whether a § 7 violation
has occurred and whether the remedies (if any) required by the Compliance
Dispute Review Officer are appropriate. The Compliance Dispute Review Officer
may deny the petition for rehearing or issue a new written opinion after
considering such a petition.

 

(f) Systemic Violations.

 

If the Compliance Dispute Review Officer determines that Company is engaged in a
systemic violation of its obligations under § 7 of this Agreement, then the
Compliance Dispute Review Officer may order appropriate remedies only as
necessary and designed to obtain compliance with the terms of this Agreement.

 

(g) Finality of the Compliance Dispute Review Officer’s Decision.

 

Upon the issuance of the Compliance Dispute Review Officer’s decision after a
rehearing, if any, the decision of the Compliance Dispute Review Officer shall
be final unless appealed to the Court, and the Compliance Dispute Review
Officer’s decision shall not be appealed by Petitioner or Company to any other
federal court, any state court, any state medical society, any arbitration panel
or any other binding or non-binding dispute resolution mechanism. In the event
that Petitioner or Company seeks review in the Court of a final decision of the
Compliance Dispute Review Officer, the Court shall consider only whether the
Compliance Dispute Review Officer’s final decision was “arbitrary, capricious,
an abuse of discretion, or otherwise not in accordance with law,” as defined by
5 U.S.C. § 706(2)(A), and/or whether the decision was contrary to or
inconsistent with the second sentence of § 12.6(d) of this Agreement. If and
only if the Court finds the final decision was “arbitrary and capricious, an
abuse of discretion, or otherwise not in accordance with law,” or that the
decision was contrary to or inconsistent with the second sentence of § 12.6(d)
of this Agreement, the Court may remand the Compliance Dispute to the Compliance
Dispute Review Officer for further proceedings.

 

(h) Enforcement by the Court.

 

If the Compliance Dispute Review Officer certifies that either Company or
Petitioner is not in compliance with any final decision issued or remedy ordered
by the Compliance Dispute Review Officer following any appeal as provided in §
12.6(g) above, such Person shall have 30 days from the date of such
certification to cure the non-compliance. If after such 30 day period, the
Person is not in compliance and the Compliance Dispute Review Officer certifies
that the Person has failed to cure the non-compliance during such 30 day period,
the other Person (Company or Petitioner, as the case may be) may petition the
Court for enforcement.

 

12.7 Internal Compliance Officer

 

In addition to and separate from the Compliance Dispute Review Officer and the
Compliance Dispute Facilitator, Company shall designate an “Internal Compliance
Officer” to generally monitor and facilitate Company’s compliance with the
obligations set forth in this Agreement. The Internal Compliance Officer shall
report to Company’s president, chief executive officer, general counsel, or
senior vice president of internal audit and compliance (“Senior Management”) and
shall take whatever steps and conduct whatever compliance checks and
investigations as he and Senior Management deem reasonably necessary and
appropriate to monitor Company’s compliance with this Agreement. Within 30 days
after the end of each calendar year during the Effective Period, the Internal
Compliance Officer

 

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shall file a written report with the Compliance Dispute Review Officer, the
Compliance Dispute Facilitator, and Class Counsel summarizing the Internal
Compliance Officer’s activities during the prior year and containing the
information specified in § 7.34, and shall simultaneously provide a copy of such
report to the Physician Advisory Committee. Each annual report shall contain all
the certifications required in the Certification to be filed at the end of the
Effective Period; provided that following the initial annual report, subsequent
reports may incorporate by reference any materials in prior year’s reports that
remain operative and have not been amended during the interim.

 

13. Release, Covenant Not to Sue, and Bar Order

 

13.1 Discharge of All Released Claims

 

(a) Upon the Effective Date, the “Released Parties,” which shall include Company
and each of its present and former parents, present and former wholly-owned
Subsidiaries, present and former divisions and Affiliates and each of their
respective current or former officers, directors, employees, agents, insurers
and attorneys (and the predecessors, heirs, executors, administrators, legal
representatives, successors and assigns of each of the foregoing), and all
persons who provided claims processing services, software, proprietary
guidelines or technology to Company or its Subsidiaries and Affiliates, and
those contracted agents processing claims on their behalf, together with each
such person’s or entity’s predecessors or successors (but only to the extent of
such person’s or entity’s services and work done pursuant to contract with
Company or its Subsidiaries or Affiliates), but excluding all Delegated
Entities, shall be released and forever discharged by the Signatory Medical
Societies and all Class Members who have not validly and timely requested to
Opt-Out of this Agreement, and by their respective heirs, executors, agents,
legal representatives, professional corporations, partnerships, assigns, and
successors, but only to the extent such claims are derived by contract or
operation of law from the claims of Class Members, (collectively, the “Releasing
Parties”) from any and all causes of action, judgments, liens, indebtedness,
costs, damages, obligations, attorneys’ fees, losses, claims, liabilities and
demands of whatever kind or character (each a “Claim”), arising on or before the
Effective Date, that are, were or could have been asserted against any of the
Released Parties by reason of, arising out of, or in any way related to any of
the facts, acts, events, transactions, occurrences, courses of conduct,
representations, omissions, circumstances or other matters referenced in the
Actions, whether any such Claim was or could have been asserted by any Releasing
Party on its own behalf or on behalf of other Persons, or to the business
practices that are the subject of § 7. This includes, without limitation and as
to Released Parties only, any aspect of any Fee for Service Claim submitted by
any Class Member to Company, and any claims of any Class Member related to or
based upon any Capitation agreement between Company and any Class Member or
other person or entity, or the delay, nonpayment or amount of any Capitation
payments by Company, and any allegation that other defendants in the Actions
and/or Company have conspired with, aided and abetted, or otherwise acted in
concert with other managed care organizations, other health insurance companies,
Delegated Entities and/or other third parties with regard to any of the facts,
acts, events, transactions, occurrences, courses of conduct, representations,
omissions, circumstances or other matters referred to in the Actions, or with
regard to Company’s liability for any other demands for payment submitted by any
Class Member to such other managed care organizations, health insurance
companies, Delegated Entities and/or other third parties.

 

(b) The Releasing Parties further agree to forever abandon and discharge any and
all Claims that exist now or that might arise in the future against BCBSA and/or
any Blue Cross and/or Blue Shield licensee or wholly-owned subsidiary of such
licensee, which Claims arise from, or are based on, conduct by any of the
Released Parties that occurred on or before the Effective Date and are, or could
have been, alleged in the Complaints, whether any such Claim was or could have
been asserted by any Releasing Party on its own behalf or on behalf of other
Persons. Except as provided in § 13.4(b), nothing in this Agreement is intended
to relieve any Person or entity that is not a Released Party from responsibility
for its own conduct or conduct of other Persons who are not Released Parties, or
to preclude any Representative Plaintiff from introducing any competent and
admissible evidence to the extent consistent with §§ 13.8(d), 14, and 16.

 

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(c) The claims and rights released and discharged pursuant to §§ 13.1(a) and
13.1(b), subject to the exception regarding Retained Claims contained in § 13.6,
shall be referred to collectively as “Released Rights” or “Released Claims.”

 

13.2 Covenant Not to Sue

 

(a) The Releasing Parties and each of them agree and covenant not to sue or
prosecute, institute or cooperate in the institution, commencement, filing, or
prosecution of any suit or proceeding in any forum based upon or related to any
Released Claim against any Released Party.

 

(b) Notwithstanding any other provision of this Agreement (including, without
limitation, this §13.2), nothing in this Agreement shall be deemed to in any way
impair, limit, or preclude the Releasing Parties’ rights to enforce any
provision of this Agreement, or any court order implementing this Agreement, in
a manner consistent with the terms of the Agreement.

 

13.3 Bar Order

 

It is an essential element of the Agreement that Company obtain the fullest
possible release from further liability to anyone relating to the Released
Claims, and it is the intention of the parties to this Agreement that the
Agreement eliminate all further risk and liability of Company relating to the
Released Claims. Accordingly, the Parties agree that the Court shall include in
the Final Order a Bar Order that meets all of the following requirements:

 

(a) The Releasing Parties are permanently enjoined from: (i) filing, commencing,
prosecuting, intervening in, participating in (as class members or otherwise) or
receiving any benefits from any lawsuit, arbitration, administrative or
regulatory proceeding or order in any jurisdiction based on any or all Released
Claims against one or more Released Parties; (ii) instituting, organizing class
members in, joining with class members in, amending a pleading in or soliciting
the participation of class members in, any action or arbitration, including but
not limited to a purported class action, in any jurisdiction against one or more
Released Parties based on, involving, or incorporating, directly or indirectly,
any or all Released Claims, and (iii) filing, commencing, prosecuting,
intervening in, participating in (as class members or otherwise) or receiving
any benefits from any lawsuit, arbitration, administrative or regulatory
proceeding or order in any jurisdiction based on an allegation that an action
taken by Company, which is in compliance with the provisions of the Settlement
Agreement, violates any legal right of any member of the Class.

 

(b) The Releasing Parties are permanently barred and enjoined from filing,
commencing, prosecuting, intervening in, participating in (as class members or
otherwise) or receiving any benefits from any lawsuit, arbitration,
administrative or regulatory proceeding or order in any jurisdiction based on
any and all Claims that exist now or that might arise in the future against
BCBSA, which Claims relate to in any way, arise from, or are based on, conduct
by any of the Released Parties that occurred on or before the Effective Date and
are, or could have been, alleged in the Complaints, whether any such Claim was
or could have been asserted by any Releasing Party on its own behalf or on
behalf of other Persons.

 

(c) All persons, including without limitation all defendants named in the
Complaints other than Released Parties, who are, have been, could be, or could
have been alleged to be joint tortfeasors, co-tortfeasors, co-conspirators, or
co-obligors with the Released Parties or any of them respecting the Released
Claims or any of them, are hereby, to the maximum extent permitted by law,
barred and permanently enjoined from making, instituting, commencing,
prosecuting, participating in or continuing any Claim, claim-over, cross-claim,
action, or proceeding, however denominated, regardless of the allegations,
facts, law, theories or principles on which they are based, in this Court or in
any other court or tribunal, against the Released Parties or any of them with
respect to the Released Claims, including without limitation equitable, partial,
comparative, or complete contribution, set-off, indemnity, assessment, or
otherwise, whether by contract, common law or statute, arising out of or
relating in any way to the Released Claims. All such claims are hereby fully and
finally barred, released, extinguished, discharged, satisfied, and made
unenforceable to the maximum extent permitted by law, and no such claim may be
commenced,

 

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maintained, or prosecuted against any Released Party. Any judgment or award
obtained by a Class Member against any such defendant or third party shall be
reduced by the amount or percentage, if any, necessary under applicable law to
relieve Company or any Released Party of all liability to such defendants or
third parties on such barred claims. Such judgment reduction, partial or
complete release, settlement credit, relief, or setoff, if any, shall be in an
amount or percentage sufficient under applicable law as determined by the Court
to compensate such defendants or third parties for the loss of any such barred
claims against Company or any Released Party. Nothing in this paragraph shall be
construed to bar any person who is alleged to be a joint tortfeasor,
co-tortfeasor, co-conspirator, or co-obligor with any of the Released Parties
from instituting, commencing, prosecuting, or participating in any claim,
claim-over, cross-claim, action, or proceeding, however denominated, against a
Released Party in any litigation in which claims against the Released Party are
not released and discharged pursuant to this order (“Non-Released Litigation”);
provided however, that such persons may serve discovery on a Released Party in
Non-Released Litigation only to the extent such discovery is directed solely to
the allegations in such litigation. Where the claims of a person who is, has
been, could be, or could have been alleged to be a joint tortfeasor,
co-tortfeasor, co-conspirator or co-obligor with a Released Party respecting the
Released Claims have been barred and permanently enjoined by this § 13.3, the
claims of Released Parties against that person respecting those Released Claims
are similarly fully and finally barred, released, extinguished, discharged,
satisfied and made unenforceable to the maximum extent permitted by law.

 

13.4 Dismissal With Prejudice

 

(a) The Releasing Parties shall take all steps necessary to dismiss the Actions
with prejudice as to Released Parties. It is the Parties’ intention that such
dismissal shall constitute a final judgment on the merits to which the
principles of res judicata shall apply to the fullest extent of the law as to
the Released Parties.

 

(b) Representative Plaintiffs and Class shall dismiss without prejudice all
claims for monetary relief against BCBSA asserted in Thomas including but not
limited to all claims for damages, restitution, and attorneys’ fees, by the
filing of a motion for leave to amend the complaint to remove BCBSA as a
defendant in Counts I and II of that complaint, while leaving BCBSA as a
defendant in Count III, which seeks injunctive and declaratory relief only. The
motion shall be in substantially the form attached hereto as Exhibit H, and
include a proposed Amended Complaint in substantially the form attached hereto
as Exhibit H1 and a proposed Order in substantially the form attached hereto as
Exhibit H2, and shall be filed within five business days of the Preliminary
Approval Date of this Agreement. Representative Plaintiffs and Class agree not
to amend the complaint at a later point in time to assert claims for monetary
relief against BCBSA unless it is impossible for the Effective Date to occur.
Upon the Effective Date, the amendment of Plaintiffs’ complaint pursuant to this
paragraph shall constitute a dismissal with prejudice of Representative
Plaintiffs’ and Class’ claims for monetary relief against BCBSA without further
order of the Court.

 

13.5 Waiver of California Civil Code § 1542

 

With respect to all Released Claims, the Releasing Parties and each of them
agree that they are expressly waiving and relinquishing to the fullest extent
permitted by law (a) the provisions, rights, and benefits conferred by § 1542 of
the California Civil Code, which provides:

 

“A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR
SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH
IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH
THE DEBTOR.”

 

and (b) any law of any state or territory of the United States, federal law or
principle of common law, or of international or foreign law, which is similar,
comparable or equivalent to § 1542 of the California Civil Code. Each Class
Member who has not validly and timely requested to Opt-Out of this Agreement and
each Signatory Medical Society may hereafter discover facts other than or
different from those which he, she or it knows or believes to be true with
respect to the claims which are the subject matter of the

 

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provisions of §13, but each such Class Member and each Signatory Medical Society
hereby expressly waives and fully, finally and forever settles and releases,
upon the entry of Final Order and Judgment, any known or unknown, suspected or
unsuspected, contingent or non contingent claim with respect to the subject
matter of the provisions of § 13, whether or not concealed or hidden, without
regard to the discovery or existence of such different or additional facts.

 

13.6 Retained Claims

 

Notwithstanding the foregoing, the Releasing Parties are not releasing claims
for payment (each a “Retained Claim” and, collectively, the “Retained Claims”)
for Covered Services provided to Plan Members prior to or on the Effective Date
as to which, as of the Effective Date, (i) no claim with respect to such Covered
Services has been submitted to Company; provided that the applicable period for
filing such claim has not elapsed; or (ii) a claim with respect to such Covered
Services has been filed with Company but such claim has not been finally
adjudicated by Company. For purposes of clause (ii), above, final adjudication
shall mean completion of Company’s internal appeals process. In the event that a
claim referred to in clause (ii) is finally adjudicated less than thirty
(30) days prior to the Effective Date, such claim shall constitute a Retained
Claim if a Physician seeks relief under § 7.10 not later than ninety (90) days
after notice of such final adjudication, but otherwise such claim shall
constitute a Released Claim. Retained Claims shall be resolved pursuant to the
appropriate remedial provisions of this Agreement.

 

13.7 Covenant Not to Sue in Any Other Forum

 

Upon the Effective Date and through the Termination Date, each Releasing Party
shall be deemed to have covenanted and agreed not to sue with respect to, or
assert, against any Released Person, in any forum (i) any Retained Claim or
(ii) any Compliance Dispute, which respectively shall be asserted and pursued
only pursuant, to the provisions of this Agreement (it being understood that
this § 13.7 shall not apply to any claims that arise within twenty (20) days
before the Termination Date that could not reasonably be presented or resolved
pursuant to the procedures set forth in this Agreement; provided that any such
claim shall be prosecuted on an individual basis only and not otherwise).

 

13.8 Non-Released Persons and Non-Released Claims

 

(a) Except as provided in § 13.4(b), nothing in this Agreement is intended to
relieve any Person that is not a Released Party from responsibility for its own
conduct or conduct of other Persons who are not Released Parties for claims that
are not Released Claims. Nothing in this Agreement is intended to preclude any
Representative Plaintiffs from introducing any competent and admissible evidence
to the extent consistent with §§ 13.8(d), 14.5, and 16.

 

(b) Nothing in this Agreement prevents the Representative Plaintiffs and Class
from pursuing claims to hold any person or party that is not either a Released
Party, BCBSA, or a Blue Cross and/or Blue Shield licensee or wholly-owned
Subsidiary of such licensee liable for damages caused by any Released Party.

 

(c) Section 13.8(b) of this Agreement is intended to be severable. Should it be
found illegal or invalid by any court for any reason, it shall be severable from
the remainder of this Agreement, and the remainder of this Agreement shall be
unchanged and shall be read as if it did not contain the § 13.8(b).

 

(d) If Plaintiffs, the Class or any Class Members pursue claims against any
person or party for damages allegedly caused by any Released Person, any
finding, judgment, opinion or other result from such proceeding under any
circumstances (i) shall not be deemed, construed or asserted as a finding,
judgment, opinion or result against any Released Person; (ii) shall not be
deemed, construed or asserted as res judicata, collateral estoppel or similar
doctrines against any Released Person; and (iii) shall not be admitted or
considered as evidence against or used for any purpose against any Released
Party in any judicial, administrative, regulatory, arbitration proceeding or any
other forum.

 

 

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13.9 Irreparable Harm

 

The Parties agree that Company shall suffer irreparable harm if a Releasing
Party takes action inconsistent with §§ 13.1, 13.2, 13.3, 13.4 and/or 13.7, and
that in that event Company may seek an injunction from the Court as to such
action without further showing of irreparable harm.

 

13.10 Legislative Changes

 

Nothing contained in this Agreement is intended, or shall be construed, to
preclude any Party from seeking legislative or regulatory changes as to matters
addressed herein or from seeking to enforce any such changes using any available
legal remedy.

 

14. Stay of Discovery, Termination, and Effective Date of Agreement

 

14.1 Suspension of Discovery

 

(a) Until the Preliminary Approval Order has been entered, including the stay of
discovery as to the Released Persons in the form contained therein, the
Releasing Parties and Class Counsel covenant and agree that Class Counsel shall
not pursue discovery against the Released Persons and shall not in any way
subsequently argue that the Released Persons have failed to comply with their
discovery obligations in any respect by reason of the Released Persons’
suspension of discovery efforts following the Execution Date and all pre-trial
proceedings in the Actions against the Released Parties shall be stayed.

 

(b) Upon entry of the Preliminary Approval Order, all proceedings against or
concerning Company in the Actions, other than proceedings as may be necessary to
carry out the terms and conditions of the Settlement, shall be stayed and
suspended until further order of the Court. The Preliminary Approval Order shall
also bar and enjoin all members of the Class from commencing or prosecuting any
action asserting any Released Claims, and stay any actions or proceedings
brought by any member of the class asserting any Released Claims. In the event
the Final Order and Judgment is not entered or is reversed for any reason, or
this Agreement terminates for any reason, the Parties shall not be deemed to
have waived any rights with respect to proceedings in the Actions that arise
during the period of the stay and shall have a full and fair opportunity to
present any position in any such proceedings.

 

14.2 Right to Terminate this Agreement

 

If, at the Preliminary Approval Hearing or within 30 days thereafter, the Court
does not enter the Preliminary Approval Order and approve the Mailed Notice, the
Published Notice and the Claim Form submitted to the Court pursuant to § 4 of
this Agreement, in each case in substantially the same form as Exhibits A, D, E,
and F, each of Class Counsel and Company shall have the right, in the sole and
absolute discretion of such Party, to terminate this Agreement by delivering a
notice of termination to the other, it being understood that, notwithstanding
the foregoing, if the Court does not grant the stay as provided in § 14.1 and
the interim injunction with respect to the Tag Along Actions, each in the form
contained in the Preliminary Approval Order, Company may in its sole and
absolute discretion terminate this Agreement by delivering a notice of
termination to Class Counsel. In the event of any termination pursuant to the
terms hereof, the Parties shall be restored to their original positions, except
as expressly provided herein.

 

14.3 Notice of Termination

 

If the Court has not entered the Final Order and Judgment substantially in the
forms attached hereto as Exhibits C1-4 before the commencement of trial in Shane
I or Shane II or the date that is 180 calendar days after the Preliminary
Approval Date, whichever comes first, each of Class Counsel and Company may, in
the sole and absolute discretion of such Party, terminate this Agreement by
delivering a notice of termination to the other.

 

14.4 Effective Date

 

If the Final Order and Judgment is entered by the Court and the time for appeal
from all of such orders and judgment has elapsed (including without limitation
any extension of time for the filing of any appeal

 

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that may result by operation of law or order of the Court) with no notice of
appeal having been filed, the “Effective Date” shall be the next business day
after the last date on which notice of appeal could have been timely filed. If
the Final Order and Judgment is entered and an appeal is filed as to any of
them, the “Effective Date” shall be the next business day after the Final Order
and Judgment, is affirmed, all appeals are dismissed, and no further appeal to,
or discretionary review in, any Court remains.

 

14.5 Suspension of Discovery After Preliminary Approval Date

 

From and after the Preliminary Approval Date, the Releasing Parties and Class
Counsel covenant and agree that the Releasing Persons and Class Counsel shall
not pursue discovery or any other proceedings against the Released Parties.
Nothing contained herein shall preclude the Releasing Parties or Class Counsel
from introducing and relying on otherwise admissible evidence as to non-Released
Parties and non-Released Claims.

 

14.6 Termination Date of Agreement

 

This Agreement shall terminate (the “Termination Date”) upon the earlier to
occur of (i) termination of this Agreement by any Party pursuant to the terms
hereof and (ii) the four-year anniversary of the Preliminary Approval Date.
Effective on the Termination Date, the provisions of this Agreement shall
immediately become void and of no further force and effect and there shall be no
liability under this Agreement on the part of any of the Parties, except for
willful or knowing breaches of this Agreement prior to the time of such
termination; provided that in the event of a termination of this Agreement as
contemplated by clause (ii) of this § 14.6, (a) the provisions of §§ 13.1, 13.2,
13.3, 13.4, 13.5, 13.7 and 13.8 and §§ 15, 16, 17, 18, and 19 shall survive such
termination indefinitely, (b) the provisions of § 7.10 and § 7.11 shall survive
such termination only with respect to, and only for so long as is necessary to
resolve, any Billing Disputes that are in the process of being resolved by the
Billing Dispute External Review Board as of the date of such termination and any
disputes described in § 7.11 that are being resolved pursuant to the External
Review process as of the date of such termination and (c) the provisions of
§§ 12.1 through 12.6 shall survive such termination only with respect to, and
only for so long as is necessary to resolve, any Compliance Disputes that are in
the process of being resolved by the Compliance Dispute Review Officer as of the
date of such termination. On the Termination Date, all of Company’s obligations
under this Agreement shall be satisfied. Except as provided below in this
§ 14.6, no decision or ruling of the Compliance Dispute Review Officer shall
have any force on the Parties after the Termination Date and Company shall be
under no obligation to continue performance of any kind under this Agreement.
Company may, in its sole and absolute discretion, elect to continue after the
Termination Date, the implementation of various business practices described in
this Agreement. Company also may, where it has a good faith basis, and
notwithstanding any Implementation Date date in § 7 of this Agreement or in
Exhibit G hereto, delay the implementation, in whole or in part, of any
provision of this Agreement upon notice to Class Counsel, in which case, and
only to the extent that implementation of a provision of this Agreement has been
delayed, the term of the Agreement shall be extended with respect to the delayed
provision for a period of time equal to the length of the delay. If Class
Counsel believe that Company has willfully delayed implementation, in whole or
in part, of any material provision of this Agreement without providing notice to
Class Counsel pursuant to the preceding sentence, then they may petition the
Compliance Dispute Resolution Officer for a recommendation that, to the extent
implementation of such a provision was delayed, the term of the Agreement be
extended with respect to the delayed provision for a period of time equal to the
length of the willful delay. Upon a finding of willful delay and a
recommendation by the Compliance Dispute Resolution Officer, Class Counsel may
petition the Court for an extension of the Effective Period equal to the length
of the willful delay with respect to the delayed provision, but only to the
extent that implementation of such provision was delayed.

 

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15. Related Provider Track Actions

 

15.1 Ordered Stays and Dismissals in Tag-Along Actions

 

As to any action brought by or on behalf of Class Members that asserts any claim
that as of the Effective Date would constitute a Released Claim against Company,
other than the Actions, that has been, or will in the future, be consolidated as
a tag-along action or otherwise with the Provider Track actions under MDL Docket
No. 1334 (the “Tag-Along Actions”), Representative Plaintiffs, the Signatory
Medical Societies, Class Counsel and Company shall cooperate to obtain an order
of the Court, to be included in the Preliminary Approval Order, providing for
the interim stay of all proceedings as to Company in each such action pending
entry of the Final Order and Judgment. In addition, no later than ten
(10) business days after the Effective Date, Representative Plaintiffs, the
Signatory Medical Societies, Class Counsel and Company shall jointly apply for
orders from the Court dismissing each of the Tag-Along Actions with prejudice as
to Company; provided that no such dismissal order shall be sought with respect
to any Tag-Along Action with respect to any named plaintiff that has timely
submitted an Opt-Out request.

 

15.2 Certain Related State Court Actions

 

As to any action that is now pending, hereafter may be filed in or remanded to
any state court that asserts any Released Claim against Company on behalf of any
Releasing Party, the Representative Plaintiffs, the Signatory Medical Societies
and Class Counsel agree that they will cooperate with Company, and file all
documents necessary, (a) to obtain an interim stay of all proceedings against
Company in any such state court action and (b) on or promptly after the
Effective Date, to obtain the dismissal with prejudice of any such action, other
than with respect to any named plaintiff in such action that has submitted a
valid and timely Opt-Out.

 

15.3 Other Related Actions

 

As to any action not referred to in §§ 15.1 or 15.2 that is now pending or
hereafter may be filed in any court that asserts any of the Released Claims
against Company on behalf of any Class Member who has not timely submitted a
valid and timely Opt-Out request, Representative Plaintiffs, the Signatory
Medical Societies and Class Counsel agree that they will cooperate with Company,
to the extent reasonably practicable, in Company’s effort to seek relief from
the Court or the forum court to obtain the interim stay and dismissal with
prejudice of such action as to Company to the extent necessary to effectuate the
other provisions of this Agreement.

 

16. Not Evidence; No Admission of Liability

 

In no event shall this Agreement, in whole or in part, whether effective,
terminated, or otherwise, or any of its provisions or any negotiations,
statements, or proceedings relating to it in any way be construed as, offered
as, received as, used as or deemed to be evidence of any kind in the Actions, in
any other action, or in any judicial, administrative, regulatory or other
proceeding, except in a proceeding to enforce this Agreement. Without limiting
the foregoing, neither this Agreement nor any related negotiations, statements
or proceedings shall be construed as, offered as, received as, used as or deemed
to be evidence, or an admission or concession of liability or wrongdoing
whatsoever or breach of any duty on the part of Company, the other defendants in
the Actions, the Representative Plaintiffs or the Signatory Medical Societies,
or as a waiver by Company, the other defendants in the Actions, the
Representative Plaintiffs or the Signatory Medical Societies of any applicable
defense, including without limitation any applicable statute of limitations.
None of the Parties waives or intends to waive any applicable attorney-client
privilege or work product protection for any negotiations, statements or
proceedings relating to this Agreement. This provision shall survive the
termination of this Agreement.

 

17. Entire Agreement; Amendment

 

17.1 Entire Agreement

 

This Agreement, including its Exhibits, contains an entire, complete, and
integrated statement of each and every term and provision agreed to by and among
the Parties; it is not subject to any condition not

 

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provided for herein. This Agreement supersedes any prior agreements or
understandings, whether written or oral, between and among Representative
Plaintiffs, Class Members, Class Counsel, Company and the Signatory Medical
Societies regarding the subject matter of the Actions or this Agreement. This
Agreement shall not be modified in any respect except by a writing executed by
Class Counsel and the Company.

 

17.2 Amendment Generally

 

This Agreement may be amended or modified only as provided in by a written
instrument signed by or on behalf of Company and Class Counsel (or their
successors in interest) and approved by the Court, or as set forth in § 17.3.

 

17.3 Amendment for Change in Circumstances

 

In the event Company encounters a change in circumstances that will cause
performance or maintenance of one or more provisions of this Agreement to become
impractical, it will provide notice thereof to Class Counsel with an explanation
of the changed circumstances and the proposed change in the Agreement. For this
purpose, “impractical” shall mean a change in circumstances that would place
Company at a meaningful competitive or operational disadvantage, or would make
performance or maintenance unduly burdensome, or would, on account of new
technology, make continued performance or maintenance inefficient or less
cost-effective relative to use of the new technology. A settlement in the
Actions at any time following Preliminary Approval on terms materially more
favorable for the other settling defendant than for Company, including but not
limited to terms relating to coding and payment, exclusions of government
programs or treatment of Delegated Entities and/or Individually Negotiated
Contracts, may constitute such a change of circumstances and Company may
initiate the process described in this § 17.3 at that time. Within thirty
(30) days of the date of such notice, counsel for Company and Class Counsel will
meet and confer regarding the proposed change and will attempt in good faith to
reach an agreement thereon. In this process, Company and Class Counsel will
consider whether there is a more efficient way in which to fulfill the intent of
the applicable aspect of the Agreement. If agreement is reached, Company and
Class Counsel will jointly apply to the Court for a modification of this
Agreement. If within thirty (30) days after the date of the initial meeting of
Company and Class Counsel, agreement has not been reached, then Company may
apply to the Court for a modification of this Agreement.

 

18. No Presumption Against Drafter

 

None of the Parties shall be considered to be the drafter of this Agreement or
any provision hereof for the purpose of any statute, case law, or rule of
interpretation or construction that would or might cause any provision to be
construed against the drafter hereof. This Agreement was drafted with
substantial input by all Parties and their counsel, and no reliance was placed
on any representations other than those contained herein. The Parties agree that
this fully integrated Agreement shall be construed by its own terms and not by
referring to, or considering, the terms of any other settlement agreement
between plaintiffs and another defendant in the Actions.

 

19. Captions and Headings

 

The use of captions and headings in this Agreement is solely for convenience and
shall have no legal effect in construing the provisions of this Agreement.

 

20. Continuing Jurisdiction and Exclusive Venue

 

20.1 Continuing Jurisdiction

 

Except as otherwise provided in this Agreement, it is expressly agreed and
stipulated that the United States District Court for the Southern District of
Florida shall have exclusive jurisdiction and authority to consider, rule upon,
and issue a final order with respect to suits, whether judicial, administrative
or

 

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otherwise, which may be instituted by any Person, individually or derivatively,
with respect to this Agreement. This reservation of jurisdiction does not limit
any other reservation of jurisdiction in this Agreement nor do any other such
reservations limit the reservation in this subsection.

 

Except as otherwise provided in this Agreement, Company, each Signatory Medical
Society and each Class Member who has not validly and timely requested to
Opt-Out of this Agreement hereby irrevocably submits to the exclusive
jurisdiction and venue of the United States District Court for the Southern
District of Florida for any suit, action, proceeding, case, controversy, or
dispute relating to this Agreement and/or Exhibits hereto and negotiation,
performance or breach of same.

 

20.2 Parties Shall Not Contest Jurisdiction

 

In the event of a case, controversy, or dispute arising out of the negotiation
of, approval of, performance of, or breach of this Agreement, and solely for
purposes for such suit, action or proceeding, to the fullest extent that they
may effectively do so under applicable law, the Parties irrevocably waive and
agree not to assert, by way of motion, as a defense or otherwise, any claim or
objection that they are not subject to the jurisdiction of such Court, or that
such Court is in any way an improper venue or an inconvenient forum.
Furthermore, the Parties shall jointly urge the Court to include the provisions
of this § 20 in its Final Order and Judgment approving this Agreement.

 

21. Cooperation

 

Representative Plaintiffs, Class Counsel and Company agree to move that the
Court enter an order to the effect that should any Person desire any discovery
incident to (or which the Person contends is necessary to) the approval of this
Agreement, the Person must first obtain an order from the Court that permits
such discovery.

 

22. Counterparts

 

This Agreement may be executed in counterparts, each of which shall constitute
an original. Facsimile signatures shall be considered valid signatures as of the
date hereof, although the original signature pages shall thereafter be appended
to this Agreement.

 

23. Additional Signatory Medical Societies

 

The Parties agree that, from and after the date of this Agreement, additional
medical societies may elect to execute a signature page to this Agreement and
thereby agree to be bound by the provisions of this Agreement that are
applicable to Signatory Medical Societies. Upon such execution of a signature
page, each such additional medical society shall be deemed to be a Signatory
Medical Society for all purposes of this Agreement and shall be bound by all of
the provisions of this Agreement that are applicable to Signatory Medical
Societies.

 

24. Successors and Assigns

 

The provisions of this Agreement shall be binding upon and inure to the benefit
of Company and its respective successors and assigns; provided that Company may
not assign, delegate or otherwise transfer any of its rights or obligations
under this Agreement to a third party that is not a successor or affiliate
without the consent of Class Counsel. The provisions of this Agreement shall not
apply with respect to Lumenos, Inc. or any corporation, business, or other
entity acquired by Company after the Preliminary Approval Date, and Company
shall have no obligations under this Agreement with respect to such corporation,
business, or entity or the business operations of such corporation, business, or
entity after the Preliminary Approval Date.

 

25. Governing Law

 

This Agreement and all agreements, exhibits, and documents relating to this
Agreement shall be construed under the laws of the State of Florida, excluding
its choice of law rules.

 

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EXECUTED and DELIVERED on July 11, 2005.

 

61

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COMPANY:

 

WELLPOINT, INC. (FORMERLY KNOWN AS ANTHEM, INC.)       ANTHEM HEALTH PLANS OF
KENTUCKY, INC.

/s/ ANGELA F. BRALY

     

/s/ ANGELA F. BRALY

Name:  Angela F. Braly Esq.

     

Name:  Angela F. Braly, Esq.

Title:    Executive Vice President and General
Counsel

        BLUE CROSS OF CALIFORNIA       ANTHEM HEALTH PLANS OF MAINE, INC.

/s/ ANGELA F. BRALY

     

/s/ ANGELA F. BRALY

Name:  Angela F. Braly, Esq.

     

Name:  Angela F. Braly, Esq.

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC.      

RIGHTCHOICE MANAGED CARE, INC.

(D/B/A BLUE CROSS AND BLUE SHIELD OF MISSOURI)

/s/ ANGELA F. BRALY

     

/s/ ANGELA F. BRALY

Name:  Angela F. Braly, Esq.

     

Name:  Angela F. Braly, Esq.

COMMUNITY INSURANCE COMPANY       ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC.

/s/ ANGELA F. BRALY

     

/s/ ANGELA F. BRALY

Name:  Angela F. Braly, Esq.

     

Name:  Angela F. Braly, Esq.

ANTHEM HEALTH PLANS, INC.       ANTHEM HEALTH PLANS OF VIRGINIA, INC.

/s/ ANGELA F. BRALY

     

/s/ ANGELA F. BRALY

Name:  Angela F. Braly, Esq.

     

Name:  Angela F. Braly, Esq.

ANTHEM INSURANCE COMPANIES, INC.       BLUE CROSS BLUE SHIELD OF WISCONSIN

/s/ ANGELA F. BRALY

     

/s/ ANGELA F. BRALY

Name:  Angela F. Braly, Esq.

     

Name:  Angela F. Braly, Esq.

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC        

/s/ ANGELA F. BRALY

        

Name:  Angela F. Braly, Esq.

       

 

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REPRESENTATIVE PLAINTIFFS:

 

/s/ J. KEVIN LYNCH, M.D.

     

/s/ JOHN WEST, M.D. BY SAM WITHERS WITH EXPRESS AUTHORITY

J. Kevin Lynch, M.D.

     

John West, M.D.

/S/ KAREN LAUGEL, M.D.       /S/ MARK VRANA, M.D.

Karen Laugel, M.D.

     

Mark Vrana, M.D.

/S/ STEVEN LEVINSON, M.D.       /S/ WILLIAM ROBERT SMITH, JR., M.D.

Steven Levinson, M.D.

     

William Robert Smith, Jr.

/S/ KENNETH A. THOMAS, M.D.       /S/ DR. ANDRES MELENDEZ DEDOS

Kenneth A. Thomas, M.D.

     

Dr. Andres Melendez Dedos

/S/ MANUAL PORTH, M.D.       /S/ JULIO TALEISNIK, M.D.

Manual Porth, M.D.

     

Julio Taleisnik, M.D.

/S/ GLENN KELLY, M.D.       /S/ ROGER WILSON, M.D.

Glenn Kelly, M.D.

     

Roger Wilson, M.D.

/S/ LEONARD KLAY, M.D.         

Leonard Klay, M.D.

        /S/ CHARLES B. SHANE, M.D.       /S/ MARTIN MORAN, M.D.

Charles B. Shane, M.D.

     

Martin Moran, M.D.

/S/ JEFFREY BOOK, D.O.       /S/ H. ROBERT HARRISON, PH.D., M.D.

Jeffrey Book, D.O.

     

H. Robert Harrison, Ph.D., M.D.

/S/ ANDRES TALEISNIK, M.D.       /S/ LANCE R. GOODMAN, M.D.

Andres Taleisnik, M.D.

     

Lance R. Goodman, M.D.

/S/ THOMAS BACKER, M.D.       /S/ JONATHAN D. WINNER, M.D.

Thomas Backer, M.D.

     

Jonathan D. Winner, M.D.

 

63

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SIGNATORY MEDICAL SOCIETIES:

 

CONNECTICUT STATE MEDICAL SOCIETY       CALIFORNIA MEDICAL ASSOCIATION /S/
TIMOTHY B. NORBECK       /S/ CATHERINE I. HANSON

Name:  Timothy B. Norbeck

     

Name:  Catherine I. Hanson

Title:    Executive Director

     

Title:    Vice President & General Counsel

         /S/ JACK LEWIN, M.D.        

Name:  Jack Lewin, M.D.

       

Title:    Chief Executive Officer

EL PASO COUNTY MEDICAL SOCIETY       MEDICAL ASSOCIATION OF GEORGIA /S/ CAROL A.
WALKER       /S/ DAVID A. COOK

Name:  Carol A. Walker

     

Name:  David A. Cook

Title:    Executive Vice President

     

Title:    Executive Director

TEXAS MEDICAL ASSOCIATION       FLORIDA MEDICAL ASSOCIATION /S/ DONALD P. WILCOX
      /S/ JOHN M. KNIGHT

Name:  Donald P. Wilcox

     

Name:  John M. Knight

Title:    General Counsel

     

Title:    General Counsel

RHODE ISLAND MEDICAL SOCIETY       LOUISIANA STATE MEDICAL SOCIETY /S/ FREDRIC
V. CHRISTIAN, M.D.       /S/ JOSEPH D. BUSBY, JR., MD

Name:  Fredric V. Christian, M.D.

     

Name:  Joseph D. Busby, Jr., MD

Title:    President

     

Title:    President

NORTHERN VIRGINIA MEDICAL SOCIETIES       COLEGIO DE MEDICOS Y CIRUJANOES DE
PUERTO RICO /S/ RUSSELL C. LIBBY, M.D.       /S/ MARISSEL VELAZQUEZ

Name:  Russell C. Libby, M.D.

     

Name:  Marissel Velazquez

Title:    Former Chair Council of Northern Virginia Medical Societies Former
President, Fairfax County Medical Society

     

Title:    President

SOUTH CAROLINA MEDICAL ASSOCIATION       NORTH CAROLINA MEDICAL SOCIETY /S/ JOHN
K. DELOACHE       /S/ ROBERT WILLIAM SELIGSON

Name:  John K. DeLoache

     

Name:  Robert William Seligson

Title:    General Counsel

     

Title:    Executive Vice President/CEO

 

64

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SIGNATORY MEDICAL SOCIETIES (CONTINUED):

 

HAWAII MEDICAL ASSOCIATION       NEBRASKA MEDICAL ASSOCIATION /S/ INAM RAHMAN,
M.D.       /S/ KRYNN KELLER BUCKLEY, M.D.

Name:  Inam Rahman, M.D.

     

Name:  Krynn Keller Buckley, M.D.

Title:    President

     

Title:    President

MEDICAL SOCIETY OF NEW JERSEY       WASHINGTON STATE MEDICAL ASSOCIATION /S/
LAWRENCE DOWNS       /S/ THOMAS J. CURRY

Name:  Lawrence Downs

     

Name:  Thomas J. Curry

Title:    Director of Public Health & Staff Counsel

     

Title:    Executive Director/CEO

TENNESSEE MEDICAL ASSOCIATION       NEW HAMPSHIRE MEDICAL SOCIETY /S/ DONALD H.
ALEXANDER       /S/ PALMER P. JONES

Name:  Donald H. Alexander

     

Name:  Palmer P. Jones

Title:    Chief Executive Officer

     

Title:    Executive Vice President

 

65

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CLASS COUNSEL:

 

LAW OFFICES OF ARCHIE C. LAMB, LLC       STEWART TILGHMAN FOX & BIANCHI /S/
ARCHIE C. LAMB       /S/ JAMES B. TILGHMAN, JR.

Name:  Archie C. Lamb

     

Name:  James B. Tilghman, Jr.

       

Title:    Vice President

KOZYAK TROPIN & THROCKMORTON, P.A.       WHATLEY DRAKE, LLC /S/ JANET L.
HUMPHREYS FOR       /S/ JOE R. WHATLEY, JR.

Name:  Harley S. Tropin, Esq.

     

Name:  Joe R. Whatley, Jr.

Title:    Partner

     

Title:    Member

DOFFERMYRE, SHIELDS, CANFIELD, KNOWLES & DEVINE       MILBERG WEISS BERSHAD &
SCHULMAN /S/ RALPH J. KNOWLES, JR.       /S/ EDITH M. KALLAS

Name:  Ralph J. Knowles, Jr.

     

Name:  Edith M. Kallas

       

Title:    Partner

EYSTER KEY TUBB WEAVER & ROTH       WIGGINS CHILDS QUINN & PANTAZIS /S/ NICHOLAS
ROTH       /S/ DENNIS G. PANTAZIS

Name:  Nicholas Roth

     

Name:  Dennis G. Pantazis

Title:    Partner

     

Title:    Member

FOOTE & MEYERS       WHITE ANDREWS ARNOLD & DOWD /S/ ROBERT M. FOOTE       /S/
J. MARK WHITE

Name:  Robert M. Foote

     

Name:  J. Mark White

Title:    Partner

        GRAY WHITE & WEISS       DRUBNER HARTLEY & O’CONNOR /S/ GRAY WHITE &
WEISS       /S/ JAMES E. HARTLEY

Name:  Janice M. Weiss, Esq.

     

Name:  James E. Hartley

Title:    Attorney at Law

     

Title:    Partner

SAVERI & SAVERI       LOWE, MOBLEY & LOWE /S/ R. ALEXANDER SAVERI       /S/
JEFFREY A. MOBLEY

Name:  R. Alexander Saveri

     

Name:  Jeffrey A. Mobley

Title:    Partner

        PODHURST ORSECK, P.A.         /S/ JANET L. HUMPHREYS FOR         

Name:  Aaron Podhurst

       

 

66