Exhibit
10.108


 


AIM


 


MEDICAL
SERVICES AGREEMENT


 












*** Confidential
Information omitted and filed separately with the Securities and Exchange
Commission.


 

















 


AIM

MEDICAL SERVICES AGREEMENT


 


TABLE OF CONTENTS


 


	
  I.

  	
  RECITALS

  	
   

  
	
   

  	
   

  	
   

  
	
  II.

  	
  DEFINITIONS

  	
   

  
	
   

  	
   

  	
   

  
	
  III.

  	
  RELATIONSHIP
  BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  IV.

  	
  PARTICIPATING
  MEDICAL GROUP SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  V.

  	
  BLUE CROSS
  SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  VI.

  	
  ELIGIBILITY
  LISTINGS

  	
   

  
	
   

  	
   

  	
   

  
	
  VII.

  	
  COMPENSATION
  TO PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  VIII.

  	
  ENROLLMENT PROTECTION

  	
   

  
	
   

  	
   

  	
   

  
	
  IX.

  	
  BLUE
  CROSS SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  X.

  	
  TERM OF AGREEMENT,
  TERMINATION

  	
   

  
	
   

  	
   

  	
   

  
	
  XI.

  	
  ARBITRATION
  OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  XII.

  	
  AIM MEMBER GRIEVANCE
  SYSTEM

  	
   

  
	
   

  	
   

  	
   

  
	
  XIII.

  	
  MISCELLANEOUS PROVISIONS

  	
   

  
	
   

  	
   

  
	
  EXHIBITS

  	
   

  
	
   

  	
   

  
	
  Exhibit A

  	
  Covered Medical Services

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit
  A(1)

  	
  Division
  of Financial Responsibilities

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit B

  	
  AIM
  Hospitals

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit
  C

  	
  Administrative
  Responsibilities of PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit D

  	
  Capitation

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit
  E

  	
  PARTICIPATING
  MEDICAL GROUP Facilities

  	
   

  
				



 

















 


AIM

MEDICAL SERVICES AGREEMENT


 


This AGREEMENT is effective on May 1, 2001, between BLUE CROSS OF CALIFORNIA and Affiliates
(jointly and severally “BLUE CROSS”)
and Professional Care IPA Medical Group,
(“PARTICIPATING MEDICAL GROUP”).


 


I.                                         RECITALS


 


1.01                 BLUE CROSS is a California Corporation
licensed by the California Commissioner of Corporations to operate a health
care service plan pursuant to the Knox-Keene Health Care Service Plan Act of
1975 and the Rules of the California Commissioner of Corporations promulgated
thereunder (California Health & Safety Code, Sections 1340 to 1399.64 and
California Code of Regulations, Sections 1300.43 to 1300.99, collectively, the
“Knox-Keene Act”), including without limitation to issue Benefit Agreements
covering the provision of health care services and to enter into agreements
with PARTICIPATING MEDICAL GROUP.


 


1.02                 PARTICIPATING MEDICAL GROUP is a medical
corporation a legal entity organized under the laws of the State of
California and comprised of physicians who desire to provide and arrange for
health services to persons who are enrolled in BLUE CROSS’ AIM Program.


 


II.                                     DEFINITIONS


 


2.01                 “Affiliate” means a corporation or other organization owned or controlled, either
directly or through parent or subsidiary corporations, by BLUE CROSS, or under
common control with BLUE CROSS.


 


2.02                 “AIM Case Manager” means a BLUE CROSS employee charged with
assisting PARTICIPATING MEDICAL GROUPs in case management.


 


2.03                 “AIM Coordinator” means an employee of PARTICIPATING MEDICAL
GROUP as set forth in Section 4.08B.


 


2.04                 “AIM Hospital” means a hospital which has entered into an
agreement with BLUE CROSS to provide Hospital Services to Members.


 


2.05                 “AIM Program” means the program for increased access to
maternity, delivery, and infant care services for low income women, offered by
BLUE CROSS as a California Care program under contract with the State of
California pursuant to California Insurance Code Section 12695 et seq. Although the AIM Program is a
California Care program, it is in some ways unique and will, therefore, be
separately identified in this Agreement.


 


2.06                 “AIM Quality Management Representative” means an employee of BLUE CROSS responsible
for the AIM Quality Management Program.


 


1

















 


2.07                 “Alternative Birthing Center Services” means services rendered by an Alternative
Birthing Center.  Alternative Birthing
Center Services include related services such as equipment, surgical and
anesthetic supplies, oxygen and drugs, blood and blood processing, laboratory
procedures and diagnostic imaging.


 


2.08                 “Ambulance Services”  means
transportation services provided by a licensed ambulance company.


 


2.09                 “Benefit Agreement(s)” means the written agreement(s) entered into
between BLUE CROSS and the State of California, under which BLUE CROSS
provides, indemnifies, or administers health benefits to persons enrolled in
the AIM Program.


 


2.10                 “BLUE CROSS Managed Care Network” means the network of health care providers
that have entered into contracts with BLUE CROSS and/or one or more of its
Affiliates pursuant to which those providers have agreed to participate in the
AIM Program.


 


2.11                 “BLUE CROSS Services” means the designated services set forth in
Article IX and Exhibit A (1).


 


2.12                 “California Care” means direct care prepayment plan(s) offered
by BLUE CROSS.


 


2.13                 “Capitation” means a uniform prepayment fee per Member per month, adjusted by age.


 


2.13                 “Capitation Services” means all AIM Covered Medical Services which
are not otherwise designated as Insured Services or the responsibility of BLUE
CROSS, in the Division of Financial Responsibilities under Exhibit A(1).


 


2.15                 “Case Management Program” means a program that assesses the Member’s
medical needs and includes working with PARTICIPATING MEDICAL GROUP and other
Participating Providers to explore and coordinate treatment alternatives that
may (1) be more cost effective; (2) result in better medical outcomes; (3)
achieve benefit savings; and (4) increase Member satisfaction.


 


2.16                 “Covered Medical Services” means the services and benefits covered under
the Benefit Agreements.  A matrix of
those services and benefits is set forth in Exhibit A (incorporated by
reference herein).  A matrix of
financial responsibility for those services and benefits is set forth in
Exhibit A(1).


 


2.17                 “Customary and Reasonable Charges” (C
& R) means:


 


A.           “Customary”
means the fee that falls within the range of prevailing fees charged by
physicians and surgeons or other licensed providers of the same service within
the same area for the performance of a specific service or procedure, and


 


B.             “Reasonable”
means the fee that meets the requirements of Customary and is justified,
considering complications or special circumstances with respect to the
performed services or procedure.


 


C & R charges are
determined by BLUE CROSS.


 


2.18                 “Emergency” means a sudden onset of a medical condition manifesting itself by acute
symptoms of sufficient severity (including, without limitation, sudden and
unexpected severe pain) such that the patient may reasonably believe that the
absence of immediate medical attention could reasonably result in any of the
following:


 


A.           Placing
the patient’s health in serious jeopardy,


 


2

















 


B.             Serious
impairment to bodily functions,


 


C.             Other
serious medical consequences, or


 


D.            Serious
and/or permanent dysfunction of any bodily organ or part.


 


2.19                 “Enrollment Protection” is a program to limit PARTICIPATING MEDICAL
GROUP’s risk with respect to any individual Member who requires Capitation
Services in excess of the limit of liability per individual Member per calendar
year, as set forth in Article VIII, ENROLLMENT PROTECTION, below.


 


2.20                 “Health Professional” means any of the following: A doctor of
medicine or osteopathy, licensed to practice medicine or osteopathy where the
care is received, or a dentist, an optometrist, a podiatrist or chiropodist, a
clinical psychologist, a chiropractor, a clinical social worker, a marriage
family and child counselor, a physical therapist, a speech pathologist, an
audiologist, an occupational therapist, a physician assistant, a registered
nurse, a nurse practitioner and/or nurse midwife providing services within the
scope of practice as defined by the appropriate clinical license and/or
regulatory board.


 


2.21                 “Hemodialysis Services” means services rendered by a Medicare
certified hemodialysis provider. 
Hemodialysis Services include facility charges, use of facility
equipment and supplies, laboratory tests and drugs administered in conjunction
with on-site treatment.


 


2.22                 “Hospital Services” means Medically Necessary acute and sub-acute
care inpatient and hospital outpatient services and supplies which are both (a)
covered by a Benefit Agreement, and (b) ordered or authorized by a
PARTICIPATING MEDICAL GROUP Physician. 
Hospital Services do not include long-term non-acute care.


 


2.23                 “Independent Practice Association” means an incorporated association of
independent physicians which has entered into an agreement with BLUE CROSS to
provide and arrange for health services to Members.


 


2.24                 “Inpatient Hospital Services” means services which include inpatient
hospital days for semi-private accommodations, or special treatment units, or
private room accommodations if specifically authorized as Medically Necessary
by PARTICIPATING MEDICAL GROUP Physician.


 


2.25                 “Insured Services”  
means the benefits and services as set forth in Article VII,
COMPENSATION TO PARTICIPATING MEDICAL GROUP, including:


 


A.           The
benefits and services referenced in Section 7.08 (expenses which are paid
directly by PARTICIPATING MEDICAL GROUP, to be reimbursed by BLUE CROSS).


 


B.             The
benefits and services referenced in Section 7.09 (expenses which are paid
directly by BLUE CROSS).


 


2.26                 “Medically Necessary” means procedures, supplies, equipment or
services that BLUE CROSS determines to be:


 


A.           Appropriate
for the symptoms, diagnosis or treatment of the medical condition; and


 


B.             Provided
for the diagnosis or direct care and treatment of the medical condition; and


 


3

















 


C.             Within
standards of good medical practice within the organized medical community; and


 


D.            Not
primarily for the convenience of the Member’s physician, or another provider;
and


 


E.              The
most appropriate procedures, supplies, equipment or service which can safely be
provided.  The most appropriate
procedures, supplies, equipment or service or supply must satisfy the following
criteria: (i) there must be valid scientific evidence demonstrating that the
expected health benefits from the procedure, supply, equipment or service are
clinically significant and produce a greater likelihood of benefit, without a
disproportionately greater risk of harm or complications, for the Member with
the particular medical condition being treated than other alternatives; and
(ii) generally accepted forms of treatment that are less invasive have been
tried and found to be ineffective or are otherwise unsuitable; and (iii) for
hospital stays acute care as an inpatient is necessary due to the kind of
services the Member is receiving or the severity of the medical condition, and
safe and adequate care cannot be received as an outpatient or in a less
intensified medical setting.


 


2.27                 “Member”
means a Subscriber or enrolled dependent covered by a Benefit Agreement.


 


2.28                 “Member
Months” means a count that records one Member month for each month the
Member is enrolled in the AIM Program.


 


2.29                 ‘Operations Manual” means the AIM PMG Operations Manual.


 


2.30                 “Out-of-Area Emergency Services” means Emergency services which are rendered
to a Member at a distance of more than twenty (20) mile radius from the medical
offices of PARTICIPATING MEDICAL GROUP or the Satellite Facility to which the
Member is assigned.  When PARTICIPATING
MEDICAL GROUP is organized as an Independent Practice Association, Out-of-Area
Emergency Services are those Emergency services which are rendered to a Member
at a distance of more than twenty (20) mile radius from each hospital
designated in Exhibit B as a Service Area hospital.  Out-of-Area Emergency Services shall also include Out of Area
urgently needed services to prevent serious deterioration of a Member’s health
resulting from unforeseen illness or injury for which treatment cannot be
delayed until the Member returns to the Service Area.


 


2.31                 “Outpatient Hospital Services” means services which include the facility
component of outpatient surgery, pre-admission testing, laboratory and
radiology services.


 


2.32                 “PARTICIPATING MEDICAL GROUP Physician” means a duly licensed physician who is a
shareholder, partner, associate, contractor or employee of PARTICIPATING
MEDICAL GROUP.


 


2.33                 “Primary Care Physician” means the PARTICIPATING MEDICAL GROUP
Physician responsible for coordinating and controlling the delivery of Covered
Medical Services to the Member.  Primary
Care Physicians include general and family practitioners, internists and
pediatricians, and such other specialists as BLUE CROSS may approve in writing
to be designated Primary Care Physicians.


 


2.34                 “Quality Management Committee” means a committee of physicians and other
licensed health care providers, at least fifty percent (50%) of whom
participate in CaliforniaCare, which meets regularly to review the Quality
Management Program.


 


2.35                 “Quality Management Program” means a program which provides review by
physicians and other health professionals of the appropriateness and adequacy
of the delivery of health services.


 


4

















 


2.36                 “Related Hospital Services” means services rendered to Members as part
of, and concurrent with Inpatient Hospital Services, Outpatient Hospital
Services, Hemodialysis Services, and Alternative Birthing Center Services,
including the use of facility equipment, surgical and anesthetic supplies,
oxygen and drugs except for take-home drugs, blood and blood processing,
laboratory procedures and diagnostic imaging.


 


2.37                 “Referral Services” means Capitation Services which are rendered
to Members through a process established by PARTICIPATING MEDICAL GROUP.


 


2.38                 “Satellite Facility” means a medical facility separate from
PARTICIPATING MEDICAL GROUP’s principal place of business, which is dependent
upon, and responsible to, PARTICIPATING MEDICAL GROUP.  It is a facility that meets the BLUE CROSS
Satellite Criteria set forth in the Operations Manual and is approved by BLUE
CROSS prior to being designated an AIM Satellite Facility.


 


2.39                 “Service Area” means the geographical area within a thirty
(30) mile radius of the medical offices of PARTICIPATING MEDICAL GROUP or any
Satellite Facility to which the Member is assigned, or, in the case of an
Independent Practice Association, the medical office of the PARTICIPATING
MEDICAL GROUP Physician.  The designation
of a particular geographical area shall not be construed as giving
PARTICIPATING MEDICAL GROUP an exclusive right to that Service Area.


 


2.40                 “Subscriber” means an individual who has qualified for and is covered under a
Benefit Agreement.


 


2.41                 “Urgent Care Center” is a facility that meets BLUE CROSS’ Urgent
Care Center criteria as set forth in the Operations Manual, and is approved by
BLUE CROSS prior to being designated as a Urgent Care Center.


 


2.42                 “Utilization Management Program” means a program approved by BLUE CROSS and
designed to review and manage the utilization of Covered Medical Services.


 


III.                                 RELATIONSHIP BETWEEN BLUE CROSS AND
PARTICIPATING MEDICAL GROUP


 


3.01                 BLUE CROSS and PARTICIPATING MEDICAL GROUP are
independent entities.  Nothing in this
Agreement shall be construed, or be deemed to create, a relationship of
employer and employee or principal and agent, or any relationship other than
that of independent parties contracting with each other solely for the purpose
of carrying out the provisions of this Agreement.


 


3.02                 BLUE CROSS and PARTICIPATING MEDICAL GROUP
agree that PARTICIPATING MEDICAL GROUP Physicians shall maintain a
physician-patient relationship with each Member assigned to PARTICIPATING
MEDICAL GROUP.  PARTICIPATING MEDICAL GROUP
shall be solely responsible to the Member for treatment and medical care with
respect to the provision of Capitation Services and arrangements for Insured
Services and BLUE CROSS Services. 
PARTICIPATING MEDICAL GROUP may freely communicate with Members
regarding the treatment options available to them, including mediation
treatment options, regardless of benefit coverage limitations.


 


3.03                 Except as specifically provided herein,
nothing in this Agreement is intended to be construed, or be deemed to create,
any rights or remedies in any third party, including, but not limited to, a
Member or a provider of services, other than PARTICIPATING MEDICAL GROUP.


 


5

















 


3.04                 PARTICIPATING MEDICAL GROUP hereby expressly
acknowledges its understanding that this Agreement constitutes a contract
between PARTICIPATING MEDICAL GROUP and BLUE CROSS as an independent
corporation, operating under a license with the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans (the
“Association”), permitting BLUE CROSS to use the Blue Cross service mark in the
State of California and that BLUE CROSS is not contracting as the agent of the
Association.  PARTICIPATING MEDICAL
GROUP further acknowledges and agrees that it has not entered into this
Agreement based upon representations by any person other than BLUE CROSS and
that no person, entity, or organization other than BLUE CROSS, or the
applicable Affiliate, shall be held accountable or liable to PARTICIPATING
MEDICAL GROUP for any of BLUE CROSS’, or the applicable Affiliate’s,
obligations to PARTICIPATING MEDICAL GROUP created under this Agreement.  This section shall not create any
additional obligations whatsoever on the part of BLUE CROSS, other than those
obligations created under other provisions of this Agreement.


 


IV.                                 PARTICIPATING MEDICAL GROUP SERVICES AND
RESPONSIBILITIES


 


PARTICIPATING MEDICAL GROUP
and PARTICIPATING MEDICAL GROUP Physicians agree as follows:


 


4.01                 Provision of Services.


 


A.           To
promptly provide, arrange through referral, or authorize all Capitation
Services and Insured Services, and to authorize or arrange for the provision of
BLUE CROSS Services, and further, to accept full financial responsibility for
all Capitation Services provided, authorized or arranged through referral, by
PARTICIPATING MEDICAL GROUP in accordance with the provisions of this
Agreement.


 


B.             To
provide a Primary Care Physician selected by the Member to oversee the
continuity of care for each Member who appears on PARTICIPATING MEDICAL GROUP’s
Eligibility Report.


 


C.             To
maintain a sufficient number of Primary Care Physicians to guarantee that there
is the equivalent of at least one full-time Primary Care Physician to each two
thousand (2,000) Members served by PARTICIPATING MEDICAL GROUP. All Primary
Care Physicians shall be PARTICIPATING MEDICAL GROUP Physicians.


 


D.            To
assure that privileges of PARTICIPATING MEDICAL GROUP Physicians at AIM
Hospitals shall be adequate to meet the requirements for the Hospital Services
to which Members are entitled under the terms of the Benefit Agreement(s).


 


E.              To
engage the Referral Services of duly licensed board certified consultants,
specialists and duly certified and licensed allied health professionals,
responsible for delivering Covered Medical Services to Members.  A list of all referral physicians and other
providers to whom PARTICIPATING MEDICAL GROUP refers Members for Referral
Services shall be provided to BLUE CROSS upon request, PARTICIPATING MEDICAL
GROUP shall provide BLUE CROSS with revised copies of its form of agreements
between PARTICIPATING MEDICAL GROUP and its contracted Referral Service
providers and PARTICIPATING MEDICAL GROUP Physicians, as such are updated.


 


F.              To
ensure that all PARTICIPATING MEDICAL GROUP Physicians and all PARTICIPATING
MEDICAL GROUP employees responsible for delivering Covered Medical Services to
Members, continually meet all applicable federal and state laws and regulations
and all legal standards of care.


 


6

















 


G.             That
if BLUE CROSS determines in good faith that any PARTICIPATING MEDICAL GROUP
Physician(s):


 


(1)          does not meet the requirements specified herein; or


 


(2)          that the health, safety or welfare of Members is jeopardized by
continuation of any PARTICIPATING MEDICAL GROUP Physician to provide services
to Members; or


 


(3)          if PARTICIPATING MEDICAL GROUP Physician(s) furnishes false, incomplete,
or inaccurate information to BLUE CROSS in the application to participate; or


 


(4)          at any time during the term of this Agreement, a PARTICIPATING MEDICAL
GROUP Physician(s) suffers revocation, termination or suspension of Physician’s
medical license or medical staff privileges; or


 


(5)          the ability of the PARTICIPATING MEDICAL GROUP Physician(s) to perform
the services covered by this Agreement is otherwise impaired;


 


PARTICIPATING MEDICAL GROUP warrants that upon written request of BLUE
CROSS said PARTICIPATING MEDICAL GROUP Physician(s) shall be excluded from
providing services to Members under this Agreement. PARTICIPATING MEDICAL GROUP
and PARTICIPATING MEDICAL GROUP Physician(s) may present to BLUE CROSS for
further consideration any additional information or explanation regarding
PARTICIPATING MEDICAL GROUP Physician’s compliance with the requirements set
forth herein.  However, BLUE CROSS
retains the right to make the final decision regarding a PARTICIPATING MEDICAL
GROUP Physician’s participation under this Agreement.


 


4.02                           Accessibility and Continuity of Care.


 


A.           To
promptly provide or arrange for available and accessible Covered Medical
Services for each Member assigned to PARTICIPATING MEDICAL GROUP, in accordance
with that Member’s Benefit Agreement and this Agreement, and to provide those
services in and through facilities designated in Exhibit F (incorporated by
reference herein).


 


B.             That
all Covered Medical Services, (including consultation and Referral Services),
ambulatory care services, diagnostic laboratory, diagnostic imaging and
therapeutic radiology services, home health services and preventive health
services, shall be available to Members a minimum of forty (40) hours per week,
except for weeks including holidays. 
The foregoing services shall be available beyond normal business hours
during additional hours to be scheduled by PARTICIPATING MEDICAL GROUP.


 


C.             To
promptly provide, arrange or authorize all Emergency services for each Member
assigned to PARTICIPATING MEDICAL GROUP. 
Authorization of any Emergency services, as set forth in
Section 2.18 herein, shall not be withheld by PARTICIPATING MEDICAL GROUP
regardless of whether PARTICIPATING MEDICAL GROUP is notified within
forty-eight (48) hours from the time such Emergency services were
rendered.  PARTICIPATING MEDICAL GROUP
shall comply with all requirements set forth in California Health and Safety
Code Section 1371.4(a) - (d).


 


D.            That
PARTICIPATING MEDICAL GROUP shall manage and facilitate access to Emergency
services within a twenty (20) mile radius of each Satellite Facility and
PARTICIPATING MEDICAL GROUP’s main facility at all times, twenty-four (24)
hours a day, seven (7) days a week.  In
the event that PARTICIPATING MEDICAL GROUP is an Independent Practice
Association, PARTICIPATING MEDICAL GROUP shall manage and facilitate access to
Emergency services within a twenty (20) mile radius of the Hospital(s)
designated in Exhibit B (incorporated by reference herein) as the AIM
Hospital(s) within PARTICIPATING MEDICAL GROUP’s Service Area.


 


7

















 


E.              To
admit, or authorize admission of, Members solely to the AIM Hospitals listed in
Exhibit B, except (a) when Medically Necessary in an Emergency situation or (b)
when Covered Medical Services are not available in a AIM Hospital or (c) as
otherwise required under Section 4.02F or (d) when requested to do so in
writing by the Member, with the written understanding that admission to a
hospital, other than those listed in Exhibit B, is not a Covered Medical
Service, except as stated above in this Section 4.02E.


 


F.              Notwithstanding
Section 4.02E, for those Members that require transplant services (solid
organ and bone marrow/stem cell) that are Covered Medical Services,
PARTICIPATING MEDICAL GROUP agrees to admit, or authorize the inpatient
admission or outpatient treatment of Members, solely at those AIM Hospitals
whose transplant programs have been approved by BLUE CROSS and identified as
such in the Operations Manual.


 


PARTICIPATING MEDICAL GROUP will provide notification to BLUE CROSS of
all potential transplant cases, including deferred or denied cases, when such
cases are considered by PARTICIPATING MEDICAL GROUP’s Utilization Management
Program Committee or other similar PARTICIPATING MEDICAL GROUP functional
committee, except for Emergencies, in which case PARTICIPATING MEDICAL GROUP
shall provide notification within two (2) business days of the admission.  The format of such notification is provided
in the Operations Manual.


 


G.             That
in circumstances where a Member requires specialized tertiary care or because
of bed unavailability in an AIM Hospital, the Member must be admitted to a
non-AIM in-area or out-of-area facility for Hospital Services, then until the
Member is transferred to an AIM Hospital, the PARTICIPATING MEDICAL GROUP will
be financially responsible for care the same as if care had been provided in an
AIM Hospital.


 


H.            To
use a referral request process by which Capitation Services are to be rendered
by Health Professionals other than the Member’s Primary Care Physician,
including PARTICIPATING MEDICAL GROUP Physicians or other Health Professionals
who do not belong to PARTICIPATING MEDICAL GROUP.  This process shall assure that:


 


(1)          All Health Professionals who provide Referral Services follow
appropriate billing procedures.


 


(2)          That the Health Professional must look only to PARTICIPATING MEDICAL
GROUP for payment of Covered Medical Services and shall not bill the Member,
except for applicable co-payments and for non-Covered Medical Services.


 


(3)          For referrals to specialists or providers, or for other services,
PARTICIPATING MEDICAL GROUP shall review and issue an authorization or denial
of a request for referral within five (5) business days of receipt of such
request or admission to hospital.


 


(4)          Members may directly access PARTICIPATING MEDICAL GROUP Physicians in
the following specialties without the prior authorization of PARTICIPATING
MEDICAL GROUP’s Utilization Management Program:


 


(a)          Dermatology


(b)         Allergy


(c)          Obstetrics/Gynecology


(d)         Ear, Nose and Throat


 


I.                 That
visits to the Member’s home within the PARTICIPATING MEDICAL GROUP Service
Area, by a Primary Care Physician, shall occur as necessary within that
Physician’s discretion.


 


8

















 


J.                To
assure that Members shall not be subject to discrimination in access to Covered
Medical Services.  PARTICIPATING MEDICAL
GROUP shall comply with State of California non-discrimination requirements.


 


K.            That
PARTICIPATING MEDICAL GROUP facilities shall be reasonably accessible to the
physically handicapped.


 


L.              To
provide health education and wellness programs for Members within the
guidelines indicated in the “CaliforniaCare Health Education and Wellness
Manual.” Programs are to be delivered in accordance with these guidelines which
provide for disease prevention and management and the promotion of healthier
life-styles.


 


M.         To
provide a patient education program on smoking for Members within the
guidelines indicated in the Operations Manual.


 


4.03                 Utilization/Quality Management and Grievance
Procedures.


 


To cooperate with BLUE CROSS’ administration of its internal quality of
care review and grievance procedures. 
The parties acknowledge and agree that authority to perform Utilization
Management Program activities and Quality Management Program activities under
this Agreement is a delegation of BLUE CROSS authority pursuant to Sections
1370 and 1370.1 of the Health and Safety Code, and all or part of this
authority may be revoked at any time. 
The scope of delegated authority shall be as set forth in the Utilization
Management Program guidelines and the Quality Management Program guidelines
issued by BLUE CROSS and provided to PARTICIPATING MEDICAL GROUP.  The proceedings of the Utilization
Management and Quality Management Committees shall be strictly confidential between
BLUE CROSS and PARTICIPATING MEDICAL GROUP and are subject to the protections
set forth in Sections 1370 and 1370.1.


 


4.04                 Quality Management Program.


 


To adopt and maintain a Quality Management Program consistent with BLUE
CROSS standards and approved by BLUE CROSS. 
This program will cover all Covered Medical Services provided or
arranged by PARTICIPATING MEDICAL GROUP for Members.  PARTICIPATING MEDICAL GROUP agrees to allow on-site review(s) of
its Quality Management Program by BLUE CROSS staff.


 


A.           The
Quality Management Program shall:


 


(1)          Provide for Quality Management review by PARTICIPATING MEDICAL GROUP
Physicians and other Health Professionals.


 


(2)          Provide for review of all services provided to Members by PARTICIPATING
MEDICAL GROUP.


 


(3)          Stress health outcomes by providing health education and wellness
programs for Members.


 


B.             The
Quality Management Program shall include, but not be limited to the following
activities:


 


(1)          Credentialing, recredentialing and peer review of all PARTICIPATING
MEDICAL GROUP Physicians and allied Health Professional providers.


 


(2)          Credentialing, recredentialing and peer review of all Health
Professionals or providers under contract with or employed by PARTICIPATING
MEDICAL GROUP.


 


(3)          Incident identification and risk management.


 


(4)          Member grievance resolution.


 


9

















 


(5)          General and focused health care audits.


 


(6)          Development and implementation of appropriate recommendations.


 


(7)          Documentation of remedial procedures for instances of inappropriate or substandard
service(s) and/or failure to provide needed Medically Necessary Covered Medical
Service(s).


 


C.             BLUE
CROSS shall validate PARTICIPATING MEDICAL GROUP’s development and
implementation of the Quality Management Program through regular audit activities
in accordance with the Operations Manual and as follows:


 


(1)          The BLUE CROSS Quality Management Department shall review PARTICIPATING
MEDICAL GROUP’s Quality Management Program on an annual basis through a
scheduled on-site audit.


 


(2)          The AIM Quality Management Representative shall notify PARTICIPATING
MEDICAL GROUP of any deficiencies or areas needing improvement.


 


(3)          PARTICIPATING MEDICAL GROUP shall take corrective action to eliminate
any deficiencies in areas needing improvement within a reasonable period of
time.


 


(4)          BLUE CROSS shall conduct follow-up reviews as necessary.


 


D.            PARTICIPATING
MEDICAL GROUP shall:


 


(1)          Make available to BLUE CROSS all minutes and notes from any and all
Quality Management Committees and/or activities which specifically relate to
Members.


 


(2)          Provide BLUE CROSS with access to all PARTICIPATING MEDICAL GROUP
Quality Management data directly or indirectly relating to Members.


 


(3)          Make available to BLUE CROSS all composite Quality Management Program
data which include Members in the composite data set and provide such detail as
is available regarding those Members.


 


(4)          Make known to BLUE CROSS any and all adverse actions taken against a
PARTICIPATING MEDICAL GROUP Physician when such action is the result of
deficiencies in quality of medical care.


 


(5)          Provide the BLUE CROSS Medical Director (or the Medical Director’s
clinical designee) with a schedule designating the time and place of all
Quality Management Committee meetings that relate to Members, in order that he
or she shall, in the Medical Director’s discretion, attend.  The BLUE CROSS Medical Director shall notify
the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall
not be excluded from any deliberation on activities related to Members.


 


(6)          Permit BLUE CROSS to evaluate and utilize the data obtained from the
Quality Management Program in a manner that satisfies BLUE CROSS’ requirements
for quality assurance, for BLUE CROSS internal use only.


 


(7)          Implement any necessary changes in procedures, in order to fully comply
with all quality assurance standards, as mutually agreed by the parties, and
provide BLUE CROSS with the minutes of Quality Management Committee meetings
and reviews that relate to Members.


 


(8)          Report to BLUE CROSS quarterly on activities or actions of PARTICIPATING
MEDICAL GROUP’s Quality Management Committee as such activities or actions
relate to Members.


 


4.05                 Utilization Management Program.


 


To adopt and maintain a Utilization Management Program consistent with
BLUE CROSS standards and approved by BLUE CROSS.  This program will cover all Covered Medical Services provided or
arranged by PARTICIPATING MEDICAL GROUP for Members.  PARTICIPATING


 


10

















 


MEDICAL GROUP agrees to allow on-site review(s) of Utilization
Management Program by BLUE CROSS.


 


11

















 


A.           The
Utilization Management Program shall:


 


(1)          Include the development and implementation of appropriate
recommendations.


 


(2)          Include documentation as described in the Operations Manual of remedial
procedures for instances of inappropriate or substandard services(s) and or
failure to provide Medically Necessary Covered Medical Services.


 


(3)          Assure that PARTICIPATING MEDICAL GROUP’s primary consideration is the
quality of services rendered to Members.


 


(4)          Assure that all services provided to Members are Medically Necessary.


 


(5)          Work closely with AIM Hospitals.


 


(6)          Encompass inpatient, outpatient, and ancillary care.


 


(7)          Utilize prospective, concurrent, and retrospective review.


 


(8)          Assure that all adverse utilization review decisions are made by a
licensed physician, and no denial of a requested service shall be made except
by a licensed physician, experienced in the area being reviewed.  Denial decisions shall be provided to
Members in writing.


 


(9)          Permit BLUE CROSS to have access to all PARTICIPATING MEDICAL GROUP
Utilization Management data directly or indirectly relating to Members.


 


B.             BLUE
CROSS shall validate PARTICIPATING MEDICAL GROUP’s development and
implementation of the Utilization Management Program through regular audit
activities in accordance with the Operations Manual and as follows:


 


(1)          The BLUE CROSS Quality Management Department shall review PARTICIPATING
MEDICAL GROUP’ Utilization Management Program on an annual basis through a
scheduled on-site audit.


 


(2)          The AIM Quality Management Representative shall notify PARTICIPATING
MEDICAL GROUP of any deficiencies or areas needing improvement.


 


(3)          PARTICIPATING MEDICAL GROUP shall take corrective action to eliminate
any deficiencies in areas needing improvement within a reasonable period of
time.


 


(4)          BLUE CROSS shall conduct follow-up reviews as necessary.


 


C.             PARTICIPATING
MEDICAL GROUP shall:


 


(1)          Make available to BLUE CROSS all minutes and notes from any and all
Utilization Management Committees and/or activities which relate to Members.


 


(2)          Make available to BLUE CROSS upon request all composite Utilization
Management data which include Members in the composite data set and provide
such detail as is available regarding those Members.


 


(3)          Provide the BLUE CROSS Medical Director (or the Medical Director’s
clinical designee) with a schedule designating the time and place of all
Utilization Management Committee meetings that relate to Members, in order that
he or she shall, in the Medical Director’s discretion, attend.  The BLUE CROSS Medical Director shall notify
the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall
not be excluded from any deliberation on activities related to Members.


 


4.06                 Records and Reserves.


 


A.           BLUE
CROSS shall have access at reasonable times upon demand to the books, records
and papers of PARTICIPATING MEDICAL GROUP relating to the services
PARTICIPATING MEDICAL GROUP provides to Members, to the cost thereof, and to
payments PARTICIPATING MEDICAL GROUP receives from Members or others on their
behalf.  PARTICIPATING MEDICAL GROUP
shall maintain such records and provide such


 


12

















 


information
to BLUE CROSS and the Commissioner of Corporations as may be necessary for BLUE
CROSS’ compliance with the requirements of the Knox-Keene Act.  PARTICIPATING MEDICAL GROUP shall maintain
such records for at least five (5) years, and such obligations shall not be
terminated upon a termination of this Agreement, whether by rescission or
otherwise.


 


B.             PARTICIPATING
MEDICAL GROUP agrees to provide BLUE CROSS with audited financial statements of
PARTICIPATING MEDICAL GROUP no later than three (3) months after the end of its
fiscal year, and BLUE CROSS shall maintain strict confidentiality of said
records.  Audited financial statements
shall illustrate net operating surplus or profit (after taxes).  Documents shall include the following:


 


(1)          Balance sheets


 


(2)          Statements of revenues and expenses


 


(3)          Statements of cash flow


 


PARTICIPATING MEDICAL GROUP further agrees that BLUE CROSS shall have
the right to require audited financial statements, in addition to the latest
fiscal year, at any time, upon request, with reasonable notice, if BLUE CROSS
pays for the audit.


 


C.             To
maintain financial reserves adequate to cover all risks assumed by
PARTICIPATING MEDICAL GROUP hereunder, including, but not limited to,
unanticipated claims for Referral Services that are the potential
responsibility of PARTICIPATING MEDICAL GROUP.


 


D.            That
all information shall be provided to each party to this Agreement pursuant to
procedures designed to protect the confidentiality of patient medical records
in accordance with applicable legal requirements, recognized standards of
professional practice and generally accepted procedures followed by health
maintenance organizations (HMOs).


 


E.              Upon
termination of this Agreement, PARTICIPATING MEDICAL GROUP shall, upon advance
written notice from BLUE CROSS, make available to BLUE CROSS and permit BLUE
CROSS to copy the medical records of each Member who has been assigned to
PARTICIPATING MEDICAL GROUP.


 


4.07                 Insurance Programs or Policies.


 


PARTICIPATING MEDICAL GROUP agrees to maintain professional liability
insurance, or other risk protection program, acceptable as defined under A. and
B. below to BLUE CROSS.  Notification by
PARTICIPATING MEDICAL GROUP of cancellation or material modification of the
coverage under such professional liability insurance or other risk protection
program is to be made to BLUE CROSS within thirty (30) days prior to any
cancellation or modification.  Copies of
the agreements or documents evidencing professional liability insurance or
other risk protection required under this section shall be provided to
BLUE CROSS upon execution of this Agreement.


 


A.           Professional
Liability Insurance


 


The coverage to be provided under this section shall be in minimum
amounts of ONE MILLION DOLLARS ($1,000,000.00) for any one (1) incident, THREE
MILLION DOLLARS ($3,000,000.00) annual aggregate.  PARTICIPATING MEDICAL GROUPs which are organized as Independent
Practice Associations shall ensure that PARTICIPATING MEDICAL GROUP Physicians
maintain professional liability insurance in minimum amounts of ONE MILLION
DOLLARS ($1,000,000.00) for any one incident and THREE MILLION DOLLARS
($3,000,000.00) annual aggregate. 
Furthermore, PARTICIPATING MEDICAL GROUPs organized as Independent
Practice Associations shall maintain directors and officers liability


 


13

















 


in minimum amounts of ONE MILLION DOLLARS ($1,000,000.00) for any one
incident, ONE MILLION DOLLARS ($1,000,000.00) annual aggregate.


 


B.             Other
Insurance


 


(1)          General Liability Insurance.  In
addition to Subsection A., above, PARTICIPATING MEDICAL GROUP shall also
maintain a policy or program of comprehensive general liability insurance (or
other risk protection) with minimum coverage including no less than ONE HUNDRED
THOUSAND DOLLARS ($100,000.00) for PARTICIPATING MEDICAL GROUP’s property,
together with combined single limit bodily injury and property damage insurance
of not less that SIX HUNDRED THOUSAND DOLLARS ($600,000.00).


 


(2)          Workers’ Compensation. 
PARTICIPATING MEDICAL GROUP’s employees shall be covered by Workers’
Compensation Insurance in an amount and form meeting all requirements of
applicable provisions of the California
Labor Code.


 


4.08                           Administrative Responsibilities.


 


A.           To
comply with all BLUE CROSS administrative policies and procedures in the areas
listed in Exhibit C (incorporated by reference herein) and as set forth in the
Operations Manual (incorporated by reference herein) and to comply with all
applicable state and federal laws and regulations relating to the delivery of
Covered Medical Services.


 


B.             To
provide an AIM Coordinator who will create a liaison with BLUE CROSS and assist
Members in accordance with the procedures set forth in the Operations Manual,
and who will be available to Members during all regular office hours of
PARTICIPATING MEDICAL GROUP for the purpose of assisting Members to resolve any
problems which may arise or be perceived by the Member.


 


C.             To
notify BLUE CROSS within Fifteen (15) days concerning:


 


(1)          Any material change in the bylaws, membership, ownership or officers of
PARTICIPATING MEDICAL GROUP which might affect BLUE CROSS or this Agreement.


 


(2)          Any legal or governmental action initiated against a PARTICIPATING
MEDICAL GROUP Physician or against PARTICIPATING MEDICAL GROUP which might
affect BLUE CROSS or this Agreement including, but not limited to, any change
in PARTICIPATING MEDICAL GROUP Physician(s) licensure, insurance,
certification, malpractice, disciplinary experience or physical or mental
health status.


 


(3)          Any other situation that may interfere with PARTICIPATING MEDICAL
GROUP’s or PARTICIPATING MEDICAL GROUP Physician’s duties and obligations under
this Agreement.


 


D.            To
obtain BLUE CROSS’ prior written approval for any literature related to AIM and
intended for Members.


 


E.              To
continually meet all criteria for PARTICIPATING MEDICAL GROUP’s, set forth in
the Operations Manual, and to continually meet all criteria for Satellite
Facilities (if applicable) set forth in the Operations Manual.


 


F.              To
provide BLUE CROSS, on a monthly basis, all ambulatory encounter data
electronically as described in the Operations Manual.


 


14

















 


G.             To
comply with BLUE CROSS programs related to the management of pharmaceutical
expenses.


 


H.            That
all financial terms of this Agreement shall be and remain confidential and
shall not be disclosed to any third party, except as required by law or as
required to supply information required by any financial institution.


 


I.                 To
provide at least ninety (90) days advance written notice to BLUE CROSS whenever
(a) a PARTICIPATING MEDICAL GROUP Physician who is a Primary Care Physician is
no longer a PARTICIPATING MEDICAL GROUP Physician; or (b) a Satellite Facility
closes, relocates or is unable to serve Members.


 


J.                To
provide at least sixty (60) days prior written notification to BLUE CROSS of
any of the following:


 


(1)          A non-Primary Care Physician’s termination of his/her affiliation with
PARTICIPATING MEDICAL GROUP or a PARTICIPATING MEDICAL GROUP provider.


 


(2)          The termination of a non-Primary Care Physician by PARTICIPATING MEDICAL
GROUP or a PARTICIPATING MEDICAL GROUP provider.


 


4.09                           Payments and Member Billing.


 


A.           To
accept the monthly Capitation payment from BLUE CROSS as payment in full for
Capitation Services (including all Referral Services) provided or arranged
hereunder, and not to seek additional payments or compensation from Members for
Covered Medical Services.  The foregoing
restriction shall not apply to co-payments, which may be collected by
PARTICIPATING MEDICAL GROUP in accordance with the applicable provisions of the
Benefit Agreement(s), nor shall it apply to billings and collections with
respect to non-Covered Medical Services rendered to Members by PARTICIPATING
MEDICAL GROUP.  However, to the extent
that the PARTICIPATING MEDICAL GROUP’s billing office is aware of the Member’s
payment responsibility, PARTICIPATING MEDICAL GROUP agrees to advise the Member
of that payment responsibility prior to rendering any service requiring a
co-payment, or any non-Covered Medical Service.


 


If PARTICIPATING MEDICAL GROUP should receive any surcharge or payment
from a Member, in addition to those permissible charges set forth above,
PARTICIPATING MEDICAL GROUP shall promptly refund the full amount thereof to
the Member.


 


B.             To
never charge any Member for any health service which has been deemed not
Medically Necessary or not appropriate after utilization review by
PARTICIPATING MEDICAL GROUP, unless the Member specifically requests the
service and acknowledges in writing that the service is not a Covered Medical
Service under the Member’s Benefit Agreement.


 


C.             That
BLUE CROSS and PARTICIPATING MEDICAL GROUP respectively acknowledge that the
authority and responsibility for coordination of benefits shall be carried out
in accordance with the provisions set forth in the Benefit Agreements and the
Operations Manual.


 


D.            That
PARTICIPATING MEDICAL GROUP shall promptly notify, in writing, the AIM Case
Management Department of all cases that reach the Enrollment Protection level
specified herein.


 


15

















 


E.              To
pay all Health Professionals who have rendered authorized Referral Services to
Members, within forty-five (45) working days following receipt of a clean,
undisputed claim, consistent with the regulations of the Commissioner of
Corporations governing BLUE CROSS.


 


F.              That
BLUE CROSS may change Exhibit E.  In the
event of such change, BLUE CROSS shall notify PARTICIPATING MEDICAL GROUP of
the change at least ninety (90) days in advance of the effective date of the
change.


 


4.10                 Membership.


 


A.           To
accept any and all Members who select PARTICIPATING MEDICAL GROUP until such
time as PARTICIPATING MEDICAL GROUP shall have provided ninety (90) days prior
written notice to BLUE CROSS that it has reached its maximum capacity as set
forth in Section 13.08 herein, or that it anticipates reaching such
maximum within ninety (90) days from the date of the notice to BLUE CROSS.  The maximum capacity of PARTICIPATING MEDICAL
GROUP designated in Section 13.08 shall be reduced only upon ninety (90)
days written notice to BLUE CROSS.  The
parties acknowledge their understanding that enrollment from individual
accounts, or changes in selection of PARTICIPATING MEDICAL GROUP by Members,
are not entirely within the control of BLUE CROSS.


 


B.             That
PARTICIPATING MEDICAL GROUP will not request, demand, require or otherwise seek
the transfer or removal of any Member from the care of PARTICIPATING MEDICAL
GROUP, based on that Member’s need of, or utilization of, Medically Necessary
services.


 


C.             PARTICIPATING
MEDICAL GROUP agrees that, in the event a Member who is covered for workers’
compensation benefits by a workers’ compensation carrier affiliated with BLUE
CROSS, seeks services for a work-related illness or injury, PARTICIPATING
MEDICAL GROUP shall have the option to (a) provide such Medically Necessary
medical services or (b) refer such Member to a provider that participates in
the Prudent Buyer Comp provider network or the CalCare Comp provider network,
whichever is applicable.  In the event
that PARTICIPATING MEDICAL GROUP elects to treat such Member, PARTICIPATING
MEDICAL GROUP shall complete a Doctor’s First Report of Injury as defined in
the California Labor Code.  As payment
for such medical services rendered, PARTICIPATING MEDICAL GROUP agrees to
accept, as payment in full, compensation in accordance with the then current
Blue Cross of California Prudent Buyer Plan Participating Physician Agreement
fee schedule for the applicable region. 
PARTICIPATING MEDICAL GROUP further agrees that, in the event such
Member requires medical services in connection with such work-related illness
or injury beyond the treatment provided at the initial visit, PARTICIPATING
MEDICAL GROUP shall refer such Member only to a provider that participates in
the Prudent Buyer Comp provider network or the CalCare Comp provider network,
whichever is applicable.


 


D.            That
unless agreed to in writing by BLUE CROSS, this Agreement shall not apply to
organized physician groups (including, but not limited to, Independent Practice
Associations) that PARTICIPATING MEDICAL GROUP acquires, manages or affiliates
with subsequent to the effective date of this Agreement.


 


4.11                 To provide BLUE CROSS, within seven (7) days
of its request, a description of any policies and procedures related to
economic profiling utilized by PARTICIPATING MEDICAL GROUP.  PARTICIPATING MEDICAL GROUP further agrees
to comply with the requirements of the Knox-Keene Act related to economic profiling,
including Health and Safety Code Section 1367.02(c).


 


16

















 


V.                                     BLUE CROSS SERVICES AND RESPONSIBILITIES


 


BLUE CROSS agrees:


 


5.01                 To perform, or arrange for the performance of,
all necessary accounting and enrollment functions with respect to marketing and
administering the AIM Program, and to issue an identification card to each
Subscriber as described in the Operations Manual.  AIM Program enrollment shall be determined by the State of
California and shall be reported to PARTICIPATING MEDICAL GROUP by BLUE CROSS
as directed by the State of California.


 


5.02                 To provide PARTICIPATING MEDICAL GROUP with
Member Eligibility Reports, as set forth in Article VI.


 


5.03                 That, to the extent compatible with its obligations
to BLUE CROSS hereunder, PARTICIPATING MEDICAL GROUP reserves the right to
provide professional services to persons who are not Members.


 


5.04                 To provide PARTICIPATING MEDICAL GROUP with
claims paid and BLUE CROSS Services data as described in the Operations Manual.


 


5.05                 To make trained personnel available to
PARTICIPATING MEDICAL GROUP to assist in Quality Management activities, the
establishment of procedures for pre-admission medical review and concurrent
medical review of Members who require, or may require, hospitalization.


 


5.06                 To undertake reasonable efforts, in accordance
with a standard of good faith, to assure that Members assigned to PARTICIPATING
MEDICAL GROUP will live or work within the Service Area defined in this
Agreement.  However, BLUE CROSS reserves
the right to assign any Members to PARTICIPATING MEDICAL GROUP when the Member
changes residence, or when BLUE CROSS determines such transfer to be in the
Member’s best interest due to special circumstances under the terms of the Member’s
Benefit Agreement.


 


5.07                 To notify and consult with PARTICIPATING
MEDICAL GROUP with respect to the development of any material changes, as
determined by BLUE CROSS, or amendments to the Benefit Agreements, and to
obtain PARTICIPATING MEDICAL GROUP’s consent to changes that BLUE CROSS
believes may materially affect PARTICIPATING MEDICAL GROUP, except for changes
required by law.  The foregoing consent
will not be unreasonably withheld by PARTICIPATING MEDICAL GROUP, so long as
Capitation payments are adjusted as mutually agreed to reflect any additional
services which may be required due to any amendment or change in Member
benefits.


 


5.08                 To accept sole responsibility for filing
reports, obtaining approvals, and complying with the applicable laws and
regulations of state, federal, and other regulatory agencies having
jurisdiction over BLUE CROSS, on the condition that PARTICIPATING MEDICAL GROUP
cooperates in providing BLUE CROSS with any information and assistance
reasonably required.  PARTICIPATING MEDICAL
GROUP is not required to provide information which is confidential in any other
existing contract of PARTICIPATING MEDICAL GROUP.


 


5.09                 That nothing contained in this Agreement is
intended to interfere with the professional relationship between any Member and
the Member’s PARTICIPATING MEDICAL GROUP Physician(s).


 


5.10                 To collect, or arrange to have collected, all
premiums, Member payments and other items of income to which BLUE CROSS is
entitled under its contracts or otherwise, except for (a) co-payments,


 


17

















 


(b) payments for non-Covered Medical Services, (c) coordination of
benefits payments for professional services which may be collected by
PARTICIPATING MEDICAL GROUP under the conditions set forth in the Member’s
Benefit Agreement, and (d) third party liability payments for professional
services.  Pursuant to the Benefit
Agreement(s) BLUE CROSS may hold a lien on third party liability payments in
the amount of benefits paid by BLUE CROSS and the value of medical care
provided under the AIM Program for the treatment of the illness, injury or
condition for which a third party is liable. 
BLUE CROSS shall assign to PARTICIPATING MEDICAL GROUP that portion of any
such lien related to professional services rendered under this Agreement by
PARTICIPATING MEDICAL GROUP. 
PARTICIPATING MEDICAL GROUP’s methods of collection of such payments
shall be conducted in a reasonable and nonegregious manner and only proper legal
procedures may be used to enforce such payment.


 


5.11                 To consult with PARTICIPATING MEDICAL GROUP
regarding any material changes, as determined by BLUE CROSS, in operating
procedures and policies, as set forth in the Operations Manual, and to provide
PARTICIPATING MEDICAL GROUP with an opportunity to comment on any policy and
procedural changes which may have a substantial impact on PARTICIPATING MEDICAL
GROUP.


 


VI.                                 ELIGIBILITY LISTINGS


 


6.01                 Eligibility listings of Members who have
personally selected, or been assigned to, PARTICIPATING MEDICAL GROUP shall be
provided in the following manner:


 


A.           BLUE
CROSS shall maintain, update and distribute monthly, Member Eligibility Reports
listing the persons who are eligible to receive Covered Medical Services during
the applicable month.


 


B.             PARTICIPATING
MEDICAL GROUP shall receive a copy of the Eligibility Reports at PARTICIPATING
MEDICAL GROUP’s main site.  Should
PARTICIPATING MEDICAL GROUP request reports in an electronic format, paper
reports will continue to be provided for an additional ninety (90) days
only.  As described in the Operations
Manual, BLUE CROSS will charge a fee of between Fifty Dollars ($50.00) and Five
Hundred Dollars ($500.00) per report, for each of the following:


 


(1)          duplicate copies of paper reports,


 


(2)          copies of paper reports delivered in addition to reports in electronic
format after the ninety (90) day parallel reporting period (tape, diskette, NDM
or other electronic medium),


 


(3)          duplicate reports for prior months.


 


C.             BLUE
CROSS will discourage retroactive cancellation of more than ninety (90) days
from BLUE CROSS’ applicable monthly billing process date.  However, when no services have been
rendered, BLUE CROSS may make occasional exceptions due to legitimate
administrative processing requirements. 
Notwithstanding any retroactive cancellation of a Member of more than
ninety (90) days, BLUE CROSS shall not be entitled to any refund of Capitation
payments made for such Member beyond the ninety (90) day period.  BLUE CROSS will attempt to discourage
retroactively adding any Member after the applicable billing is
reconciled.  In the event BLUE CROSS
finds it necessary to assign, up to ninety (90) days retroactively, a new
Member to PARTICIPATING MEDICAL GROUP, Capitation payment for that Member shall
be made, and PARTICIPATING MEDICAL GROUP agrees to be responsible for all
Covered Medical Services due that Member under the terms of the Member’s
Benefit Agreement which were provided or arranged by PARTICIPATING MEDICAL
GROUP, from the date the Member was assigned.


 


18

















 


D.            In
the event care is provided to an ineligible person, based on an erroneous or
delayed Eligibility Report, BLUE CROSS shall be financially responsible for all
care provided by PARTICIPATING MEDICAL GROUP prior to the time PARTICIPATING
MEDICAL GROUP received notice of that person’s ineligibility and, on the
condition that PARTICIPATING MEDICAL GROUP shall supply BLUE CROSS with
evidence that PARTICIPATING MEDICAL GROUP has unsuccessfully sought payment for
all or a portion of the charges from the ineligible person, or the person
having legal responsibility for the ineligible person, through two billing
cycles, or through a period of sixty (60) days, whichever is greater.  In that event, BLUE CROSS’ responsibility
for physician compensation shall be measured as set forth in the then current
Blue Cross of California Prudent Buyer Plan Participating Physician fee
schedule for the applicable region or the actual billed amount, whichever
is less.  The obligations of BLUE CROSS
under this Subsection D shall be conditioned upon the (1) exercise of
prudent judgment by PARTICIPATING MEDICAL GROUP, evidenced by reasonable
efforts to contact BLUE CROSS for verification of the eligibility of each
Member prior to providing or arranging Covered Medical Services, and (2)
submission to BLUE CROSS of both the claim and evidence of its unsuccessful
collection efforts within twelve (12) months of the date of service.


 


VII.                             COMPENSATION TO PARTICIPATING MEDICAL GROUP 


 


7.01                           CAPITATION


 


A.           Exhibit
D (incorporated by reference herein), sets forth the Capitation payments.  The applicable Capitation payment for each
Member assigned to PARTICIPATING MEDICAL GROUP, shall be paid monthly, prorated
in accordance with Member eligibility.


 


B.             The
Capitation payment to PARTICIPATING MEDICAL GROUP for each mother will begin on
the date the mother is assigned to PARTICIPATING MEDICAL GROUP and will
continue up to sixty (60) days after delivery.


 


C.             In
the event BLUE CROSS assigns a mother to PARTICIPATING MEDICAL GROUP
retroactively, the Capitation payment will be made from the date the mother is
assigned to PARTICIPATING MEDICAL GROUP. 
BLUE CROSS will discourage retroactive additions beyond a ninety (90)
day period.


 


D.            The
Capitation payment to PARTICIPATING MEDICAL GROUP will be made for each infant
for professional services related to normal pregnancy and cesarean
section delivery including the administration of pediatric immunizations,
periodic checkups, other covered professional services and covered outpatient
services.  The Capitation payment made
under this Section 7.01.D will begin from the date of birth and continue
for a period of up to twenty-four (24) months after birth.


 


E.              The
provision of professional services for treatment of complications for an infant
on an inpatient basis will be paid at the rates set forth at in the then
current Blue Cross of California Prudent Buyer Plan Participating Physician
Agreement fee schedule for the applicable region.  “Complications” means it is Medically
Necessary to admit the infant to a Level II or Level III intensive care newborn
nursery (hereafter referred to as “Complications”).  PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for services
rendered in conjunction with the treatment of Complications within twelve (12)
months of date of service.


 


19

















 


F.              All
covered professional services and supplies for infants treated for
Complications will be paid in accordance to the coverage limits of the Benefit
Agreement, not to exceed total expense incurred for those services and
supplies.


 


G.             The
Capitation payment for infants treated for Complications will be suspended and
resume when further confinement in a Level II or Level III intensive care
newborn nursery is not Medically Necessary. 
BLUE CROSS will reconcile the Capitation payment for infants on a
retroactive basis pursuant to the date an infant begins treatment for
Complications and therefore the PARTICIPATING MEDICAL GROUP commences receiving
payment under Paragraphs E and F above.


 


H.            PARTICIPATING
MEDICAL GROUP will not be at risk for the provision of Institutional services
to Members.  For Members, hospitals and
other institutions will be paid based on BLUE CROSS contracted rates and/or
fee-for-service.


 


7.02                 Capitation shall be paid in consideration for
providing Capitation Services and Insured Services and arranging BLUE CROSS
Services for each Member assigned to PARTICIPATING MEDICAL GROUP and in
consideration for all Capitation Services and Insured Services arranged through
referral for Members by PARTICIPATING MEDICAL GROUP.  The Capitation payment shall be made by the tenth of each month
and shall be computed on the basis of the most current information available.  In the event that an error is made in the
computation of the Capitation payment, resulting in an overpayment or
underpayment to PARTICIPATING MEDICAL GROUP, BLUE CROSS reserves the right to
adjust subsequent Capitation payments to PARTICIPATING MEDICAL GROUP to offset
such overpayment or underpayment.


 


Each Capitation payment shall be accompanied by a remittance
summary.  The remittance summary
identifies the total Capitation amount payable, including retroactivity and
identifies those Members whose retroactivity had a financial impact on the
total Capitation payment.  A complete
listing of Members that are eligible for Capitation Services is provided in the
monthly Eligibility Report, as set forth in Article VI.


 


7.03                 PARTICIPATING MEDICAL GROUP agrees that in no
event shall any allowable co-payment or reimbursement amount, or sum thereof,
due PARTICIPATING MEDICAL GROUP, exceed the cost to PARTICIPATING MEDICAL GROUP
of providing the service or item which was billed.


 


7.04                 PARTICIPATING MEDICAL GROUP agrees to be
responsible for professional and facility charges, as described in Exhibit A(1)
(incorporated by reference herein).


 


7.05                 In the event a referral provider has not been
reimbursed for authorized Referral Services or that any other provider has not
been reimbursed by PARTICIPATING MEDICAL GROUP as required under their
agreement for services provided to Members within forty-five (45) working days
following receipt of a clean, undisputed claim, then after notice BLUE CROSS
shall have the option to pay a clean and uncontested claim and deduct such
payment (including any interest payable under Health & Safety Code
Section 1371), plus an administrative charge equal to ten percent (10%) of
the claim amount, from any money due from BLUE CROSS to PARTICIPATING MEDICAL
GROUP.  If a total of five (5) or more
instances occur where any provider associated with PARTICIPATING MEDICAL GROUP
bills a Member in violation of this Agreement during any calendar year, BLUE
CROSS may, in its sole discretion, suspend the assignment of new Members to
PARTICIPATING MEDICAL GROUP until such time as PARTICIPATING MEDICAL GROUP has
rectified the problem to BLUE CROSS’ satisfaction.


 


20

















 


7.06                 Transplant Services.


 


For those transplant (bone marrow/stem cell and solid organ) services
for which PARTICIPATING MEDICAL GROUP is financially responsible (i.e.,
professional component), PARTICIPATING MEDICAL GROUP shall pay for services at
the applicable rate negotiated by BLUE CROSS for professional transplant
services or at the rate negotiated by PARTICIPATING MEDICAL GROUP.  If such payment has been made directly by
BLUE CROSS to the provider, PARTICIPATING MEDICAL GROUP shall remit payment to
BLUE CROSS within forty-five (45) days of BLUE CROSS’ written request or BLUE
CROSS may adjust subsequent Capitation payments to offset such payment amount.


 


7.07                 With respect to BLUE CROSS’ AIM Program,
pregnancy and maternity services (as set forth in the Benefit Agreement)
rendered by PARTICIPATING MEDICAL GROUP to a Member shall, at the date of
delivery, be compensated at *** per applicable Member (hereafter referred to as
the “Global Fee”).  For the purposes of
this Section, “delivery” shall mean a live birth, either by vaginal or cesarean
delivery with both a minimum fetal weight of 500 grams and a minimum length of
20 centimeters or with a minimum of 20 weeks gestation.  Alternately, “delivery” shall mean the
vaginal delivery of a stillbirth of a minimum of 20 weeks gestation, labor
induced by pitosin or prostoglandin, with a licensed obstetrician in
attendance.  The Global Fee payment is
compensation for pregnancy and maternity care services, professional services
provided to the mother for delivery including prenatal and postnatal physician’s
office visits, other covered professional services and covered outpatient
services.  PARTICIPATING MEDICAL GROUP
shall bill BLUE CROSS for a Global Fee within twelve (12) months of “delivery”.


 


7.08                 INSURED SERVICES, as defined in this
Agreement, shall include each of the services and benefits set forth in this
Section 7.08, which shall be provided according to the Benefit Agreement
and paid directly by PARTICIPATING MEDICAL GROUP.  Except as stated below, reimbursement to PARTICIPATING MEDICAL
GROUP for the following Insured Services shall be made by BLUE CROSS in
accordance with the lesser of (i) actual billed charges; (ii) the Blue Cross of
California Prudent Buyer Plan Physician Agreement fee schedule for the
applicable region; (iii) the rate negotiated between BLUE CROSS and the provider
of service; or (iv) the amount actually paid by PARTICIPATING MEDICAL GROUP,
within forty-five (45) working days following receipt of a clean, undisputed
claim as follows, on the condition that such claim shall be submitted to BLUE
CROSS no later than twelve (12) months after the date of service:


 


A.           Chemotherapy
drugs, intravenously administered, exclusive of professional charges.


 


B.             Durable
medical equipment and prosthetic devices.


 


C.             Mammography.
Reimbursement for routine mammograms shall be limited to *** per Member per
calendar year.


 


D.            Pregnancy
and maternity services.  Reimbursement
shall equal the Global Fee *** as
set forth in Section 7.07 above.


 


E.              Professional
hemodialysis services.


 


F.              Hepatitis
B vaccine and gamma globulin.


 


G.             Pediatric
immunization serums.


 


7.09                 The provider of Insured Services may bill BLUE
CROSS directly, in which case, BLUE CROSS shall reimburse said provider within
forty-five (45) working days following receipt of a clean, undisputed claim
accompanied by an Authorization from PARTICIPATING MEDICAL GROUP.  This section shall only apply for the
following Insured Services: Chemotherapy drugs, durable medical equipment and
prosthetics devices, and professional hemodialysis services.


 


21

















 


             BLUE CROSS shall pay contracting providers at the rate
negotiated between BLUE CROSS and said provider.  In the case of non-contracting providers, BLUE CROSS shall pay
the lesser of the actual billed charges, or the maximum allowable rate according
to the BLUE CROSS Customary and Reasonable Charges, or the rate arranged for by
an AIM Case Manager.


 


VIII.                         ENROLLMENT
PROTECTION


 


8.01                 Enrollment Protection is a program designed to
limit PARTICIPATING MEDICAL GROUP’s liability for Capitation Services expense.


 


8.02                 The liability of PARTICIPATING MEDICAL GROUP
for expenses for Capitation Services rendered to any single Member enrolled in
BLUE CROSS’ AIM Program shall be limited to the first *** of such expenses
during the mother’s enrollment and each calendar year of the infant’s
enrollment if PARTICIPATING MEDICAL GROUP elects Enrollment Protection as set
forth in Exhibit D herein.


 


8.03                 The total expenses of PARTICIPATING MEDICAL
GROUP for Capitation Services rendered to any single Member during the mother’s
enrollment and each calendar year of the infant’s enrollment shall be
calculated according to the then current Blue Cross of California Prudent Buyer
Plan Participating Physician Agreement fee schedule for the applicable
region.  In the event the foregoing
calculation for any given procedure results in a figure greater than the actual
cost of the procedure as billed by a third party, then the actual cost for that
procedure shall be deemed to be the amount actually paid by PARTICIPATING
MEDICAL GROUP.


 


8.04                 Expenses in connection with the following
services shall not be included as Capitation Services expenses incurred by
PARTICIPATING MEDICAL GROUP in reaching the Enrollment Protection level:


 


A.           Pregnancy
and maternity services covered by the Global Fee under Section 7.07
herein.


 


B.             Services
rendered to infants for treatment of Complications pursuant to Sections 7.01E
and F.


 


C.             Services
rendered in connection with Workers’ Compensation cases.


 


D.            Services
for which payment is obtained from third-party sources.


 


E.              Services
for which payment is obtained from BLUE CROSS through any coverage other than
the AIM Program.


 


             All copayments applicable for Capitation Services
rendered to Members shall be subtracted from Capitation Services expenses.  When the PARTICIPATING MEDICAL GROUP is
capitated by two coverages for one Member, the PARTICIPATING MEDICAL GROUP
agrees to coordinate all related copayments under the Coordination of Benefits
rules in the Member’s Benefit Agreement.


 


8.05                 PARTICIPATING MEDICAL GROUP shall maintain
records necessary to evidence having reached the Enrollment Protection
level.  After reaching the Enrollment
Protection level with regard to any Member, during the remainder of the
mother’s enrollment or the remainder of the calendar year of the infant’s
enrollment PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for one hundred
percent (100%) of services rendered, or provided, to that Member by
PARTICIPATING MEDICAL GROUP, calculated in accordance with Sections 8.02, 8.03,
and 8.04.  Reimbursement to
PARTICIPATING MEDICAL GROUP for Enrollment Protection shall be made by BLUE
CROSS in accordance with the lesser of (i) actual billed charges; (ii) the then


 


22

















 


current Blue Cross of California Prudent Buyer Plan Participating
Physician Agreement fee schedule for the applicable region; (iii) the rate
negotiated between BLUE CROSS and the provider of service; or (iv) the amount
actually paid by PARTICIPATING MEDICAL GROUP. 
Such reimbursement shall be made on a monthly basis, within forty-five
(45) working days of submission of complete and accurate documentation by
PARTICIPATING MEDICAL GROUP, Services which are not set forth in the then
current Blue Cross of California Prudent Buyer Plan Participating Physician
Agreement fee schedule for the applicable region shall be reimbursed by
BLUE CROSS at the actual charges paid by PARTICIPATING MEDICAL GROUP.


 


8.06                 PARTICIPATING MEDICAL GROUP and BLUE CROSS
acknowledge and agree that PARTICIPATING MEDICAL GROUP limitations of liability
as set forth in this Article VIII shall be conditioned upon submission of
clean undisputed claims to BLUE CROSS no later than twelve (12) months after
the date of the service rendered to Members. 
Any claims under the Enrollment Protection program which would otherwise
be the responsibility of BLUE CROSS under this Agreement shall be the financial
responsibility of PARTICIPATING MEDICAL GROUP if a clean undisputed claim is
not submitted within twelve (12) months of the date of service.  For the purpose of this Agreement, a clean
claim shall mean a claim that meets all BLUE CROSS requirements with respect to
back-up information.


 


IX.                                BLUE CROSS SERVICES


 


9.01                 BLUE CROSS Services, as defined in this
Article, shall include Covered Medical Services, as set forth in the applicable
Benefit Agreement and as authorized or referred by PARTICIPATING MEDICAL GROUP.


 


The Covered Medical Services encompassed in BLUE CROSS Services are
delineated in Exhibit A(1) and include, but are not limited to:


 


A.           Inpatient
Hospital Services (exclusive of professional charges).


 


B.             Outpatient
Hospital Services (exclusive of professional charges).


 


C.             Hemodialysis
Services (exclusive of professional charges).


 


D.            In-Area
Emergency Room Facility Services (exclusive of professional charges).


 


E.              Related
Hospital Services.


 


F.              Ambulance
Services.


 


G.             Home
Health Services.


 


H.            Alternative
Birthing Center Services (exclusive of professional charges).


 


I.                 Out-of-Area
Emergency Services (Facility and Professional Expenses).


 


9.02                 The provider of BLUE CROSS Services shall bill
BLUE CROSS directly.  BLUE CROSS shall
reimburse said provider within forty-five (45) working days following receipt
of a clean, undisputed claim accompanied by an authorization from PARTICIPATING
MEDICAL GROUP.


 


23

















 


BLUE CROSS shall pay contracting providers at the rate negotiated
between BLUE CROSS and said provider. 
In the case of non-contracting providers, BLUE CROSS shall pay the lesser
of: the actual billed charges, or the maximum allowable rate according to the
BLUE CROSS Customary and Reasonable charges, or the rate arranged for by an AIM
Case Manager.


 


X.                                    TERM OF AGREEMENT, TERMINATION


 


10.01           This Agreement shall be in effect for a ONE  (1) year
period (the “Initial Term”) from the date noted on page 1.  Unless written notice of intent not to renew
or of intent to modify this Agreement is provided at least one hundred twenty
(120) days prior to completion of the Initial Term or any subsequent renewal
period, this Agreement shall renew upon the same terms and conditions for
consecutive one year periods each year thereafter.


 


10.02           Should this Agreement be terminated pursuant to Section 10.01
above, PARTICIPATING MEDICAL GROUP agrees to continue to provide or arrange
Capitation Services, Insured Services and BLUE CROSS Services for all Members
assigned to PARTICIPATING MEDICAL GROUP, including any Members who become
eligible during the notice period set forth in Section 10.01 above; and to
provide these services consistent with the terms and conditions of the
applicable Benefit Agreements.  In such
case, Capitation Services rendered to Members shall be compensated at the
applicable rates set forth in the then current Blue Cross of California Prudent
Buyer Plan Participating Physician Agreement fee schedule for the
appropriate region until the services being rendered to that Member are
completed or reasonable and medically appropriate provision is made for the
assumption of such services by another contracting provider, but in no event
later the annual anniversary dates of the Benefit Agreements of Members
assigned to PARTICIPATING MEDICAL GROUP. 
The foregoing anniversary date limitation shall not apply with respect
to the continuation of services, as required under Section 1373.95 of the
California Health and Safety Code.


 


In the event this Agreement is terminated, any and all outstanding
deficits owed to BLUE CROSS under this Agreement shall be immediately due and
payable, and BLUE CROSS may offset the entire such deficit against any and all
amounts then due or thereafter due to PARTICIPATING MEDICAL GROUP under this
Agreement or any other agreement with PARTICIPATING MEDICAL GROUP.


 


The right to set off such payments against any amounts due under this
Agreement shall be in addition to any other rights BLUE CROSS may have under
this Agreement, or in law or in equity.


 


10.03           Termination of this Agreement shall not affect any rights or obligations
hereunder which shall have previously accrued, or shall thereafter arise, with
respect to any occurrence prior to termination, and such rights and obligations
shall continue to be governed by the terms of this Agreement.


 


Without limiting the foregoing, if this Agreement is terminated, at BLUE
CROSS’ sole discretion, PARTICIPATING MEDICAL GROUP shall continue to provide
and be compensated under the terms of this Agreement for Covered Medical
Services provided to Members who at the time of termination are undergoing a
course of treatment from a PARTICIPATING MEDICAL GROUP Physician for an acute
condition, serious chronic condition, high-risk pregnancy, or a pregnancy that
has reached the second or third trimester. 
For cases involving an acute condition or a serious chronic condition,
such services may continue for up to ninety (90) days or a longer period if
necessary for a safe transfer to another participating medical group physician
as determined by BLUE CROSS in consultation with the PARTICIPATING MEDICAL
GROUP Physician, consistent with good professional practice.  For pregnancy cases as specified above, such
services will


 


24

















 


continue until postpartum services related to the delivery are completed
or for a longer period if necessary for a safe transfer to another
participating medical group physician, consistent with good professional
practice.


 


10.04           In the event of a material breach of this Agreement the party claiming
the breach shall give written notice to the other, with registered or certified
mail.  The notice shall specify the
breach with as much detail as possible. 
The party receiving the notice shall then have thirty (30) days to
commence curing the breach.  If the
breach is not cured to the satisfaction of the complaining party within sixty (60)
days after the notice is received by the other party, this Agreement shall
terminate at the end of the sixtieth (60th) day or, if the breach is by
PARTICIPATING MEDICAL GROUP, BLUE CROSS may in the alternative freeze
enrollment of PARTICIPATING MEDICAL GROUP and/or withhold *** of the Capitation
until such breach is cured to BLUE CROSS’ satisfaction.


 


XI.                           ARBITRATION OF DISPUTES BETWEEN BLUE CROSS AND
PARTICIPATING MEDICAL GROUP


 


11.01           PARTICIPATING MEDICAL GROUP and BLUE CROSS agree to meet and confer in
good faith to resolve any problems or disputes that may arise under this
Agreement.


 


11.02           Any problem or dispute arising under this Agreement and/or concerning
the terms of this Agreement that is not satisfactorily resolved under
Section 11.01 shall be arbitrated. 
The arbitration shall be initiated by either party making a written
demand for arbitration on the other party. 
Arbitration shall be conducted by the American Arbitration Association
(AAA) under the Commercial Rules of the AAA. 
The arbitration shall also be subject to California Code of Civil
Procedure, Title Nine, Section 1280, et.
seq., unless otherwise mutually agreed.  The parties agree that the decision of the arbitrator shall be
final and binding as to each of them, except to the extent that California or
Federal law provide for the review of arbitration proceedings.  BLUE CROSS waives any right to pursue, on a
class basis, any such problem or dispute against PARTICIPATING MEDICAL GROUP,
and PARTICIPATING MEDICAL GROUP waives any right to pursue, on a class basis,
any such problem or dispute against BLUE CROSS.  Issues as to whether malpractice was committed by a physician
shall not be subject to Arbitration by the AAA unless otherwise agreed in writing
by the parties and the AAA.


 


11.03           Arbitration Fee.  In
all cases submitted to AAA, the parties agree to share equally the AAA
administrative fee as well as the arbitrator’s fee, if any, unless otherwise
assessed by the arbitrator.  The
administrative fee shall be advanced by the initiating party.


 


11.04           Enforcement of Award.  The
parties agree that the arbitrator’s award may be enforced in any court having
jurisdiction thereof by the filing of a petition to enforce said award.  Costs of filing may be recovered by the
party that initiates the action to have an award enforced.


 


11.05           Alternative Dispute Settlement Techniques. 
Should the parties, prior to submitting a dispute to arbitration, desire
to utilize other impartial dispute settlement techniques, such as mediation or
fact-finding, a joint request for such services may be made to the AAA, or the
parties may initiate such other procedures as they may mutually agree upon.


 


11.06           Limitation.  Nothing contained herein is
intended to create, nor shall it be construed to create, any right of any
Member to independently initiate the arbitration procedure established in this
Article.  This limitation shall not
prevent BLUE CROSS from initiating such procedures as the representative of its
Members, or PARTICIPATING MEDICAL GROUP from initiating such procedures on
behalf of Members for whom they have assumed responsibility for the provision
of Capitation Services, and for arranging Non-Capitated Services provided that
in any such case


 


25

















 


BLUE CROSS or PARTICIPATING MEDICAL GROUP, respectively, shall be
considered the initiating party for the purposes of Section 11.03 hereof.


 


11.07           Each party hereto agrees to notify the other at the earliest reasonable
time in the event of any dispute which may be arbitrated, and in the event
either party becomes aware of facts or circumstances which indicate a
reasonable possibility of litigation with any third person or entity, and which
are relevant to any rights, obligations, or other responsibilities under this
Agreement.


 


XII.                            AIM MEMBER GRIEVANCE SYSTEM


 


12.01           In the event a Member perceives a problem which the AIM Coordinator is
unable to satisfactorily resolve, the Member shall be advised to complete a
Grievance Form and submit it to the AIM Coordinator.  The grievance shall be reviewed and resolved if possible, by the
PARTICIPATING MEDICAL GROUP’s Quality Management Committee.


 


12.02           PARTICIPATING   MEDICAL GROUP
shall maintain a log of all grievances heard by PARTICIPATING MEDICAL GROUP’s
Quality Management Committee filed by Members who are assigned to PARTICIPATING
MEDICAL GROUP and shall, on a quarterly basis, forward a copy of each grievance
to the AIM Quality Management Representative.


 


12.03           PARTICIPATING MEDICAL GROUP shall provide a written response to Member
within fifteen (15) working days of receipt of grievance.  In the event a grievance cannot be resolved
by the PARTICIPATING MEDICAL GROUP’s Quality Management Committee to the
complaining Member’s satisfaction within fifteen (15) working days of receipt,
the Member may appeal to BLUE CROSS using the procedures in the Member’s
Benefit Agreement and in the Operations Manual.  In the event that the Member appeals to BLUE CROSS, PARTICIPATING
MEDICAL GROUP agrees to provide BLUE CROSS with a response to the grievance and
the pertinent medical records within ten (10) days from the date of such
request by BLUE CROSS.


 


12.04           The Member shall be notified of the disposition of the complaint by BLUE
CROSS within fifteen (15) working days of making the appeal.


 


XIII.                        MISCELLANEOUS
PROVISIONS


 


13.01           Amendment.  This Agreement or any part or
section of it may be amended at any time during the term of the Agreement
by mutual written consent of duly authorized representatives of BLUE CROSS and
PARTICIPATING MEDICAL GROUP.


 


13.02           Assignment.  BLUE CROSS and PARTICIPATING
MEDICAL GROUP, pursuant to mutual written agreement, may assign rights and
duties established under this Agreement, provided that no such assignment shall
adversely affect the rights or duties of Members or be in conflict with the
requirements of state or federal laws or regulations under which BLUE CROSS is
licensed or regulated.


 


13.03           Marketing, Advertising and Publicity.  BLUE
CROSS shall have the right to use the name of PARTICIPATING MEDICAL GROUP for
purposes of informing Members and prospective Members of the identity of
PARTICIPATING MEDICAL GROUP.


 


Except as provided above, BLUE CROSS and PARTICIPATING MEDICAL GROUP
each reserve the right to control the use of their respective names and all symbols,
trademarks or service marks presently existing, or later established.  In addition, except as provided above,
neither BLUE CROSS nor PARTICIPATING MEDICAL GROUP shall use the other party’s
name,


 


26

















 


symbols, trademarks or service marks in advertising or promotional
materials, or otherwise, without the prior written consent of that party, and
shall cease any such usage immediately upon written notice of the party, or on
termination of this Agreement, whichever first occurs.  Any prohibition, restriction or limitation
on advertising hereunder shall comply with the requirements of the Knox-Keene
Act, including Health and Safety Code Section 1395.5.


 


13.04           Sole Agreement.  This
Agreement with its Exhibits and the Operations Manual, represents the entire
agreement between the parties hereto and supersedes any and all prior or
contemporaneous, written or oral agreements, representations or understandings.


 


13.05           Independent Contractors. 
PARTICIPATING MEDICAL GROUP shall furnish care or other benefits to
Members as an independent contractor, and BLUE CROSS shall not be liable for
any claim or demand on account of damages arising out of, or in connection
with, any injuries suffered by any Member while receiving care from, or care
authorized by, PARTICIPATING MEDICAL GROUP or any of its Member Physicians.


 


13.06           Severability.  If any term, provision,
covenant or condition of this Agreement is held by a court of competent
jurisdiction to be invalid, void or unenforceable, the remainder of the
provisions hereof shall remain in full force and effect and shall in no way be
affected, impaired, or invalidated as a result of such decision.


 


13.07           Notices.  Any notice which is required or
permitted to be given pursuant to this Agreement shall be in writing and shall
either be personally delivered, or sent by registered or certified mail, in the
United States Postal Service, return receipt requested, postage prepaid,
addressed to each party at the address provided below.  Notices shall be effective when received.


 


	
  To
  Blue Cross:

  	
   

  	
  21555
  Oxnard Street -12D

  
	
   

  	
   

  	
  Woodland
  Hills, CA 91367

  
	
   

  	
   

  	
  ­

  
	
  To
  PARTICIPATING MEDICAL GROUP:

  	
   

  	
   

  



 


 


13.08           Maximum Capacity.  The
Maximum Capacity of PARTICIPATING MEDICAL GROUP during the term of this
Agreement shall be *** Members.


 


13.09           Knox-Keene Act.  BLUE
CROSS is subject to the requirements of the Knox-Keene Act and any provision
required to be in this Agreement thereunder shall bind BLUE CROSS and
PARTICIPATING MEDICAL GROUP, whether or not expressly provided in this
Agreement.


 


13.10           Solicitation of Members.  The
business relationship between BLUE CROSS and its Members shall be deemed the
property of BLUE CROSS.  Similarly, all
lists of Members accepted by PARTICIPATING MEDICAL GROUP under the provisions
of this Agreement shall be deemed the property of BLUE CROSS.  During the term of this Agreement or any
renewal thereof, and for a period of one (1) year from the date of termination,
PARTICIPATING MEDICAL GROUP agrees and will require its PARTICIPATING MEDICAL
GROUP Physicians and all other contracted Health Professionals to agree, that
they will not, within the service area of BLUE CROSS: (1) interfere with BLUE
CROSS’ contract and/or property rights; (2) advise or counsel any Member to
disenroll from BLUE CROSS; (3) solicit such Member to become enrolled with any
other health maintenance organization, preferred provider organization or any
other similar hospitalization or medical payment plan or insurance company; or
(4) disclose proprietary BLUE CROSS information.  This section shall not apply to general mailings unless the
mailings specifically target BLUE CROSS Members and as long as the mailings do
not violate the intent of this section.


 


27

















 


13.11           Confidentiality. 
PARTICIPATING MEDICAL GROUP and BLUE CROSS agree to keep confidential,
except as otherwise required by applicable law or this Agreement, the terms and
conditions of this Agreement and any amendments thereto.  Violation of the above shall be deemed a
material breach.


 


13.12           Waiver.  The waiver by either party of
a failure to perform any covenant or condition set forth in this Agreement
shall not act as a waiver of performance for a subsequent breach of the same or
any other covenant or condition set forth in this Agreement.


 


13.13           Governing Law.  This
Agreement and the rights and obligations of the parties hereunder shall be
construed and interpreted and enforced in accordance with, and governed by, the
laws of the State of California, and the United States and all regulations
promulgated pursuant thereto.  Any
provisions required to be in this Agreement by any of the above laws and
regulations shall bind BLUE CROSS and PARTICIPATING MEDICAL GROUP whether or
not expressly provided in this Agreement.


 


 


	
  BLUE CROSS OF CALIFORNIA

  	
  PARTICIPATING MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
   

  
	
  Signature:

  	
   

  	
  /s/ Lorraine Salvatore

  	
   

  	
  Signature:

  	
   

  	
  /s/
  Edward Rotan

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
   

  	
  Lorraine Salvatore

  	
   

  	
  Name:

  	
   

  	
  Edward
  Rotan

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Vice President

  	
   

  	
   

  	
   

  	
   

  
	
  Title

  	
   

  	
  Network
  Development &

  Management

  	
   

  	
  Title

  	
   

  	
  President

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
   

  	
  5/4/01

  	
   

  	
  Date:

  	
   

  	
  4/26/01

  	
   

  



 


28

















 


EXHIBIT A


 


COVERED MEDICAL SERVICES


 


I.                                         Medical and Surgical Services


 


A.           Physician’s
services at the:


 


(1)          Physician’s office; the Member shall pay any applicable copayment
directly to the physician for each such visit


 


(2)          Hospital


 


B.             Professional
services of an anesthetist or anesthesiologist


 


C.             Diagnostic
X-ray examinations


 


D.            Laboratory
tests


 


E.              Radiation
therapy in Physician’s office, including use of X-ray, radium, cobalt and other
radioactive substances


 


F.              Professional
services of other participating Health Professionals


 


G.             Professional
services of a physician at the Member’s home when the Member is too ill or
disabled to be seen during regular office hours.  The Member shall pay the amounts set forth in the Member’s
Benefit Agreement to the physician for each such visit.


 


II.                                   Psychiatric Care Benefits


 


A.           Inpatient
Visits


 


Physician’s hospital visits shall be limited as set forth in the
Member’s Benefit Agreement during each calendar year and the Member shall pay
the amounts set forth in the Member’s Benefit Agreement to the physician for
each such visit.


 


B.             Outpatient
Visits or Sessions


 


Outpatient care shall be provided for short-term evaluation of the
Member’s condition when such care is ordered by the attending PARTICIPATING
MEDICAL GROUP Physician.  Charges and
limitations as set forth in the Member’s Benefit Agreement.  This care shall not include visits for psychoanalysis.


 


III.                             Covered Preventive Care Benefits


 


The following services shall be provided when performed by, authorized
by, or deemed appropriate by the Member’s Primary Care Physician.  The Member shall pay any copayment listed in
the Member’s Benefit Agreement directly to the physician for each service
performed.


 


A.           Well
baby care through age 2 years, including immunizations.


 


B.             Scheduled
physical examinations as set forth in the Member’s Benefit Agreement.


 


C.             Pediatric
and adult immunizations.


 


D.            Eye
examinations


 


E.              Ear
examinations.


 


F.              Health
education services as follows:


 


 


 


A-1

















 


(1)          Health education services and education in the appropriate use of health
services and in the contribution each Member can make to the maintenance of
his/or her own health.


 


(2)          Instruction in personal health care measures.


 


(3)          Information about services provided, including recommendations on
generally accepted medical standards for use and frequency of such services.


 


G.             Services
such as pre- and post-hospitalization planning; referral to services provided
through community health and social welfare agencies and related family
counseling for the physical, emotional and economic impact of illness and
disability.


 


H.            Allergy
testing and administration of injections.


 


A-2

















 


EXHIBIT A (1)


AIM

DIVISION OF FINANCIAL RESPONSIBILITY


 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ACUPUNCTURE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALLERGY
  TESTING & TREATMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Serums

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMBULANCE:
  Air or Ground

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMNIOCENTESIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ANESTHETICS,
  Administration of

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  EYE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  INSEMINATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  LIMBS (Prosthetic Device)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BLOOD
  AND BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  From
  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Autologous
  Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMICAL
  DEPENDENCY REHABILITATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMOTHERAPY
  DRUGS (intravenously administered)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Chemotherapy
  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*** All references to
division of financial responsibility have been deleted.


 


A(1)-1

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHIROPRACTIC
  (Referred Service only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CIRCUMCISION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In
  Conjunction with Home Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DENTAL
  SERVICES

  (accidental
  injury to sound natural teeth and dental work

  necessary for the construction of non-dental structures)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DETOXIFICATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DURABLE
  MEDICAL EQUIPMENT (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ADMISSIONS: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ADMISSIONS: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ROOM: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMPLOYMENT
  PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*** All references to
division of financial responsibility have been deleted.


 


A(1)-2

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ENDOSCOPIC STUDIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EXPERIMENTAL PROCEDURES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FAMILY PLANNING SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FETAL MONITORING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  GENETIC TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEALTH EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEALTH EVALUATIONS / PHYSICALS (1) 

  (required by third party or outside
  agency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEPATITIS B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOME HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPICE (in lieu of acute inpatient or SNF care)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












(1)
Routine physical examinations or tests which do not directly treat an actual
illness, injury or condition unless authorized by a Primary Care Physician,
except in no event will any physical examination or test required by employment
or government authority, or at the request of a third party such as a school,
camp or sport affiliated organization be covered


*** All references to
division of financial responsibility have been deleted.


 


A(1)-3

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITAL
  BASED PHYSICIANS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurosurgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedic Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITALIZATION / INPATIENT SERVICES,

  SUPPLIES & TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out-of-Area (Emergency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE - In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE - Out Of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*** All references to
division of financial responsibility have been deleted.


 


A(1)-4

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT
  APNEA MONITOR (DME)

  (in conjunction with or concurrent with
  authorized inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFERTILITY(Diagnosis
  / Treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFUSION
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Infused
  Substances

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INJECTABLE MEDICATIONS:
  Outpatient
    (excluding
  take-home insulin)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LABORATORY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MAMMOGRAPHY
  (2)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  NUTRITIONIST
  / DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












(2)
Limited to $75.00 per member per year


*** All references to
division of financial responsibility have been deleted.


 


 


A(1)-5

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OBSTETRICAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component (3)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  (non-hospital facility) Diagnostic Services (4)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OFFICE
  VISIT SUPPLIES, SPLINTS, CASTS,

  BANDAGES, DRESSINGS etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ORGAN
  TRANSPLANTS (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Primary
  Care Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Specialty
  Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  CLINIC OR NON-HOSPITAL FACILITY

  COMPONENT FOR DIAGNOSTIC SERVICES &

  TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  These
  services include, but are not limited to the following:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CAT
  Scan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2-D
  Echo

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EKG
  (aka: ECG)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Holter
  Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












(3)
Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery.


(4)
Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery.


*** All references to
division of financial responsibility have been deleted.


 


A(1)-6

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*** All references to
division of financial responsibility have been deleted.


 


A(1)-7

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services 

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PEDIATRIC
  SERVICES (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICAL
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Skilled Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Patient Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Specialty
  Visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PODIATRY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREADMISSION
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREGNANCY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component (5)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PROSTHETIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIATION
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












(5)
Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery.


*** All references to
division of financial responsibility have been deleted.


 


A(1)-8

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RECONSTRUCTIVE SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REFRACTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REHABILITATION SERVICES

  (Physical Therapy, Occupational Therapy, Speech

  Therapy, Cardiac Therapy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ROUTINE PHYSICAL EXAMINATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SKILLED NURSING FACILITY (SNF)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SPECIALIST CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGICAL SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Dental Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  (for the diagnosis and medically
  necessary correction)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSFUSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Autologous Blood Donations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*** All references to
division of financial responsibility have been deleted.


 


A(1)-9

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Refraction

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Lenses / Frames (covered by optional rider)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Contact lenses (fitting only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*** All references to
division of financial responsibility have been deleted.


 


A(1)-10

















 


EXHIBIT B


 


AIM HOSPITALS


 


B-1

















 


EXHIBIT C


 


ADMINISTRATIVE RESPONSIBILITIES OF PARTICIPATING
MEDICAL GROUP


 


This
exhibit lists the areas in which PARTICIPATING MEDICAL GROUP and PARTICIPATING
MEDICAL GROUP Physicians will have administrative responsibility.  The extent and type of responsibility to be
undertaken will be agreed upon by the PARTICIPATING MEDICAL GROUP and BLUE
CROSS through an annual audit process.


 


A.           PROFESSIONAL
SERVICES ADMINISTRATION


 


Professional Services - Schedule, control, process and report encounter
information


 


Outside Referrals - Control, process and report encounter information


 


Ancillary - Control, process and report encounter information


 


B.             INSTITUTIONAL SERVICES ADMINISTRATION


 


Preadmission certification process


 


Medical Review of claims


 


Length-of-stay (monitoring and control)


 


C.             UTILIZATION
REVIEW


 


D.            PEER
REVIEW, EDUCATION AND CREDENTIALING


 


E.              QUALITY
MANAGEMENT


 


F.              GRIEVANCE
PROCEDURE COMPLIANCE


 


G.             MONITOR
AND REVISE SPECIALIST/OTHER REFERRAL CONTRACTS


 


H.            PATIENT
EDUCATION


 


I.                 CASE
MANAGEMENT


 


C-1

















 


EXHIBIT D


 


CAPITATION


 


I.                                        Mother With Enrollment Protection Provided by
BLUE CROSS


 


	
  1.

  	
   

  	
  Non-Pregnancy
  and

  Non-Maternity

  	
   

  	
  $***
  per month from enrollment through 60 days after termination of pregnancy

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Pregnancy
  and

  Maternity

  	
   

  	
  Global
  Fee applies per Section 7.07 

  



 


Child With Enrollment Protection Provided by BLUE CROSS


 


	
  1.

  	
   

  	
  Age
  0 - 1 year

  	
   

  	
  $***
  per month from birth through first birthday

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Age
  1 - 2 years

  	
   

  	
  $*** per month from 13 through 24 months

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.

  	
   

  	
  Complications
  for

  infants

  	
   

  	
  Then
  current Blue Cross of California Prudent Buyer Plan Participating Physician
  Agreement fee schedule for the applicable region applies per Sections
  7.01.1E and F

  



 


II.                                   Mother Without Enrollment Protection Provided
by BLUE CROSS


 


	
  1.

  	
   

  	
  Non-Pregnancy
  and

  Non-Maternity

  	
   

  	
  $***
  per month from enrollment through 60 days after termination of pregnancy

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Pregnancy
  and

  Maternity

  	
   

  	
  Global
  Fee applies per Section 7.07

  



 


Child Without Enrollment Protection Provided by BLUE CROSS


 


	
  1.

  	
   

  	
   Age 0 - 1 year

  	
   

  	
  $***
  per month from birth through first birthday

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Age
  1 - 2 years

  	
   

  	
  $***
  per month from 13 through 24 months

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.

  	
   

  	
  Complications
  for

  infants

  	
   

  	
  Then
  current Blue Cross of California Prudent Buyer Plan Participating Physician
  Agreement fee schedule for the applicable region applies per Sections
  7.01.1E and F

  



 


 


 


D-1

















 


PARTICIPATING
MEDICAL GROUP agrees to accept risk under either Subsection A or
Subsection B as indicated below.


 


A.                                   PARTICIPATING MEDICAL GROUP agrees to
participate in Article VIII, Enrollment Protection as set forth in
Sections 8.02, 8.03, 8.04, 8.05, 8.06 of this Agreement; or


 


B.                                     PARTICIPATING MEDICAL GROUP, at it sole
expense, agrees to obtain and maintain stop loss insurance for all expenses
incurred under this Agreement in amounts acceptable to BLUE CROSS.  Upon request, PARTICIPATING MEDICAL GROUP
shall provide BLUE CROSS with copies of its stop loss insurance policy
referenced in this Subsection B.


 


PARTICIPATING MEDICAL
GROUP hereby elects to accept risk pursuant to


 


	
  Subsection

  	
   

  	
  o   A.

  	
   

  	
  or

  	
   

  	
  ý   B.

  	
   

  	
  (check one)

  



 


D-2

















 


EXHIBIT E


 


PARTICIPATING
MEDICAL GROUP FACILITIES


 


E-1