Exhibit 10.165


 


CaliforniaCare Medical Services Agreement,
effective January 1, 2001, between Blue Cross of California and Affiliates
and Prospect Health Source Medical Group.


 












*** Confidential Treatment requested


 

















 


CaliforniaCare


 


MEDICAL SERVICES AGREEMENT


 

















 


CALIFORNIACARE

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.

  	
   

  	
  NON-CAPITATED SERVICES

  
	
  X.

  	
   

  	
  OUTPATIENT
  PRESCRIPTION DRUG EXPENSE

  
	
  XI.

  	
   

  	
  QUALITY MANAGEMENT BONUS

  
	
  XII.

  	
   

  	
  BILLING
  FOR HMO-USA AWAY FROM HOME CARE SERVICES

  
	
  XIII.

  	
   

  	
  TERM OF AGREEMENT, TERMINATION

  
	
  XIV.

  	
   

  	
  ARBITRATION
  OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  
	
  XV.

  	
   

  	
  CALIFORNIACARE
  MEMBER GRIEVANCE SYSTEM

  
	
  XVI.

  	
   

  	
  MISCELLANEOUS PROVISIONS

  



 


EXHIBITS


 


	
  Exhibit A

  	
   

  	
  Covered Medical Services

  
	
  Exhibit A(1)

  	
   

  	
  Division of Financial Responsibilities

  
	
  Exhibit B

  	
   

  	
  CALIFORNIACARE Hospitals

  
	
  Exhibit C

  	
   

  	
  Administrative Responsibilities of
  PARTICIPATING MEDICAL GROUP

  
	
  Exhibit D

  	
   

  	
  Capitation

  
	
  Exhibit E

  	
   

  	
  [Intentionally Omitted]

  
	
  Exhibit F

  	
   

  	
  Non-Capitated Performance Settlement Schedule

  
	
  Exhibit G

  	
   

  	
  Compensation for Services to BLUE CROSS PLUS
  Members

  
	
  Exhibit G(1)

  	
   

  	
  BLUE CROSS PLUS 1997 Baseline Capitation

  
	
  Exhibit H

  	
   

  	
  Outpatient Prescription Drug Settlement
  Schedule

  
	
  Exhibit I

  	
   

  	
  Quality Management Bonus Schedule

  
	
  Exhibit J

  	
   

  	
  PARTICIPATING MEDICAL GROUP Facilities

  
	
  Exhibit K

  	
   

  	
  Division of Responsibilities For Compliance
  Activities

  
	
  Exhibit K(1)

  	
   

  	
  Compliance Activity Performance
  Measurements

  



 

















 


CALIFORNIACARE


 


MEDICAL SERVICES
AGREEMENT


 


This AGREEMENT is effective on January 1, 2001 between BLUE CROSS OF
CALIFORNIA and Affiliates (jointly and severally “BLUE CROSS”) and Prospect Health Source Medical Group,
(“PARTICIPATING MEDICAL GROUP”).


 


I.              RECITALS


 


1.01             BLUE CROSS is a California Corporation
licensed by the Director of the California Department of Managed Health Care to
operate a health care service plan pursuant to the Knox-Keene Health Care
Service Plan Act of 1975 and the Rules of the Director of the California
Department of Managed Health Care 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 Professional 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’ CALIFORNIACARE programs.


 


II.            DEFINITIONS


 


2.01             “Adjusted Per Member Per
Month Non-Capitated Expense” means the PARTICIPATING MEDICAL GROUP’s Per Member
Per Month Non-Capitated Expense after adjustments for the PARTICIPATING MEDICAL
GROUP’s mix of Member age/sex and plan, and the PARTICIPATING MEDICAL GROUP’s
stop-loss and regional relativities for use in identifying the PARTICIPATING
MEDICAL GROUP’s Non-Capitated Performance Settlement.


 


2.02             “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.


 


2.03             “Age/Sex Factors” means the factors
used to adjust PARTICIPATING MEDICAL GROUP’s Per Member Per Month Non-Capitated
Expenses to account for cost variations attributable to the mix of Member age
and sex.


 


2.04             “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.


 


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


 


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2.06             “Attachment Point” is the point at
which no settlement shall be made if the PARTICIPATING MEDICAL GROUP’s Adjusted
Per Member Per Month Non-Capitated Expense equals or exceeds that amount.  The Attachment Point is shown in the
Non-Capitated Performance Settlement Schedule as set forth in Exhibit F.


 


2.07             “Away From Home
Care” means urgent care, Away from Home Emergency Care, routine care, and
follow-up care as defined in the HMO-USA member’s plan certificate or benefit
agreement.


 


2.08             “Benefit
Agreement(s)” means the written agreement(s) entered into between BLUE CROSS and
groups or individuals, under which BLUE CROSS provides, indemnifies, or
administers health benefits to persons enrolled in BLUE CROSS programs
including, but not limited to, the CALIFORNIACARE programs or the BLUE CROSS
PLUS program.  “Benefit Agreement(s)”
also mean arrangements established by BLUE CROSS and/or one or more of its
Affiliates, or by persons or entities utilizing the BLUE CROSS Managed Care
Network pursuant to a contract with BLUE CROSS and/or one or more of its
Affiliates.  Subject to the terms
hereof, BLUE CROSS and/or one or more of its Affiliates may contract, on
PARTICIPATING MEDICAL GROUP’s behalf, with Other Payors wishing to utilize the
services of the BLUE CROSS Managed Care Network, incorporating the terms and
conditions of this Agreement.


 


2.09             “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 CALIFORNIACARE, BLUE
CROSS PLUS and other programs that are to be conducted pursuant to Benefit
Agreements.


 


2.10             “BLUE CROSS
Services” means all CALIFORNIACARE Covered Medical Services which are designated
in this Agreement or in the Division of Financial Responsibility as BLUE CROSS
Services.


 


2.11             “BLUE CROSS PLUS” means a point of
service option benefit plan offered by BLUE CROSS under which enrolled Members
may, at the time benefits are selected, elect to receive benefits from either a
CALIFORNIACARE provider or another licensed provider.


 


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


 


2.13             “CALIFORNIACARE
Case Manager”  means a CALIFORNIACARE employee
charged with assisting PARTICIPATING MEDICAL GROUPs in case management.


 


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


 


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


 


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


 


2.17             “Capitation” means a uniform
prepayment fee per Member per month, adjusted by age-sex, based on the Benefit
Agreement issued to each Subscriber and the services due thereunder.


 


2 18             “Capitation
Services” means all CALIFORNIACARE Covered Medical Services which are not
otherwise defined in this Agreement or in the Division of Financial
Responsibilities (Exhibit A-1 hereto) as Non-Capitated Services.


 


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2.19             “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.


 


2.20             “Case Management
Stop-Loss Threshold” means the level at which stop-loss under
Section 9.03 herein shall apply to PARTICIPATING MEDICAL GROUP’s
Non-Capitated Performance Settlement.


 


2.21             “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).


 


2.22             “Covered Persons” means Members,
enrollees, dependents and other beneficiaries who are covered by an Affiliate’s
Benefit Agreement or by an Other Payor.


 


2.23             “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.


 


2.24             “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 or psychiatric attention could reasonably result
in any of the following:


 


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


 


B.             Serious impairment
to bodily functions,


 


C.             Other serious
medical or psychiatric consequences, or


 


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


 


2.25             “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.


 


2.26             “Extension of Benefits” means extended
benefits which may be available to Members who are totally disabled on the date
of termination of their Benefit Agreement. 
Extended benefits shall have the meaning set forth in the group coverage
agreement applicable to the Member.


 


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2.27             “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.


 


2.28             “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.


 


2.29             “HMO-USA”
means a nationwide network of Blue Cross and Blue Shield Plan HMOs (Participating
Plans) sponsored by Blue Cross and Blue Shield Association (BCBSA).  BCBSA Participating Plan HMOs have entered
into Agreements to provide each other’s members with guest memberships, urgent
care and Emergency care, routine care, and follow-up care as pre-approved and
authorized by BLUE CROSS when the member is traveling away from his or her Home
HMO-USA participating plan.


 


2.30             “Home HMO”
means the participating plan in which a HMO-USA participating plan member is
enrolled.


 


2.31             “Hospice Services”
means services rendered to terminally ill patients, by a Medicare certified
hospice provider that are (a) covered by a Benefit Agreement and (b) ordered or
authorized by PARTICIPATING MEDICAL GROUP.


 


2.32             “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.


 


2.33             “Host HMO”
means any participating plan in whose Service Area a HMO-USA participating plan
member temporarily stays except the member’s Home HMO.


 


2.34             “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.


 


2.35             “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.


 


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


 


(1)          Appropriate for the
symptoms, diagnosis or treatment of the medical condition; and


 


(2)          Provided for the
diagnosis or direct care and treatment of the medical condition; and


 


(3)          Within standards of
good medical practice within the organized medical community; and


 


(4)          Not primarily for
the convenience of the Member’s physician, or another provider, and


 


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(5)          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.


 


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


 


2.38             “Mental Health
Parity Services” means those mental health services related to the
diagnosis and Medically Necessary treatment of “severe mental illnesses” and
“serious emotional disturbances of a child,” as such terms are defined in
Section 1374.72 of the California Health and Safety Code.


 


2.39             “Member Months”
means a count that records one Member month for each month the Member is
enrolled in the CALIFORNIACARE program or the BLUE CROSS PLUS program.


 


2.40             “Non-Capitated
Expenses” means the actual expenses incurred by BLUE CROSS to provide
Non-Capitated Services to Members, as ordered, authorized or referred by
PARTICIPATING MEDICAL GROUP Physicians.


 


2.41             “Non-Capitated
Performance Settlement” means amount paid to PARTICIPATING MEDICAL GROUP
for managing Non-Capitated Services.


 


2.42             “Non-Capitated
Performance Settlement Schedule” means a schedule of PMPM
Non-Capitated Performance Settlement amounts associated with varying PMPM
Non-Capitated Expenses.  The
Non-Capitated Performance Settlement Schedule is set forth in Exhibit F.


 


2.43             “Non-Capitated
Services” means the designated services set forth in Article IX and
Exhibit A-1.


 


2.44             “Operations
Manual” means the CaliforniaCare PMG Operations Manual, as found on BLUE
CROSS’ Internet web site at www.bluecrossca.com.


 


2.45             “Other Payor” means persons or
entities utilizing the BLUE CROSS Managed Care Network pursuant to an agreement
with BLUE CROSS, including without limitation, other Blue Cross and/or Blue
Shield Plans, self-administered or self-insured programs providing health care
benefits, or employers or insurers.


 


2.46             “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.


 


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


 


2.48             “Outpatient
Prescription Drug Expense” means the benefit amount paid by BLUE CROSS to
pharmacies or pharmacists for a Member’s covered outpatient prescription drugs.


 


2.49             “Outpatient
Prescription Drug Settlement” means an amount paid to PARTICIPATING MEDICAL
GROUP for managing Outpatient Prescription Drug Expenses.


 


2.50             “Outpatient
Prescription Drug Settlement Schedule” means a schedule of outpatient
prescription drug settlement amounts associated with varying Per Member per
Month Outpatient Prescription Drug Expenses. 
The Schedule is set forth in Exhibit H.


 


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


 


2.52             “Per Member Per
Month (PMPM) Non-Capitated Expense” means the average monthly medical
Non-Capitated Expense per Member attributable to the PARTICIPATING MEDICAL
GROUP.


 


2.53             “Per Member Per
Month (PMPM) Outpatient Prescription Drug Expense” means the average
monthly Outpatient Prescription Drug Expenses per Member for PARTICIPATING
MEDICAL GROUP’s Members with outpatient prescription drug benefits.


 


2.54             “Plan Factors”
means factors used to adjust the PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expense to account for cost variations attributable to the mix of
Member Benefit Agreements.  The
Non-Capitated Expense Plan Factors include a durational factor for the
durational plans.


 


2.55             “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.


 


2.56             “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.


 


2.57             “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.


 


2.58             “Related
Hospital Services” means services rendered to Members as part of, and
concurrent with Inpatient Hospital Services, Outpatient Hospital Services,
Hemodialysis Services, Skilled Nursing Facility Services, Alternative Birthing
Center Services and Hospice 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.


 


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


 


2.60             “Region Factor”
means the factors used to adjust PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expense to account for cost variations across BLUE CROSS’
corporate regions.


 


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2.61             “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 CALIFORNIACARE Satellite Criteria set forth in the
Operations Manual and is approved by BLUE CROSS prior to being designated a
CALIFORNIACARE Satellite Facility.


 


2.62             “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.


 


2.63             “Skilled Nursing
Facility Services” means inpatient and related services provided by a
licensed skilled nursing facility. 
Skilled Nursing Facility Services excludes custodial care.


 


2.64             “Stop-Loss
Factor” means the factor used to adjust the PARTICIPATING MEDICAL GROUP’s
PMPM Non-Capitated Expense to account for cost variations due to different Case
Management Stop-Loss thresholds.


 


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


 


2.66             “Urgent Care”
means services to prevent serious deterioration of an enrollee’s health resulting
from unforeseen illness or injury for which treatment cannot be delayed.  For purposes of this Agreement, “Immediate
Care” shall have the same meaning as Urgent Care.


 


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


 


2.68             “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 Non-Capitated Services.  PARTICIPATING MEDICAL GROUP may freely communicate with Members
regarding the treatment options available to them, including medication
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.


 


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3.04             PARTICIPATING
MEDICAL GROUP consents to the memorializing of its legal obligations with BLUE
CROSS and each particular Affiliate in one or more separate written agreements
that shall not alter the substance of those obligations.


 


3.05             PARTICIPATING
MEDICAL GROUP agrees that each arrangement by which PARTICIPATING MEDICAL GROUP
performs services for Covered Persons that utilize the BLUE CROSS Managed Care
Network shall constitute an independent legal relationship between
PARTICIPATING MEDICAL GROUP and that Affiliate or Other Payor.


 


3.06             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 to
authorize or arrange for the provision of all Non-Capitated 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 or for 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 CALIFORNIACARE
Hospitals shall be adequate to meet the requirements for the CALIFORNIACARE 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


 


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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.


 


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 J (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 2.24 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).


 


9

















 


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 CALIFORNIACARE Hospital(s) within
PARTICIPATING MEDICAL GROUP’s Service Area.


 


E.              To admit, or
authorize admission of, Members solely to the CALIFORNIACARE 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 CALIFORNIACARE
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 CALIFORNIACARE
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 a CALIFORNIACARE Hospital, the Member must be admitted to
a non-CaliforniaCare in-area or out-of-area facility for Hospital Services,
then until the Member is transferred to a CALIFORNIACARE Hospital, the PARTICIPATING
MEDICAL GROUP will be financially responsible for care the same as if care had
been provided in a CALIFORNIACARE Hospital, and the Non-Capitated Services
arrangement as set forth in Article IX. of this Agreement will apply.


 


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)          Primary Care
Physicians who determine that a referral is necessary, may issue a referral
without the prior authorization of PARTICIPATING MEDICAL GROUP’s Utilization
Management Program to physicians in the following specialties: Allergy,
Cardiology, Dermatology, Endocrinology, Ear, Nose and Throat, Gastroenterology,
General Surgery.


 


10

















 


Hematology, Neurology, Obstetrics-Gynecology,
Oncology, Ophthalmology, Orthopedic Surgery, Podiatry, Routine Laboratory,
Routine X-ray and Urology.


(4)          For referrals to
specialists or providers, or services other than those listed in (3) above,
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.


(5)          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.


 


J.                To assure that
Members shall not be subject to discrimination in access to Covered Medical
Services.


 


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.


 


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:


 


11

















 


(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.


(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 CALIFORNIACARE
Quality Management Department shall review PARTICIPATING MEDICAL GROUP’s
Quality Management Program on an annual basis through a scheduled on-site
audit.


(2)          The CALIFORNIACARE
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
CALIFORNIACARE 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 CALIFORNIACARE 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.


 


12

















 


(6)          Permit BLUE CROSS
to evaluate and utilize the data obtained from the CALIFORNIACARE 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 MEDICAL GROUP agrees
to allow on-site review(s) of Utilization Management Program by BLUE CROSS.


 


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
CALIFORNIACARE 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 CALIFORNIACARE
Quality Management Department shall review PARTICIPATING MEDICAL GROUP’
Utilization Management Program on an annual basis through a scheduled on-site
audit.


(2)          The CALIFORNIACARE
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:


 


13

















 


(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
CALIFORNIACARE 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 CALIFORNIACARE 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)          Comply with all
applicable laws and regulations concerning utilization management criteria and
processes, including, without limitation, California Health and Safety Code
Sections 1363.5 and 1367.01.


 


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 information to BLUE CROSS and the Director of the
Department of Managed Health Care 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 financial information to BLUE CROSS or its
designated agent and to meet any other financial requirements that assist BLUE
CROSS in maintaining the financial viability of its arrangements for the
provision of health care services in the manner described in
Section 1375.4 of the California Health and Safety Code and applicable
regulations.  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).


 


14

















 


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 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
CALIFORNIACARE 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 a
CALIFORNIACARE 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.


 


15

















 


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 CALIFORNIACARE and
intended for Members.


 


E.              To continually meet
all criteria for PARTICIPATING MEDICAL GROUPs, 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.


 


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.


 


16

















 


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 CALIFORNIACARE Case
Management Department of all cases that reach the Enrollment Protection or Case
Management Stop-Loss levels specified herein.


 


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 Director of the Department of Managed
Health Care governing BLUE CROSS.


 


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 16.08 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 16.08 shall be reduced only upon ninety (90)
days written notice to BLUE CROSS provided that PARTICIPATING MEDICAL GROUP
demonstrates to BLUE CROSS’ reasonable satisfaction, that PARTICIPATING MEDICAL
GROUP is unable to provide, due to overcapacity, Covered Medical Services to
Members in accordance with BLUE CROSS guidelines as set forth in the Operations
Manual and Medical Policy Guidelines, and PARTICIPATING MEDICAL GROUP has
reached maximum capacity for all of its health maintenance organization
members.  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.  Nothing in this Section shall
require that BLUE CROSS reassign any Members assigned to PARTICIPATING MEDICAL
GROUP as of the effective date of the ninety (90) day notice referenced herein.


 


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.


 


17

















 


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.


 


E.              BLUE CROSS will
comply with all requirements of California Health and Safety Code
Section 1395.6.  The BLUE CROSS
Managed Care Network may be sold, leased, transferred or conveyed to Other
Payors, which may include workers’ compensation insurers or automobile
insurers.  BLUE CROSS will disclose upon
initial signing of this Agreement and within 30 days of receipt of a written
request from PARTICIPATING MEDICAL GROUP a summary of all Other Payors
currently eligible to pay the negotiated rates under this Agreement as a result
of their arrangement with BLUE CROSS. 
BLUE CROSS requires such Other Payors to actively encourage Covered
Persons to use network participating providers when obtaining medical care
through the use of one or more of the following: reduced copayments, reduced
deductibles, premium discounts directly attributable to the use of a
participating provider, financial penalties directly attributable to the
non-use of a participating provider, providing Covered Persons with the names,
addresses and phone numbers of participating providers in advance of their
selection of a health care provider through the use of provider directories,
toll-free telephone numbers and internet web site addresses.  In the event BLUE CROSS enters into an
arrangement with an Other Payor that does not require such active encouragement
of the use of the BLUE CROSS Managed Care Network, PARTICIPATING MEDICAL GROUP shall
be allowed to decline to provide services to such Other Payor.  When the BLUE CROSS Managed Care Network is
utilized by an Affiliate or Other Payor, PARTICIPATING MEDICAL GROUP agrees to
provide services to Covered Persons of that Affiliate or Other Payor in
accordance with the terms of this Agreement. 
BLUE CROSS shall compensate PARTICIPATING MEDICAL GROUP in accordance
with the terms of this Agreement for services provided to Covered Persons of
any such Other Payor.  If BLUE CROSS
contracts with another Knox-Keene licensed health care service plan to permit
access to the BLUE CROSS Managed Care Network, BLUE CROSS will notify all
affected participating providers in the service area by mail identifying such
health care service plan.  When an Other
Payor utilizes the BLUE CROSS Managed Care Network, such Other Payor shall
comply with the terms of this Agreement.


 


In the event the BLUE CROSS Managed Care Network is to be utilized by
an Other Payor that has operational requirements that are materially different
from those required under this Agreement, BLUE CROSS agrees to notify
PARTICIPATING MEDICAL GROUP in writing thirty (30) days prior to the
commencement of such utilization. 
PARTICIPATING MEDICAL


 


18

















 


GROUP may decline to provide services to such
Other Payor by providing written notice of such decision to BLUE CROSS within
ten (10) days of receipt of notice by BLUE CROSS referenced above.


 


4.11             Compliance
Activities


 


A.           PARTICIPATING
MEDICAL GROUP acknowledges that BLUE CROSS is responsible for the performance
of certain activities (“Compliance Activities”) related to medical services in
order to comply with applicable state and federal laws and accreditation and
certification requirements of managed care organization oversight agencies, including,
but not limited to, the California Department of Managed Health Care (“DMHC”),
the National Committee for Quality Assurance (“NCQA”) and the Health Care
Financing Administration (“HCFA”), if applicable.  PARTICIPATING MEDICAL GROUP understands that BLUE CROSS may
delegate responsibility for some or all Compliance Activities (“Delegated
Compliance Activities”) to qualified PARTICIPATING MEDICAL GROUPs.


 


B.             Delegation of
Compliance Activities


 


(1)          BLUE CROSS hereby
authorizes PARTICIPATING MEDICAL GROUP to perform, and PARTICIPATING MEDICAL
GROUP agrees to perform on BLUE CROSS’ behalf, the Delegated Compliance
Activities delineated in the Division of Responsibilities For Compliance
Activities, Exhibit K (incorporated by reference herein).


 


(2)          BLUE CROSS retains
primary responsibility for Compliance Activities that are not specifically
delegated to PARTICIPATING MEDICAL GROUP. 
PARTICIPATING MEDICAL GROUP shall cooperate and comply with BLUE CROSS’
performance of such activities, as necessary.


 


(3)          If PARTICIPATING
MEDICAL GROUP attains and maintains NCQA Physician Organization Certification
(“POC”), or other certification deemed acceptable by BLUE CROSS during the term
of this Agreement, BLUE CROSS agrees to exempt PARTICIPATING MEDICAL GROUP from
predelegation, annual, and follow-up onsite audits of Delegated Compliance
Activities, except to the extent those Delegated Compliance Activities must be
monitored by BLUE CROSS as required by any regulatory agency having
jurisdiction over BLUE CROSS.  PARTICIPATING
MEDICAL GROUP shall supply written evidence of such POC certification to BLUE
CROSS no less than once every twelve (12) months and upon renewal.  PARTICIPATING MEDICAL GROUP shall
immediately notify BLUE CROSS in the event such certification is revoked or is
not renewed.


 


(4)          Notwithstanding any
delegation of credentialing or recredentialing activities to PARTICIPATING
MEDICAL GROUP, BLUE CROSS retains the right to approve, suspend or deny any
Health Professional from providing services to Members under this Agreement.


 


C.             Compliance
Activities Performance Measurement


 


(1)          PARTICIPATING
MEDICAL GROUP agrees to comply with the Compliance Activity Performance
Measurements indicated in Exhibit K (1) (incorporated by reference herein) for
each listed Compliance Activity Standard for which it is delegated
responsibility.


 


19

















 


(2)          PARTICIPATING
MEDICAL GROUP shall submit all required written documentation demonstrating
compliance with the Compliance Activity Performance Measurement, as delineated
in Exhibit K(1).  Such materials must be
submitted to the appropriate BLUE CROSS contact person as indicated in Exhibit
K (1) by the deadlines set forth therein. 
PARTICIPATING MEDICAL GROUP will be monitored for compliance with
meeting submission time frames.


 


(3)          PARTICIPATING
MEDICAL GROUP agrees to give BLUE CROSS a continuing right of access to
PARTICIPATING MEDICAL GROUP’s records and information pertaining to Delegated
Compliance Activities as necessary to evaluate ongoing qualification for
delegation, and to copy those records and information as needed.


 


D.            Corrective Actions
and Revocation of Delegation


 


(1)          In the event that
BLUE CROSS determines that PARTICIPATING MEDICAL GROUP is in breach of the
terms of this Section 4.11 and/or that PARTICIPATING MEDICAL GROUP fails
to satisfactorily fulfill its responsibilities for performing any Delegated
Compliance Activity, BLUE CROSS may, in addition to any other available remedy:


 


(a)          Require that
PARTICIPATING MEDICAL GROUP submit, within thirty (30) calendar days of
request, a corrective plan of action acceptable to BLUE CROSS and adhere to
such plan; or


(b)         Revoke
PARTICIPATING MEDICAL GROUP’s delegation status, in whole or in part, by giving
thirty (30) calendar days prior written notice to PARTICIPATING MEDICAL GROUP.


 


(2)          In the event BLUE
CROSS determines that continued performance by PARTICIPATING MEDICAL GROUP of
any Delegated Compliance Activity poses a risk of physical, mental, emotional,
or financial harm to a Member, BLUE CROSS may revoke the delegation of such
Compliance Activity, immediately upon written notice to PARTICIPATING MEDICAL
GROUP.


 


(3)          BLUE CROSS retains
the right to modify Exhibits K and K(1) on an annual basis or as may be
reasonably necessary or required to comply with applicable laws or regulations
or the accreditation requirements of regulatory agencies and managed care
organization oversight bodies.  In any
such event, BLUE CROSS shall provide PARTICIPATING MEDICAL GROUP with written
notice.


 


4.12                           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).


 


4.13                           The parties agree
that the financial risk provisions of this Agreement have been negotiated and
agreed to by BLUE CROSS and PARTICIPATING MEDICAL GROUP.


 


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 CALIFORNIACARE
program, and to issue an identification card to each Subscriber or to each
Subscriber and one additional eligible Member covered under a two-party or
family contract as described in the Operations Manual.


 


20

















 


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 Non-Capitated 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 notify
PARTICIPATING MEDICAL GROUP of any CALIFORNIACARE Group Benefit Agreements
between BLUE CROSS and employers, government agencies, or any other groups,
which may substantially affect enrollment at PARTICIPATING MEDICAL GROUP.


 


5.07             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 at the Member’s open enrollment period, or 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.


 


5.08             To exercise
reasonable efforts to negotiate special rates with hospitals and other
providers who contract with BLUE CROSS to render Non-Capitated Services to
Members and to pay hospitals in accord with those agreements.


 


5.09             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.


 


5.10             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.


 


5.11             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).


 


5.12             To collect, or
arrange to have collected, all premiums, Member payments and other items of
income to which BLUE CROSS is entitled under its group and individual contracts
or otherwise, except for (a) co-payments, (b) payments for non-Covered Medical
Services, (c) coordination of benefits payments for professional services which
may be collected by PARTICIPATING


 


21

















 


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 CALIFORNIACARE 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.


 


5.13             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.


 


5.14             To authorize and
arrange for the provision of BLUE CROSS Services to Members, effective
July 1, 2000, for new and renewing business.


 


5.15             To disclose
information to PARTICIPATING MEDICAL GROUP that enables PARTICIPATING MEDICAL
GROUP to be informed regarding the financial risk assumed under this Agreement,
as required in California Health and Safety Code Section 1375.4 and
applicable regulations.


 


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 by an employer group 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 by an employer
group 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


 


22

















 


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.


 


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 (1) the 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             Exhibits D, G and
G-1 (all incorporated by reference herein), set forth Capitation payments for
new and renewing business.  The
applicable Capitation payment for each Member assigned to PARTICIPATING MEDICAL
GROUP, shall be paid monthly, prorated in accordance with Member eligibility.


 


Such Capitation payment shall be adjusted for Member age, sex and
Benefit Agreement in accordance with age, sex and plan relativities that have
been developed by BLUE CROSS based upon actuarial assumptions and BLUE CROSS’
utilization experience.  BLUE CROSS
reserves the right to adjust such relativity factors, upon contract renewal,
based upon BLUE CROSS’ experience.


 


7.02             Capitation shall be
paid in consideration for providing Capitation Services and arranging
Non-Capitated Services for each Member assigned to PARTICIPATING MEDICAL GROUP,
and in consideration for all Capitation 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 group and individual
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.


 


23

















 


7.04             PARTICIPATING
MEDICAL GROUP agrees to continue to provide or arrange for all Covered Medical
Services and benefits to any Member, or former Member, who is eligible for
coverage under the Extension of Benefits provision of the Benefit Agreements,
in exchange for the then current Capitation amount per Member per month of the
Benefit Agreement type under which the Member is, or was, enrolled.  Under the circumstances described in this
Section 7.04 BLUE CROSS shall be financially responsible for Non-Capitated
Services.


 


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


 


7.06             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.


 


7.07             Transplant Services.


 


For those transplant Professional Capitation
Services, including without limitation, bone marrow/stem cell and solid organ
for which PARTICIPATING MEDICAL GROUP is financially responsible (i.e.,
professional component), PARTICIPATING MEDICAL GROUP shall pay for such
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 by
BLUE CROSS, 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.


 


VIII.        ENROLLMENT PROTECTION


 


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


 


8.02             For PARTICIPATING
MEDICAL GROUPs with less than two thousand (2,000) Members, on the effective
date of this Agreement, the liability of PARTICIPATING MEDICAL GROUP for
expenses for Capitation Services rendered to any single Member during the
calendar year shall be limited to the first SIX THOUSAND DOLLARS ($6,000.00) of
such expenses.


 


8.03             If PARTICIPATING
MEDICAL GROUP’s assigned CALIFORNIACARE and BLUE CROSS PLUS enrollment is two
thousand (2,000) or more Members, on the effective date of this Agreement,
PARTICIPATING MEDICAL GROUP agrees to accept risk under either
Subsection A or Subsection B, as indicated below.


 


A.           The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered to
any single Member during the calendar year, shall be limited to the first EIGHT
THOUSAND DOLLARS ($8,000.00) of Capitation Services expenses, which have been
incurred by PARTICIPATING MEDICAL GROUP for that Member, or


 


24

















 


B.             The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered to
any single Member during the calendar year, shall be limited to the first
TWENTY-FIVE THOUSAND DOLLARS ($25,000.00) of Capitation Services expenses which
have been incurred by PARTICIPATING MEDICAL GROUP for that Member.


 


PARTICIPATING MEDICAL GROUP hereby elects to
accept risk pursuant to Section 8.03. 


  A.  B.  (Check one).


 


8.04             Notwithstanding
Section 8.02 or 8.03 above, the liability of PARTICIPATING MEDICAL GROUP
for expenses for Capitation Services for Members who have been diagnosed as
having Acquired Immune Deficiency Syndrome (AIDS) shall be limited to FIFTEEN
HUNDRED DOLLARS ($1,500.00) for any Member who has been diagnosed as having
AIDS according to the most current criteria established by the Center for
Disease Control (CDC) at the time of the diagnosis.


 


8.05             The total expenses
of PARTICIPATING MEDICAL GROUP for Capitation Services rendered to any single
Member during the calendar year 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.


 


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


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


 


C.             Services for which
payment is obtained from BLUE CROSS through any coverage other than
CALIFORNIACARE.


 


All co-payments applicable to 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 co-payments under the Coordination of Benefits
rules in the Member’s Benefit Agreement.


 


8.07             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 calendar year 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, 8.04, 8.05 and 8.06. 
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 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.


 


25

















 


8.08             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.           NON-CAPITATED SERVICES


 


9.01             Non-Capitated
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 Non-Capitated Services are
delineated in Exhibit A(1).  For
purposes of calculating the Non-Capitated Performance Settlement, these
services include, but are not limited to the following:


 


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.              Skilled Nursing
Facility Services.


 


G.             Ambulance Services.


 


H.            Home Health
Services.


 


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


 


J.                Ten percent (10%)
of expenses related to Out-of-Area Emergency Services (Facility and
Professional Expenses).


 


K.            Durable Medical
Equipment and prosthetic devices.


 


L.              Hospice Services.


 


M.         Fifty percent (50%)
of the average wholesale price (AWP) related to chemotherapy drugs (intravenously
administered) and injectable medications (excluding take-home insulin).


 


N.            Mammography
Services.


 


9.02             Billing for
Non-Capitated Services shall be as follows:


 


26

















 


A.           The provider of
Non-Capitated 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; or,


 


B.             The provider of
Non-Capitated Services may bill PARTICIPATING MEDICAL GROUP, in which case,
PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for reimbursement.  BLUE CROSS shall reimburse PARTICIPATING
MEDICAL GROUP within forty-five (45) working days following BLUE CROSS’ receipt
of a clean undisputed claim from PARTICIPATING MEDICAL GROUP, on the condition
that such claim shall be submitted to BLUE CROSS no later than twelve (12)
months after the date of service.  This
section shall only apply for the following Non-Capitated Services:  mammography services, DME, prosthetics and
injectabte medications (including chemotherapy drugs and infused substances).


 


In either case described above, 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 a CALIFORNIACARE Case Manager.


 


9.03             Case Management
Stop-Loss.


 


A.           The Case Management
Program is a program in which a Member’s medical needs are assessed by
PARTICIPATING MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager
to explore and coordinate treatment alternatives.  PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case
Manager prior to the Member achieving the applicable Case Management Stop-Loss
Threshold, as described below.


 


B.             For PARTICIPATING
MEDICAL GROUPs with enrollment of Twenty-Four Thousand (24,000) or more Member
Months for the calendar year, the Case Management Stop-Loss Threshold for an
individual Member shall be SIXTY THOUSAND DOLLARS ($60,000.00) of Non-Capitated
Expenses incurred during that calendar year.


 


For PARTICIPATING MEDICAL GROUPs with enrollment of less than
Twenty-Four Thousand (24,000) Member Months, the Case Management Stop-Loss
Threshold shall be THIRTY-FIVE THOUSAND DOLLARS ($35,000.00) of Non-Capitated
Expenses incurred during that calendar year.


 


C.             Authorized expenses
for Member’s Non-Capitated Services, up to the Case Management Stop-Loss
Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s
PMPM Non-Capitated Expenses. 
Additionally, ten percent (10%) of expenses between the applicable Case
Management Stop-loss Threshold and ONE HUNDRED AND FIFTY THOUSAND DOLLARS
($150,000) incurred by an individual Member will be accrued toward
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.  Non-Capitated expenses greater than ONE
HUNDRED AND FIFTY THOUSAND DOLLARS ($150,000) for any individual Member will
not be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.


 


27

















 


D.            The Case Management
Stop-loss Thresholds described above will apply to Members whose treatment
includes transplants (solid organ and bone marrow/stem cell), except in those
cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as
described in Section 4.02F.  When
PARTICIPATING MEDICAL GROUP fails to provide such notice, all of that Member’s
Non-Capitated Expenses will be included in PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses.


 


9.04             Calculating
PARTICIPATING MEDICAL GROUP PMPM Non-Capitated Expenses.


 


The Non-Capitated Expenses shall include actual expenses incurred by
BLUE CROSS to provide Non-Capitated Services to Members, as authorized or
referred by the PARTICIPATING MEDICAL GROUP. 
Expenses above the Case Management Stop-Loss Threshold, as set forth in
Section 9.03, and expenses incurred by Members or former Members covered
under the Extension of Benefits provision of the Benefit Agreements are
excluded from PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses for purposes
of determining the Non-Capitated Performance Settlement.


 


BLUE CROSS shall accrue Non-Capitated
Expenses by each PARTICIPATING MEDICAL GROUP by the calendar year the services
were incurred and paid through March 31st after year-end.  Beginning in year two (2) of this Agreement,
any claims received after calculation of the final Non-Capitated Performance
Settlement will be charged to the following year’s Non-Capitated Expenses.  Any Non-Capitated Service admissions,
including, but not limited to, inpatient hospital, skilled nursing facility,
hospice and alternative birthing center admissions that occur in one calendar
year and extend into the next year shall accrue to the year the admission
occurred.  Notwithstanding the
aforementioned, any claims for Non-Capitated Services or Shared Risk Services
(as defined in the CALIFORNIACARE Medical Services Agreement in effect for
years prior to the Initial Term of this Agreement) paid after the
March 31st immediately following the effective date hereof will be charged
to the Non-Capitated Expense for the first calendar year, or portion thereof,
of this Agreement.


 


9.05             Non-Capitated
Performance Settlement Schedule.


 


Non-Capitated Performance Settlement
Schedule shall mean a schedule that will be the basis for determining
the Non-Capitated Performance Settlement. 
This schedule presents BLUE CROSS’ prior year aggregate PMPM
Non-Capitated Expenses adjusted by factors to account for medical
inflation.  Exhibit F (incorporated by
reference herein) sets forth the Non-Capitated Performance Settlement Schedule.


 


9.06             Calculating the
Non-Capitated Performance Settlement.


 


A.           PARTICIPATING
MEDICAL GROUP’s Adjusted PMPM Non-Capitated Expense.


 


PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expenses is the quotient of PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses divided by the composite of PARTICIPATING MEDICAL
GROUP’s Age/Sex, Plan, Stop-Loss and Region Factors.


 


The PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expense is adjusted to account for the PARTICIPATING MEDICAL
GROUP’s mix of Members and make the PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses comparable to the Non-Capitated Performance Settlement
Schedule, as set forth in Exhibit F.


 


28

















 


B.             Non-Capitated
Performance Settlement.


 


If the PARTICIPATING MEDICAL GROUP’s Adjusted
PMPM Non-Capitated Expense is equal to or greater than the Attachment Point,
the PARTICIPATING MEDICAL GROUP will not receive a Non-Capitated Performance
Settlement.  If the PARTICIPATING
MEDICAL GROUP’s Adjusted PMPM Non-Capitated Expense is less than the Attachment
Point, the PARTICIPATING MEDICAL GROUP will receive a Non-Capitated Performance
Settlement.


 


The PMPM Non-Capitated Performance Settlement
is determined by allocating a portion of the difference between the Attachment
Point and the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM Non-Capitated
Expense.  The proportion of the
difference allocated to the PMPM Non-Capitated Performance Settlement is according
to the Non-Capitated Performance Settlement Schedule, set forth in Exhibit
F.  The PMPM Non-Capitated Performance
Settlement amount multiplied by the PARTICIPATING MEDICAL GROUP’s calendar year
Member Months determines the total Non-Capitated Performance Settlement.


 


Within one hundred eighty (180) days after
the end of BLUE CROSS’ fiscal year, BLUE CROSS shall pay the Non-Capitated
Performance Settlement if a Non-Capitated Performance Settlement amount is due
to the PARTICIPATING MEDICAL GROUP.


 


Notwithstanding the above, in the event this Agreement
is terminated, BLUE CROSS shall calculate the Non-Capitated Performance
Settlement in accordance with this Article IX and shall pay PARTICIPATING
MEDICAL GROUP a preliminary Non-Capitated Performance Settlement equal to
eighty percent (80%) of any amount due PARTICIPATING MEDICAL GROUP based upon
this calculation.  Twelve (12) months
following the calculation and payment of the preliminary Non-Capitated
Performance Settlement, BLUE CROSS shall calculate a final Non-Capitated
Performance Settlement in accordance with this Article IX and shall pay
any amount due PARTICIPATING MEDICAL GROUP, less any amounts paid at the time
of preliminary Non-Capitated Performance Settlement.  In the event monies paid PARTICIPATING MEDICAL GROUP at the time
of the preliminary Non-Capitated Performance Settlement exceed the final
Non-Capitated Performance Settlement, PARTICIPATING MEDICAL GROUP shall
reimburse BLUE CROSS any amounts owed within forty-five (45) working days of
notification from BLUE CROSS.


 


X.            OUTPATIENT
PRESCRIPTION DRUG EXPENSE


 


10.01       Calculating
PARTICIPATING MEDICAL GROUP PMPM Outpatient Prescription Drug Expenses (“PMPM
OPDE”).


 


The Outpatient Prescription Drug Expense
(“OPDE”) shall include only those amounts paid by BLUE CROSS to pharmacies or
pharmacists to provide covered outpatient prescription drugs to Members
assigned to PARTICIPATING MEDICAL GROUP. 
Any rebates or other similar arrangements between BLUE CROSS and
manufacturers/vendors shall not be considered in determining the Outpatient
Prescription Drug Expense Target, the OPDE, or the Outpatient Prescription Drug
Settlement.


 


BLUE CROSS shall accrue OPDE for each
PARTICIPATING MEDICAL GROUP by the calendar year the services were incurred and
paid through March 31st after year-end. 
Beginning in year two (2) of this Agreement, any claims received after
calculation of the final Outpatient Prescription Drug Settlement will be
charged to the following year’s OPDE. 
Notwithstanding the aforementioned, any claims for outpatient
prescription drug services incurred prior to the Initial Term of this Agreement
paid after the March 31st immediately following the effective date hereof
and if applicable, for subsequent years, will be charged to the OPDE for the
first calendar year of this Agreement, or portion thereof.


 


29

















 


10.02       Outpatient
Prescription Drug Settlement Schedule.


 


The Outpatient Prescription Drug Settlement
Schedule set forth at Exhibit H (incorporated by reference herein) will be
the basis for determining PARTICIPATING MEDICAL GROUP’s Outpatient Prescription
Drug Settlement.


 


10.03       Calculating the
Outpatient Prescription Drug Settlement.


 


If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is
less than the Outpatient Prescription Drug Expense Target, the PARTICIPATING
MEDICAL GROUP will receive an Outpatient Prescription Drug Settlement.  If the PARTICIPATING MEDICAL GROUP’s PMPM
Outpatient Prescription Drug Expense is equal to or greater than the Outpatient
Prescription Drug Expense Target, the PARTICIPATING MEDICAL GROUP will not
receive an Outpatient Prescription Drug Settlement.


 


A.           Outpatient
Prescription Drug Settlement.


 


The PMPM Outpatient Prescription Drug
Settlement is determined by allocating a portion of the difference between the
OPDE Target, and the PARTICIPATING MEDICAL GROUP’s PMPM Outpatient Prescription
Drug Expense.  The proportion of the
difference allocated to the PMPM Outpatient Prescription Drug Settlement is
determined in accordance with the Outpatient Prescription Drug Schedule, set
forth in Exhibit H.


 


B.             Formulary
Utilization Incentive.


 


If PARTICIPATING MEDICAL GROUP’s use of the
BLUE CROSS Outpatient Prescription Drug Formulary (the “Formulary”) is equal to
or greater than ninety-five percent (95%), as described in Exhibit H, and
PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than the OPDE Target, an
additional $0.10 PMPM will be added to PARTICIPATING MEDICAL.  GROUP’s PMPM Outpatient Prescription Drug
Settlement.


 


The amount of the Outpatient Prescription
Drug Settlement and Formulary utilization incentive will be based on the
applicable PMPM Settlement calculation under Exhibit H multiplied by
PARTICIPATING MEDICAL GROUP’s Member Months for Members with outpatient
prescription drug benefits.  Within one
hundred eighty (180) days after the end of BLUE CROSS’ fiscal year, BLUE CROSS
will pay any Outpatient Prescription Drug Settlement that is due PARTICIPATING
MEDICAL GROUP for the previous year.


 


Notwithstanding the above, in the event this
Agreement is terminated, BLUE CROSS shall calculate the Outpatient Prescription
Drug Settlement in accordance with this Article X and shall pay
PARTICIPATING MEDICAL GROUP a preliminary Outpatient Prescription Drug
Settlement equal to eighty percent (80%) of any amount due PARTICIPATING MEDICAL
GROUP based upon this calculation. 
Twelve (12) months following the calculation and payment of the
preliminary Outpatient Prescription Drug Settlement, BLUE CROSS shall calculate
a final Outpatient Prescription Drug Settlement in accordance with this
Article X and shall pay any amount due PARTICIPATING MEDICAL GROUP, less
any amounts paid at the time of preliminary Outpatient Prescription Drug
Settlement.  In the event monies paid
PARTICIPATING MEDICAL GROUP at the time of the preliminary Outpatient
Prescription Drug Settlement exceed the final Outpatient Prescription Drug
Settlement, PARTICIPATING MEDICAL GROUP shall reimburse BLUE CROSS any amounts
owed within forty-five (45) working days of notification from BLUE CROSS.


 


30

















 


XI.           QUALITY MANAGEMENT BONUS


 


Blue Cross will evaluate PARTICIPATING
MEDICAL GROUP’s Quality Management Program and Member quality of care using a
scorecard.  PARTICIPATING MEDICAL GROUP
will be notified of the scorecard parameters and scoring methodology prior to
the start of each year, as described in the Operations Manual.


 


PARTICIPATING MEDICAL GROUP must meet minimum
eligibility criteria to receive a scorecard score and therefore to be eligible
for a Quality Management Bonus.  These
criteria include a minimum of 12,000 Member months for a calendar year and
submission to BLUE CROSS of all necessary encounter data.


 


A Quality Management Bonus will be paid if
PARTICIPATING MEDICAL GROUP’s performance on the scorecard is average or above
average.  No Quality Management Bonus
will be paid if PARTICIPATING MEDICAL GROUP’s scorecard performance is below
average.  BLUE CROSS will notify
PARTICIPATING MEDICAL GROUP of the scorecard results sixty (60) days following
the end of the calendar year.


 


The Quality Management Bonus paid to
PARTICIPATING MEDICAL GROUP, should a payment be due in accordance with the
PMPM Quality Management Bonus Schedule shown in Exhibit I (incorporated by
reference herein), will be made by the fifteenth of June following the end
of the calendar year for which it is based.


 


XII.         BILLING FOR HMO-USA
AWAY FROM HOME CARE SERVICES


 


12.01       PARTICIPATING MEDICAL GROUP agrees to render or
refer urgent care, Emergency services, follow-up care and routine services, as
Host HMO to out-of-state members of HMO-USA participating plans, when such care
is prearranged by BLUE CROSS.  Urgent
care as it relates to the HMO-USA Away From Home Care Program means outpatient
medical care which the Host HMO determines is required for an unexpected
illness or injury that is not life threatening, but which cannot reasonably be
postponed until the HMO-USA participating plan member returns to the service
area of the member’s Home HMO.


 


All medical services rendered at
PARTICIPATING MEDICAL GROUP or Satellite Facilities and all Referral Services
rendered to members of HMO-USA participating plans, due to unavailability of
the required services at PARTICIPATING MEDICAL GROUP, shall be paid by BLUE
CROSS.  For services PARTICIPATING
MEDICAL GROUP provides directly to members of HMO-USA participating plans, BLUE
CROSS shall reimburse PARTICIPATING MEDICAL GROUP at PARTICIPATING MEDICAL
GROUP’s invoiced amount, not to exceed reimbursement in accordance with the
then current Blue Cross of California Prudent Buyer Plan Participating
Physician Agreement fee schedule for the applicable region.  For Referral Services, PARTICIPATING MEDICAL
GROUP may instruct providers of Referral Services to bill BLUE CROSS directly
or, such providers may bill PARTICIPATING MEDICAL GROUP, in which case,
PARTICIPATING MEDICAL GROUP shall be reimbursed by BLUE CROSS.  In all cases, PARTICIPATING MEDICAL GROUP or
provider of Referral Services shall note on the claim that services were rendered
to a member of an HMO-USA participating plan. 
Neither PARTICIPATING MEDICAL GROUP nor provider of Referral Services
shall bill members of HMO-USA participating plans.


 


12.02       BLUE CROSS agrees
to pay PARTICIPATING MEDICAL GROUP within forty-five (45) working days of
receipt of a completed professional services claim form for authorized services
rendered to members of HMO-USA participating plans.  Any claim under the HMO-USA Away From Home Care Program which
would otherwise be the responsibility of BLUE CROSS under this Agreement shall
be the responsibility of PARTICIPATING MEDICAL GROUP if such claim is not
submitted to BLUE CROSS within twelve (12) months of the date of service.


 


31

















 


XIII.        TERM OF AGREEMENT, TERMINATION


 


13.01       This Agreement shall
be in effect for a three (3) 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.


 


13.02       In the event this
Agreement is terminated, PARTICIPATING MEDICAL GROUP agrees to continue to
provide Capitation Services and to arrange Non-Capitated Services for all
Members assigned to PARTICIPATING MEDICAL GROUP, including any Members who
become eligible during the notice period set forth in Section 12.01 above;
and to provide these services consistent with the terms and conditions of the
applicable Benefit Agreements.  In such
cases, 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
applicable 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.


 


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


 


13.04       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 fifteen percent (15%) of the Capitation until
such breach is cured to BLUE CROSS’ satisfaction.


 


32

















 


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


 


14.01       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.


 


14.02       Any problem or
dispute arising under this Agreement and/or concerning the terms of this
Agreement that is not satisfactorily resolved under Section 13.01 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.


 


14.03       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.


 


14.04       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.


 


14.05       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.


 


14.06       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 BLUE CROSS or PARTICIPATING MEDICAL GROUP, respectively, shall be
considered the initiating party for the purposes of Section 14.03 hereof.


 


14.07       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.


 


14.08       With respect to
settlements and/or bonuses under Articles IX, X or XI hereof, PARTICIPATING
MEDICAL GROUP shall review such payment and/or the settlement statement
prepared by BLUE CROSS and shall within forty-five (45) days of receipt notify
BLUE CROSS in writing of any problem or discrepancy; otherwise the right to
challenge the calculation and/or amount of the settlement or bonus shall be
deemed waived by PARTICIPATING MEDICAL GROUP.


 


33

















 


XV.         CALIFORNIACARE
MEMBER GRIEVANCE SYSTEM


 


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


 


15.02       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 CALIFORNIACARE Quality Management Representative.


 


15.03       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.


 


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


 


XVI.        MISCELLANEOUS
PROVISIONS


 


16.01       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.


 


16.02       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.


 


16.03       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, 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.


 


16.04       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.


 


34

















 


16.05       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.


 


16.06       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.


 


16.07       Notices.  Any notice required to be given pursuant to
the terms of this Agreement shall be in writing, and shall be either personally
delivered, or sent by registered or certified mail, in the United States Postal
Service, return receipt requested, postage prepaid, addressed to BLUE CROSS or
PARTICIPATING MEDICAL GROUP at the applicable address below.  The notice shall be effective on the date
received.


 


	
  If to BLUE CROSS:

  	
  Blue Cross of California

  
	
   

  	
  21555 Oxnard Street

  
	
   

  	
  Woodland Hills, CA 91367

  
	
   

  	
   

  
	
  If to PARTICIPATING MEDICAL GROUP:

  
			



 


16.08       Maximum Capacity.  The Maximum Capacity of PARTICIPATING
MEDICAL GROUP during the term of this Agreement shall be 50,000 Members.


 


16.09       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.


 


16.10       Solicitation of
Members.  The business relationship
between BLUE CROSS and its Members, and BLUE CROSS and the employer groups with
which it contracts, shall be deemed the property of BLUE CROSS.  Similarly, all lists of Members accepted by
PARTICIPATING MEDICAL GROUP under the provisions of this Agreement and of the
employer groups to which they belong, 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 or employer groups to disenroll from BLUE CROSS;
(3) solicit such Member or employer group 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.


 


16.11       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.


 


16.12       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.


 


35

















 


16.13       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

  	
  PROSPECT HEALTH SOURCE MEDICAL

  
	
   

  	
   

  	
  GROUP

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Signature:

  	
  /s/ Barry Ford

  	
   

  	
  Signature:

  	
  /s/ Peter G. Goll

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Barry Ford

  	
   

  	
  Name:

  	
  Peter G. Goll

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Vice President

  	
   

  	
  Title:

  	
  Senior Vice President

  	
   

  
	
   

  	
  Network Development & Management

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  1-18-01

  	
   

  	
  Date:

  	
  1-03-01

  	
   

  
								



 


36

















 


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 copayment directly to the physician for each such
visit


 


(2)          Hospital or Skilled
Nursing Facility


 


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


 


Care shall be provided for (i) short-term
evaluation of the Member’s condition when such care is ordered by the attending
PARTICIPATING MEDICAL GROUP Physician and (ii) the diagnosis and medically
necessary treatment of “severe mental illnesses” and “serious emotional disturbances
of a child” as such terms are defined in California Health and Safety Code
Section 1374.72.  Co-payments and
limitations are 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.              Infertility studies
for Members aged 18 or over.


 


F.              Ear examinations.


 


G.             Health education
services as follows:


 


(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.


 












*** Confidential Treatment requested


 


A-1

















 


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


 


H.            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.


 


I.                 Allergy testing and
administration of injections.


 


A-2

















 


EXHIBIT A(1)

CALIFORNIACARE


 


DIVISION OF FINANCIAL RESPONSIBILITIES


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in
the applicable Benefit Agreement


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


 


A(1)-1

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  CHEMOTHERAPY DRUGS
  (intravenously administered)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Chemotherapy Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in the
applicable Benefit Agreement


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


 


A(1)-2

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EMERGENCY ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  EMPLOYMENT PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  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

  (required by third party or outside agency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  *

  	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  HEARING SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Inpatient /Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in the
applicable Benefit Agreement


**          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
the division of financial responsibility have been deleted.


 


A(1)-3

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEPATITIS B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  HOME HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  HOSPICE (in lieu of acute inpatient or SNF care)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in the
applicable Benefit Agreement


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


 


A(1)-4

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  IMMEDIATE CARE - Out Of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  IMMUNIZATION SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  IMMUNIZATION SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  INFANT APNEA MONITOR
  (DME)

  (in conjunction with or concurrent with authorized
  inpatient admiss)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in
the applicable Benefit Agreement


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


 


A(1)-5

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  MENTAL HEALTH SERVICES (PARITY & NON-PARITY)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  *Inpatient Facility
  Component’

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  *lnpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  *Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  NUTRITIONIST/DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  OBSTETRICAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Outpatient Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  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)c

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Holter Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                                         As set forth in the
applicable Benefit Agreement


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


 


A(1)-6

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component
  for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in the
applicable Benefit Agreement


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


 


A(1)-7

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT SURGERY:
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PRE-EXISTING PREGNANCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in the
applicable Benefit Agreement


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


 


A(1)-8

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREGNANCY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PROSTHETIC DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIATION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Outpatient Hospital
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Outpatient Clinic
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in the
applicable Benefit Agreement


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


 


A(1)-9

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Autotogous Blood
  Donations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  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)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*                 As set forth in the
applicable Benefit Agreement


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


 


A(1)-10

















 


EXHIBIT B


 


CALIFORNIACARE HOSPITALS


 


(1)           Century City hospital - 050579


 


(2)           Cedars Sinai Medical Center 050625


 


(3)           Midway hospital Medical Center 050477


 


(4)           Brotman Medical Center 050144


 












*** Confidential Treatment requested


 


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


 


•                            If PARTICIPATING
MEDICAL GROUP selects the Section 8.03A Enrollment Protection level of
EIGHT THOUSAND DOLLARS ($8,000.00), once PARTICIPATING MEDICAL GROUP reaches
two thousand (2,000) Members at the beginning of the calendar year
PARTICIPATING MEDICAL GROUP will receive an additional payment of $ 0.26 PMPM.


 


•                            If PARTICIPATING
MEDICAL GROUP selects the Section 8.03B Enrollment Protection level of
TWENTY-FIVE THOUSAND DOLLARS ($25,000.00), once PARTICIPATING MEDICAL GROUP
reaches two thousand (2,000) Members at the beginning of the calendar year
PARTICIPATING MEDICAL GROUP will receive an additional payment of $ 1.02 PMPM.


 


D-1

















 


EXHIBIT
F


 


NON-CAPITATED PERFORMANCE SETTLEMENT SCHEDULE


For Non-Capitated
Medical Services


 


Based on Plan C, $60,000 Stop Loss, Age/Sex
Factor = 1.00 and Regional Factor = 1.00


 


Non-Capitated Performance Settlement
Calculation Method:


 


1)                                      Identify
the payment band that contains the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expense.


2)                                      Subtract
the PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense from the high
value of the payment band


3)                                      Multiply
the result from Step 2 by the multiplier column for the payment band


4)                                      Add
the result from Step 3 to the minimum payment amount for the payment band to
get the PMPM Non-Capitated Performance Settlement


5)                                      Multiply
the PMPM Non-Capitated Performance Settlement from Step 4 by the PARTICIPATING
MEDICAL GROUP’s Member Months to calculate the Non-Capitated Performance
Settlement


 


	
   

  	
   

  	
  Non-Capitated Expense Ranges

  (PMPM Non-Capitated Expense)

  	
   

  	
   

  	
   

  	
   

  
	
  Payment Bands

  	
   

  	
  Low

  	
   

  	
  High

  	
   

  	
  Multiplier

  	
   

  	
  Minimum Payment Amount

  
	
  1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0

  	
  %

  	
  ***

  
	
  2

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  25

  	
  %

  	
  ***

  
	
  3

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  40

  	
  %

  	
  ***

  
	
  4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  55

  	
  %

  	
  ***

  
	
  5

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65

  	
  %

  	
  ***

  
	
  6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  75

  	
  %

  	
  ***

  
	
  7

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65

  	
  %

  	
  ***

  
	
  8

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  50

  	
  %

  	
  ***

  
	
  9

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  40

  	
  %

  	
  ***

  
	
  10

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0

  	
  %

  	
  ***

  



 












* Attachment Point


 


Example of Non-Capitated Performance
Settlement Calculation


 


Assume: 
PARTICIPATING MEDICAL GROUP has an PMPM Non-Capitated Expense of
[ILLEGIBLE]; and there are 100,000 member months


 


(1)          Identify the payment band that contains the
PARTICIPATING MEDICAL GROUP’s Adjusted PMPM Non-Capitated Expense.  The PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated
Expense of *** falls between the low and high values of payment band 5.


(2)          Subtract the PARTICIPATING MEDICAL GROUP’s
PMPM Non-Capitated Expense from the high value for the payment band.


***


(3)          Multiply the result from Step 2 by the
multiplier for the payment band.


***


(4)          Add the result from Step 3 to the minimum
payment amount for the payment band to get the PMPM Non-Capitated Performance
Settlement ***


*** PMPM Non-Capitated Performance Settlement


(5)          Multiply the PMPM Non-Capitated Performance
Settlement from Step 4 by the PARTICIPATING MEDICAL GROUP’s Member Months to
calculate the Non-Capitated Performance Settlement.


*** PMPM Non-Capitated Performance Settlement
x 100,000 member months = *** Non-Capitated Performance Settlement.


 


F-1

















 


EXHIBIT G


 


COMPENSATION
FOR SERVICES TO BLUE CROSS PLUS MEMBERS


 


In
consideration for the mutual promises herein set forth, PARTICIPATING MEDICAL
GROUP and BLUE CROSS hereby agree as follows:


 


I.              DEFINITIONS


 


A.        “Advance
Supplemental Capitation Payment” means a supplemental Capitation payment
apportioned monthly and paid in advance of the date it is earned.  Advance Supplemental Capitation Payments are
subject to recoupment by BLUE CROSS if not actually earned prior to the end of
the calendar quarter.


 


B.          “Baseline
Capitation Payment” means the monthly Capitation payment for each Member
covered by a  BLUE CROSS PLUS
Benefit Agreement and assigned to PARTICIPATING MEDICAL GROUP.


 


C.          “In-Network
Services” means those services which are provided, arranged by, referred or
authorized by PARTICIPATING MEDICAL GROUP for BLUE CROSS PLUS Members and which
would be CALIFORNIACARE Capitation Services if they had been rendered under the
Agreement to a CALIFORNIACARE Member.


 


D.         “In-Network
Utilization Factor” means the quotient of the Baseline Capitation Payment,
divided by the sum of Baseline Capitation Payments plus expenses for
Out-of-Network Services, modified each calendar quarter to allow for incurred
but not reported expenses (IBNR) based on BLUE CROSS’ overall BLUE CROSS PLUS
experience, as follows:


 


	
  Baseline
  Capitation Payment

  	
   

  	
  =
  A

  
	
   

  	
   

  	
   

  
	
  Expenses for Out-of-Network Services

  (Modified to allow for IBNR)

  	
   

  	
  =
  B

  
	
   

  	
   

  	
   

  
	
  In-Network
  Utilization Factor

  	
   

  	
  =
  C

  
	
   

  	
   

  	
   

  
	
  C
  =

  	
  A

  	
   

  	
   

  	
   

  
	
  A + B

  	
   

  



 


E.           “Non-Participating
Provider” means a Health Professional, hospital, emergency facility,
skilled nursing facility, ambulance service, home health agency, or Alternate
Birthing Center that has rendered services to a BLUE CROSS PLUS Member without
authorization from the PARTICIPATING MEDICAL GROUP to which the Member is
assigned.


 


F.           “Out-of-Network
Services” means those services rendered to BLUE CROSS PLUS Members by a
Non-Participating Provider, and which would be Capitation Services if rendered
by PARTICIPATING MEDICAL GROUP under the Agreement to CALIFORNIACARE Members,
except for Out-of-Area Emergency Services.


 


G.          “Supplemental
Capitation Payment” means a Capitation payment per BLUE CROSS PLUS Member
per month, which may be earned based on the In-Network Utilization Factor as
set forth in Exhibit G(1).


 


G-1

















 


II.                                     COMPENSATION FOR SERVICES TO BLUE CROSS PLUS
MEMBERS


 


The parties agree that the terms of Exhibit D of the Agreement shall
apply only to CALIFORNIACARE Members. 
BLUE CROSS shall compensate PARTICIPATING MEDICAL GROUP for services to
BLUE CROSS PLUS Members as follows:


 


A.        BLUE
CROSS shall pay a Baseline Capitation Payment per Member per month in the
amounts set forth in Exhibit G(1), adjusted to account for age and sex
characteristics of the Member, and Member Benefit Agreement.


 


B.          PARTICIPATING
MEDICAL GROUP may earn Supplemental Capitation Payments by achieving an
In-Network Utilization Factor greater than 0.42 in any calendar quarter, as set
forth in Exhibit G(1).  For any calendar
quarter in which PARTICIPATING MEDICAL GROUP achieves an In-Network Utilization
Factor of 0.42 or above, BLUE CROSS shall make a Supplemental Capitation
Payment in accordance with Exhibit G(1) due sixty (60) working days after the
end of such calendar quarter. 
PARTICIPATING MEDICAL GROUP shall review such payment and/or the
settlement statement prepared by BLUE CROSS and shall within forty-five (45)
days of receipt notify BLUE CROSS in writing of any problem or discrepancy;
otherwise the right to challenge the calculation and/or amount of the
Supplemental Capitation Payment shall be deemed waived by PARTICIPATING MEDICAL
GROUP.


 


C.          PARTICIPATING
MEDICAL GROUP may elect to receive advance Supplemental Capitation Payments
prior to the time PARTICIPATING MEDICAL GROUP’s In-Network Utilization Factor
is known, i.e., during the applicable calendar quarter.  However, if at the end of such calendar
quarter, PARTICIPATING MEDICAL GROUP’s In-Network Utilization Factor is below
0.42, then BLUE CROSS shall have the right to set off the amount of advance
Supplemental Capitation Payments made during such quarter from Capitation
payments due PARTICIPATING MEDICAL GROUP in subsequent months.


 


D.         BLUE
CROSS shall calculate the In-Network Utilization Factor on a  PARTICIPATING MEDICAL GROUP specific
basis for each PARTICIPATING MEDICAL GROUP with 1200 or more BLUE CROSS PLUS
Member Months for the applicable calendar quarter.  All PARTICIPATING MEDICAL GROUPs with 450 to 1199 BLUE CROSS PLUS
Member Months, for the applicable calendar quarter, will be pooled for
determining the In-Network Utilization Factor. 
All PARTICIPATING MEDICAL GROUPs with fewer than 450 BLUE CROSS PLUS
Member Months, for the applicable calendar quarter, will be grouped into a
second pool for determining the In-Network Utilization Factor.


 


E.           Total
claims for Out-of-Network Expenses rendered to any single BLUE CROSS PLUS
Member during the calendar year shall be limited to 140% of the Enrollment
Protection level selected by PARTICIPATING MEDICAL GROUP for CALIFORNIACARE and
BLUE CROSS PLUS Members under Article VIII, Sections 8.02 or 8.03 of the
Agreement.


 


F.           The
liability of PARTICIPATING MEDICAL GROUP for expenses for Capitation Services
rendered during the calendar year to any single Member enrolled in BLUE CROSS
PLUS shall be limited to the applicable Enrollment Protection amount defined in
Sections 8.02, 8.03 and 8.04.  Expenses
considered under Enrollment Protection shall include expenses incurred by
PARTICIPATING MEDICAL GROUP.  Expenses
for out-of-network services are not included.


 


G.          BLUE
CROSS may complete an audit of BLUE CROSS PLUS capitation payments within six
(6) months after the end of the calendar year to reconcile any annual over or
underpayments.


 


G-2

















 


EXHIBIT G(1)


 


BLUE CROSS
PLUS BASELINE CAPITATION


 


•                  If
PARTICIPATING MEDICAL GROUP selects the Section 8.03A Enrollment
Protection level of EIGHT THOUSAND DOLLARS ($8,000.00), once PARTICIPATING MEDICAL
GROUP reaches two thousand (2,000) Members at the beginning of the calendar
year PARTICIPATING MEDICAL GROUP will receive an additional payment of $        PMPM.


 


•                  If
PARTICIPATING MEDICAL GROUP selects the Section 8.03B Enrollment
Protection level of TWENTY-FIVE THOUSAND DOLLARS ($25,000.00), once
PARTICIPATING MEDICAL GROUP reaches two thousand (2,000) Members at the
beginning of the calendar year PARTICIPATING MEDICAL GROUP will receive an
additional payment of $          PMPM.


 


G(1)-1

















 


EXHIBIT H


 


OUTPATIENT
PRESCRIPTION DRUG SETTLEMENT SCHEDULE


 


PMPM
Outpatient Prescription Drug Expense Target: 
*** PMPM


 




	
  PMPM Expense Range

  	
   

  	
  Settlement Calculation

  
	
  Greater than ***

  	
   

  	
  ***

  
	
  *** to ***

  	
   

  	
  (*** - PMPM OPDE) x 45%

  
	
  *** to ***

  	
   

  	
  (*** - PMPM OPDE) x 50%

  
	
  Less than ***

  	
   

  	
  *** PMPM

  






 


If
PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than the OPDE Target, an
additional $0.10 PMPM will be due to PARTICIPATING MEDICAL GROUP if
PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal to or greater than
95%.


 


	
  Formulary
  Utilization:

  	
   

  	
  Is
  the quotient of the number of prescriptions for Members with outpatient
  prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP using
  drugs listed in the Blue Cross of California Outpatient Prescription Drug
  Formulary divided by the total number of prescriptions for Members with
  outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL
  GROUP.

  



 


H-1

















 


EXHIBIT I


 


QUALITY
MANAGEMENT BONUS SCHEDULE


 


	
  Quality Management Scorecard Rating

  	
   

  	
  PMPM Quality Bonus Settlement

  
	
  Below Average

  	
   

  	
  ***

  
	
  Average

  	
   

  	
  ***

  
	
  Above Average

  	
   

  	
  ***

  



 


Where:


 


“Average”
is the numeric average of all PARTICIPATING MEDICAL GROUP scorecard scores plus
or minus one standard deviation.


 


“Above
Average” is a score that is greater than one standard deviation above the
numeric average of all PARTICIPATING MEDICAL GROUP scorecard scores.


 


“Below
Average” is a score that is less than one standard deviation below the numeric
average of all PARTICIPATING MEDICAL GROUP scorecard scores.


 


I-1

















 


EXHIBIT J


 


PARTICIPATING
MEDICAL GROUP FACILITIES


 












*** Confidential Treatment requested


 


J-1

















 


1/15/01


 


PROSPECT
HEALTH SOURCE MEDICAL GROUP PRIMARY CARE PHYSICIANS ALPHA LISTING


 


	
  SPECIALTY/CLASS

  	
   

  	
  PROVIDER
  NAME

  	
   

  	
  PHONE

  	
   

  	
  FAX

  	
   

  	
  STREET

  	
   

  	
  CITY

  	
   

  	
  STATE

  	
   

  	
  ZIP CODE

  
	
  IM

  	
   

  	
  1

  	
   

  	
  BAHARVAR
  JAMES

  	
   

  	
  (310)
  ?2?-6?68

  	
   

  	
  (310)
  828-9597

  	
   

  	
  2001
  SANTA MONICA BL #690

  	
   

  	
  SANTA
  MONICA

  	
   

  	
  CA

  	
   

  	
  90404

  
	
  IM

  	
   

  	
  1

  	
   

  	
  BAILEY-WALTON,
  PAULA

  	
   

  	
  (310)
  657-9413

  	
   

  	
  (310)
  657-7433

  	
   

  	
  150
  N ROBERTSON #250

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  PD

  	
   

  	
  1

  	
   

  	
  BALLOU,
  NICOLETTE

  	
   

  	
  (310)
  659-7??7

  	
   

  	
  (310)
  659-0?04

  	
   

  	
  892
  WILSHIRE BL #604

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  PD

  	
   

  	
  C

  	
   

  	
  BASS,
  BRENDA

  	
   

  	
  (310)
  273-7401

  	
   

  	
  (310)
  273-7403

  	
   

  	
  9201
  SUNSET BL #406

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  900??

  
	
  IM

  	
   

  	
  1

  	
   

  	
  BATRA,
  GOPAL

  	
   

  	
  (310)
  829-3385

  	
   

  	
  (310)
  828-6635

  	
   

  	
  2428
  SANTA MONICA BL #402

  	
   

  	
  SANTA
  MONICA

  	
   

  	
  CA

  	
   

  	
  90404

  
	
  IM

  	
   

  	
  1

  	
   

  	
  BHUTA,
  MAHESH

  	
   

  	
  (310)
  559-9884

  	
   

  	
  (310)
  836-8422

  	
   

  	
  9711
  VENICE BL

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90034

  
	
  PD

  	
   

  	
  C

  	
   

  	
  BLUESTONE,
  DAVID A

  	
   

  	
  (323)
  936-7294

  	
   

  	
  (323)
  954-9295

  	
   

  	
  6221
  WILSHIRE BL #215

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90048

  
	
  IM

  	
   

  	
  1

  	
   

  	
  BROWN,
  HARVEY V

  	
   

  	
  (310)
  274-7303

  	
   

  	
  (310)
  274-8572

  	
   

  	
  435
  N ROXBURY DR #311

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  PD

  	
   

  	
  1

  	
   

  	
  BUSH,
  ROSETTA

  	
   

  	
  (310)
  641-2095

  	
   

  	
  (310)
  337-2740

  	
   

  	
  6610
  S SEPULYEDA BL #206

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90045

  
	
  FP

  	
   

  	
  1

  	
   

  	
  CANTOR,
  HARVEY

  	
   

  	
  (310)
  360-7670

  	
   

  	
  (310)
  360-7877

  	
   

  	
  150
  N ROBERTSON #350

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  PD

  	
   

  	
  1

  	
   

  	
  COOPER,
  BERTAN

  	
   

  	
  (310)
  673-?061

  	
   

  	
  (310)
  673-3247

  	
   

  	
  101
  N LA BREA AV #105

  	
   

  	
  INGLEWOOD

  	
   

  	
  CA

  	
   

  	
  90301

  
	
  FP

  	
   

  	
  1

  	
   

  	
  COVINGTON,
  ELIZABETH

  	
   

  	
  (323)
  290-2107

  	
   

  	
  (323)
  290-0632

  	
   

  	
  3701
  STOCKER ST #100

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90008

  
	
  IM

  	
   

  	
  1

  	
   

  	
  DANEL,
  JAMES

  	
   

  	
  (310)
  3?0-7670

  	
   

  	
  (310)
  360-7877

  	
   

  	
  150
  N ROBERTSON #350

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  PD

  	
   

  	
  1

  	
   

  	
  DELEAVER-RUSSELL,
  MARCO

  	
   

  	
  (310)
  838-404?

  	
   

  	
  (310)
  838-0491

  	
   

  	
  3831
  HUGHES AV #601

  	
   

  	
  CULVER
  CITY

  	
   

  	
  CA

  	
   

  	
  90232

  
	
  IM

  	
   

  	
  1

  	
   

  	
  DITLOVE,
  JACK

  	
   

  	
  (310)
  273-1150

  	
   

  	
  (310)
  273-7926

  	
   

  	
  435
  N ROXBURY DR #102

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  IM

  	
   

  	
  1

  	
   

  	
  DOOSTAN,
  JAYE

  	
   

  	
  (310)
  859-0415

  	
   

  	
  (310)
  859-0642

  	
   

  	
  465
  N ROXBURY DR #909

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  PD

  	
   

  	
  1

  	
   

  	
  EISEN,
  HERMAN

  	
   

  	
  (310)
  670-1455

  	
   

  	
  (310)
  670-0951

  	
   

  	
  8725
  LA TUERA BL

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90045

  
	
  IM

  	
   

  	
  1

  	
   

  	
  EASENMAN,
  DANA G

  	
   

  	
  (310)
  380-7670

  	
   

  	
  (310)
  360-7677

  	
   

  	
  150
  N RCBERTSON #350

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  FICHMAN,
  MARSHAL

  	
   

  	
  (310)
  271-5784

  	
   

  	
  (310)
  288-8801

  	
   

  	
  8635
  W 3RD ST #292-W

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90048

  
	
  FP

  	
   

  	
  1

  	
   

  	
  FLETCHER,
  BETTY

  	
   

  	
  (310)
  313-4555

  	
   

  	
  (310)
  313-455?

  	
   

  	
  12099
  W WASHINGTON #402

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90066

  
	
  IM

  	
   

  	
  1

  	
   

  	
  FRISCH,
  DAVID M

  	
   

  	
  (310)
  659-6718

  	
   

  	
  (310)
  652-5656

  	
   

  	
  150
  N ROBERTSON #350

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  PD

  	
   

  	
  1

  	
   

  	
  GIVELBER,
  ANNAI

  	
   

  	
  (323)
  850-1177

  	
   

  	
  (323)
  650-1?93

  	
   

  	
  7531
  SANTA MONICA BL #201

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90046

  
	
  PD

  	
   

  	
  1

  	
   

  	
  GUCLICH,
  DONALD

  	
   

  	
  (310)
  670-1455

  	
   

  	
  (310)
  670-0951

  	
   

  	
  8725
  LA TUERA BL

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90045

  
	
  IM

  	
   

  	
  1

  	
   

  	
  GOLDBERG,
  HOWARD

  	
   

  	
  (310)
  659-7537

  	
   

  	
  (310)
  289-7941

  	
   

  	
  8631
  W 3RD ST #445-E

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90048

  
	
  IM

  	
   

  	
  I

  	
   

  	
  HAUPTSCHEIN,
  MARTIN

  	
   

  	
  (310)
  553-6777

  	
   

  	
  (310)
  277-632?

  	
   

  	
  2080
  CENTURY PK E #906

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90067

  
	
  IM

  	
   

  	
  C

  	
   

  	
  HAWKINS,
  RANDY

  	
   

  	
  (310)
  674-5353

  	
   

  	
  (310)
  674-7712

  	
   

  	
  644
  E REGENT ST #200

  	
   

  	
  INGLEWOOD

  	
   

  	
  CA

  	
   

  	
  90301

  
	
  PD

  	
   

  	
  1

  	
   

  	
  HEKMAT,
  FARAHO

  	
   

  	
  (310)
  276-0541

  	
   

  	
  (310)
  276-9244

  	
   

  	
  9601
  WILSHIRE BL #402

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  IM

  	
   

  	
  1

  	
   

  	
  HELFENSTEIN,
  JEFFREY S

  	
   

  	
  (310)
  276-2379

  	
   

  	
  (310)
  27?-93?5

  	
   

  	
  436
  N ROXBURY DR #222

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  PD

  	
   

  	
  1

  	
   

  	
  KEENE,
  DAVID N

  	
   

  	
  (310)
  273-0330

  	
   

  	
  (310)
  273-8358

  	
   

  	
  250
  ROBERTSON BL #404

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  KIM,
  KRISTY Y

  	
   

  	
  (310)
  659-7473

  	
   

  	
  (310)
  652-0442

  	
   

  	
  8635
  W 3RD ST #670-W

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90048

  
	
  PD

  	
   

  	
  1

  	
   

  	
  KIRKSEY,
  DAVID J

  	
   

  	
  (310)
  670-1455

  	
   

  	
  (310)
  670-0??1

  	
   

  	
  8725
  LA TJERA BL

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90045

  
	
  IM

  	
   

  	
  1

  	
   

  	
  KLEIN,
  KEITH

  	
   

  	
  (310)
  657-9841

  	
   

  	
  (310)
  657-9?93

  	
   

  	
  8920
  WILSHIRE BL #620

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  KORNFELD,
  HERBERT

  	
   

  	
  (310)
  553-2122

  	
   

  	
  (310)
  28?-1911

  	
   

  	
  2060
  CENTURY PK E #1150

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90067

  
	
  IM

  	
   

  	
  1

  	
   

  	
  LANDS,
  KENNETH

  	
   

  	
  (310)
  677-8881

  	
   

  	
  (310)
  677-0577

  	
   

  	
  501
  E HARDY ST #407

  	
   

  	
  INGLEWOOD

  	
   

  	
  CA

  	
   

  	
  90301

  



 


1

















 


	
  SPECIALTY/CLASS

  	
   

  	
  PROVIDER
  NAME

  	
   

  	
  PHONE

  	
   

  	
  FAX

  	
   

  	
  STREET

  	
   

  	
  CITY

  	
   

  	
  STATE

  	
   

  	
  ZIP CODE

  
	
  IM

  	
   

  	
  1

  	
   

  	
  LANE,
  WILLIAM

  	
   

  	
  (310)
  670-4447

  	
   

  	
  (310)
  670-9415

  	
   

  	
  6801
  PARK TERR DR #620

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90045

  
	
  FP

  	
   

  	
  1

  	
   

  	
  LAVET,
  NORMAN O

  	
   

  	
  (310)
  360-7670

  	
   

  	
  (310)
  3?0-7?77

  	
   

  	
  150
  N ROBERTSON #350

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  LEITNER,
  PAUL

  	
   

  	
  (310)
  410-1944

  	
   

  	
  (310)
  410-3925

  	
   

  	
  8540
  S SEPULVEDA BL #910

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90045

  
	
  IM

  	
   

  	
  1

  	
   

  	
  LEVIN,
  WILLIAM

  	
   

  	
  (310)
  553-6777

  	
   

  	
  (310)
  277-?32?

  	
   

  	
  2080
  CENTURY PK E #08

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90067

  
	
  IM

  	
   

  	
  C

  	
   

  	
  LEVINE,
  SEYMOUR

  	
   

  	
  (310)
  ?57-2855

  	
   

  	
  (310)
  657-7433

  	
   

  	
  150
  N ROBERTSON #250

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  PD

  	
   

  	
  1

  	
   

  	
  LIPIN,
  JEROME L

  	
   

  	
  (310)
  ?52-3981

  	
   

  	
  (310)
  652-3155

  	
   

  	
  8733
  BEVERLY BL #200

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90048

  
	
  IM

  	
   

  	
  1

  	
   

  	
  LIPPER,
  ARTHUR

  	
   

  	
  (310)
  ?59-8077

  	
   

  	
  (323)
  659-8890

  	
   

  	
  150
  N ROBERTSON #350

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  MERRILL,
  WAYMAN D

  	
   

  	
  (323)
  ?74-5353

  	
   

  	
  (310)
  674-7041

  	
   

  	
  644
  E REGENT ST

  	
   

  	
  INGLEWOOD

  	
   

  	
  CA

  	
   

  	
  90301

  
	
  IM

  	
   

  	
  1

  	
   

  	
  METH,
  ROBERT

  	
   

  	
  (310)
  556-1377

  	
   

  	
  (310)
  556-1650

  	
   

  	
  2080
  CENTURY PK E #810

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90067

  
	
  IM

  	
   

  	
  1

  	
   

  	
  MARAHMADI,
  MIKE

  	
   

  	
  (310)
  ?58?5090

  	
   

  	
  (310)
  276-550?

  	
   

  	
  435
  N BEDFORD DR #312

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  IM

  	
   

  	
  1

  	
   

  	
  MURO,
  JESUS

  	
   

  	
  (310)
  ?3?-7381

  	
   

  	
  (310)
  204-5497

  	
   

  	
  3831
  HUGHES AV #707

  	
   

  	
  CULVER
  CITY

  	
   

  	
  CA

  	
   

  	
  90232

  
	
  IM

  	
   

  	
  1

  	
   

  	
  MUSNGI,
  EDGAR

  	
   

  	
  (310)
  301-0015

  	
   

  	
  (310)
  388-1466

  	
   

  	
  4844
  LINCOLN BL #?40

  	
   

  	
  MARINA
  DELREY

  	
   

  	
  CA

  	
   

  	
  90292

  
	
  IM

  	
   

  	
  1

  	
   

  	
  NEIOORF,
  BARRY S

  	
   

  	
  (323)
  277-2771

  	
   

  	
  (323)
  277-51?4

  	
   

  	
  2080
  CENTURY PKE #906

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90067

  
	
  FP

  	
   

  	
  1

  	
   

  	
  PATT,
  STEPHEN

  	
   

  	
  (310)
  444-?350

  	
   

  	
  (310)
  444-6353

  	
   

  	
  11687
  NATIONAL BL

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90064

  
	
  PD

  	
   

  	
  1

  	
   

  	
  PEACE,
  DEVAUGHN K

  	
   

  	
  (310)
  299-9914

  	
   

  	
  (310)
  292-3254

  	
   

  	
  4326
  S WESTERN #500

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90062

  
	
  IM

  	
   

  	
  1

  	
   

  	
  RICE?ERG,
  EDWARD

  	
   

  	
  (310)
  550-8028

  	
   

  	
  (310)
  27?-1570

  	
   

  	
  9400
  BRIGHTON WY #404

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  FP

  	
   

  	
  1

  	
   

  	
  RICHMOND,
  HARVEY

  	
   

  	
  (310)
  273-4160

  	
   

  	
  (310)
  273-3932

  	
   

  	
  435
  N BEDFORD DR #10

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90214

  
	
  IM

  	
   

  	
  1

  	
   

  	
  RIEUX,
  SHERRK

  	
   

  	
  (310)
  657-9413

  	
   

  	
  (310)
  657-7433

  	
   

  	
  150
  N ROBERTSON #250

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  ROSE,
  ROBERT

  	
   

  	
  (310)
  204-1146

  	
   

  	
  (310)
  204-5921

  	
   

  	
  3831
  HUGHES AV #702

  	
   

  	
  CULVER
  CITY

  	
   

  	
  CA

  	
   

  	
  90232

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  (310)
  278-3400

  	
   

  	
  (310)
  278-1240

  	
   

  	
  414
  N CAMDEN #1100

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  IM

  	
   

  	
  1

  	
   

  	
  ROTHBART,
  ROBERT

  	
   

  	
  (310)
  274-7303

  	
   

  	
  (310)
  274-8572

  	
   

  	
  435
  N ROXBURY DR #311

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  PD

  	
   

  	
  1

  	
   

  	
  RUSSELL
  HUBERT

  	
   

  	
  (310)
  204-0223

  	
   

  	
  (310)
  204-4251

  	
   

  	
  3831
  HUGHES AV #601

  	
   

  	
  CULVER
  CITY

  	
   

  	
  CA

  	
   

  	
  90232

  
	
  PD

  	
   

  	
  1

  	
   

  	
  SAKHAI,
  YUSSEF

  	
   

  	
  (323)
  653-3500

  	
   

  	
  (323)
  785-30?6

  	
   

  	
  6360
  WILSHIRE BL #305

  	
   

  	
  CULVER
  CITY

  	
   

  	
  CA

  	
   

  	
  90048

  
	
  IM

  	
   

  	
  1

  	
   

  	
  SALTZMAN,
  ROBERT

  	
   

  	
  (310)
  550-8020

  	
   

  	
  (310)
  278-1570

  	
   

  	
  9400
  BRIGHTON WY #404

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  IM

  	
   

  	
  1

  	
   

  	
  SCOTT,
  CRANFORD

  	
   

  	
  (310)
  873-65?1

  	
   

  	
  (310)
  419-4483

  	
   

  	
  625
  E HARDY ST

  	
   

  	
  INGLEWOOD

  	
   

  	
  CA

  	
   

  	
  90301

  
	
  IM

  	
   

  	
  1

  	
   

  	
  SHWAYDER,
  MICHAEL

  	
   

  	
  (310)
  301-0015

  	
   

  	
  (310)
  388-1468

  	
   

  	
  4644
  LINCOLN BL #540

  	
   

  	
  MARINA
  DEL REY

  	
   

  	
  CA

  	
   

  	
  90292

  
	
  IM

  	
   

  	
  1

  	
   

  	
  SIMONS,
  STEVEN M

  	
   

  	
  (310)
  274-7303

  	
   

  	
  (310)
  274-8572

  	
   

  	
  435
  N ROXBURY DR #311

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  IM

  	
   

  	
  1

  	
   

  	
  SLADEK,
  JULIA

  	
   

  	
  (310)
  657-1780

  	
   

  	
  (310)
  652-2269

  	
   

  	
  8920
  WILSHIRE BL #321

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  TABIBIAM
  BLALICK

  	
   

  	
  (310)
  665-9005

  	
   

  	
  (310)
  665-9004

  	
   

  	
  8540
  S SEPULVEDA BL #1100

  	
   

  	
  LOS
  ANGELES

  	
   

  	
  CA

  	
   

  	
  90045

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  (310)
  665-9005

  	
   

  	
  (310)
  865-9004

  	
   

  	
  435
  N BEDFORD DR #312

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90210

  
	
  IM

  	
   

  	
  1

  	
   

  	
  TATUM,
  VANESSA D

  	
   

  	
  (310)
  ?74-9372

  	
   

  	
  (310)
  674-4680

  	
   

  	
  501
  E HARDY ST #425

  	
   

  	
  INGLEWOOD

  	
   

  	
  CA

  	
   

  	
  90301

  
	
  IM

  	
   

  	
  1

  	
   

  	
  THEARD,
  LOWELL

  	
   

  	
  (310)
  838-6801

  	
   

  	
  (310)
  838-5385

  	
   

  	
  3831
  HUGHES AV #705

  	
   

  	
  CULVER
  CITY

  	
   

  	
  CA

  	
   

  	
  90232

  
	
  IM

  	
   

  	
  1

  	
   

  	
  WAKS,
  ABRAHAM U

  	
   

  	
  (310)
  657-9841

  	
   

  	
  (310)
  ?57-9893

  	
   

  	
  8920
  WILSHIRE BL #520

  	
   

  	
  BEVERLY
  HILLS

  	
   

  	
  CA

  	
   

  	
  90211

  
	
  IM

  	
   

  	
  1

  	
   

  	
  WALDMAN,
  ROBERT P

  	
   

  	
  (310)
  301-0015

  	
   

  	
  (310)
  388-1486

  	
   

  	
  4644
  LINCOLN BL #540

  	
   

  	
  MARINA
  DEL REY

  	
   

  	
  CA

  	
   

  	
  90292

  



 


2

















 


EXHIBIT K


 


DIVISION OF
RESPONSIBILITIES FOR COMPLIANCE ACTIVITIES


 


K-1

















 


EXHIBIT K(1)


 


COMPLIANCE
ACTIVITY PERFORMANCE MEASUREMENTS


 


K(1)-1

















 


Attachment 1


 


CaliforniaCare



Division
of Responsibilities for Compliance Activities


 


	
  PARTICIPATING MEDICAL GROUP: Prospect
  Health Source Medical Group

  	
   

  	
  Effective Date: 1/1/2001

  
	
   

  	
   

  	
   

  
	
  PMG/IPA Code: (OMP)

  	
   

  	
   

  



 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Quality Management Compliance
  Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  QI 1 *Program Structure

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  QM program description in writing

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Program is accountable to governing body

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Program updated/evaluated/approved annually

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Designated physician has substantial involvement

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Committee involvement

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.6

  	
   

  	
  Program specifies committee role, structure/function

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.7

  	
   

  	
  Annual QM work plan

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.8

  	
   

  	
  Program resources adequate to meet needs

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 2 *Program Operations

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.1

  	
   

  	
  Committee recommends policy decisions, evaluates results of QM
  activities

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.2

  	
   

  	
  Contemporaneous/dated/stgned minutes of QM committee decisions and
  actions

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.3

  	
   

  	
  Practitioners actively participate in QM program

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 3 Health Services Contracting

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 4 Availability of Practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *4.4

  	
   

  	
  When practitioner’s contract is discontinued, a member undergoing
  active course of treatment is allowed continued access to that practitioner

  	
   

  	
  X

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required 


 

















 


 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  	 

	
  Quality Management Compliance
  Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  	 

	
  QI 5 *Accessibility of Services

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	 

	
   

  	
   

  	
  5.1

  	
   

  	
  Establishes standrards for:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • timeliness
  of preventive care appointments

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • timeliness
  of routine primary care appointments

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • timeliness
  of urgent care appointments

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • timeliness
  of emergency care

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • access
  to after-hours care

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • key
  elements of telephone service

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.2

  	
   

  	
  Collects/analyzes data to measure performance against standards

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.3

  	
   

  	
  Identifies opportunities for improvement

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.4

  	
   

  	
  Implements interventions to improve performance

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.5

  	
   

  	
  Measures effectiveness of interventions

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 6 *Member Satisfaction

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.1

  	
   

  	
  Assesses member satisfaction by:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • evaluating
  member complaints/appeals

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • evaluating
  requests to change practitioners and/or sites

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.2

  	
   

  	
  Utilizes appropriate methods to collect data

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • appropriate
  population is identified

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • appropriate
  samples drawn from population

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • valid
  and reliable data collected

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.3

  	
   

  	
  Analyzes data for activities in QI 6.1 and HEDIS consumer survey

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.4

  	
   

  	
  Identifies opportunities for improvement

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.5

  	
   

  	
  Implements interventions to improve performance

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.6

  	
   

  	
  Measures effectiveness of interventions

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.7

  	
   

  	
  Informs practitioners/providers of results of member satisfaction
  activities

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 7 *Health Management Systems

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  7.1

  	
   

  	
  Identifies members with chronic conditions and offers services to
  manage their conditions

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  7.2

  	
   

  	
  Informs/educates practitioners regarding health management programs
  for members assigned to them

  	
   

  	
  X

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Quality Management Compliance
  Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  QI 8 *Clinical Practice Guidelines

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  Guidelines are based on reasonable medical evidence

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.2

  	
   

  	
  Practitioner involvement in adoption of guidelines

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.3

  	
   

  	
  Reviews/updates guidelines every 2 years

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.4

  	
   

  	
  Distributes guidelines to practitioners

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.5

  	
   

  	
  Annually, measures performance against 2 guidelines

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.6

  	
   

  	
  Decision making in those areas where clinical guidelines are
  applicable is consistent with guidelines

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 9 Continuity and Coordination of Care

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *9.1

  	
   

  	
  Continuity and coordination of care that members receive across
  practices and provider sites is monitored including at a minimum primary care
  sites with 50 or more members

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  9.2

  	
   

  	
  Ensures continuity and coordination with behavioral healthcare.  There is collaboration with behavioral
  health specialists to:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • *exchange
  information in an effective, timely and confidential manner, including
  patient-approved communications between medical practitioners and behavioral
  health practitioners and providers

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • *promote
  appropriate diagnosis, treatment & referral of behavioral health
  disorders commonly seen in primary care

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • psychopharmacological
  medication

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • *timely
  access for treatment and followup for individuals with coexisting medical and
  behavioral disorders

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  9.3

  	
   

  	
  Collect/analyze data to evaluate continuity and coordination of care

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • analyzes
  data to Identify any opportunities for improvement

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • collaborates
  with its behavioral health specialists to identify an opportunity to improve
  coordination of behavioral health with general medical care

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  9.4

  	
   

  	
  Implementation to improve continuity and coordination of care

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • interventions
  identify opportunity for improvement

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • *collaborates
  with behavioral health specialists to take action to improve coordination of
  behavioral health with general medical care

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  QI 10 CIinical Measurement Activities

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 11 Intervention and Follow-Up for
  Clinical Issues

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI 12 Effectiveness of the QI Program

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *12.1

  	
   

  	
  Annual written evaluation of QM program includes:

  	
   

  	
  X

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Quality Management Compliance
  Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • description of
  completed/ongoing activities

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • trending of
  measures to assess performance

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • analysis of
  demonstrated improvements in clinical care/quality of service to members

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • evaluation of
  effectiveness of QM program

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.2

  	
   

  	
  QM
  activities provide meaningful improvement in quality of clinical care and of
  service to members

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.3

  	
   

  	
  Information
  regarding QM program, including description/report on progress, is available
  to members and practitioners

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  QI
  13 *Delegation of QI Activity

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  13.1

  	
   

  	
  A
  mutually agreed upon documents describes:

  	
   

  	
  Not Applicable

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • responsibilities
  of delegated agency and entity

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • the delegated
  activities

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • frequency of reporting

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • process
  utilized to evaluate the delegated agency’s performance

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  13.2

  	
   

  	
  There
  is evidence that:

  	
   

  	
  Not Applicable

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • delegated
  agency’s capacity to perform activities prior to delegation is evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • the delegated
  agency’s QM workplan/QM program description is approved annually

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • regular reports
  as specified in 13.1 are evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • there is an
  annual evaluation on whether delegated agency activities are conducted in
  accordance with the entities expectations/NCQA standards

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Utilization Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  UM 1 *Utilization Management Structure

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  UM program description in writing

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Designated senior physician has substantial involvement in program implementation

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Description includes scope, processes and information sources used to
  make determinations of benefit coverage and medical appropriateness

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Program updated/evaluated/approved annually

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  UM 2 *Clinical UM Criteria

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.1

  	
   

  	
  Criteria for determination of medical appropriateness are clearly
  documented and include procedures for applying criteria based on the needs of
  individual patients and characteristics of the local delivery system

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  2.2

  	
   

  	
  Actively practicing practitioners are involved in development or
  adoption of criteria and in the development and review of procedures for
  applying the criteria

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  2.3

  	
   

  	
  Reviews and updates criteria as necessary

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  2.4

  	
   

  	
  How practitioners can obtain criteria is stated in writing and
  criteria is provided to practitioners upon request

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  2.5

  	
   

  	
  Annually, evaluates how practitioners involved consistently apply
  criteria in decision making

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  UM 3 *Appropriate Professionals

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.1

  	
   

  	
  Licensed health professionals supervise review decisions

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.2

  	
   

  	
  Licensed physician reviews denials based on medical appropriateness

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.3

  	
   

  	
  Board certified physicians from appropriate specialty areas are used to
  assist in making determination of medical appropriateness

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  UM 4 *Timeliness of UM Decision

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  NCQA standards for timeliness of UM decision making are followed

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.2

  	
   

  	
  Procedures for registering/responding to expedited appeals are
  established:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  initiated by member/practitioner on behalf of member

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • decision
  is made no later than 72 hours after review and member and practitioner are
  notified

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • there
  is written confirmation within 2 working days of providing notification of
  decision, if initial decision not in writing

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Utilization Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  UM 5 *Medical Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  When making a determination of coverage based on medical
  appropriateness, relevant clinical information is obtained and the treating
  physician is consulted

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  UM 6 *Denial Notices

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The reasons for each denial are clearly documented and communicated

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.1

  	
   

  	
  Physician reviewer available to physician to discuss determinations
  based on medical appropriateness

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.2

  	
   

  	
  Written notification to members/practitioners of reason for denial,
  including specific utilization review criteria or benefits provisions used in
  the determination

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.3

  	
   

  	
  Information regarding appeal process included in denial notifications

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  UM 7 Evaluation of New Technology

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  UM 8 *Satisfaction with the UM Process

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  Every 2 years, information is gathered from members and practitioners
  regarding satisfaction with UM process

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  8.2

  	
   

  	
  Addresses identified sources of dissatisfaction

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  UM 9 Emergency Services

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  *There is provision, arrangement for or otherwise facilitation of all
  needed emergency services, including appropriate coverage of costs

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  •9.1

  	
   

  	
  Any emergency services necessary to screen/stabililze members without
  precertification of ER services where prudent layperson believed emergency
  medical condition existed is covered

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  *9.2

  	
   

  	
  ER services if practitioner has authorized is covered

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  UM 10 Drug Formulary Use

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The MCO has processes to ensure that its drug formulary, if any, is
  based on sound clinical evidence and is reviewed and updated at specified
  intervals.  The MCO develops its
  formulary with input from actively practicing practitioners and makes the
  formulary available to its practitioners. 
  The MCO with a closed formulary has an exceptions policy in place.

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  UM 11 Ensuring Appropriate Service and
  Coverage

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *11.1

  	
   

  	
  Data to detect potential underutilization and overutilization is
  monitored

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  monitors utilization data for organization as a whole/for individual product
  lines

  	
   

  	
  X

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Utilization Management Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *monitors utilization data across practices and provider sites for PCP and
  high volume specialists to detect potential under/overutilization

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  *11.2

  	
   

  	
  All data collected to detect underutilization and overutilization is
  routinely analyzed

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  *11.3

  	
   

  	
  Implements appropriate interventions whenever it identifies under
  utilization or over utilization

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  *11.4

  	
   

  	
  There are measurements to ascertain whether the interventions have
  been effective and implements strategies to achieve appropriate utilization

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  *11.5

  	
   

  	
  Policies for informing practitioners, providers and staff who make
  utilization-related decisions of the need for special concern about the risks
  of under utilization are implemented. 
  A statement to all practitioners, providers, members and employees is
  distributed which affirms that:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  decision making based on appropriateness of care and service

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is no compensation of practitioners or other individuals conducting
  utilization review for denials of service or coverage

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  financial incentives for UM decision makers do not encourage denials of
  coverage or service

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  UM 12 *Delegation of UM

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.1

  	
   

  	
  A mutually agreed upon document describes:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  responsibilities of delegated agency and entity

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated activities

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  frequency of reporting

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  process utilized to evaluate delegated agency’s performance

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  remedies available if obligations are not fulfilled

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.2

  	
   

  	
  There is evidence that

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated agency’s UM program is approved annually

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  reports as specified in 12.1 are evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is annual evaluation on whether delegated agency’s activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Credentialing and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  CR 1 *Credentialing Policies

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  Scope of practitioners covered

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Criteria and primary source verification information used to meet
  criteria

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Process used to make decisions

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1,4

  	
   

  	
  Extent of delegated credentialing/recredentialing arrangements

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Practitioner’s right to review information submitted in support of
  applications

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.6

  	
   

  	
  Notification of information obtained that varies from information
  provided by practitioner

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.7

  	
   

  	
  Practitioner’s right to correct erroneous information

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.8

  	
   

  	
  Medical director or designated physician’s
  responsibility/participation in credentialing program

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.9

  	
   

  	
  Confidentiality of all information obtained in process

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 2 *Credentialing Committee

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  A credentialing committee that makes recommendations regarding
  credentialing decisions is designated

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 3 *Initial Primary Source Verification

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.1

  	
   

  	
  License

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.2

  	
   

  	
  Clinical privileges

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.3

  	
   

  	
  DEA

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.4

  	
   

  	
  Education/training

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  MDs/DOs: medical school/residency

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  DCs: chiropractic college

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • DDSs:
  dental school/specialty training

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • DPMs:
  podiatry school/residency

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.5

  	
   

  	
  Board certification

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.6

  	
   

  	
  Work history

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.7

  	
   

  	
  Malpractice insurance

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  3.8

  	
   

  	
  Professional liability claims

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 4 *Application and Attestation

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  Inability to perform essential functions

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.2

  	
   

  	
  Lack of present illegal drug use

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.3

  	
   

  	
  History of loss of license/felony convictions

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.4

  	
   

  	
  History of loss/limitation of privileges/disciplinary activity

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.5

  	
   

  	
  Attestation by applicant of the correctness/completeness of
  application

  	
   

  	
   

  	
   

  	
  X

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Credentialing and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  CR 5 *Initial Sanction Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.1

  	
   

  	
  NPDB

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  5.2

  	
   

  	
  Sanctions/limitations on license from following agencies:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board Medical Examiners, FSMB or Department of Professional Regulations

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board of Chiropractor/ClN-BAD

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board of Dental Examiners

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board of Podiatric Examiners

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.3

  	
   

  	
  Medicare and Medicaid

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 6 *Initial Credentialing Site Visits
  (All potential Primary Care Practitioners and Obstetricians/Gynecologists)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.1

  	
   

  	
  Review that evaluates site

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.2

  	
   

  	
  Evaluation of medical record keeping practices

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 7 *Recredentialing Primary Source
  Verification:

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Practitioners are formally recredentialed at least every two
  years.  During the recredentialing
  process, verification of at least the following information from primary
  sources is obtained:

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  7.1

  	
   

  	
  License

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  7.2

  	
   

  	
  Clinical privileges

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  7.3

  	
   

  	
  DEA

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  7.4

  	
   

  	
  Board certification

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  7.5

  	
   

  	
  Malpractice insurance

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  7.6

  	
   

  	
  Professional liability claims

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  7.7

  	
   

  	
  Attestation by applicant regarding:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  inability to perform essential functions

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  lack of present illegal drug use

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CR 8 *Recredentialing Sanction Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  NPDB

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  8.2

  	
   

  	
  Sanctions/limitations on license from following agencies:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board Medical Examiners, FSMB or Department of Professional Regulations

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board of Chiropractor/CIN-BAD

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board of Dental Examiners

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  State Board of Podiatric Examiners

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Credentialing and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
   

  	
   

  	
  8.3

  	
   

  	
  Medicare and Medicaid

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 9 * Performance Monitoring

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The following data is incorporated into the recredentialing
  decision-making process for primary care practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  9.1

  	
   

  	
  Member complaints

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  9.2

  	
   

  	
  Information from quality improvement activities

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  9.3

  	
   

  	
  Member satisfaction (optional)

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 10 *Recredentialing Site Visits (All
  Primary Care Practitioners who have more than 50 Members)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  10.1

  	
   

  	
  Review that evaluates site

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  10.2

  	
   

  	
  Evaluation of medical record keeping practices

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 11 *Practitioner Appeal Rights

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  There are policies and procedures for altering the conditions of the
  practitioner’s participation with the entity based on issues of quality of
  care and service

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  11.1

  	
   

  	
  Procedures for reporting quality deficiencies that could result in a
  practitioner’s suspension or termination

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  11.2

  	
   

  	
  Description of appeal process/practitioners are informed of the
  appeal process

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  CR 12 *Assessment of Organizational
  Providers (hospitals, home health agencies, skilled nursing facilities and
  nursing homes and free standing surgical centers)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  There are written policies and procedures for the initial and ongoing
  assessment of organizational providers with which it intends to contract.

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.1

  	
   

  	
  Confirms good standing with state/federal regulatory bodies

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.2

  	
   

  	
  Confirms accreditation

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.3

  	
   

  	
  If not approved, develop/implement standards of participation and
  review for compliance

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  12.4

  	
   

  	
  At least every 3 years, confirms continued good standing with
  state/federal regulatory bodies and, if applicable, accrediting body

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  CR 13 *Delegation of Credentialing

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  13.1

  	
   

  	
  A mutually agreed upon document describes:

  	
   

  	
  X

  	
   

  	
  X

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Credentialing and Recredentialing Compliance

  Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  responsibilities of delegated agency and entity

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated activities

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  process utilized to evaluate delegated agency’s performance

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  remedies available if obligations are not fulfilled

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  13.2

  	
   

  	
  The right to approve/retain/terminate/suspend practitioners,
  providers and sites is retained

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  13.3

  	
   

  	
  There is evidence that:

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • delegated agency’s capacity to perform
  activities prior to delegation is evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is annual evaluation on whether delegated agency’s activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Members’ Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  RR 1 *Statement of Members’ Rights and
  Responsibilities

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  A written policy addresses the following members’
  rights/responsibilities:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  Right to receive information about the entity, its services, its
  practitioners/providers

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Right to be treated with respect, recognition of their dignity and
  right to privacy

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Right to participate with practitioners in decision making

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Right to a candid discussion of treatment options

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Right to voice complaints/appeals about the entity or care provided

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.6

  	
   

  	
  Responsibility to provide information regarding care

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.7

  	
   

  	
  Responsibility to follow instructions for care

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  RR 2 *Distribution of Rights Statements to
  Members and Practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The policy on members’ rights and responsibilities is distributed to
  members and participating practitioners

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  RR 3 Policies for Complaints and Appeals

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *3.1

  	
   

  	
  Procedures for registering and responding to oral/written complaints include:

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  documentation of complaint/action taken

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  investigation of complaint

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  notification to member of disposition of complaint/right to appeal

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  timeliness in responding to complaints that accommodate clinical urgency of
  the situation

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *3.2

  	
   

  	
  Procedures for registering/responding to oral and written 1st level
  appeals include:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  appeal process notification to member within 5 working days of receiving
  request for 1st level appeal

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  documentation of appeal and action taken

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  investigation of appeal

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  resolution of the appeal, including:

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  panel appointed to review 1st level appeal not involved in initial
  determination

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Members’ Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  of appointed panel, at least 1 practitioner in similar or same specialty

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  if written decision is not made within 15 days, reason for the delay is
  issued to the member/Health Plan by the 15th day and resolution by the 30th
  day is provided

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  for acute/urgent appeal, the expedited appeals procedure is followed:

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  written notification to member of disposition of appeal/right to appeal
  further

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.3

  	
   

  	
  Procedure for registering/responding to 2nd level appeals

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  *3.4

  	
   

  	
  Procedure for allowing practitioner/member representative to act on
  behalf of the member

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
  RR 4 *Appropriate Handling of Complaints
  and Appeals

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Members’ complaints and 1st level appeals are adjudicated in a
  thorough, appropriate, and timely manner. 
  All the requirements of standard RR3 for 1st level appeals and its own
  standards for handling the following are met:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  Complaints about clinical care

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.2

  	
   

  	
  Complaints about service

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  4.3

  	
   

  	
  Appeals

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  RR 5 Subscriber Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Each subscriber is provided with the information needed to understand
  benefit coverage and obtain care

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.1

  	
   

  	
  Written information about benefits/charges applicable to subscriber
  addresses:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  benefits/services included in, and excluded from, coverage

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  drug formulary information

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  copayments/other charges for which the member is responsible

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  restrictions on benefits

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  instructions on submitting claims

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.2

  	
   

  	
  Written instructions provided to members addresses how to obtain
  primary/specialty care:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *information regarding participating practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *primary care services, including points of access

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Members’ Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *specialty, behavioral and hospital care/services

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *care after normal office hours

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *emergency care

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  care/coverage when out of area

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.3

  	
   

  	
  Written information provided to members addresses how to:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *voice a complaint

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  *appeal decision that affects member’s coverage/benefits/relationship to
  organization

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  how new technology for inclusion as a covered benefit is evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  5.4

  	
   

  	
  Notification to members of practitioner or practice site termination
  and helps with selection of new practitioner or practice site

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  RR 6 Member Confidentiality

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  The confidentiality of member information and records is protected

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *6.1

  	
   

  	
  Written confidentiality policies and procedures to ensure
  confidentiality of member information is adopted/implemented

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  *6.2

  	
   

  	
  Contract explicitly states expectations regarding confidentiality of
  member information/records

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.3

  	
   

  	
  Data shared with employers, whether fully insured or self-insured,
  are not implicitly or explicitly member identifiable, unless specific consent
  is provided by members

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  6.4

  	
   

  	
  Patients have opportunity to consent/deny release of information,
  except when required by law

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.5

  	
   

  	
  Communicates to prospective members its policies/practices regarding
  collection/use/disclosure of medical information

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.6

  	
   

  	
  Informs members, practitioners and providers of policies/procedures
  on obtaining consents for use of member medical information, allowing members
  access to their medical records and protecting access to member medical
  information

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  6.7

  	
   

  	
  Designates internal review board to create/review confidentiality
  policies and procedures

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
  RR 7 Marketing Information

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  BCC ensures that communications with prospective members correctly
  and thoroughly represent the benefits and operating procedures of the
  organization

  	
   

  	
  X

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Members’ Rights and Responsibilities

  Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  RR 8 *Delegation of Members’ Rights and
  Responsibilities

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.1

  	
   

  	
  A mutually agreed upon document describes:

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  responsibilities of delegated agency and entity

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated activities

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  frequency of reporting

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  process utilized to evaluate the delegated agency’s performance

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  remedies available if obligations are not fulfilled

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  8.2

  	
   

  	
  There is evidence that:

  	
   

  	
  X

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • regular
  reports as specified in 8.1 are evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is an annual evaluation on whether delegated agency activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Preventive Health Services Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  PH 1 *Adoption of Preventive Health (PH) Guidelines

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  There
  are guidelines for following categories:

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • preventive care
  for infants up to 24 months

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • preventive care
  for children/adolescents, 2-19 years

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • prenatal and
  perinatal care

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • preventive care
  for adults 20-64 years

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • preventive care
  for elderly 65 and older

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Guidelines
  describe recommended prevention and/or early detection interventions and frequency/conditions
  under which interventions are required. 
  Documents scientific basis/authority upon which guidelines are based

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Practitioners
  are involved in adoption of guidelines

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.4

  	
   

  	
  Guidelines
  have been available for at least 2 years

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1.5

  	
   

  	
  Guidelines
  in place at least 2 years are reviewed/updated at least every 2 years

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  PH 2 *Distribution of Guidelines to Practitioners

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Distribution
  of preventive health guidelines and any updates to practitioners occurs

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  PH 3 Health Promotion with Members

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  3.1

  	
   

  	
  Guidelines
  distributed to members annually

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *3.2

  	
   

  	
  Members
  are encouraged to use health promotion, education and services available

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  *3.3

  	
   

  	
  Members,
  identified as high risk, are urged to use health promotion/prevention
  services

  	
   

  	
  X

  	
   

  	
   

  	
   

  
	
  PH 4 *Delegation of PH

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  A
  mutually agreed upon document describes:

  	
   

  	
  Not Applicable

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  responsibilities of delegated agency and entity

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • the delegated
  activities

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • frequency of
  reporting

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • process
  utilized to evaluate the delegated agency’s performance

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • remedies
  available if obligations are not fulfilled

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.2

  	
   

  	
  There
  is evidence that:

  	
   

  	
  Not Applicable

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  • delegated
  agency’s capacity to perform activities prior to delegation is evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Preventive Health Services Compliance Activity

  Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated agency’s PH workplan is approved annually

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  regular reports as specified in 4.1 are evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is an annual evaluation on whether delegated agency activities are
  conducted in accordance with the entity’s expectations/NCQA standards

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Party
  Responsible For

  Compliance Activity

  	
   

  
	
  Medical Record Compliance Activity Standard

  	
   

  	
  NCQA

  Std

  	
   

  	
  Compliance
  Activity Performance Measurement

  	
   

  	
  Blue Cross

  	
   

  	
  Participating

  Medical Group

  	
   

  
	
  MR 1 *Medical Record Documentation
  Standards

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Medical records will be maintained in a manner that is current,
  detailed, and organized and permits effective and confidential patient care
  and quality review

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.1

  	
   

  	
  Medical record confidentiality policies and procedures are maintained

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.2

  	
   

  	
  Medical record documentation standards are maintained and distributed
  to practice sites

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  1.3

  	
   

  	
  Organized medical record keeping system and standards for the
  availability of medical records appropriate to the practice site

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  MR 2 *MCO Review of Medical Records

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  2.1

  	
   

  	
  At least every 2 years, review of medical records from primary care
  practice sites is conducted

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
  2.2

  	
   

  	
  There is a mechanism to assess the effectiveness of corrective action
  plans to ascertain improved compliance

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  MR 3 *Compliance with NCQA Medical Records
  Standards

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  Documentation of items on the NCQA medical record review summary
  sheet demonstrates that medical records are in conformity with good
  professional medical practice and appropriate health management

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
  MR 4 *Delegation of Medical Records

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.1

  	
   

  	
  A mutually agreed upon document describes:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  responsibilities of delegated agency and entity

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated activities

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  frequency of reporting

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  process utilized to evaluate the delegated agency’s performance

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  remedies available if obligations are not fulfilled

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  4.2

  	
   

  	
  There is evidence that:

  	
   

  	
   

  	
   

  	
  X

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  delegated agency’s capacity to perform activities prior to delegation is
  evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  the delegated agency’s MR workplan/MR program description if approved
  annually

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  regular reports as specified in 4.1 are evaluated

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  •
  there is an annual evaluation on whether delegated agency activities are
  conducted in accordance with the entity’s expectations/NCQA

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*BCC Oversight Monitoring Required


 

















 


Attachment 2


 


CaliforniaCare

Annual Documentation Submission Requirements


 


	
  Delegated Compliance Activity

  Standards Group

  	
   

  	
  Required Documentation Materials

  	
   

  	
  Documentation

  Submission

  Deadline

  	
   

  	
  BLUE CROSS

  Contact

  Person

  
	
  Utilization Management

  	
   

  	
  Written and approved Utilization Management Plan (including signature
  page) consistent with BLUE CROSS HMO criteria.

  	
   

  	
  15 days following PARTICIPATING MEDICAL GROUP
UM Committee
  approval

  	
   

  	
  Quality Management Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  UM Workplan

  	
   

  	
  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Quarterly Utilization Management Reports (California HMO Quality
  Management Coalition format preferred)

  	
   

  	
  4/30, 7/31, 10/31, 1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Annual UM Program Evaluation

  	
   

  	
  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Quality Management

  	
   

  	
  Written and approved Quality Management Plan (including signature
  page) consistent with BLUE CROSS HMO criteria.

  	
   

  	
  15 days following PARTICIPATING MEDICAL GROUP
QM Committee
  Approval

  	
   

  	
  Quality Management Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  QM Workplan

  	
   

  	
  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Quarterly Quality Management Reports (California HMO Quality
  Management Coalition format preferred).

  	
   

  	
  4/30,7/31,10/31.

  1/31

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Annual QM Program Evaluation

  	
   

  	
  1/31

  	
   

  	
   

  



 

















 


	
  Delegated Compliance Activity

  Standards Group

  	
   

  	
  Required Documentation Materials

  	
   

  	
  Documentation

  Submission

  Deadline

  	
   

  	
  BLUE CROSS

  Contact

  Person

  
	
  Credentialing/

  Recredentialing/Peer

  Review

  	
   

  	
  Written
  and approved Credentialing/Recredentialing/Peer Review Policies and
  Procedures consistent with BLUE CROSS HMO criteria.

  	
   

  	
  15 days following PARTICIPATING MEDICAL
  GROUP  Credentialing
  Committee approval

  	
   

  	
  Quality
  Management Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Practitioner/Provider
  Roster.

  	
   

  	
  Prior
  to on-site audits

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Grievances and Appeals

  	
   

  	
  Grievances
  and Appeals data consistent with BLUE CROSS HMO’s sample format.

  	
   

  	
  Quarterly

  	
   

  	
  Care
  Management Department

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Health Management

  	
   

  	
  Roster
  of Health Education/Promotion Programs and offered to members.

  

  Health Management program effectiveness evaluation (may be included in Annual
  QM Program Evaluation).

  	
   

  	
  10/31

  

  

  1/31

  	
   

  	
  Health
  Promotion Department

  

  Quality Management Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Corrective Action Plan

  (if applicable)

  	
   

  	
  Corrective
  action plan addressing any identified audit deficiencies in BLUE CROSS Audit
  Summation letter.

  	
   

  	
  30
  days from letter notification

  	
   

  	
  Quality
  Management Analyst

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Encounter Data

  	
   

  	
  Electronic
  submission of ambulatory encounter data.

  	
   

  	
  Monthly

  	
   

  	
  Integrated
  Medical Systems

  



 


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