Exhibit
10.154


 


PACIFICARE OF
CALIFORNIA


MEDICAL GROUP/IPA
SERVICES AGREEMENT


(SPLIT CAPITATION)


 


THIS PACIFICARE MEDICAL GROUP/IPA SERVICES AGREEMENT
(this “Agreement”) is made and entered into this 1st day of January, 2001, by
and between PACIFICARE OF CALIFORNIA, INC., a California corporation
(“PacifiCare”), and Northwest Orange County Medical Group (“Medical Group”),
with reference to the following facts:


 


WHEREAS, PacifiCare operates various prepaid health
plans for the provision of Covered Services to persons enrolled as Members in
such plans in a manner consistent with the laws of the State of California and
the United States; and


 


WHEREAS, Medical Group and its Participating Providers
desire to participate in PacifiCare’s prepaid health service delivery system by
providing or arranging for Covered Services to Members on a prepaid basis in
coordination with PacifiCare and its Participating Providers under the terms
specified in this Agreement.


 


NOW, THEREFORE, it is agreed as follows:


 


ARTICLE 1

DEFINITIONS


 


Whenever used in this Agreement, the following terms
shall have the definitions contained in this Article 1:


 


1.1           Accreditation
Organization is any organization, including, without limitation, the
National Committee for Quality Assurance (NCQA), engaged in accrediting or
certifying PacifiCare, any Managed Care Plans, or any Participating Providers.


 


1.2           Agreement is
this Medical Group/IPA Services Agreement between PacifiCare and Medical Group,
and any amendments, exhibits and attachments hereto, including Product
Attachments.


 


1.3           Base Agreement
is this Medical Group/IPA Services Agreement between PacifiCare and Medical
Group, and any amendments, exhibits and attachments hereto, excluding Product
Attachments.


 


1.4           Capitation Payments
are monthly payments made to Medical Group on a prepaid basis for Covered
Services provided or arranged by Medical Group under this Agreement.


 


1.5           Commencement Date
is the commencement date of this Agreement as specified in Section 6.1.


 


1.6           Copayment is a
fee that may be charged to Members for certain Medical Group Services and


 


 











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


 


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collected by Medical
Group or its Participating Providers at the time Medical Group Services are
provided, as set forth in the applicable Managed Care Plan.


 


1.7           Cost of Care is
the valuation of Covered Services and other health care services provided or
arranged by Medical Group, as described in Section 5.7.


 


1.8           Covered Services
are those medically necessary health care services, supplies and benefits which
are required by a Member as determined by Medical Group or PacifiCare in
accordance with the Member’s Managed Care Plan and PacifiCare’s Quality
Improvement Program and Utilization Management Program.  For purposes of this Agreement, “medically
necessary” shall have the meaning set forth in the applicable Subscriber
Agreement.


 


1.9           Division of
Financial Responsibility is the matrix for each Managed Care Plan which
specifies the financial responsibility of PacifiCare, Medical Group and
Hospital for Covered Services.  The
Division of Financial Responsibility is an integral part of this Agreement.


 


1.10         Eligibility List
is the list of Members for whom Medical Group shall provide or arrange Covered
Services.


 


1.11         Emergency Services
are Covered Services required by a Member as the result of a medical condition
manifesting itself by the sudden onset of symptoms of sufficient severity,
which may include severe pain, such that a reasonable person would expect the
absence of immediate medical attention to result in: (i) placing the health of
the Member in serious jeopardy; (ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any bodily part. 
The final determination of whether Emergency Services were required
shall be made by the PacifiCare medical director or designee, subject to appeal
under the applicable Member appeals procedure.


 


1.12         Government Agency
shall mean any local, State or Federal government agency or entity with
regulatory or other authority over PacifiCare, this Agreement or any Managed
Care Plan.


.13           Hospital is the
licensed acute care hospital (or hospitals), identified in Exhibit 1 to
this Agreement, which has (or have) entered into a written agreement with
PacifiCare to provide Hospital Services to Medical Group Members assigned to
Hospital in the Medical Group Service Area.


 


1.14         Hospital Services
are Covered Services for Medical Group Members assigned to Hospital which are
the financial responsibility of Hospital, as specified in the Division of
Financial Responsibility for each Managed Care Plan.


 


1.15         Insolvent or the
condition of Insolvency means that Medical Group or any management company
providing material management services to Medical Group (i) ceases or fails to
be solvent because it lacks the financial resources to fullfill Medical Group’s
obligations pursuant to this Agreement, or fails to pay, or admits in writing
its inability to pay its debts as they become due, subject to applicable grace
periods, if any, whether at stated maturity or otherwise; (ii) fails to
maintain the financial reserves specifically required either by this Agreement
or State and Federal Law or otherwise agreed to in writing by the parties;
(iii) 


 


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voluntarily ceases to conduct its business; (iv)
commences any Insolvency proceeding with respect to itself; or (v) takes any
action to effectuate or authorize an Insolvency proceeding.  No Insolvency shall be deemed to exist if
such conditions are solely the result of PacifiCare’s failure to pay Medical
Group amounts that are currently due and payable by PacifiCare after
consideration of PacifiCare’s withhold, recoupment, offset and other rights
pursuant to this Agreement.


 


1.16         Managed
Care Plan is any one of the various health plans or products sponsored or
administered by PacifiCare or its subsidiaries or affiliates including, without
limitation, a commercial prepaid health plan (“PacifiCare Commercial Health
Plan”), a commercial point-of-service plan (“PacifiCare Commercial POS Health
Plan”), and a Medicare + Choice plan (“Secure Horizons Health Plan”).  Each Managed Care Plan is described in the
applicable Subscriber Agreement and Product Attachment.  PacifiCare may make available some, and not
all, of the Managed Care Plans under this Agreement.  For purposes of this Agreement, PacifiCare Affiliates shall mean
all entities which currently are controlled by, controlling, or under common
control with PacifiCare or which in the future may be controlled by,
controlling, or under common control with PacifiCare, including, without
limitation, PacifiCare Life and Health Insurance Company and PacifiCare Life
Assurance Company.  When a PacifiCare
Affiliate is responsible for payment under this Agreement, “PacifiCare” shall
mean and refer to the PacifiCare Affiliate.


 


1.17         Medical Group Service
Area is the geographic area as defined in Exhibit 1 to this
Agreement.


 


1.18         Medical Group Facility
is each office of Medical Group and its Participating Providers, identified in Exhibit
1 to this Agreement, where Medical Group Services may be provided to Medical
Group Members.


 


1.19         Medical Group Members
are the Members listed on the Eligibility List.


 


1.20         Medical Group Services
are Covered Services for Medical Group Members which are the financial
responsibility of Medical Group, as specified in the Division of Financial
Responsibility for each Managed Care Plan.


 


1.21         Member is an
individual who is enrolled in a Managed Care Plan and meets all the eligibility
requirements for membership in the Managed Care Plan and for whom the
applicable Premium has been received by PacifiCare.


 


1.22         Out-of-Area Medical
Services are those Urgently Needed Services and Emergency Services provided
while a Member is outside the Medical Group Service Area which would have been
the financial responsibility of Medical Group had the services been provided
within the Medical Group Service Area. 
Medical Services which are to be provided outside of the Medical Group
Service Area and are arranged by Medical Group for Assigned Members are not
considered Out-of-Area Medical Services.


 


1.23         Participating
Providers are (i) physicians and health care professionals who are shareholders,
partners or employees of Medical Group and (ii) physicians, medical groups,
individual


 


 


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practice associations
(“IPA”), health care professionals, hospitals, facilities and other providers
of health care services or supplies that have entered into written contracts
with PacifiCare, Medical Group or Hospital to provide Covered Services to
Members pursuant to Managed Care Plans.


 


1.24         Premium is the
payment for Covered Services under each Managed Care Plan as defined in the
applicable Product Attachment.


 


1.25         Primary Care Physician
is any of Medical Group’s Participating Providers who meet PacifiCare’s
criteria for providing initial and primary care Covered Services to Medical
Group Members, for maintaining the continuity of patient care, and for
initiating and coordinating referrals for Covered Services to Medical Group
Members.


 


1.26         Product Attachments
are the attachments to the Base Agreement which set forth additional terms and
conditions under which Medical Group shall provide or arrange Covered Services
to Medical Group Members pursuant to the Managed Care Plans.  All Product Attachments which are signed by
both PacifiCare and Medical Group shall become a part of this Agreement and are
incorporated herein.


 


1.27         Provider Manual is
the PacifiCare Provider Policies and Procedures Manual and related written
materials which shall be provided to Medical Group by PacifiCare prior to or
concurrent with the execution of this Agreement.  The Provider Manual is incorporated into this Agreement, and may
be updated from time to time by PacifiCare as provided in this Agreement.


 


1.28         Quality Management and
Improvement (“QI”)  Program
are those standards, protocols, policies and procedures adopted by PacifiCare to
monitor and improve the quality of clinical care and quality of services
provided to Members.  The QI Program is
described in the Provider Manual, and may be updated from time to time by
PacifiCare as provided in this Agreement.


 


1.29         State and Federal Law
shall mean any and all laws and regulations of the State of California or of
the United States and all orders and other requirements of any government
agency which are applicable to PacifiCare, this Agreement, Managed Care Plans,
and Medical Group and its Participating Providers.


 


1.30         Subscriber Agreement
and Evidence of Coverage are the PacifiCare documents that describe the
costs, benefits or services, procedures, conditions, limitations, exclusions,
and other obligations to which Members are entitled and subject to under a
Managed Care Plan.  A copy of a current
standard Subscriber Agreement and Evidence of Coverage for each Managed Care
Plan shall be provided to Medical Group by PacifiCare and may be updated from
time to time by PacifiCare.


 


1.31         Subscriber or
Subscriber Group is the individual or employer, organization, firm or other
entity which contracts with PacifiCare under a Subscriber Agreement to obtain
the benefits of a Managed Care Plan.


 


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1.32         Urgently Needed
Services are Covered Services under a Managed Care Plan which are required
without delay in order to prevent the serious deterioration of a Member’s
health as a result of an unforeseen illness or injury and it was not reasonable
given the circumstances to obtain the services in accordance with the terms of
the applicable Managed Care Plan.


 


1.33         Utilization Management
(“UM”) Program are those standards, protocols, policies and procedures
adopted by PacifiCare regarding the management, review and approval of the
provision of Covered Services to Members. 
The UM Program is described in the Provider Manual, and may be updated
from time to time by PacifiCare as provided in this Agreement.


 


ARTICLE 2

DUTIES OF MEDICAL GROUP


 


2.1           Provide or Arrange
Covered Services.  Medical Group,
through its Participating Providers, shall provide or arrange Covered Services
in the Medical Group Service Area to Medical Group Members, in coordination
with PacifiCare and PacifiCare’s Participating Providers and in accordance with
the terms and conditions set forth in this Agreement and the Managed Care
Plans.  Medical Group shall be
financially responsible for Medical Group Services.


 


2.2           Professional
Standards.  The primary concern of
Medical Group and its Participating Providers under this Agreement shall be the
quality of Covered Services provided to or arranged for Medical Group
Members.  Nothing stated in this
Agreement shall be interpreted to diminish this responsibility.  All Covered Services provided or arranged by
Medical Group shall be provided or arranged by duly licensed, certified or
otherwise authorized professional personnel in a culturally competent manner
and at physical facilities in accordance with (i) the generally accepted
medical and surgical practices and standards prevailing in the applicable
professional community at the time of treatment, (ii) the provisions of
PacifiCare’s QI Program and UM Program, (iii) the requirements of State and
Federal Law and (iv) the standards of Accreditation Organizations.


 


PacifiCare and Medical
Group acknowledge and agree that Medical Group or each of Medical Group’s
Participating Providers shall maintain the physician-patient relationship with
each Medical Group Member.  Nothing contained
in this Agreement is intended to interfere with such physician-patient
relationship.  Nothing in this Agreement
shall be interpreted to discourage or prohibit Medical Group and its
Participating Providers from discussing treatment options or providing other
medical advice or treatment deemed appropriate by Medical Group or its
Participating Providers.  Medical Group
or its Participating Providers shall have the sole responsibility for the
medical care and treatment of Medical Group Members.


 


2.2.1        Licensure of Medical
Group.  Medical Group is legally
organized and incorporated under the laws of the State of California.  Medical Group shall maintain in good
standing at all times during the term of this Agreement any and all licenses,
certificates and/or approvals required under State and Federal Law for the
performance by Medical Group of the duties required by this Agreement.


 


Medical Group shall
notify PacifiCare upon receiving any notice from the


 


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Department of Managed
Health Care or any other entity with the regulatory or contractual authority to
audit Medical Group relating to compliance with applicable law, including,
without limitation, notices of medical surveys or financial audits.


 


2.2.2        Licensure/Certification
of Medical Group’s Participating Providers.  Each of Medical Group’s Participating Providers shall maintain in
good standing at all times during the term of this Agreement the necessary
licenses or certifications required by State and Federal Law and by the Managed
Care Plans to provide or arrange Covered Services to Medical Group Members.


 


2.2.3        Hospital Privileges for
Medical Group’s Participating Providers. 
Unless otherwise specified by Medical Group and approved by PacifiCare
for specific Participating Providers, each of Medical Group’s Participating
Providers who is a physician shall maintain in good standing at all times
during the term of this Agreement medical staff membership and clinical
privileges at Hospital necessary to provide or arrange Covered Services to
Medical Group Members.


 


2.3           Medical Group’s
Participating Providers.  Medical
Group shall have a sufficient number of Participating Providers throughout the
Medical Group Service Area to provide or arrange Covered Services and meet the
needs of PacifiCare and Medical Group Members as determined by PacifiCare’s QI
Program and in accordance with State and Federal Law.  Medical Group’s Participating Providers shall provide or arrange
Covered Services, including Emergency Services, to Medical Group Members
twenty-four (24) hours a day, seven (7) days a week.  Medical Group’s Participating Providers must meet PacifiCare’s
credentialing standards and must be approved by PacifiCare before providing or
arranging Covered Services to Medical Group Members.


 


2.3.1        Participating Provider
Information.  Medical Group shall
provide PacifiCare with a complete list of its Participating Providers,
together with the provider specific information required by PacifiCare for
credentialing and for administration of the Managed Care Plans, at the time
this Agreement is signed.


 


2.3.2        Notice of Participating
Provider Additions.  Medical Group
shall use its best efforts to provide at least sixty (60) calendar days prior
written notice to PacifiCare of the addition of any Participating
Providers.  Such notice shall include
the provider-specific information required by PacifiCare.  All Participating Providers must be approved
by PacifiCare before providing or arranging Covered Services to Medical Group
Members.  PacifiCare shall use its best
efforts to approve Participating Providers as quickly as possible after
receiving the written notice from Medical Group.


 


2.3.3        Notice of Participating
Provider Terminations.  Medical
Group shall provide sixty (60) calendar days’ prior written notice to
PacifiCare of the termination of any of its Participating Providers; provided,
however, that if any Participating Providers are terminated with less than
sixty (60) calendar days’ notice, then Medical Group shall provide written
notice to PacifiCare within five (5) business days of Medical Group becoming
aware of such termination. 
Notwithstanding the termination of any


 


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Participating Providers,
Medical Group shall remain responsible for providing or arranging Covered
Services through its remaining Participating Providers and shall remain
financially responsible for Medical Group Services provided to Medical Group
Members under this Agreement.


 


2.3.4        Restriction, Suspension
or Termination of Participating Providers. 
Medical Group shall, as warranted, immediately restrict, suspend or
terminate its Participating Providers from providing or arranging Covered
Services to Medical Group Members in the following circumstances: (i) the
Participating Provider ceases to meet the licensing/certification requirements
or other professional standards described in this Agreement; (ii) PacifiCare or
Medical Group reasonably determines that there are serious deficiencies in the
professional competence, conduct or quality of care of the Participating
Provider which affects or could adversely affect the health or safety of
Medical Group Members; or (iii) the Participating Provider files an affidavit
with the Medicare Program promising to furnish Medicare-covered services to
Medicare beneficiaries only through private contracts under Section 1802 (b) of
the Social Security Act.  Medical Group
shall immediately notify PacifiCare of any of its Participating Providers who
cease to meet the licensing/certification requirements or other professional
standards described in this Agreement and Medical Group’s actions under this
Section.  If Medical Group fails to act
as required by this Section with respect to any of its Participating Providers,
PacifiCare shall have the right to immediately prohibit such Participating
Providers from continuing to provide Covered Services to Medical Group Members.


 


2.3.5        Adverse Changes in
Capacity.  Medical Group and its
Participating Providers will continue to accept Members enrolled by PacifiCare
for so long as Medical Group and its Participating Providers have the capacity
to provide and arrange Covered Services under this Agreement and for so long as
Medical Group continues to accept new patients from any HMO or other prepaid
health plan.  Medical Group shall
provide at least seventy five (75) calendar days’ or as soon as Medical Group
becomes aware, prior written notice to PacifiCare of any significant changes in
the capacity of Medical Group to provide or arrange Covered Services that would
prevent Medical Group from accepting additional Members.  Medical Group shall use reasonable efforts
to eliminate or remedy any condition which results in a significant adverse
change in capacity.  A significant
change in capacity includes, without limitation, the following: (i) inability
of Medical Group to properly serve additional Members due to a lack of Primary
Care Physicians or other Participating Providers; (ii) inability of any one of
Medical Group’s Primary Care Physicians or other Participating Providers to
serve additional Members; or (iii) closure of any Medical Group Facility.  PacifiCare may continue to enroll Members
with Medical Group until the expiration of the notice period required under
this Section, and in such event, Medical Group and its Primary Care Physicians
and other Participating Providers shall continue to accept such Members.  PacifiCare shall discontinue the enrollment
of Members with Medical Group upon expiration of the notice period required
under this Section until such time, if any, that Medical Group provides written
notification to PacifiCare that it has the capacity to accept additional
Members.


 


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2.4           Medical Group’s
Subcontracts with Participating Providers. 
Medical Group shall demonstrate and certify to PacifiCare prior to the
Commencement Date and upon PacifiCare’s written request at any time during the
term of this Agreement (in the format specified by PacifiCare) that its
subcontracts with Participating Providers comply with requirements of this
Agreement.  Medical Group shall amend
any and all of its existing subcontracts with Participating Providers which do
not comply with this Agreement within thirty (30) calendar days following the
execution of this Agreement and shall provide PacifiCare with written
certification thereof.  Without limiting
any other provision of this Agreement, all of Medical Group’s subcontracts
shall contain the requirements set forth at Sections 8.3.3 of this Agreement
pertaining to the provision of Covered Services in Special Circumstances.


 


2.4.1        Compliance with
Provisions of Agreement.  Medical
Group’s subcontracts with Participating Providers shall be in writing.  All such subcontracts shall be consistent
with the terms and conditions of this Agreement (including the Product
Attachments) and shall meet PacifiCare’s requirements for Participating
Provider subcontracts.  If this
Agreement is amended or modified, all such subcontracts shall be amended or modified
within sixty (60) calendar days to be consistent with such amendments or
modifications.


 


2.4.2        Compliance with
Standards of Accreditation Organizations and Requirements of State and Federal
Law.  Medical Group’s subcontracts
with Participating Providers shall comply with the standards of Accreditation
Organizations and requirements of State and Federal Law.  If there are changes in such standards
and/or requirements, Medical Group shall amend its subcontracts with
Participating Providers to comply with such changes within thirty (30) calendar
days following notice thereof from PacifiCare.


 


2.4.3        Access by PacifiCare,
Accreditation Organizations and Government Agencies to Subcontracts and Books
and Records of Participating Providers. 
Medical Group shall make available for inspection, examination and
copying by PacifiCare, Accreditation Organizations and Government Agencies
during normal business hours (i) its Participating Provider subcontracts and
(ii) books and records of its Participating Providers relating to Covered
Services provided to Medical Group Members. 
Copies of subcontracts and the books and records of Participating
Providers shall be maintained for at least six (6) years from the close of the
fiscal year in which the Covered Services were provided.


 


2.4.4        Medical Group’s Responsibility
for Providing or Arranging Covered Services.  Notwithstanding the existence of Medical Group’s subcontracts
with its Participating Providers, Medical Group shall remain responsible for
satisfying the obligations of Medical Group set forth in this Agreement.  If any of Medical Group’s subcontracts with
Participating Providers are terminated, Medical Group shall remain responsible
for providing or arranging Covered Services through its remaining Participating
Providers and shall remain financially responsible for Medical Group Services
provided to Medical Group Members under this Agreement.


 


2.4.5        Performance of
Subcontract Rights.  Medical Group’s
subcontracts shall require its


 


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Participating Providers
who are independent contractors to agree to perform their obligations under
their subcontract, and reimbursement shall be according to the terms of the
subcontracts between Medical Group and its Participating Providers who arc
independent contractors, for the benefit of PacifiCare in the event of
dissolution or Insolvency of Medical Group, in the event of termination of this
Agreement by PacifiCare for cause pursuant to Section 6.2.2 or in the event of
termination by PacifiCare pursuant to Section 6.3.  Such obligation shall continue through the continuing care period
provided by this Agreement.


 


2.5           Acceptance and
Transfer of Members.  Medical Group
and its Participating Providers may not impose any limitations on the
acceptance of Members for care or treatment that are not imposed on other
patients.  PacifiCare, Medical Group and
its Participating Providers shall not request, demand, require or seek directly
or indirectly the transfer, discharge or removal of any Member for reasons of
Member’s need for, or utilization of, Covered Services, except in accordance
with the procedures established by PacifiCare for such action.  Medical Group and its Participating
Providers shall not refuse or fail to provide or arrange Covered Services to
any Member except in accordance with procedures established by PacifiCare for
such action.


 


PacifiCare and Medical
Group shall exercise reasonable efforts in following the procedures for
transfer, discharge or removal of Members as set forth in the Provider
Manual.  Nevertheless, PacifiCare may
require transfer of Medical Group Members for any reason, and Medical Group may
request that PacifiCare transfer Medical Group Members to another of
PacifiCare’s Participating Providers if Medical Group is unable to provide the
Covered Services required by this Agreement for reasons related to capacity of
Medical Group and its Participating Providers. 
In addition, Medical Group may request that PacifiCare transfer a
Medical Group Member to another of PacifiCare’s Participating Providers in the
event of a material breakdown in the physician-patient relationship.  PacifiCare shall evaluate such requests
considering the best interests of the Member. 
In the event PacifiCare grants a request for transfer of a Member by
Medical Group, the transfer shall not be effective until the end of the month
following the month in which the Member receives notice of transfer, unless the
Member agrees to an earlier transfer and PacifiCare has made arrangements with
another of PacifiCare’s Participating Providers to accept the Member.


 


2.6           Medical Records.  Medical Group and its Participating
Providers shall maintain all patient medical records relating to Covered
Services provided to Members, in such form and containing such information as
required by the QI Program, Accreditation Organizations and State and Federal
Law.  Medical records shall be
maintained in a manner that is current, detailed, organized and permits
effective patient care and quality review by Medical Group and PacifiCare
pursuant to the QI Program.  Medical
records shall be maintained in a form and physical location which is accessible
to Medical Group’s Participating Providers, PacifiCare, Government Agencies and
Accreditation Organizations.  Upon
request and within the time frame requested, Medical Group and its
Participating Providers shall provide to PacifiCare, at Medical Group’s or
Participating Provider’s expense, copies of Member medical records for purposes
of conducting quality assurance, case management and utilization reviews, credentialing
and peer review, claims processing, verification and payment, resolving Member
grievances and appeals and other activities reasonably necessary


 


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for the proper
administration of the Managed Care Plans consistent with State and Federal
Law.  If Medical Group or its
Participating Providers do not provide copies of Member medical records to
PacifiCare within the time frame requested, Medical Group and its Participating
Providers shall allow PacifiCare immediate access to such medical records for
onsite copying and shall reimburse PacifiCare for the actual copying
expense.  Medical Group and its
Participating Providers shall maintain the confidentiality of all Member
medical records and treatment information in accordance with State and Federal
Law.  Medical records shall be retained
by Medical Group and its Participating Providers for at least six (6) years
following the provision of Covered Services and as required by State and
Federal Law.  The provisions of this
Section shall survive termination of this Agreement for the period of time
required by State and Federal Law.


 


2.7           Insurance.  Medical Group, at its sole cost and expense,
shall maintain throughout the term of this Agreement and, if coverage is
provided on a claims-made basis, for a period of four years following
termination of this Agreement, professional liability insurance (i.e., medical
malpractice insurance) and, if delegated for any Managed Care Services, managed
care errors and omissions insurance in the minimum amount of one million
dollars ($1,000,000) per occurrence and three million dollars ($3,000,000)
annual aggregate, the annual aggregate to apply separately for each physician
and health care practitioner who is insured under the policy (or policies)
purchased by Medical Group.


 


Medical Group, at its
sole cost and expense, shall also maintain throughout the term of this
Agreement, workers’ compensation insurance as required by the State of
California and general liability insurance, including but not limited to
premises, personal injury and contractual liability insurance, in a minimum
amount of one million dollars ($1,000,000) per occurrence, combined single
limit, bodily injury and property damage, to insure Medical Group and its
employees, agents, and representatives against claims for damages arising by
reason of (i) personal injuries or death occasioned in connection with the
performance of any Covered Services provided under this Agreement, (ii) the use
of any property and facilities of the Medical Group, and (iii) activities
performed in connection with this Agreement.


 


Medical Group’s
Participating Providers who are not insured under the Medical Group’s policy
(or policies) shall maintain the same insurance coverage required of Medical
Group under this Section, unless otherwise consented to by PacifiCare in
writing.


 


All insurance required
under this Agreement shall be provided by insurers licensed to do business in
the State of California and who have obtained an A.M. Best rating of A:VIII or
better.


 


If any of the required
coverage is proposed to be provided by a self insurance agreement, a wholly
owned insurance subsidiary (captive) or a risk retention group, the above
insurance requirements may be waived in the sole discretion of PacifiCare, but
only after review of the self insured’s, captive’s or risk retention group’s
audited financial statement and latest actuarial report.


 


A certificate of
insurance shall be issued to PacifiCare prior to the Commencement Date and upon
the renewal of the insurance coverage specified in this Section.  The certificate shall


 


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provide that PacifiCare
shall receive thirty (30) days’ prior written notice of cancellation or
material reduction in the insurance coverage specified in this Section.  Notwithstanding anything to the contrary, if
Medical Group has a claims-made based policy and anticipates that such policy
(or policies) will be canceled or not renewed, Medical Group agrees to exercise
any option contained in the policy (or policies) to extend the reporting period
to the maximum period permitted; provided, however, that Medical Group need not
exercise such option if the superseding insurer will accept all prior claims.  Notwithstanding any other provision of this
Agreement, failure to provide the certificate of insurance, upon written
request by PacifiCare, shall be grounds for immediate termination of this
Agreement.


 


2.8           Financial Statements.


 


2.8.1        Copies of Financial
Statements.  Upon written request by
PacifiCare, Medical Group shall provide to PacifiCare within forty-five (45)
calendar days of the end of each calendar quarter copies of its quarterly
financial statements, which shall include a balance sheet, statement of income
and statement of cash flow (the ‘‘Financial Statements”) prepared in accordance
with generally accepted accounting principles. 
Such quarterly Financial Statements shall be certified by the chief
financial officer of Medical Group as accurately reflecting the financial
condition of Medical Group, including without limitation, its operations in the
Medical Group Service Area for the period indicated.  In addition, upon written request by PacifiCare, Medical Group
shall provide to PacifiCare, within one hundred twenty (120) calendar days of
the end of each fiscal year, copies of its audited annual Financial Statements
together with copies of all auditor’s letters to management in connection with
such audited annual financial statements.


 


2.8.2        Letter of Credit.  As a material condition to PacifiCare’s
obligations pursuant to this Agreement, Medical Group shall obtain for the
benefit of PacifiCare a Letter of Credit to secure the obligations of Medical
Group under either the Agreement with Harriman Jones Medical Group or Northwest
Orange County Medical Group (“Letter of Credit”).  The Letter of Credit shall be in the minimum amount of ***.


 


All the terms and
conditions of the Letter of Credit shall be subject to PacifiCare’s
approval.  Without limiting the
foregoing, the Letter of Credit shall provide that at such time that Medical
Group is Insolvent, the Letter of Credit funds shall be unconditionally
available to PacifiCare to satisfy Medical Group’s obligations under this
Agreement.  The Letter of Credit shall
be effective as of the Commencement Date and shall remain in full force and
effect throughout the entire term of this Agreement.  PacifiCare shall not be responsible for any cost, expense, or
administrative fee in connection with the establishment or maintenance of the
Letter of Credit.


 


2.8.3        Security Deposit.  If at March 31, 2002, the Combined Current
Ratio (as defined below) is less than 0.80, Medical Group shall establish a
deposit with PacifiCare as set forth below in this Section 2.8.3 The initial
amount shall be an amount reasonably estimated by PacifiCare to equal three
months of the Medical Group’s IBNP


 


11

















 


Expenses less the Letter
of Credit amount.  If at March 31, 2002
the Combined Current Ratio (as defined below) is greater than or equal to 0.80,
a Security Deposit will not be required. 
Combined Current Ratio is defined to mean a weighted average financial
measurement of current assets divided by current liabilities for Harriman Jones
Medical Group and Northwest Orange County IPA. 
The calculation of a weighted average will be based upon the numbers of
Medical Group Members of the two entities. 
The calculation will be prepared by the Medical Group and submitted to
PacifiCare by April 15, 2002.  If the
Medical Group cannot reasonably demonstrate a Combined Current Ratio of 0.80,
PacifiCare may at its sole discretion establish the aforementioned Security
Deposit.


 


Capitation Withhold to
Establish Security Deposit. 
In the event Medical Group is unable to fund the entire Security Deposit
amount PacifiCare may, at its sole discretion, allow Medical Group to establish
such required Security Deposit amount through a Capitation withhold as
follows.  PacifiCare will withhold ***
from Harriman Jones Medical Group’s monthly Capitation Payments, and *** from
Northwest Orange County Medical Group’s monthly Capitation Payments and deposit
such amounts directly into the Security Deposit until the full amount of the
Security Deposit is established (“Security Deposit Withhold”).  The initial Security Reserve Withhold amount
will be set to establish the full Security Deposit during the remainder of this
Agreement.  Any adjustments made to the
Security Deposit Withhold amount will be in accordance with this Section 2.8.3.


 


Condition to Agreement.  The Security Deposit shall remain in place
until the later of the termination of this Agreement or the performance of all
financial obligations of Medical Group arising under this Agreement.


 


Terms of Security Deposit.  PacifiCare shall have no obligation to
maintain the Security Deposit in accounts separate from PacifiCare’s own
accounts and may be commingled with other funds of PacifiCare.  PacifiCare shall not pay interest on the
Security Deposit.


 


Application of Security
Deposit.  PacifiCare
shall be entitled to apply the Security Deposit to satisfy Medical Group’s
financial obligations under the Agreement without notice to the Medical Group
in PacifiCare’s sole and absolute discretion. 
The exercise of PacifiCare’s rights with respect to the Security Deposit
shall not be deemed to be an election of any remedy or the forfeiture of any
rights by PacifiCare.  All of
PacifiCare’s rights are cumulative and the exercise of any remedy shall not
preclude the exercise of any other remedies available to PacifiCare under this
Agreement and applicable law.


 


2.9           Administrative
Requirements


 


2.9.1        Administrative
Guidelines.  Medical Group agrees to
perform its duties under this Agreement in accordance with the administrative
guidelines, policies and procedures set forth in the Provider Manual and State
and Federal Law.  Medical Group shall be


 


12

















 


responsible for
distributing copies of the Provider Manual, as necessary, to its Participating
Providers.


 


2.9.2        Medical Director,
Health Plan, Coordinator, Quality Improvement Committee and Utilization
Management Committee.  Medical Group
shall designate one of its Participating Providers who is a physician or
osteopath to act as Medical Group’s medical director and shall designate an
individual to act as the health plan coordinator with PacifiCare.  The duties of Medical Group’s medical
director and health plan coordinator shall be set forth in the Provider Manual.  In addition, Medical Group shall establish
and maintain a quality improvement committee and a utilization management
committee to assist PacifiCare in implementing the QI Program and UM Program
with respect to PacifiCare Members.


 


2.9.3        Participation in
PacifiCare Orientation and Training Programs.  Medical Group shall require its administrative personnel and its
Participating Providers to participate in PacifiCare’s orientation and training
programs.


 


2.9.4        Encounter Data.  Medical Group shall maintain and provide to
PacifiCare, no later than the thirtieth (30th) day of each month, unless a
shorter time is required by any regulatory agency, (i) the utilization data
pertaining to Covered Services which are provided directly by Medical Group and
its Participating Providers and (ii) the utilization data pertaining to Covered
Services which are paid for by Medical Group during the preceding month,
including data not provided in the most recent submission, as required by
PacifiCare (the “Encounter Data”).  Medical
Group shall submit Encounter Data in accordance with the procedures and
standards established by PacifiCare. 
Medical Group shall submit Encounter Data in an electronic format
acceptable to PacifiCare.


 


After ninety (90)
consecutive days of non-submission of Encounter Data as described above in this
Section, PacifiCare shall deduct one percent (1.0%) of the Medical Group’s
Capitation Payment until such data is submitted.


 


2.9.5        General Data and
Information Requirements.  Medical
Group shall maintain and provide to PacifiCare, upon written request, any and
all information required by PacifiCare, State and Federal Law, Government
Agencies or Accreditation Organizations for the administration of Managed Care
Plans.  Medical Group shall submit such
information and data to PacifiCare in the format and within the time periods
specified by PacifiCare.  Medical Group
shall accurately and completely maintain all Encounter Data, all other
information and data required by this Agreement, including medical records,
necessary to characterize the scope and purpose of Covered Services provided to
Members.  Medical Group shall provide to
PacifiCare and to HCFA any required certification as to Medical Group’s
compliance with the foregoing.


 


2.10         Medical Group’s
Failure to Comply with Agreement, Provider Manual or Managed Care Plans.  If Medical Group fails to comply with any
provision(s) of this Agreement, the Provider Manual or the Managed Care Plans,
PacifiCare may provide written notice of such


 


13

















 


failure to Medical Group,
specifying a date at least thirty (30) days following the date of the notice,
or longer if mutually agreeable, by which Medical Group must be in compliance
with such provision(s), as reasonably determined by PacifiCare.  If Medical Group fails to comply with such
provision(s) by the date specified in the notice, PacifiCare shall have the
right to cease marketing efforts on behalf of Medical Group and/or discontinue
assignment of Members to Medical Group until such time as Medical Group complies
with such provision(s), as reasonably determined by PacifiCare.  PacifiCare’s rights and remedies under this
Section shall be in addition to all other rights and remedies available to
PacifiCare to enforce this Agreement, including the right of termination.


 


2.11         Reciprocity
Arrangements.  If any Member who is
not a Medical Group Member or if any individual who is enrolled in a benefit
plan and program of any PacifiCare affiliated entity (“PacifiCare Affiliate”)
receives services or treatment from Medical Group or its Participating
Providers, Medical Group or the Participating Provider agrees to bill
PacifiCare or the PacifiCare Affiliate (or their respective designees), as
applicable, at billed charges and to accept the Cost of Care amount less any applicable
Copayments, coinsurance and/or deductibles as payment in full for such services
or treatment.  PacifiCare or the
PacifiCare Affiliate will process payment for such services or treatment in
accordance with the payment procedures for the applicable benefit plan or
program.


 


If any Medical Group
Member receives Covered Services from a PacifiCare Participating Provider or
PacifiCare Affiliate contracted provider, PacifiCare shall, where contractually
available, provide reciprocity to Medical Group at PacifiCare rates for such
Covered Services.  Medical Group shall
comply with the procedures established by PacifiCare or the PacifiCare
Affiliate for reimbursement of such Covered Services.


 


Only medically
appropriate Covered Services, as determined by PacifiCare, shall be subject to
the reciprocity arrangement specified in this Section.  Medical Group shall abide by all provisions
of this Agreement relating to non-billing of Members with respect to all
services and treatment subject to this reciprocity arrangement.


 


2.12         Hospital Admissions.  In recognition of the need for coordination
of Covered Services provided to Medical Group Members and to ensure continuity
and quality of care, Medical Group agrees to utilize Hospital as the provider
of Hospital Services for Medical Group Members, subject to the following
exceptions:


 


(i)            Medical Group Members
admitted for Emergency Services or Urgently Needed Services;


 


(ii)           Medical Group Members
requiring Hospital Services not available at Hospital; and


 


(iii)          Medical Group Members
directed to any other PacifiCare Participating Provider in accordance with
PacifiCare’s Utilization Management Program.


 


Notwithstanding the
foregoing, Medical Group Member requests for treatment at another PacifiCare
Participating Provider may be granted due to limited Hospital bed capacity or
if such request is in the Member’s best interest, as determined by PacifiCare.


 


14

















 


2.13       PacifiCare Rights in the
Event of Insolvency of Medical Group. 
In  the event that Medical
Group is Insolvent, Medical Group shall be in material breach of this Agreement
and shall cooperate with PacifiCare in developing a corrective action plan for
addressing Medical Group’s Insolvency. 
Notwithstanding such cooperation, PacifiCare reserves the right to
terminate this Agreement in the event of Medical Group’s Insolvency in
accordance with the termination provisions of this Agreement.


 


ARTICLE 3

ADMINISTRATIVE DUTIES OF PACIFICARE


 


3.1         Administration and
Provision of Data.  PacifiCare shall
perform administrative, accounting, enrollment, eligibility verification and
other functions necessary for the administration and operation of the Managed
Care Plans.  PacifiCare shall provide
Medical Group with management information and data reasonably necessary to
carry out the terms and conditions of this Agreement and for the operation of
the Managed Care Plans.


 


3.2         Marketing.  PacifiCare shall make reasonable efforts to
market the Managed Care Plans.  Medical
Group agrees that PacifiCare may, in its discretion, use Medical Group’s name,
address and telephone number as well as the names, addresses and telephone
numbers and specialties of its Participating Providers in PacifiCare’s
marketing and informational materials including, without limitation,
PacifiCare’s directory of Participating Providers.  Nothing in this Agreement shall be deemed to require PacifiCare
to conduct any specific marketing activities on behalf of Medical Group and its
Participating Providers or to identify Medical Group or its Participating
Providers in any specific PacifiCare marketing or informational materials.


 


3.3         Enrollment and
Assignment of Members.  PacifiCare
shall be responsible for distributing the PacifiCare Enrollment Packet to
Members upon enrollment and at open enrollment periods.  PacifiCare shall provide benefit information
to Members concerning the type, scope and duration of benefits to which Members
are entitled under the Managed Care Plans. 
Nothing in this Agreement shall be construed to require PacifiCare to
assign any minimum or maximum number of Members to Medical Group or to utilize
Medical Group for any Members in the Medical Group Service Area.


 


3.4         Eligibility
Information.  PacifiCare shall
provide the Eligibility List to Medical Group on or about the fifteenth (15th)
day of each month.


 


3.5         Benefit Design and
Interpretation; Coverage Decisions. 
PacifiCare shall be solely responsible for the benefit design of all
Managed Care Plans, including establishing benefits, Premiums and Copayments.  PacifiCare shall be solely responsible for
interpreting the terms of and making final coverage determinations under the
Managed Care Plans.


 


3.6         Case Management.  PacifiCare shall manage and coordinate
Covered Services for Medical Group Members (including Emergency Services and
Urgently Needed Services) with complex medical conditions to ensure that care
is provided in a manner which encourages quality, continuity of care and
cost-effectiveness (“Case Management”). 
Medical Group


 


15

















 


shall cooperate fully
with PacifiCare in providing information that may be required in determining
the need for Case Management and in the transfer of Medical Group Members to
designated PacifiCare Participating Providers for cost effective care.


 


3.7         Out-of-Area Medical
Services.  PacifiCare shall manage
and coordinate Out-of-Area Medical Services. 
Medical Group shall cooperate fully with PacifiCare in providing
information that may be required for transferring Members back into the Medical
Group Service Area, including promptly notifying PacifiCare of known or
suspected Out-of-Area Medical Services, and shall accept the prompt transfer of
Members to the care of Medical Group and its Participating Providers following
the receipt of Out-of-Area Medical Services. 
PacifiCare, in conjunction with Medical Group and Hospital, shall make
all decisions regarding the duration of a Member’s care at the Out-of-Area
facility and transfer of the Member to a Medical Group Service Area facility.


 


ARTICLE 4

MANAGED CARE PROGRAM SERVICES


 


4.l          Managed Care Program
Services.  Consistent with the
requirements of State and Federal Law and the standards of Accreditation
Organizations, PacifiCare shall be accountable for the performance of the following
services for all Managed Care Plans: (i) quality management and improvement,
(ii) utilization management, (iii) credentialing, (iv) Member rights and
responsibilities, (v) preventive health services, (vi) medical record review
and (vii) payment and processing of claims (collectively, “Managed Care Program
Services”).  Medical Group and its
Participating Providers shall cooperate with PacifiCare in the performance of
all Managed Care Program Services and conduct their activities in a manner
consistent with the provisions of this Article 4 including specifically, but
without limitation, PacifiCare’s QI Program, UM Program, Credentialing Program,
Member Services activities, and Claims Processing Guidelines.


 


4.1.1        Quality Management and
Improvement.  PacifiCare shall
maintain an ongoing Quality Management and Improvement Program (“QI Program”)
to assess and improve the quality of clinical care and the quality of service
provided to Members under the Managed Care Plans.  The QI Program shall be maintained in accordance with the
requirements of State and Federal Law and the standards of Accreditation
Organizations.


 


Medical Group shall, at
the written request of PacifiCare, make available its Participating Providers
who are physicians to serve on PacifiCare’s QI Committee.  Medical Group shall establish and maintain
an independent quality improvement committee which shall meet as frequently as
advisable (but not less than ten (10) times throughout the year).  A member of the PacifiCare medical services
staff may participate in Medical Group’s quality improvement committee
meetings.  Medical Group shall keep
minutes of its quality improvement committee and subcommittee meetings, copies
of which shall be made available to PacifiCare upon ten (10) days’ written notice
by PacifiCare to Medical Group.  If the
functions of the quality improvement committee are performed together with its
utilization review committee, Medical Group shall implement and maintain
procedures which maintain all


 


16

















 


applicable
confidentiality protections for quality assurance activities and decisions.


 


Medical Group shall
develop and provide for PacifiCare’s review and approval written procedures for
focused review or remedial action whenever it is determined by PacifiCare’s QI
Committee that inappropriate or substandard Covered Services have been
furnished or Covered Services that should have been furnished have not been
furnished.  Upon request, PacifiCare
shall assist Medical Group in the formulation of such focused review and
remedial procedures.


 


4.1.2        Utilization Management.  PacifiCare shall maintain an ongoing
Utilization Management Program (“UM Program”) to address pre-authorization,
concurrent and retrospective review of the quality, appropriateness, level of
care and utilization of all Covered Services provided or to be provided to
Members under the Managed Care Plans. 
The UM Program shall be maintained in accordance with the requirements
of State and Federal Law and the standards of Accreditation Organizations.


 


Medical Group shall
establish and maintain a utilization review committee which shall meet as
frequently as necessary.  A member of
the PacifiCare medical services staff may participate in Medical Group’s
utilization review committee meetings. 
Medical Group shall keep minutes of its utilization review committee
meetings, copies of which shall be made available to PacifiCare upon ten (10)
days’ written notice by PacifiCare to Medical Group.  Medical Group’s utilization review committee shall review, as
necessary, elective referrals and hospital and skilled nursing facility
admissions on a prospective basis, and Emergency Services and Urgently Needed
Services requiring hospital admissions on a retrospective basis.  The committee shall also be responsible for
monitoring patterns of care, isolating inappropriate utilization and performing
other management and review duties as specified in the UM Program.


 


4.1.3        Credentialing.  PacifiCare shall maintain standards,
policies and procedures for credentialing and recredentialing physicians,
hospitals and other health care professionals and facilities that provide
Covered Services to Members under the Managed Care Plans (“Credentialing
Program”).  The Credentialing Program
shall be maintained in accordance with the requirements of State and Federal
Law and the standards of Accreditation Organizations.


 


4.1.4        Member Rights and
Responsibilities.  PacifiCare shall
inform Members of their rights and responsibilities under each Managed Care Plan,
provide Members with membership cards and member handbooks, distribute periodic
communications to Members, process Member complaints and grievances and respond
to inquiries and requests from Members regarding Managed Care Plans
(collectively “Member Services”).


 


4.1.5        Preventive Health
Services.  PacifiCare shall develop
preventive health guidelines for the prevention and early detection of illness
and disease (“Preventive Health Guidelines”) and shall encourage Members to use
preventive health services.  The
Preventive Health Guidelines shall be maintained in accordance with the
standards of


 


17

















 


Accreditation
Organizations and shall be distributed to Participating Providers.  Medical Group and its Participating
Providers shall provide preventive health services required pursuant to the
applicable Subscriber Agreements to Medical Group Members in accordance with
the Preventive Health Guidelines.


 


4.1.6        Medical Record Review.  PacifiCare shall on an ongoing basis review
medical records maintained by Medical Group and its Participating Providers to
assess compliance with the requirements of State and Federal Law and the
standards of Accreditation Organizations. 
Medical Group and its Participating Providers shall maintain medical
records in accordance with the provisions of this Agreement regarding medical
records and in accordance with PacifiCare’s guidelines regarding medical
records.


 


4.1.7        Claims Processing.  PacifiCare shall establish and maintain
standards, policies and procedures for the timely and accurate processing and
payment of claims for Covered Services provided to Members (“Claims Processing
Guidelines”) The Claims Processing Guidelines shall be maintained in accordance
with the requirements of State and Federal Law and the Managed Care Plans.


 


4.1.8        Policies and Procedures.  For Managed Care Program Services not
delegated to Medical Group, Medical Group agrees to abide by PacifiCare’s
policies and procedures pertaining to the administration of such services.  The applicable policies and procedures may
include, but not be limited to, policies and procedures pertaining to
PacifiCare’s Utilization Management Program, Credentialing Program, and Claims
Processing Guidelines.  Such policies
and procedures will outline the non-delegated requirements for claims
submission, subcontract rate information, utilization management, and
Credentialing.


 


4.2           Delegation of
Managed Care Activities.


 


4.2.1        Delegation Audits and
Determinations.  PacifiCare may, in
its discretion, delegate utilization management, credentialing, medical records
review, claims processing, and/or other activities consistent with regulatory
and accrediting standards to Medical Group. 
Such delegation may occur at any time during the term of this Agreement
if PacifiCare determines the Medical Group is capable of performing such
activities and if Medical Group consents in writing to such delegation.  Medical Group’s consent and written
agreement may be evidenced by this Agreement, amendments to this Agreement, or
a separate delegation agreement between PacifiCare and Medical Group.


 


Managed Care Program
Services which are delegated to Medical Group shall be specified in Exhibit 2
to this Agreement (collectively, the “Delegated Activities”).  Exhibit 2 may be amended from time to time
during the term of this Agreement by PacifiCare to reflect changes in
delegation standards; delegation status; performance measures; reporting
requirements; and other provisions of Exhibit 2.  Any and all changes to Exhibit 2 to this Agreement, shall to the
extent provided at Section 5.2 of this Agreement result in an automatic
adjustment to Medical Group’s Capitation


 


18

















 


Payment.


 


4.2.2        Medical Group’s
Responsibility for Delegated Activities. 
Medical Group shall be responsible for the performance of all Delegated
Activities, as specified in Exhibit 2. 
Medical Group shall have no right to modify Exhibit 2 or Medical Group’s
obligations to perform Delegated Activities without PacifiCare’s prior written
consent.


 


4.2.3        PacifiCare Policies.  For all Delegated Activities, PacifiCare
shall provide Medical Group with PacifiCare’s standards and requirements
applicable to the Delegated Activities, as amended from time to time (the
“PacifiCare Delegation Policies”) and shall notify Medical Group of all
substantive changes to the PacifiCare Delegation Policies.  Medical Group may utilize its own policies
and procedures for the Delegated Activities, provided that such policies and
procedures are consistent with the PacifiCare Delegation Policies and are
provided to PacifiCare for its review and approval.  If Medical Group’s policies and procedures are inconsistent with
the PacifiCare Delegation Policies, the PacifiCare Delegation Policies shall
apply.


 


4.2.4        Sub-Delegation.  Medical Group shall not further delegate the
performance of Delegated Activities to any of its Participating Providers or
any other organization or entity without the prior written consent of
PacifiCare.


 


4.2.5        Maintenance of
Information and Records.  Medical
Group shall maintain all information and records reviewed or created in
connection with performing the Delegated Activities in a form acceptable to
PacifiCare, provide PacifiCare with access to such information and records, and
permit PacifiCare to review and copy such information and records.


 


4.2.6        Reporting Obligations.  Medical Group shall provide PacifiCare with
periodic written reports regarding all Delegated Activities in the formats
specified by PacifiCare for each of the Delegated Activities.  Medical Group’s arrangements with its
Participating Providers shall provide that Medical Group may disclose to
PacifiCare its Participating Provider credentialing files.


 


4.2.7        Monitoring/Audits.  PacifiCare shall oversee Medical Group’s
performance of Delegated Activities through review of periodic written reports
provided by Medical Group as described above and meetings with appropriate
Medical Group representatives and on-site audits and assessments of Medical
Group.  Medical Group shall cooperate,
participate and comply with PacifiCare in such monitoring and oversight
activities.  Such audits and assessments
will be performed in accordance with the requirements of State and Federal Law
and the standards of Accreditation Organizations, PacifiCare’s Delegation
Policies and the terms of this Agreement.


 


4.2.8        Insurance.  Medical Group shall comply with the
insurance provisions of this Agreement relating to managed care errors and
omissions insurance.


 


4.3           Payment for
Delegated Activities.  PacifiCare’s
payment for Delegated Activities is specified


 


19

















 


in Section 5.2 of this Agreement.


 


4.4           Revocation
and Resumption of Delegated Activities.


 


4.4.1        PacifiCare’s Right to
Revoke Delegated Activities. 
PacifiCare may revoke any or all Delegated Activities at any time if
PacifiCare determines that such Delegated Activities are not being performed in
accordance with the standards and requirements established by PacifiCare or if
Medical Group’s performance of Delegated Activities is inconsistent with, or in
violation of, State and Federal Law or the standards of any Accreditation
Organization.


 


4.4.2        Revocation Notices.


 


(a)           Deficiencies Capable
of Cure.  For deficiencies in Medical
Group’s performance of Delegated Activities, which PacifiCare determines are
capable of being cured, PacifiCare shall provide Medical Group with reasonable
prior written notice of not less than thirty (30) days specifying the Delegated
Activities which PacifiCare intends to revoke (the “revocation notice”).  PacifiCare shall specify in its revocation
notice the specific material deficiency, the specific standard and the
corrective actions to be taken by Medical Group to continue performance of
Delegated Activities and the timeframes within which such corrective actions
must be completed (the “cure period”). 
Promptly following the cure period, PacifiCare shall advise the Medical
Group, in writing, whether PacifiCare will proceed with revocation of the
Delegated Activities.


 


(b)           Deficiencies Not
Capable of Cure.  For deficiencies
which PacifiCare determines are not capable of being cured, including but not
limited to PacifiCare’s determination that Medical Group’s continued
performance of Delegated Activities presents a risk of imminent harm to
PacifiCare Members or would be contrary to the requirements of any Government
Agency, State or Federal Law or Accreditation Standard, PacifiCare shall
provide Medical Group with written notice that the Delegated Activities shall
be revoked by the effective date of revocation.


 


(c)           Contents of Notices.  The written notices from PacifiCare to
Medical Group under this Section shall, where applicable, specify (i) the
adjustments to Capitation Payments as a result of the revocation of any
Delegated Activities in accordance with the allocations set forth in Section
5.2 of this Agreement, (ii) in the event that claims processing is revoked, the
adjustments to Capitation Payments for claims payment as set forth in Section 5.3
of this Agreement, and (iii) any and all changes to Exhibit 2 resulting from revocation.


 


4.4.3        Continued Cooperation
Following Revocation.  Upon
revocation of any of the Delegated Activities, or any portion thereof,
PacifiCare will resume responsibility for performing such activities, and
Medical Group and its Participating Providers shall


 


20

















 


continue to cooperate
with PacifiCare with respect to the performance of Managed Care Services.


 


4.4.4        Revocation Not
Exclusive Remedy.  Notwithstanding
PacifiCare’s right to revoke the Delegated Activities, Medical Group’s failure
to perform the Delegated Activities shall be a breach of the Agreement.  In such event, PacifiCare may exercise all
of its other rights and remedies to enforce the Agreement, including the right
of termination.


 


4.4.5        Resumption of Delegated
Activities.  Following the
revocation of Delegated Activities by PacifiCare, any resumption by Medical
Group of responsibility for Delegated Activities shall be pursuant to the
provisions of Section 4.2.1, above.


 


ARTICLE 5

COMPENSATION


 


Capitation Payments.  PacifiCare shall make monthly Capitation
Payments to Medical Group as payment for providing and arranging Covered
Services to Medical Group Members for each Managed Care Plan, as specified in
this Agreement and the applicable Product Attachment.


 


5.1.1        Due Date.  Each Capitation Payment shall be due and
payable on the tenth (10th) day of the month for the current month’s Covered
Services.  In the event the tenth (10th)
day of the month is not a business day, the Capitation Payment shall be due and
payable on the next business day following the tenth (10th) day of the month.


 


5.1.2        Documentation.  PacifiCare shall provide Medical Group with
documentation, as specified in the Provider Manual, in support of each
Capitation Payment.


 


5.1.3        Retroactive Adjustments.  Capitation Payments shall be subject to
retroactive adjustments either upward or downward due to retroactive changes in
the age/gender and plan type adjustment for each Managed Care Plan as specified
in the applicable Product Attachment and retroactive changes in the number of
Medical Group Members for each Managed Care Plan.  Retroactive adjustments to Capitation Payments for Medical Group
Members enrolled in Managed Care Plans which are government funded (including,
without limitation, Medicare, Medicaid, public employees) shall be made within
ninety (90) days after the adjustment is determined.  Retroactive adjustments to Capitation Payments for Medical Group
Members enrolled in Managed Care Plans which are not government funded shall be
made within one hundred fifty (150) days after the end of the month for which
the Capitation Payment applies.


 


5.2           Payment
for Performance of Delegated Activities. 
PacifiCare’s payment for performance of the Delegated Activities by
Medical Group is included in Capitation Payments made to Medical Group.  The Capitation Payment rates set forth in
each Product Attachment assume that the Medical Group is fully delegated to
perform Managed Care Program Services. 
Accordingly, for each month in which any Delegated Activity is not
delegated or has been


 


21

















 


revoked by PacifiCare as
provided at Article 4, the Medical Group’s Capitation Payment shall be reduced
by the following percentages:


 


	
  Activity Not Delegated

  	
   

  	
  Percentage

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Utilization
  Management

  	
   

  	
  3.6

  	
  %

  
	
  Credentialing

  	
   

  	
  0.45

  	
  %

  
	
  Claims
  Processing

  	
   

  	
  2.7

  	
  %

  



 


If only a portion of a
specific Delegated Activity is delegated or revoked, PacifiCare shall have the
right to adjust percentages set forth above to reflect the portion of the
specific Delegated Activity performed by Medical Group.  PacifiCare may modify the payment for Delegated
Activities by providing Medical Group with sixty (60) days’ prior written
notice.  Any modification for the
payment for Delegated Activities shall be upon mutual agreement between Medical
Group and PacifiCare.


 


5.3         Withhold to Pay Claims.  If PacifiCare docs not delegate performance
of claims processing to Medical Group or if the delegation of claims processing
is revoked by PacifiCare, PacifiCare shall deduct from Medical Group’s monthly
Capitation Payments an amount reasonably estimated based on prior claims
history by PacifiCare to be necessary for PacifiCare to process and pay claims
for Medical Group Services which are not provided directly by Medical Group and
its employed Participating Providers. 
Initially, this amount shall be ten percent (10%) of Medical Group’s
monthly Capitation Payment.  This amount
may reasonably be increased or decreased each month with five (5) days advanced
notice to more accurately reflect Medical Group’s actual claims experience and
any changes in Covered Services which are provided or arranged by Medical Group
and its Participating Providers, with adjustments for claims incurred but not
received.


 


5.4         Incentive Programs.  Incentive programs are designed to ensure
that PacifiCare, Medical Group and, for some programs, Hospital work
collaboratively to provide or arrange Covered Services in an effective and
efficient manner by ensuring appropriate utilization of Covered Services.  The incentive programs may be administered
by Medical Group and Hospital or by PacifiCare for each Managed Care Plan as
described below and set forth in the applicable Product Attachment.


 


5.4.1        Incentive Program
Withhold.  PacifiCare may establish
and/or adjust a withhold from Medical Group’s monthly Capitation Payment for
purposes of offsetting potential incentive program deficits.  PacifiCare shall provide full and complete
data, of which shall be in mutually agreeable format and which calculations,
including IBNR, shall be consistent with industry standards and accounting
principles, which demonstrates the basis of the withhold modification to the
group prior to any withhold modification. 
The group will have thirty (30) days to review and respond to the
data.  At no time will the Incentive
Program Withhold exceed the downside risk limit proposed, or any mutually
agreed upon limit.  The Incentive
Program Withhold shall be refunded to the Medical Group at the time of the
incentive program settlements, except that Medical Group’s share of any
incentive program deficits shall be deducted from such refund.  As of the date of this Agreement, it is
understood that the withhold


 


22

















 


is set at zero percent
(0%).


 


5.4.2        Medical Group and
Hospital Incentive Program Settlements. 
Medical Group and Hospital shall conduct settlements for Medical Group
and Hospital incentive programs for Managed Care Plans in which PacifiCare does
not share in the surpluses or deficits. 
Any incentive program between Medical Group and Hospital pertaining to
the Managed Care Plans under this Agreement must first be approved by
PacifiCare.


 


5.4.3        PacifiCare Incentive
Program Settlements.  PacifiCare
shall conduct combined settlements applicable to Medical Group and Hospital for
all incentive programs administered by PacifiCare.  Surpluses and deficits under each of the incentive programs shall
be aggregated and offset against one another. 
PacifiCare will conduct an estimated calculation after six (6) months
(the “Interim Calculation”) and a final calculation annually (the “Final Calculation”)
based on the calendar year.  The
incentive program withhold described above shall be refunded to the Medical
Group at the time of the incentive program settlements, except that Medical
Group’s share of any incentive program deficits shall be deducted from such
refund.  Payments under the combined
incentive program settlements will be due from the owing party within one
hundred and twenty (120) days following the end of the six (6) months for the
Interim Calculation and within one hundred and eighty (180) days following the
end of the calendar year for the Final Calculation.  For the Interim Calculation, the payment due will be limited to
seventy-five percent (75%) of the calculated amount due to account for incurred
but not received claims.  To the extent
a Medical Group deficit has been carried forward from a prior settlement
period, this deficit shall be offset against amounts due to Medical Group
hereunder.  Medical Group shall have
thirty (30) days from the date of written notice to audit and submit any
revisions to the incentive program settlement to PacifiCare.  Any submitted revisions must be approved by
PacifiCare and such approval shall not be unreasonably withheld.  PacifiCare shall then have thirty (30) days
to make necessary adjustment to the calculation and return the itemized
calculation to Medical Group.  Such
calculation shall be considered the final calculation unless Medical Group and
PacifiCare agree to extend the calculation process.  Any amounts owing shall be paid to the appropriate party within
thirty (30) days of the release of the final itemized calculation.  In the event that claims for providers were
incurred during the calendar year in question but were not paid until after the
final calculation, such costs shall be carried forward and applied to the
subsequent calendar year’s incentive program as an expense for that calendar
year.


 


5.4.4        Incentive Program
Compliance with State and Federal Law. 
PacifiCare and Medical Group acknowledge and agree that the payments
which may be made directly or indirectly under the incentive programs described
in this Agreement are not made as an inducement to reduce or limit Covered
Services to any specific Member. 
Medical Group acknowledges and agrees that any payments which may be
made directly or indirectly under physician incentive programs Medical Group
may utilize with respect to its Participating Providers shall not be made as an
inducement to reduce or limit Covered Services to any specific Member.  Medical Group further acknowledges and


 


23

















 


agrees that the incentive
programs described in this Agreement shall be subject to modification by
PacifiCare during the term of this Agreement in order to comply with changes in
State and Federal Law, and Medical Group further agrees to modify any physician
incentive programs utilized with respect to its Participating Providers to
comply with such changes.


 


5.4.5        Limitation on Medical
Group’s Risk.  In the event Medical
Group incurs an obligation under the overall incentive program settlement
described above, Medical Group shall not be responsible for reimbursing
PacifiCare nor shall PacifiCare offset the Medical Group’s obligations as the
result of an incentive program obligation and the amount carried forward shall
be offset against amounts otherwise due to Medical Group under future
settlements for the combined incentive programs.  Notwithstanding the foregoing, Medical Group shall be responsible
for reimbursing PacifiCare for deficits in pharmacy incentive programs to the
extent there are insufficient surpluses due Medical Group from other incentive
programs to offset pharmacy deficits; such reimbursement shall be made within
ninety (90) days following completion of the Final Calculation for all
incentive program settlements described above. 
In the event that the pharmacy incentive programs have a deficit greater
than five hundred thousand dollars ($500,000), reimbursement to PacifiCare
shall be made as an offset to the monthly Capitation Payments from the Medical
Group over a period of six (6) months.


 


5.5           Individual Stop-Loss
Program.  PacifiCare shall provide
Individual Stop-Loss (“ISL”) protection in order to limit Medical Group’s
financial risk for Medical Group Services (“ISL Program”).  The ISL Program is designed to limit Medical
Group’s financial responsibility for Medical Group Services to a specified
dollar amount per Medical Group Member per calendar year (“ISL Deductible”),
while encouraging Medical Group’s continuing involvement with Medical Group
Member’s care by sharing a portion of the financial responsibility for Medical
Group Services which exceed the ISL Deductible (“ISL Coinsurance”).  PacifiCare shall charge a premium (“ISL
Premium”) as consideration for the ISL Program.  The ISL Deductible, ISL Coinsurance and ISL Premium for Medical
Group are specified in each Product Attachment.  Notwithstanding any other provision of this Agreement, PacifiCare
may amend the ISL Deductible, ISL Coinsurance and ISL Premium on an annual
basis effective at the beginning of any calendar year by providing sixty (60)
calendar days’ prior written notice to Medical Group.  For Medical Group Services which exceed the ISL Deductible,
PacifiCare will pay Cost of Care, less the Medical Group’s ISL Coinsurance
amount, subject to the Medical Group’s compliance with the procedures set forth
in the Provider Manual and the provisions set forth below.


 


5.5.1        Submission of ISL
Claims.  Medical Group shall submit
all claims under the ISL Program in accordance with the procedures set forth in
the Provider Manual.  PacifiCare shall
pay claims under the ISL Program only if such claims are submitted within one
(1) year following the date the claim is incurred.


 


5.5.2        Notification of ISL
Claims.  Medical Group shall provide
written notification to PacifiCare when Medical Group Services for any Medical
Group Member(s) equal fifty percent (50%) of the ISL Deductible.  Such written notification shall be provided


 


24

















 


to PacifiCare no later
than the fifteenth (15th) day of the month following the month in which such
threshold is reached.  Medical Group
acknowledges and agrees that if Medical Group fails to provide the written
notice required by this Section within the time frame specified in this
Section, Medical Group shall be financially responsible for ten percent (10%)
of all Medical Group Services provided to the Medical Group Member(s) in excess
of the ISL Deductible, which amount shall be in addition to the ISL
Coinsurance.


 


5.5.3        Opt Out from ISL
Program.  Subject to PacifiCare’s
approval, Medical Group may elect to opt out of the ISL Program, effective upon
the Commencement Date or at the beginning of any calendar year.  In such event, Medical Group shall be
required to obtain stop-loss coverage from a third-party insurance carrier
acceptable to PacifiCare and in the amounts required by PacifiCare and State
and Federal Law.  In order to opt out of
PacifiCare’s ISL Program, Medical Group must provide written notice to PacifiCare
at least thirty (30) days prior to the beginning of the calendar year.  Such notice shall specify the name of the
third-party insurance carrier, and proposed effective date, coverage levels and
charges.  If PacifiCare does not object
to such coverage in writing within fifteen (15) days of the date of the notice
from Medical Group, Medical Group shall be required to purchase such coverage
as of the effective date specified in the notice.


 


Medical Group shall
provide PacifiCare with a certificate of insurance evidencing the ISL coverage
as described in the Medical Group’s notice within ten (10) days following the
effective date of such insurance.  The
certificate of insurance shall provide that PacifiCare shall receive thirty
(30) days’ prior written notice of cancellation or material reduction in
Medical Group’s ISL coverage.  If the
Medical Group does not purchase coverage acceptable to PacifiCare or provide
PacifiCare with evidence of the ISL coverage as described herein, PacifiCare
shall have the right to provide the ISL protection at the ISL Deductible level
determined by PacifiCare to be appropriate for Medical Group and shall deduct
the applicable ISL Premium from Medical Group’s Capitation Payments.


 


5.6         Payments Following
Termination of this Agreement. 
Following termination of this Agreement, PacifiCare shall make payments
to Medical Group, at the cost of care rates, as compensation for providing and
arranging Covered Services to remaining Medical Group Members until such
Members are assigned to other PacifiCare Participating Providers.  For Members who are assigned to other
PacifiCare Participating Providers but who will continue to receive certain
ongoing services from Medical Group Participating Providers in accordance with
the provisions of Section 8.3 of this Agreement, Medical Group shall be paid
for such services at the Cost of Care or as otherwise agreed in writing by
Medical Group.


 


5.7         Cost of Care.  Certain provisions of this Agreement require
that Medical Group provide or arrange health care services which are not
covered by Capitation Payments at Cost of Care and certain provisions of this
Agreement require that Covered Services be valued at Cost of Care.  For purposes of this Agreement, “Cost of
Care” shall be calculated using the lesser of billed charges or in accordance
with the PacifiCare Fee Schedule.  The
PacifiCare Fee


 


25

















 


Schedule shall be based
upon the following: (i) for professional services that are included under the
Medicare RBRVS Fee Schedule, reimbursement shall be one hundred percent (100%)
of Medicare’s geographically adjusted fee schedule according to the Medicare
payment locality the provider resides in; (ii) for all other health care
services (other than inpatient and outpatient Hospital Services) that are not included
in RBRVS but included in a Medicare Fee Schedule, reimbursement shall be one
hundred percent (100%) of the Medicare rate for the current period as released
by HCFA by December of the preceding year; (iii) for inpatient and outpatient
Hospital Services, the Cost of Care shall be the actual amounts paid by
PacifiCare; (iv) for any other Covered Services that do not fall within any of
the above specified categories, (other than inpatient and outpatient Hospital
Services), reimbursement shall be the lesser of seventy-five percent (75%) of
billed charges or amount determined under PacifiCare’s Fee Schedule.


 


5.8         Collection of
Copayments.  Medical Group and its
Participating Providers shall be responsible for the collection of Copayments
upon rendering Medical Group Services to Medical Group Members in accordance
with the applicable Subscriber Agreement. 
Any Copayments which are stated as a percentage shall be calculated
using the Cost of Care for such Medical Group Services.


 


5.9         Collection of Charges
from Third Parties.  If a Member is
entitled to payment from a third party (excluding a workers’ compensation
carrier or primary insurance carrier under applicable coordination of benefits
rules), PacifiCare hereby assigns to Medical Group for collection, any claims
or demands against such third parties for amounts due for Medical Group
Services, subject to the following conditions: (i) To the extent liens are
utilized, Medical Group shall utilize lien forms which are provided by
PacifiCare or approved in advance by PacifiCare; (ii) Medical Group shall
notify PacifiCare each time it pursues and each time it obtains a signed lien
from a Member; (iii) Medical Group shall not commence any legal action as it
relates to this Agreement against a third party for amounts due for Covered
Services without obtaining the prior written consent of PacifiCare (collection
and demand letters consistent with the Provider Manual shall not constitute
commencement of legal action); and (iv) PacifiCare may immediately rescind the
assignment on a claim-by-claim basis by providing written notice of rescission
to Medical Group if Medical Group fails to comply with the terms of this
Section 5.9, or if PacifiCare reasonably determines that Medical Group’s
collection activities are detrimental to the relationship between PacifiCare
and a Member or a Contracting Employer Group.


 


If Medical Group obtains
ISL coverage from PacifiCare, the following also shall apply:


 


(i)            Medical Group shall
make no demand upon PacifiCare for reimbursement under the ISL Program until
all third-party claims have been pursued and it is determined that full payment
cannot be obtained within twelve (12) months from the date of the provision of
Medical Group Services; and


 


(ii)           In the event Medical
Group receives payment from a third party after receipt of an ISL payment from
PacifiCare, Medical Group shall reimburse PacifiCare to the extent that the
combined amounts received from all parties exceeds one hundred percent (100%)
of Medical Group’s usual and customary fee-for-service rates.


 


26

















 


5.10       Coordination of Benefits.  Medical Group shall cooperate with and
support, as mutually agreed upon by the parties, PacifiCare’s coordination of
benefits rights.


 


5.10.1      Plan Is Primary.  If a Medical Group Member possesses health
benefits coverage through another policy which is secondary to PacifiCare under
applicable coordination of benefits rules, including the Medicare secondary
payor program, Medical Group shall accept payment from PacifiCare for Covered
Services as provided herein as full payment for such Covered Services, except
for applicable Copayments.  Medical
Group Member shall have no obligation for any fees, regardless of whether
secondary insurance is available.


 


5.10.2      Plan is Secondary.  If a Medical Group Member possesses health
benefits coverage through another policy which is primary to PacifiCare under
applicable coordination of benefits rules, including the Medicare secondary
payor program, or if Medical Group Member is entitled to payment under a
workers’ compensation policy or automobile insurance policy, Medical Group may
pursue payment from the primary payor or workers’ compensation carrier
consistent with applicable law and regulations and Medical Group’s contract, if
any, with the primary payor.  In such
event, PacifiCare’s responsibility shall equal the amount of out-of-pocket
expenses (i.e., Copayments, coinsurance, and deductibles) that Medical Group
Member would incur in the absence of PacifiCare’s secondary coverage, minus the
ISL Deductible and ISL Coinsurance.


 


5.11       Recoupment Rights.  Except as may otherwise be specifically
provided in this Agreement, PacifiCare shall have the right to recoup any and
all amounts owed by Medical Group to PacifiCare against amounts, including
Capitation Payments, owed by PacifiCare to Medical Group.  Before exercising such right, PacifiCare
shall provide Medical Group with at least thirty (30) days’ prior written
notice specifying the amount to be recouped, and if PacifiCare receives payment
of such amount from Medical Group prior to the expiration of such thirty (30)
day period, such amount shall not be recouped. 
This right shall include, without limitation, PacifiCare’s right to
recoup the following amounts owed to PacifiCare by Medical Group: (i) amounts
owed by Medical Group due to overpayments or payments made in error by
PacifiCare; (ii) amounts owed by Medical Group as a result of claims for
Medical Group Services that PacifiCare may pay on behalf of Medical Group;
(iii) amounts owed by Medical Group as a result of the outcome of the Member
appeals and grievance procedure; (iv) amounts owed by Medical Group in
connection with any other prior or existing agreement between Medical Group and
PacifiCare or any PacifiCare Affiliate. 
As a material condition to PacifiCare’s obligations under this
Agreement, Medical Group agrees that all recoupment and any offset rights
pursuant to this Agreement shall be deemed to be and to constitute rights of
recoupment authorized in State or Federal law or in equity to the maximum
extent possible under law or in equity and that such rights shall not be
subject to any requirement of prior or other approval from any court or other
government authority that may now or hereafter have jurisdiction over Medical
Group.


 


5.12         Adequacy
of Compensation.  Medical Group
agrees to accept payment as provided herein as payment in full for providing
and arranging the Covered Services required under this


 


27

















 


Agreement, whether that
amount is paid in whole or in part by Member, PacifiCare or any Subscriber,
including other health care plans that pay before PacifiCare as required by
applicable State or Federal coordination of benefits provisions.  This Section does not prohibit Medical Group
from collecting applicable Copayments, coinsurance or deductibles consistent
with the Managed Care Plans.


 


5.13       Character of
Payments from PacifiCare. 
Capitation Payments to Medical Group pursuant to this Agreement are prepayments
for Medical Group’s performance of its obligations under this Agreement.  PacifiCare may at any time, adjust from any
funds to be transferred to Medical Group such amounts as reasonably determines
are necessary to compensate PacifiCare for any claims, which PacifiCare may
have against Medical Group resulting from Medical Group’s failure to perform
its obligations under this Agreement. 
Capitation Payments to Medical Group are subject to repayment until such
time as there is a final settlement in accordance with the terms of this
Agreement..


 


ARTICLE 6

TERM AND TERMINATION


 


6.1         Term.  The term of this Agreement shall commence on
January 1, 2001 (the “Commencement Date”) and end on December 31, 2002.  Thereafter, the term of this Agreement shall
be automatically extended for twelve (12) months (“Anniversary Date”), unless
either party provides the other with written notice of such party’s intention
not to extend the term at least one hundred eighty (180) calendar days prior to
the Anniversary Date or until this Agreement is appropriately terminated by
either party as provided herein.


 


6.2         Termination of
Agreement with Cause.  Either
PacifiCare or Medical Group may terminate this Agreement for cause as set forth
below, subject to the notice requirement and cure period set forth below.


 


6.2.1        Cause for Termination
of Agreement by Medical Group.  The
following shall constitute cause for termination of this Agreement by Medical
Group:


 


(i)            Non-Payment.  Failure by PacifiCare to pay Capitation
Payments due Medical Group hereunder within thirty (30) days of the Capitation
Payment due date or failure by PacifiCare to make any other payments due
Medical Group hereunder within forty-five (45) days of any such payment’s due
date.


 


(ii)             Breach of Material
Term and Failure to Cure. 
PacifiCare’s breach of any material term, covenant, or condition and
subsequent failure to cure such breach as provided below.


 


6.2.2        Cause for Termination
of Agreement by PacifiCare.  The
following shall constitute cause for termination of this Agreement by
PacifiCare:


 


(i)            Financial Failure
of Medical Group.  Insolvency of
Medical Group.  Medical Group shall have
the opportunity to dispute such determination by PacifiCare by providing
reasonable evidence and assurances of financial stability and


 


28

















 


capacity to perform under
this Agreement within fifteen (15) days of PacifiCare’s determination.


 


(ii)           Failure to Provide
Quality Services.  Medical Group’s
failure to arrange or provide Covered Services in accordance with the standards
set forth in this Agreement and PacifiCare’s QI Program and UM Program.  Notwithstanding the foregoing, PacifiCare
reserves the right to immediately withdraw from Medical Group or any of its
Participating Providers any or all Members in the event the health or safety of
Members is endangered by the actions of Medical Group or any of its
Participating Providers or as a result of continuation of this Agreement.


 


(iii)          Change in Medicare
Status.  Such time as Medical Group
files an affidavit with the Medicare Program promising to furnish Medicare
covered services to Medicare beneficiaries only through private contracts under
Section 1802 (b) of the Social Security Act.


 


(iv)          Breach of Material
Term and Failure to Cure.  Medical
Group’s breach of any material term, covenant or condition of this Agreement
and subsequent failure to cure such breach as provided below.


 


6.2.3        Notice of Termination
and Effective Date of Termination. 
The party asserting cause for termination of this Agreement (the
“terminating party”) shall provide written notice of termination to the other
party.  The notice of termination shall
specify the breach or deficiency underlying the cause for termination.  The party receiving the written notice of
termination shall have thirty (30) calendar days from the receipt of such
notice, or longer if mutually agreeable, to cure the breach or deficiency to
the satisfaction of the terminating party (the “Cure Period”).  If such party fails to cure the breach or
deficiency to the satisfaction of the terminating party within the Cure Period
or if the breach or deficiency is not curable, the terminating party shall
provide written notice of failure to cure the breach or deficiency to the other
party following expiration of the Cure Period. 
This Agreement shall terminate upon receipt of the written notice of
failure to cure or at such other date as may be specified in such notice.  During the Cure Period, PacifiCare may cease
marketing efforts for Medical Group, discontinue enrollment of Members with
Medical Group and begin transferring Medical Group Members to other PacifiCare
Participating Providers.


 


6.3         Automatic Termination
Upon Revocation of License or Certificate. 
This Agreement shall automatically terminate upon the revocation,
suspension or restriction of any license, certificate or other authority
required to be maintained by Medical Group or PacifiCare in order to perform
the services required under this Agreement or upon the Medical Group’s or
PacifiCare’s failure to obtain such license, certificate or authority.


 


3.1         Termination for
Transfer to a Successor Entity.  As
set forth in Section 7.11, PacifiCare shall have the right to terminate this
Agreement on ninety (90) days’ prior written notice to Medical Group if
PacifiCare reasonably determines that any successor entity or management
company, as defined in Section 7.11, cannot satisfactorily perform the
obligations of Medical


 


29

















 


Group under this Agreement.


 


6.5         Transfer of Medical
Records.  Following termination of
this Agreement, at PacifiCare’s request, Medical Group and its Participating
Providers shall copy all requested Medical Group Member patient medical files
in the possession of Medical Group or its Participating Providers and forward
such files to another provider of Covered Services designated by PacifiCare,
provided such copying and forwarding is not otherwise objected to by such
Members.  The copies of such medical
files may be in summary form.  The cost
of copying the patient medical files shall be borne equally by Medical Group
and PacifiCare.  Medical Group shall
cooperate with PacifiCare in maintaining the confidentiality of such Member
medical records at all times.


 


6.6           Repayment
Upon Termination.  Within one
hundred eighty (180) calendar days of the effective date of termination of this
Agreement, an accounting shall be made by PacifiCare of the monies due and
owing either party and payment shall be forthcoming by the appropriate party to
settle such balance within thirty (30) calendar days of such accounting.  Either party may request an independent
audit of such PacifiCare accounting by a mutually acceptable independent
certified public accountant and such audit shall be equally paid for by both
parties.  The parties agree to abide by
the findings of such independent audit. 
Appropriate payment, if any, by the appropriate party shall be made
within thirty (30) calendar days of such independent audit.


 


6.7         Termination Not an
Exclusive Remedy.  Any termination
by either party pursuant to this Article is not meant as an exclusive remedy
and such terminating party may seek whatever action in law or equity as may be
necessary to enforce its rights under this Agreement.


 


ARTICLE 7

GENERAL PROVISIONS


 


7.1         Independent Contractor
Relationship.  The relationship
between PacifiCare and Medical Group is an independent contractor
relationship.  Neither Medical Group nor
its Participating Providers, employees or agents are employees or agents of
PacifiCare and neither PacifiCare nor its employees or agents are members,
partners, employees or agents of Medical Group.  None of the provisions of this Agreement shall be construed to
create a relationship of agency, representation, joint venture, ownership, control
or employment between the parties other than that of independent parties
contracting solely for the purpose of effectuating this Agreement.  Nothing contained in this Agreement shall
cause either party to be liable or responsible for any debt, liability or
obligation of the other party or any third party unless such liability or
responsibility is expressly assumed by the party sought to be charged
therewith.


 


7.2         Responsibility For Own
Acts.  Each party shall be
responsible for its own acts or omissions and for any and all claims,
liabilities, injuries, suits, demands and expenses of all kinds which may
result or arise out of any alleged malfeasance or neglect caused or alleged to
have been caused by that party or its employees or representatives in the
performance or omission of any act or responsibility of that party under this
Agreement.


 


30

















 


7.3           Member Appeals and
Grievances.  PacifiCare shall be
responsible for resolving Member claims for benefits under the Managed Care
Plans and all other claims against PacifiCare. 
PacifiCare shall resolve such claims utilizing the Member Appeals and
Grievance Procedures set forth in the Subscriber Agreement and the Provider
Manual.  Medical Group shall assist PacifiCare
in the handling of Member complaints, grievances and appeals, consistent with
the Member Appeals and Grievance Procedures. 
In the event an oral or written complaint, grievance or appeal is
presented to Medical Group or any of its Participating Providers relating to
benefits or coverage under a Managed Care Plan, Medical Group or its
Participating Providers will immediately refer Members to contact PacifiCare or
deliver any written complaint, grievance or appeal to PacifiCare for handling
pursuant to the Member Appeals and Grievance Procedures.  Medical Group and its Participating
Providers shall comply with all final determinations made by PacifiCare through
the Member Appeals and Grievance Procedures. 
Member claims against Medical Group or its Participating Providers,
other than claims for benefits under the Managed Care Plans, are not subject to
the Member Appeals and Grievance Procedures and are not governed by this
Agreement.


 


7.4           Disputes Between
Medical Group or its Participating Providers and Member.  Any controversies or claims between Medical
Group or its Participating Providers and a Member arising out of the
performance of this Agreement by Medical Group or the Medical Group’s
Participating Provider, other than claims for benefits under Managed Care
Plans, are not governed by this Agreement. 
Medical Group or its Participating Provider and the Member may seek any
appropriate legal action to resolve such controversy or claim deemed necessary.


 


7.5           Disputes Between
PacifiCare and Medical Group


 


7.5.1        Dispute Resolution
Procedure.  PacifiCare has
established a Provider Dispute Resolution Procedure, set forth in the Provider
Manual, to provide a mechanism by which PacifiCare’s Participating Providers,
including Medical Group and any of its Participating Providers, may submit to
PacifiCare certain disputes arising out of the performance of this Agreement or
relating to the decisions made by PacifiCare under this Agreement for
resolution on an informal basis.  Any
dispute submitted pursuant to the Provider Dispute Resolution Procedure should
be addressed to the appropriate PacifiCare person(s) or department(s) at the
address and/or telephone number identified in the Provider Manual.  Any provider dispute which is not resolved
informally through the Provider Dispute Resolution Procedure may be submitted
for arbitration as provided in Section 7.5.2 below.


 


7.5.2        Arbitration.  Any controversy, dispute or claim arising
out of the interpretation, performance or breach of this Agreement which is not
resolved pursuant to the Provider Dispute Resolution Procedure specified above
shall be resolved by binding arbitration at the request of either party, in
accordance with the Commercial Rules of the American Arbitration Association.  Such arbitration shall occur in Los Angeles,
California, unless the parties mutually agree to have such proceeding in some
other locale.  The arbitrators shall
apply California substantive law and Federal substantive law where State law is
preempted.  Civil discovery for use in
such arbitration may be conducted in accordance with the provisions of
California law, and the arbitrator(s)


 


31

















 


selected shall have the
power to enforce the rights, remedies, duties, liabilities and obligations of
discovery by the imposition of the same terms, conditions and penalties as can
be imposed in like circumstances in a civil action by a court of competent
jurisdiction of the State of California. 
The provisions of California law concerning the right to discovery and
the use of depositions in arbitration are incorporated herein by reference and
made applicable to this Agreement.


 


The arbitrators shall
have the power to grant all legal and equitable remedies and award compensatory
damages provided by California law, except that punitive damages shall not be
awarded.  The arbitrators shall prepare
in writing and provide to the parties an award including factual findings and
the legal reasons on which the award is based. 
The arbitrators shall not have the power to commit errors of law or
legal reasoning.


 


Notwithstanding the
above, in the event either Medical Group or PacifiCare wishes to obtain
injunctive relief or a temporary restraining order, such party may initiate an
action for such relief in a court of general jurisdiction in the State of
California.  The decision of the court
with respect to the requested injunctive relief or temporary restraining order
shall be subject to appeal only as allowed under California law.  However, the courts shall not have the
authority to review or grant any request or demand for damages.


 


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


 


If to PacifiCare:


 


PacifiCare of California


10833 Valley View St


Cypress, CA 90630


Attention: Vice
President, Network Management


 


If to Medical Group:


 


Northwest Orange County
Medical Group


2600 Redondo Ave


Long Beach, CA 90806


Attention: Chief
Executive Officer


 


The parties may change
the names and addresses noted above through written notice in compliance with
this Section.  Any notice sent by
registered or certified mail, return receipt requested, shall be deemed given
on the date of delivery shown on the receipt card, or if no delivery date is
shown, the postmark date.  Notices
delivered by U.S. Postal Service Express


 


32

















 


mail, Federal Express or
overnight courier that guarantees next day delivery shall be deemed given
twenty-four (24) hours after delivery of the notice to the United States Postal
Service, Federal Express or overnight courier. 
If any notice is transmitted by facsimile transmission or similar means,
the notice shall be deemed served or delivered upon telephone confirmation of
receipt of the transmission, provided a copy is also delivered via delivery or
mail.


 


7.7           Assignment.  This Agreement and the rights, interests and
benefits hereunder shall not be assigned, transferred or pledged in any way by
Medical Group or PacifiCare and shall not be subject to execution, attachment
or similar process.  However, PacifiCare
may assign this Agreement and its rights, interests and benefits hereunder to
any entity which is a corporate affiliate of PacifiCare.


 


7.8           Amendments


 


7.8.1        Amendments or
Modifications to Agreement.  Except
as otherwise provided in this Section 7.8, all amendments or modifications to
this Agreement shall be effective only upon mutual written agreement of the
parties.


 


7.8.2        Amendments to Provider
Manual.  PacifiCare may amend the
Provider Manual by providing thirty (30) calendar days’ prior written notice to
Medical Group.  Such amendments shall be
binding upon Medical Group at the end of the thirty (30) calendar-day
period.  Medical Group shall be bound by
such amendment unless (i) Medical Group provides PacifiCare with notice of
objection within the thirty (30) calendar-day notice period, (ii) such change
is not made in order to comply with a change in State or Federal Law, (iii)
such change is not made in order to address a change in PacifiCare’s Managed
Care Plans, (iv) such change affects a material duty or responsibility of
Medical Group, and (v) the change has a material adverse economic effect upon
Medical Group as reasonably demonstrated by Medical Group to PacifiCare.  In such event, Medical Group and PacifiCare
shall seek to agree to an amendment to this Agreement which satisfactorily
addresses the effect on Medical Group’s material duty or responsibility and
reimburses the material economic detriment caused to Medical Group.  In such event, the amendment to the Provider
Manual shall not be effective until the parties amend the Agreement through a
written amendment signed by both parties.


 


7.8.3        Amendments to Agreement
to Comply with State and Federal Law. 
PacifiCare may amend this Agreement by providing thirty (30) calendar
days’ prior written notice to Medical Group in order to maintain compliance
with State and Federal Law.  Such
amendment shall be binding upon Medical Group at the end of the thirty (30)
calendar-day period and shall not require the consent of Medical Group.


 


7.8.4        Amendments to Managed
Care Plans.  PacifiCare may amend or
change any or all provisions of the Managed Care Plans by providing thirty (30)
calendar days’ prior written notice to Medical Group.  Such amendment shall be binding upon Medical Group at the end of
the thirty (30) calendar-day period.  In
the event Medical Group believes that the change has a material adverse
economic effect upon Medical Group as reasonably demonstrated by Medical Group
to PacifiCare, Medical Group shall


 


33

















 


provide PacifiCare with
notice of objection within the thirty (30) calendar day notice period.  In such event, Medical Group and PacifiCare
shall seek to agree to a resolution, which satisfactorily addresses the effect
on Medical Group’s material duty or responsibility, and reimburses the material
economic detriment caused to Medical Group. 
Until a resolution is reached, Medical Group shall implement the
amendment and any reimbursement determined to be due to Medical Group will be
made retroactive to the effective date of the change.


 


7.9           Confidential and
Proprietary Information


 


7.9.1        Information
Confidential and Proprietary to PacifiCare.  Medical Group and its Participating Providers shall maintain
confidential all information designated in this Section.  The information which Medical Group and its
Participating Providers shall maintain confidential (the “Confidential
Information”) consists of: (i) the Eligibility List and any other information
containing the names, addresses and telephone numbers of Members which has been
compiled by PacifiCare; (ii) lists or documents compiled by PacifiCare which
include the names, addresses and telephone numbers of employers, employees of
such employers responsible for health benefits and the officers and directors
of such employers; (iii) PacifiCare’s Provider Manual and any of PacifiCare’s
member, employer and administrative service manuals and all forms related
thereto; (iv) the financial arrangements between PacifiCare and any of
PacifiCare’s Participating Providers; (v) PacifiCare underwriting and rating
information and any other information utilized by PacifiCare for determining
eligibility or rates for the Managed Care Plans; and (vi) any other information
compiled or created by PacifiCare which is proprietary to PacifiCare and which
PacifiCare identifies in writing to Medical Group.


 


7.9.2        Non-Disclosure of
Confidential Information.  Medical
Group and its Participating Providers shall not disclose or use the
Confidential Information for their own benefit or gain either during the term
of this Agreement or after the date of termination of this Agreement.  Medical Group and its Participating
Providers may use the Confidential Information to the extent necessary to
perform their duties under this Agreement or upon express prior written permission
of PacifiCare.  Upon the effective date
of termination of this Agreement, Medical Group and its Participating Providers
shall provide and return to PacifiCare the Confidential Information in their
possession in the manner specified by PacifiCare.


 


7.9.3        Information
Confidential and Proprietary to Medical Group.  Medical Group shall provide PacifiCare with a written description
of all information proprietary to Medical Group which is confidential or
contains trade secrets of Medical Group (the “Medical Group Information”).  PacifiCare shall maintain and shall
cooperate with Medical Group to maintain the confidentiality of Medical Group
Information.  PacifiCare shall not disclose
or use any Medical Group Information for its own benefit either during the term
of this Agreement or after the effective date of termination of this
Agreement.  Upon termination of this
Agreement, PacifiCare shall provide and return to Medical Group all Medical
Group Information in its possession in the manner to be specified by Medical
Group.


 


34

















 


7.9.4        PacifiCare Names, Logos
and Service Marks.  Medical Group
shall obtain the written consent of PacifiCare prior to using PacifiCare’s
name, product names, logos and service marks in any of Medical Group’s
promotional, marketing or advertising materials or for any other reason.


 


7.10         Solicitation of
PacifiCare Members or Subscriber Groups. 
Medical Group and its Participating Providers shall not engage in the
practice of solicitation of Members, Subscribers and Subscriber Groups without
PacifiCare’s prior written consent. 
Solicitation shall mean conduct by an officer, agent, employee of
Medical Group or its Participating Providers or their respective assignees or
successors during the term of this Agreement and continuing for a period of six
(6) months after the effective date of termination of this Agreement which may
be reasonably interpreted as designed to persuade Members, Subscribers or
Subscriber Groups to disenroll from any Managed Care Plan or discontinue their
relationship with PacifiCare. 
Notwithstanding any other provision of this Agreement, Medical Group
agrees that PacifiCare shall, in addition to any other remedies provided for
under this Agreement, have the right to seek a judicial temporary restraining
order, preliminary injunction, or other equitable relief against Medical Group
and its Participating Providers to enforce its rights under this Section.  Nothing in this Agreement shall be
interpreted to discourage or prohibit Medical Group and its Participating
Providers from discussing a Member’s health care including, without limitation,
communications regarding treatment options, alternative plans or other coverage
arrangements, unless such communications are for the primary purpose of
securing financial gain.


 


7.11          Notification and
Approval of Sale or Change in Management of Medical Group.  Medical Group agrees that it shall provide
prior written notice to PacifiCare of its intent to either (i) sell, transfer
or convey its business or any substantial portion of its business assets to
another entity (“successor entity”) or (ii) enter into a management contract
with a physician practice management company (“management company”) which does
not manage Medical Group as of the Commencement Date.  Such prior written notice shall be given immediately upon Medical
Group selling its business or entering into such contract.  As set forth in Section 6.4, PacifiCare
shall have the right to terminate this Agreement upon ninety (90) days’ written
notice to Medical Group if PacifiCare reasonably determines that any successor
entity or any management company cannot satisfactorily perform the obligations
of Medical Group under this Agreement or is a licensed HMO competitor to
PacifiCare.  Medical Group warrants and
assures that this Agreement, if not otherwise terminated by PacifiCare, will be
assumed by all successor entities and that all successor entities and
management companies will be bound by the terms and conditions of this Agreement.


 


7.12          Confidentiality of
this Agreement.  To the extent
reasonably possible, each party agrees to maintain this Agreement as a
confidential document and not to disclose the Agreement or any of its terms
without the approval of the other party.


 


7.13          Invalidity of
Sections of Agreement.  The
unenforceability or invalidity of any paragraph or subparagraph of any section
or subsection of this Agreement shall not affect the enforceability and
validity of the balance of this Agreement.


 


35

















 


7.14          Captions.  Captions in this Agreement are descriptive
only and do not affect the intent or interpretation of the Agreement.


 


7.15          Waiver of Breach.  The waiver by either party to this Agreement
of a breach or violation of any provision of this Agreement shall not operate
as or be construed to be a waiver of any subsequent breach or violation
thereof.


 


7.16          Medical Group’s
Authorized Representative.  Unless
otherwise indicated in writing to PacifiCare, Medical Group warrants and
authorizes its administrator to act as its fully authorized representative to
represent Medical Group in this Agreement and to receive any and all
communications and notices hereunder.


 


7.17          No Third Party
Beneficiaries.  This Agreement shall
not create any rights in any third parties who have not entered into this
Agreement, nor shall this Agreement entitle any such third party to enforce any
rights or obligations that may be possessed by such third party.


 


7.18          Entire Agreement.  This Agreement, including all exhibits,
attachments and amendments hereto, contains all the terms and conditions agreed
upon by the parties regarding the subject matter of this Agreement.  Any prior agreements, promises, negotiations
or representations of or between the parties, either oral or written, relating
to the subject matter of this Agreement, which are not expressly set forth in
this Agreement are null and void and of no further force or effect.


 


7.19          Applicable Federal
Laws.  The compensation payable to
Medical Group pursuant to this Agreement consists partially of federal funds;
accordingly, Medical Group acknowledges that it will be required to comply with
certain laws applicable to entities and individuals receiving federal funds.


 


7.20          Incorporation of
Exhibits, Attachments and Provider Manual. 
The exhibits and attachments to this Agreement and the Provider Manual
are an integral part of this Agreement and are incorporated in full herein by
this reference.


 


 


ARTICLE 8

GOVERNING LAW AND REGULATORY REQUIREMENTS


 


8.1           Governing Law.  This Agreement and the rights and
obligations of the parties hereunder shall be construed, interpreted, and
enforced in accordance with, and governed by, the laws of the State of
California and the United States of America, including, without limitation, the
Knox-Keene Health Care Service Plan Act of 1975, as amended, and the
regulations adopted thereunder by the California Department of Managed Health
Care, the federal Health Maintenance Organization Act of 1973, as amended, and
the regulations adopted thereunder by the United States Department of Health
and Human Services.  Any provisions
required to be in this Agreement by State and Federal Law or by Government
Agencies shall bind PacifiCare and Medical Group whether or not expressly provided
in this Agreement.


 


8.2           No Billing of
Members (Member Hold Harmless Provision). 
With the exception of Copayments and charges for non-Covered Services
delivered on a fee-for-service basis to


 


36

















 


Members, Medical Group
and its Participating Providers shall in no event, including, without
limitation, non-payment by PacifiCare, insolvency of PacifiCare, or breach of
this Agreement, bill, charge, collect a deposit from, seek compensation or
remuneration or reimbursement from, or have any recourse against any Member or
any person (other than PacifiCare) acting on behalf on any Member or attempt to
do any of the foregoing for Covered Services provided or arranged pursuant to
this Agreement.


 


Medical Group and its
Participating Providers shall not maintain any action at law or equity against
a Member to collect sums owed by PacifiCare to Medical Group.  Upon notice of any such action, PacifiCare
may terminate this Agreement as provided above and take all other appropriate
action consistent with the terms of this Agreement to eliminate such charges,
including, without limitation, requiring Medical Group and its Participating
Providers to return all sums collected as surcharges from Members or their
representatives.  For purposes of this
Agreement, “Surcharges” are additional fees for Covered Services which are not
disclosed to Members in the Subscriber Agreement and/or Evidence of Coverage,
are not allowable Copayments and are not authorized by this Agreement.  Nothing in this Agreement shall be construed
to prevent Medical Group from providing non-Covered Services on a usual and
customary fee-for-service basis to Members.


 


Medical Group and its
Participating Providers’ obligations under this Section shall survive the
termination of this Agreement with respect to Covered Services provided or
arranged during or after the term of this Agreement, regardless of the cause
giving rise to such termination, and this Section shall be construed to be for
the benefit of Members.  This Section
supersedes any oral or written contrary agreement now existing or hereafter
entered into between Medical Group and any Member or a person acting on behalf
of any Member.


 


Any modification,
additions, or deletions to the provisions of this Section shall be effective
only following any required notice to HCFA or other applicable Government
Agency.


 


8.3           Continuing Care
Obligations of Medical Group.


 


8.3.1        General Obligations.  In the event of termination of this
Agreement for any reason, Medical Group and its Participating Providers shall
continue to provide or arrange Covered Services to Members, including any
Members who become eligible during the termination notice period, beginning on
the effective date of termination and continuing until the later of (a) twelve
(12) months following the effective date of termination of this Agreement, (b)
December 31 of the then current calendar year, or (c) the expiration of the
period in which Medical Group is obligated to arrange or provide Covered Services
in Special Circumstances as provided at Section 8.3.3 below.  Notwithstanding the foregoing, with respect
to Members for whom PacifiCare arranges for a transfer to another PacifiCare
Participating Provider and provides written notice to Medical Group of such
transfer, this Agreement shall cease to apply for such Members, as of the
effective date of such Member’s transfer. 
In addition to the foregoing, Medical Group and its Participating
Providers will continue to provide or arrange Covered Services to any Members
who cannot be transferred within the time period specified above in accordance
with PacifiCare’s legal and contractual obligations to (i) provide Covered
Services under the Managed Care Plans and


 


37

















 


Subscriber Agreement
and/or Evidence of Coverage, (ii) provide notice of termination to Members and
(iii) ensure continuity of care for its Members.


 


8.3.2        Obligations if
PacifiCare Ceases Operating or Termination of Agreement for Nonpayment.  Notwithstanding any other provisions of this
Agreement, Medical Group agrees that in the event PacifiCare ceases operations
for any reason, including insolvency, Medical Group and its Participating
Providers shall provide or arrange Covered Services and shall not bill, charge,
collect or receive any form of payment from any Member for Covered Services
provided after PacifiCare ceases operations. 
Such obligation shall be for the period for which Premium has been paid,
but shall not exceed a period of thirty (30) calendar days, except for those
Members who are hospitalized on an inpatient basis as provided below.


 


In the event PacifiCare
ceases operations or Medical Group terminates this Agreement on the basis of
PacifiCare’s failure to make timely Capitation Payments, Medical Group and its
Participating Providers shall continue to provide or arrange for Covered
Services to those Members who are hospitalized on an inpatient basis at the
time PacifiCare ceases operations or Medical Group terminates this Agreement until
such Members are discharged from the hospital. 
Practitioner shall not bill, charge, collect or receive any form of
payment from any Member for such Covered Services.


 


8.3.3        Obligations to Continue
to Provide Covered Services in Special Circumstances.


 


(a)           Definitions.  For the purposes of this Section 8.3.3, the
terms set forth below shall have the following meanings:


 


(i)            “Covered Services in
Special Circumstances” shall mean Covered Services provided by a Medical Group
Participating Provider following termination to a Member who is undergoing a
course of treatment from the Participating Provider for an acute condition,
serious chronic condition, high-risk pregnancy, or a pregnancy that has reached
the second or third trimester at the time of termination.  The foregoing definition shall be
interpreted in a manner consistent with applicable law, including California
Health and Safety Code Section 1373.96.


 


(ii)           “Termination” or
“terminated,” as used in this Section 8.3.3, shall mean (i) any circumstance which
terminates, non-renews or otherwise ends the arrangement by which a
Participating Provider provides Covered Services to Members or (ii) termination
of this Agreement.


 


(iii)          “Participating
Provider,” as used in this Section 8.3.3, shall be limited to persons who are
physicians, podiatrists, clinical psychologists, dentists, and chiropractors,
as applicable.


 


(b)           Notifications
Regarding Termination.  Medical
Group shall provide advance written notice to PacifiCare of the impending
termination of a Participating


 


38

















 


Provider in accordance
with Section 2.3.3 of this Agreement. 
Additionally, Medical Group and the Participating Provider shall
identify to PacifiCare, in writing, any Members who are receiving treatment
from the Participating Provider for an acute condition or serious chronic
condition, high-risk pregnancy or pregnancy in the second or third trimester at
the time of such written notice and on the effective date of termination.  In the event of termination of this
Agreement, Medical Group shall provide information to PacifiCare to identify
Members who may be eligible for Covered Services in Special Circumstances from
a Medical Group Participating Provider.


 


(c)           Termination of
Participating Provider.  Following
the termination of any Medical Group Participating Provider, Medical Group
shall, at the request of the applicable Member and in accordance with
PacifiCare’s policies and procedures, assure that such Participating Provider
shall provide Covered Services in Special Circumstances to Members as required
by this Section 8.3.3.


 


(d)           Termination of this
Agreement.  Following termination of
this Agreement, Medical Group shall, at the request of the applicable Member
and in accordance with PacifiCare’s policies and procedures, assure that all of
its Participating Providers shall provide Covered Services in Special
Circumstances to Members as required by this Section 8.3.3.


 


(e)           Exceptions.  Medical Group is not obligated to arrange
for its Participating Provider(s) to provide Covered Services in Special
Circumstances to Members if the terminated Participating Provider (i) was
terminated for a medical disciplinary cause or reason, fraud or other criminal
activity, (ii) voluntarily terminated his or her agreement with Medical Group,
(iii) does not agree to comply or does not comply with the same terms and
conditions set forth in the terminated Participating Provider’s subcontract
with Medical Group in providing Covered Services in Special Circumstances, including,
but not limited to, credentialing, hospital privileging, utilization review,
peer review, and quality assurance requirements, or (iv) has not agreed in
advance to compensation terms for the provision of Covered Services in Special
Circumstances or does not otherwise accept payment rates for such services
similar to rates and methods of payment used by Medical Group for its
contracted providers providing similar services who are not capitated and who
are practicing in the same or a similar geographic area as the terminated
Participating Provider.


 


(f)            Time Periods for
Provision of Covered Services in Special Circumstances.


 


(i)            In the case of a
Member who has an acute condition or serious chronic condition, the Covered
Services in Special Circumstances shall be provided to the Member by the
terminated Participating Provider for up to ninety (90) days following the
termination date or a longer period if necessary for a safe transfer to another
Participating Provider


 


39

















 


as determined by Medical
Group in consultation with the terminated Participating Provider.


 


(ii)           In the case of a Member
who has a high-risk pregnancy or a pregnancy that has reached the second or
third trimester, the Covered Services in Special Circumstances shall be
provided to the Member by the terminated Participating Provider until
postpartum services related to the delivery are completed or for a longer
period if necessary for a safe transfer to another Participating Provider as
determined by Medical Group in consultation with the terminated Participating
Provider.


 


(g)           Compensation of
Medical Group Participating Providers. 
Medical Group shall be solely responsible for compensating any
terminated Participating Provider for the provision of Covered Services in
Special Circumstances to Members as agreed upon in writing between the
terminated Participating Provider and Medical Group or at the rate and method
of payment used by Medical Group for its contracting providers providing similar
services who are not capitated and who are practicing in the same or a similar
geographic area as the terminated Participating Provider.


 


8.3.4        Survival of Provisions
following Termination.  Medical
Group agrees that the provisions of this Section and the obligations of Medical
Group and its Participating Providers herein shall survive termination of this
Agreement regardless of the cause giving rise to such termination, and shall be
construed to be for the benefit of Members.


 


8.3.5        Services to be Provided
to Members Transferred to Medical Group from a Terminated Participating
Provider.  Subject to Medical
Group’s capacity to accept additional Members, Medical Group agrees to accept
transfers of Members from other Participating Providers in circumstances in
which such Participating Provider’s agreement with PacifiCare has
terminated.  Upon such transfer, Medical
Group agrees that it shall accept prior authorizations for Covered Services
provided to such Members and shall be financially responsible for all continuing
Covered Services to be provided or arranged for such transferred Members
following termination of the other Participating Provider’s agreement with
PacifiCare.  Medical Group will review
authorizations for appropriateness and will redirect, where medically
appropriate and in accordance with PacifiCare’s Continuity of Care Policy, to
Medical Group Participating Providers.


 


8.4           Inspection
and Audit of Records and Facilities. 
Medical Group and its Participating Providers shall provide access at
reasonable times upon demand by PacifiCare, Accreditation Organizations and
Government Agencies to periodically audit or inspect the facilities, offices,
equipment, books, documents and records of Medical Group and its Participating
Providers relating to the performance of this Agreement and the Covered
Services provided to Members, including, without limitation, all phases of
professional and ancillary medical care provided or arranged for Members by
Medical Group and its Participating Providers, Member medical records and
financial records pertaining to the cost of operations and


 


40

















 


income received by
Medical Group for Covered Services rendered to Members.  Medical Group and its Participating
Providers shall comply with any requirements or directives issued by
PacifiCare, Accreditation Organizations and Government Agencies as a result of
such evaluation, inspection or audit of Medical Group and its Participating
Providers.  Medical Group and its
Participating Providers shall retain the books and records described in this
Section for at least six (6) years and acknowledge that certain Government
Agencies may have the right to inspect and audit Medical Group’s books and
records following termination of this Agreement.  Without limiting the foregoing, following the commencement of any
audit by a Government Agency, Medical Group shall retain its relevant books and
records until completion of said audit. 
The provisions of this Section shall survive termination of this
Agreement for the period of time required by State and Federal Law.


 


8.5           Nondiscrimination.  Medical Group assures that Covered Services
shall be provided to Members in the same manner as such services are provided
to other patients of Medical Group and its Participating Providers, except as
required pursuant to this Agreement. 
Medical Group and its Participating Providers shall not unlawfully
discriminate against any Member on the basis of source of payment or in any
manner in regards to access to, and the provision of, Covered Services.  Medical Group and its Participating
Providers shall not unlawfully discriminate against any Member, employee or
applicant for employment on the basis of race, religion, color, national
origin, ancestry, physical handicap, medical condition, marital status, age or
sex.


 


ARTICLE 9

EXPRESS REFERRALS


 


Medical Group has elected
to not participate in the Express Referrals program.


 


41

















 


IN WITNESS
WHEREOF, the parties hereto have executed this Agreement in LONG BEACH,
California.


 


	
   

  	
  PACIFICARE OF
  CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
   /s/ Brian Jeffrey

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Title:

  	
   Vice President

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
  4/17/01

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL GROUP

  
	
   

  	
  Northwest Orange County
  Medical Group

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Prathiba Patel

  	
   

  
	
   

  	
   

  	
  PRATIHBA PATEL, MD

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Title:

  	
  President

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
  4/2/01

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  /s/ James P. Agronick

  	
  , CEO

  
	
   

  	
   

  	
  PREMIER PHYSICIAN
  SERVICES

  
	
   

  	
   

  	
  4/2/01

  



 


42

















 


PACIFICARE OF CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES AGREEMENT

(SPLIT CAPITATION)


 


EXHIBIT 1


MEDICAL GROUP
FACILITIES AND HOSPITAL(S)

(This Exhibit 1 is an integral part of this Agreement)


 


Medical Group
Facilities:


 


Prior to the
Commencement Date, Medical Group shall provide PacifiCare with a list of all
Medical Group Facilities.


 


Facilities shall
also include each facility at which a Medical Group Participating Provider
routinely provides services pursuant to this Agreement.


 


All Medical Group
Facilities shall, in accordance with PacifiCare’s policies and procedures, be
subject to PacifiCare’s prior written approval.


 


Hospital(s):


La Palma
Intercommunity Hospital for Northwest Orange County Medical Group


West Anaheim
Medical Center for Northwest Orange County Medical Group-Anaheim


 


 


Medical Group
Service Area:


 


The Medical Group
Service Area is the geographic area within a thirty (30) mile radius of each of
the Medical Group Facilities, excluding the offices of specialists as approved
by PacifiCare in writing.  The Medical
Group Service Area shall be determined by PacifiCare, based upon the shortest
route using public streets and highways.


 


43

















 


PACIFICARE OF
CALIFORNIA


 


MEDICAL GROUP/IPA
SERVICES AGREEMENT


(SPLIT CAPITATION)


 


EXHIBIT 2


DELEGATED
ACTIVITIES


(This Exhibit 2 is
an integral part of this Agreement)


 


The purpose of the following Grids is to specify the
responsibilities of PacifiCare and Medical Group under the Agreement with
respect to: (i) claims processing and payment, (ii) credentialing and
recredentialing, (iii) medical records, (iv) quality management, and
improvement and (v) utilization management.


 


The Grids set forth the specific activities with
respect to (i) claims processing and payment, (ii) credentialing and
recredentialing, (iii) medical records, (iv) quality management and improvement
and (v) utilization management, which PacifiCare has delegated to Medical Group
and which Medical Group shall perform on behalf of PacifiCare.  The Grids also set forth the specific
activities with respect to: (i) claims processing and payment, (ii)
credentialing and recredentialing, (iii) medical records, (iv) quality
management and improvement and (v) utilization management, which PacifiCare has
not delegated to Medical Group under the Agreement and which PacifiCare shall
perform directly utilizing its own personnel. 
Medical Group is responsible for cooperating, participating and
complying with PacifiCare’s performance of such activities.


 


PacifiCare does not formally delegate to its
contracting medical groups the responsibility for performing quality management
and improvement activities on behalf of PacifiCare.  However, PacifiCare does require contracting medical groups to
maintain a quality improvement and management program, participate and
cooperate in PacifiCare’s quality improvement program, collect data for
PacifiCare’s quality improvement activities, and carry out corrective actions
as required by PacifiCare.  Accordingly,
the Grids set forth certain quality improvement activities which PacifiCare has
not delegated to Medical Group to perform on behalf of PacifiCare, but which
PacifiCare and Medical Group shall perform concurrently under the
Agreement.  PacifiCare also does not
formally delegate to contracting medical groups the responsibility for
performing member services.  However,
PacifiCare does require contracting medical groups under the Agreement to
participate, cooperate and comply with PacifiCare’s activities relating to
member services, preventive health services, and medical record reviews as required
by PacifiCare.


 


The Grids also identify (i) the elements and
performance measures established by PacifiCare for the Delegated Activities in
accordance with the NCQA accreditation standards and State and Federal law and
regulatory requirements, (ii) the reports which shall be provided to PacifiCare
by Medical Group for each of the Delegated Activities and the frequency of
reporting, and (iii) the oversight activities which PacifiCare shall perform
with respect to each of the Delegated Activities.


 


Exhibit 2 may be amended from time to time during the
term of this Agreement by PacifiCare to reflect changes in delegation
standards; delegation status; performance measures; reporting requirements; and
other provisions of Exhibit 2.


 


44

















 


CLAIMS
DELEGATION GRID


 


	
  Function

  	
   

  	
  Delegation

  Status

  	
   

  	
  Medical
  Group Responsibility/

  Performance Measure

  	
   

  	
  Reporting

  Frequency

  	
   

  	
  PacifiCare
  Oversight

  
	
  HCFA Regulations

  	
   

  	
  Delegated

  	
   

  	
  Compliance with all HCFA regulations &
  guidelines for claims processing and payment including:

  •   Claims payment turnaround
  times

  •   Appropriate reimbursement for
  contracted and non-contracted providers

  •   Interest payments

  •   Denials/denial letters

  •   BBA regulations

  •   Provider reporting

  •   Y2K compliance

  	
   

  	
  Monthly

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool.

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PacifiCare Standards for Commercial Products

  	
   

  	
  Delegated

  	
   

  	
  Compliance with PacifiCare’s standards for
  processing and payment of claims for Commercial Products including:

  •   Claims payment turnaround
  times

  •   Appropriate reimbursement for
  contracted and non-contracted providers

  •   Interest payments

  •   Denials/denial letters

  •   Provider reporting

  •   Appropriate IBNR reserves

  	
   

  	
  Monthly

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool.

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  State Regulations

  	
   

  	
  Delegated

  	
   

  	
  Compliance with State Regulations for claims
  processing:

  •   COB and TPL review

  •   Compliance with all Medicaid
  Regulations

  	
   

  	
  N/A

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool.

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OPM Requirements

  	
   

  	
   

  	
   

  	
  Compliance with Office of Personnel Management for
  Federal Employees requirements for claims processing and payment including:

  •   COB identification

  •   Debarred providers suspended

  	
   

  	
  N/A

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Standards for Employer Performance Guarantees

  	
   

  	
  Delegated

  	
   

  	
  Meet Employer performance guarantee measurements for
  claims processing and payment

  	
   

  	
  As required by employer

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool.

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Eligibility and Benefits

  	
   

  	
  Not Delegated

  	
   

  	
  Medical Group must:

  Verify eligibility at time of claim review

  •   Update eligibility and
  benefit information in their system as often as communicated by the plan.

  	
   

  	
  N/A

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool.

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Financial Accounting

  	
   

  	
  Delegated

  	
   

  	
  Meets PacifiCare financial accounting requirements
  and solvency requirements including those for:

  •   Financial statements

  •   IBNR reserves

  •   Processes for expense
  reduction

  	
   

  	
  Annually

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool

  •   Implementation of Corrective
  Action

  



 


45

















 


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Plan(s) for elements of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Check Production Processes

  	
   

  	
  Delegated

  	
   

  	
  Compliance with timely claims payments and IRS
  requirements including:

  •   Check production processes

  •   Performing Provider
  Satisfaction Survey

  •   Process to settle claims in
  collections

  •   1099 production processes

  	
   

  	
  N/A

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment utilizing
  approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Staffing

  	
   

  	
  Delegated

  	
   

  	
  Staffing sufficient to support claims volume and
  processing timeliness requirements including:

  •   Staffing levels

  •   Customer Service capabilities

  •   Past experience for claims
  resolution

  •   Staff available to answer
  claims questions during normal hours of operation

  	
   

  	
  N/A

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool.

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audit Reporting

  	
   

  	
  Delegated

  	
   

  	
  Appropriate and adequate audit reporting available
  including:

  •   Reports provided for audit

  	
   

  	
  As needed for audits

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Encounter Data

  	
   

  	
  Delegated

  	
   

  	
  The Medical Group must have an encounter data
  submission process with encounter data reported and submitted to PacifiCare
  monthly

  	
   

  	
  Monthly

  	
   

  	
  •   Initial onsite assessment
  utilizing approved oversight tool.

  •   Annual oversight assessment
  utilizing approved oversight tool.

  •   Additional onsite reviews as
  warranted by the plan utilizing approved oversight tool.

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance.

  



 


PacifiCare’s
responsibilities relating to Claims and those responsibilities which PacifiCare
has delegated to the Medical Group, are outlined above.


 


The
Medical Group agrees to be accountable for all responsibilities delegated by
PacifiCare and will not further delegate any such responsibilities without
prior written approval by PacifiCare.


 


PacifiCare
will perform audits annually and as needed to evaluate the group’s delegated
status.  In the event there are
deficiencies identified in the audit, PacifiCare will provide a specific
corrective action plan.  If the group is
not able to comply with the corrective action plan within the specified time
frame, PacifiCare may revoke the group’s delegated status.


 


46

















 


CREDENTIALING DELEGATION GRID


 


	
  Function

  	
   

  	
  Delegation

  Status

  	
   

  	
  Medical
  Group Responsibility/

  Performance Measure

  	
   

  	
  Reporting

  Frequency

  	
   

  	
  PacifiCare
  Oversight

  
	
  Credentialing

  Policies and

  Procedures

  	
   

  	
  Delegated

  	
   

  	
  Full Compliance with NCQA

  Standards:

  •   Identify scope

  •   Define criteria
  and verification of criteria

  •   Describe
  decision making process, including how advice is received from participating
  practitioners

  •   Describe extent
  of any delegated credentialing/recredentialing arrangements

  •   Describe right
  of practitioner to review information.

  •   Develop process
  to notify practitioner of discrepancies.

  •   Include
  practitioner’s right to correct erroneous information.

  •   Ensure
  confidentiality.

  •   Define Medical
  Director responsibilities and participation

  	
   

  	
  Submit

  Credentialing

  Program

  annually



  Revised

  credentialing

  policies and

  procedures

  submitted

  quarterly, if

  applicable.

  	
   

  	
  •   Initial onsite assessment

  •   Annual oversight assessment

  •   Annual PacifiCare Committee
  approval

  •   Evaluate and approve written
  Credentialing Program

  •   Implementation of Corrective

  •   Action Plan(s) for elements
  of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Credentialing

  Committee

  	
   

  	
  Delegated

  	
   

  	
  Full Compliance with NCQA Standards:



  •   The MG designates a
  credentialing committee or other review body that makes recommendations
  regarding credentialing decisions

  	
   

  	
  Annual

  credentialing

  program to

  include

  committee

  structure.

  	
   

  	
  •   Initial onsite assessment

  •   Annual oversight assessment

  •   Annual PacifiCare Committee
  approval

  •   Annual Review of Committee
  minutes

  •   Annual review of membership

  •   Frequency of meetings

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Primary source

  verification of

  credentialing

  information

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Standards regarding
  verification of information within 180 days of Committee approval date.



  Meet 90% of all NCQA credentialing standards (exempt
  from primary source verification of license).



  Meet 100% of NCQA standards related to primary
  source verification of licenser.



  •   Primary source verification
  to include:

  •   License

  •   Clinical privileges

  •   DEA/CDS

  •   Education

  •   Board certification

  •   Work history

  •   Malpractice insurance

  •   Professional liability claims

  	
   

  	
  Submit current

  list of physicians

  credentialed and

  recredentialed

  with quarterly

  report.

  	
   

  	
  •   Initial onsite assessment

  •   Annual oversight assessment

  •   Annual PacifiCare Committee
  approval

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  •   Audit conducted of provider
  credentialing and recredentialing files (5% or 50 credentialing files
  reviewed, whichever is less, with a minimum of 10 credentialing and 10
  recredentialing files reviewed).

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Application/

  Attestation

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Standards



  The PMG/IPA application must include a statement
  regarding:

  •   Reasons for any inability to
  perform.

  •   Lack of present illegal drug
  use.

  •   History of loss of license or
  felony conviction.

  •   History of loss or limitation
  of privileges or disciplinary activity.

  •   Attestation by applicant of
  the

  	
   

  	
  Immediate

  submission of

  any changes to

  application

  	
   

  	
  •   Initial onsite assessment

  •   Annual oversight assessment

  •   Annual PacifiCare Committee
  approval.

  •   Annual review of
  credentialing files (5% or 50 credentialing files reviewed, whichever is
  less, with a minimum of 10 credentialing and 10 recredentialing files

  •   Implementation of Corrective Action
  Plan(s) for elements of non-compliance.

  



 


47

















 


	
   

  	
   

  	
   

  	
   

  	
  correctness and
  completeness of the application.

  •   Signed within 180 days of
  Committee approval date

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  National Practitioner Data Base (NPDB)
  Information/Sanction Information

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Standards regarding
  verification of information within 180 days of Committee Approval date



  For all Medicare and/or Medicaid sanctions as
  appropriate:



  •   State Board of Dental Examiners

  •   State Board of Pediatric
  Examiners

  •   State Board of Medical
  Examiners

  •   Federation of State Medical
  Boards or Department of Professional Regulations

  •   State Board of Chiropractic
  Examiners of the Federation of Chiropractic Licensing Boards

  	
   

  	
  NONE

  	
   

  	
  •   Initial onsite assessment

  •   Annual oversight assessment

  •   Annual PacifiCare committee
  approval

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Initial office visit of

  all PCPs and

  OB/GYNs and

  medical record

  keeping review

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Standards regarding
  Initial site visit/medical record review and subsequent biannual site
  visit/medical record review.



  Structured review that evaluates the office site
  against standards in the following areas:



  •   Physical accessibility

  •   Physical appearance

  •   Adequacy of waiting room and
  exam room space

  •   Availability of appointments
  vs. expected performance standards

  •   Documentation of an
  evaluation of medical record keeping practices for conformity with standards

  •   Incorporation of this
  information into the credentialing process

  	
   

  	
  Include list of all initial site reviews

  completed on an annual basis.

  	
   

  	
  •   Initial onsite assessment

  •   Annual oversight assessment

  •   Annual PacifiCare Committee
  approval

  •   Biannual site review

  •   Biannual medical record
  review

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  •   Annual review of audit tool

  •   Verification of all sites
  completed within 2 years prior to initial credentialing

  •   Review of credential files
  annually as above to include evidence of initial site review and record
  keeping review

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Recredentialing

  Primary source

  verification (PSV)

  	
   

  	
  Delegated

  	
   

  	
  Meet 90% of all NCQA Recredentialing standards
  (except PSV of Licenser).



  Meet 100% of NCQA Standards related to PSV of
  Licenser



   Recredentialing to include:

  License, clinical
  privileges, DEA/CDS, Board Certification, Malpractice Insurance, Professional
  Liability claims, signed Attestation regarding any inability to perform and
  lack of present illegal drug use.

  	
   

  	
  Include list of all providers recredentialed on a
  quarterly basis (with quarterly report)

  	
   

  	
  •   Annual audit of files of 5%
  or random sample of 50 to represent entire contracted network

  •   Annual onsite assessment

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Recredentialing National Practitioner Data Base
  (NPDB) information/Sanction information

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Recredentialing Standards
  regarding verification of information within 180 days of Committee approval
  date



  Recredentialing conducted biannually by the
  Provider.



  Recredentialing must be completed within 24 months
  of prior credentialing or recredentialing activity



  Recredentialing information found in

  	
   

  	
   

  	
   

  	
  •   Initial onsite assessment

  •   Annual oversight assessment

  •   Annual PacifiCare Committee
  approval

  •   Implementation of Corrective
  Action Plan(s) for elements of non-compliance

  •   Annual audit of files of 5%
  or random sample of 50 to represent the entire contracted network to include
  sanction information.

  



 


48

















 


	
   

  	
   

  	
   

  	
   

  	
  credentialing files includes the following:



  •   Information from NPDB

  •   Sanction information, as appropriate

  •      State Board
  of Medical Examiners, Federation of State Medical Boards

  •      Department
  of Professional Regulations

  •      State Board
  of Chiropractic Examiners on the Federation of Chiropractic Licensing Boards

  •      State Board
  of Dental Examiners

  •   For all providers: review of Medicare/ Medicaid
  sanctions

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Incorporation of the following data in the
  Recredentialing decision-making process:

  •      Member complaints

  •      QI activities

  •      UM

  •      Member Satisfaction

  •      MCO uses performance monitoring in the
  recredentialing of PCPs.

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Recredentialing Standards



  Recredentialing conducted biannually by the
  Provider.



  Recredentialing must be completed within 24 months
  of prior credentialing or recredentialing activity



  Incorporate the following information into the
  recredentialing decision making process for PCPs:

  •      Member complaints

  •      Information
  from quality improvement activities

  •      Member
  satisfaction

  •      Site visits
  conducted

  	
   

  	
  List of all recredentialing site reviews completed
  on an annual basis

  	
   

  	
  •      Initial onsite assessment

  •      Annual oversight assessment

  •      Annual PacifiCare Committee approval

  •      Implementation of Corrective Action Plan(s) for
  elements of non-compliance

  •      Annual review of audit tool

  •      Verification of all sites completed within 2
  years prior to recredentialing

  •      Review of files annually includes verification
  of recredentialing site visit

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Site Visits

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Standards regarding
  biannual recredentialing site visit/medical record review



  Visit to offices of all PCP sites with 50 or more members within 2 years prior  to Recredentialing.



  Review office vs. standards in
  areas  listed under PSV section and
  documented evaluation of medical  record keeping practices.

   

  	
   

  	
  List of all recredentialing site reviews completed
  on an annual basis

  	
   

  	
  •      Initial onsite assessment

  •      Annual oversight assessment

  •      Annual PacifiCare committee approval

  •      Biannual Site Review

  •      Biannual Medical Record Review

  •      Implementation of Corrective Action Plan(s) for
  elements of non-compliance

  •      Annual review of audit tool

  •      Verification of all sites completed within 2
  years prior to recredentialing

  •      Review of files annually includes verification
  of recredentialing site visit

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Peer Review/

  Disciplinary Action

  	
   

  	
  Delegated

  	
   

  	
  Full compliance with NCQA Standards Policy and
  Procedures (P&Ps) for reporting of quality deficiencies



  P&Ps for range of actions to be taken to improve
  performance prior to termination.



  P&Ps to describe appeals process.



  P&Ps for altering the conditions of the
  practitioner’s participation with PacifiCare based on quality of care of
  service

  	
   

  	
  New P&Ps submitted quarterly

  	
   

  	
  •      Initial onsite assessment

  •      Annual oversight assessment

  •      Annual PacifiCare committee approval

  •      Implementation of Corrective Action Plan(s) for
  elements of non-compliance

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Assessment of Organizational

  	
   

  	
  Delegated

  	
   

  	
  For subcontracted acute care hospitals, home health
  agencies, SNFs, and free-

  	
   

  	
  Submit list of subcontracted

  	
   

  	
  •      Annual assessment including P&Ps and random
  pull of files;

  



 


49

















 


	
  Providers (hospitals, home health agencies, SNFs, and
  free-standing surgical centers)

  	
   

  	
   

  	
   

  	
  standing surgical centers:

  1.     Confirms good standing with State
  and Federal regulatory bodies, and

  2.     Confirms accreditation; or

  3.     If not accredited, develops
  standards of participation and reviews for compliance; and

  4.     At least every three years,
  confirms continued good standing of regulatory bodies, and if applicable,
  accreditation

  	
   

  	
  organizational providers on an annual basis

  	
   

  	
  two in each of the four
  categories; one accredited, one non-accredited as applicable.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Sub-Delegation of Credentialing

  	
   

  	
  Delegated

  	
   

  	
  If MG sub-delegates Credentialing to a CVO, Hospital, IPA,
  etc:

  1.     Detailed documentation of
  delegation agreement

  2.     Initial evaluation

  3.     Annual evaluation, including file
  review

  4.     MG retains right to approve/

  disapprove new providers and to discipline providers

  	
   

  	
  Submit copies of sub-delegation agreements to PacifiCare
  on an annual basis

  	
   

  	
  •      Annual assessment of sub-delegation process
  agreements, and polices and procedures.

  



 


PacifiCare’s
responsibilities relating to Credentialing and those responsibilities, which
PacifiCare has delegated to the Medical Group, are outlined above.


 


The
Medical Group agrees to be accountable for all responsibilities delegated by
PacifiCare and will not further delegate any such responsibilities without the
prior approval by PacifiCare.


 


PacifiCare
will perform audits annually and as needed to evaluate the group’s delegated
status.  In the event there are
deficiencies identified in the audit, PacifiCare will provide a specific
corrective action plan.  If the group is
not able to comply with the corrective action plan within the specified time
frame, PacifiCare may revoke the group’s delegated status.


 


50

















 


MEDICAL
RECORDS DELEGATION GRID


	
  Function

  	
   

  	
  Delegation Status

  	
   

  	
  Medical Group

  Responsibility/

  Performance Measure

  	
   

  	
  Reporting Frequency

  	
   

  	
  PacifiCare Oversight

  
	
  Systematic Review and Action

  	
   

  	
  Delegated

  	
   

  	
  •      Audit medical records from at least 90% of all
  primary care practice sites with 50 members or more, and 2 years
  participation in the Medical Group.



  •      Audit tool to include all elements required by NCQA
  and PacifiCare.



  •      Trend results by practice-site and
  organization-wide. Identify opportunities for improvement, describe
  interventions, and assess subsequent performance.

  	
   

  	
  Annual submission of medical records review workplan.



  At least twice a  year
  report at a minimum: the number of physicians whose medical records were
  reviewed; any practice-specific or organization-wide actions taken for
  improvement; and the results of those actions 

  	
   

  	
  •      Quality Improvement Committee or their designee
  reviews and approves Annual Workplan and monitoring report.



  •      Audit Medical Group’s policies and processes on an
  annual basis to include 5% or 50 worksheets to ensure conformance to standards
  and note deficiencies identified. 
  Facilitate and monitor Medical Group’s compliance with work plan and
  corrective action plans



  •      Site visit assessments correlates with review of
  medical records

  



 


PacifiCare’s
responsibilities relating to Medical Records and those responsibilities, which
PacifiCare has delegated to the Medical Group, are outlined above.


 


The
Medical Group agrees to be accountable for all responsibilities delegated by
PacifiCare and will not further delegate any such responsibilities without the
prior approval by PacifiCare.


 


PacifiCare
will perform audits annually and as needed to evaluate the group’s delegated
status.  In the event there are
deficiencies identified in the audit, PacifiCare will provide a specific
corrective action plan.  If the group is
not able to comply with the corrective action plan within the specified time
frame, PacifiCare may revoke the group’s delegated status.


 


51

















 


QUALITY
IMPROVEMENT DELEGATION GRID


	
  Function

  	
   

  	
  Delegation

  Status

  	
   

  	
  Medical Group Responsibility/

  Performance Measure

  	
   

  	
  Reporting Frequency

  	
   

  	
  PacifiCare Oversight

  
	
  Program

  Status

  	
   

  	
  Not Delegated

  	
   

  	
  Medical Group is required to maintain the following:

  •      QM Program

  •      Structure to carry out Quality Mgmt. Program

  •      QM Program outlining structure and content

  •      Program description must be evaluated annually and
  updated as necessary

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Program

  Operations

  	
   

  	
  Not Delegated

  	
   

  	
  •      Participate and cooperate in PacifiCare’s Quality
  Improvement program

  •      Collect data for PacifiCare’s Quality Improvement
  Activities

  •      Carry out corrective actions required by PacifiCare

  •      Have a peer review process

  •      Participate in PacifiCare Quality Improvement
  Committee, (if requested)

  •      Provide PacifiCare access to Medical Records

  •      Identify barriers to improving key initiatives

  •      Implement interventions

  •      Comply with PacifiCare’s confidentiality standards

  	
   

  	
   

  	
   

  	
   

  



 


PacifiCare does not formally delegate
to its contracting Medical Groups the responsibility for performing quality
management and improvement activities on behalf of PacifiCare.


 


52

















 


UTILIZATION
MANAGEMENT DELEGATION GRID


	
  Function

  	
   

  	
  Delegation

  Status

  	
   

  	
  PacifiCare
  Responsibility

  	
   

  	
  Medical
  Group Responsibility/

  Performance Measure

  	
   

  	
  Reporting

  Frequency

  	
   

  	
  PacifiCare

  Oversight

  
	
  Prior

  Authorization

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits appropriately followed.

  •      Responsible for ensuring appropriate structure,
  standards and Policies and Procedures followed.

   

  	
   

  	
  For prior authorization Medical Group (MG) must.

  •      Comply with PacifiCare’s Turn Around Times

  •      Follow PacifiCare’s approved medical necessity
  criteria

  •      Develop and document program to perform prior
  authorization function of OP and IP care meeting all regulatory and
  PacifiCare standards

   

  	
   

  	
  •      Weekly submission of authorization/ denial logs

  •      Monthly submission of encounter data

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function

  •      Annual onsite assessment to determine ability
  to perform function

   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Concurrent

  Review

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits appropriately followed.

  •      Responsible for ensuring
  appropriate structure, standards and Policies and Procedures followed

  	
   

  	
  For concurrent review MG must:

  •      Comply with PacifiCare’s Turn Around Times

  •      Follow PacifiCare’s approved medical necessity
  criteria

  •      Develop and document programs to perform
  concurrent review of acute and Skilled Nursing Facility inpatients meeting
  all regulatory and PacifiCare standards

  	
   

  	
  •      Daily submission of inpatient census

  •      Monthly submission of Bed Days per thousand
  members per year

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function

  •      Annual onsite assessment to determine ability
  to perform function

   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Discharge

  Planning

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring benefits appropriately
  followed.

  •      Responsible for ensuring appropriate structure,
  standards and Policies and Procedures followed.

   

  	
   

  	
  Develop and document program to perform discharge
  planning functions for Acute and Skilled Nursing Facility meeting all
  regulatory and PacifiCare standards

  	
   

  	
   

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function

  •      Annual onsite assessment to determine ability
  to perform function

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out Of Area

  (OOA)

  	
   

  	
  Not Delegated

  	
   

  	
  •      If Group NOT delegated, responsible for
  concurrent review, authorization of services

  •      PacifiCare responsible to report OOA cases to
  Group, and coordinate with Group returning patient to network providers

  •      If Group is delegated, responsible for ensuring
  eligibility and benefits appropriately followed

  •      Responsible for ensuring appropriate structure,
  standards and Policies and Procedures followed.

  	
   

  	
  Develop and document program to perform OOA
  concurrent review meeting all regulatory and PacifiCare standards

  	
   

  	
  If Group delegated should be included in weekly
  authorization/ denial log

  submission

   

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function

  •      Annual onsite assessment to determine ability to
  perform function

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Case Management

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits appropriately followed

  •      Responsible for ensuring appropriate structure,
  standards and Policies and Procedures followed

  •      If NOT delegated, responsible for performing
  Case Management functions and coordinating care with Group

  	
   

  	
  Develop and document program to perform Case
  Management function meeting all regulatory and PacifiCare standards



  If NOT delegated, responsible to coordinate care
  with PacifiCare Case Managers

  	
   

  	
  Monthly submission of Case Management Log

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function

  •      Annual onsite assessment to determine ability
  to perform function

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Transplants

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits appropriately followed.

  	
   

  	
  Develop and document case management program to
  include transplants

  	
   

  	
  Monthly submission of transplant cases

  	
   

  	
  •      Pre-delegation onsite assessment to determine

  



 


53

















 


	
   

  	
   

  	
   

  	
   

  	
  •      Responsible for ensuring appropriate structure,
  standards, and Policies and Procedures followed.

  •      If not delegated to MG, responsible for
  providing medical necessity determination to MG and notification of status
  for pending transplants.

  	
   

  	
   

  •      Required to case manage these cases if
  delegated.

  •      If not delegated, responsible to provide
  PacifiCare with all necessary information to make medical determination.

  	
   

  	
   

  	
   

  	
  ability to perform
  function.

  •      Annual onsite assessment to determine ability
  to perform function.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  New Technology

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits for new technology, and new uses for existing technology.

  •      Medical case review for determining
  appropriateness and medical necessity.

  •      Technology Assessment Committee will develop
  guidelines to support new technology and new uses for existing technology

  	
   

  	
  Develop and document Policies and Procedures to
  support notification to PacifiCare of requests for new technology and
  coordination of making determinations.

  	
   

  	
  Ad Hoc

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function.

  •      Annual onsite assessment to determine ability
  to perform function.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Retroactive-review

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits appropriately followed.

  •      Responsible for ensuring appropriate structure,
  standards and Policies and Procedures followed.

  	
   

  	
  For Retroactive-review MG must:

  •      Comply with PacifiCare’s Turn Around Times.

  •      Follow PacifiCare’s approved medical necessity
  criteria.

  •      Develop and document program to perform
  retrospective review function.

  	
   

  	
  Weekly submission of authorization/denial logs

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function.

  •      Annual onsite assessment to determine ability
  to perform function.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Denials

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits appropriately followed.

  •      Responsible for ensuring appropriate structure,
  standards and Policies and Procedures followed.

  	
   

  	
  For Denials MG must:

  •      Comply with PacifiCare’s Turn Around Times.

  •      Follow PacifiCare’s approved medical necessity
  criteria.

  •      Develop and document of program to perform
  denial function meeting all regulatory and PacifiCare standards.

  	
   

  	
  Weekly submission of denial logs.

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function.

  •      Annual onsite assessment to determine ability
  to perform function.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Benefit Interpretations

  	
   

  	
  Delegated

  	
   

  	
  •      Responsible for ensuring eligibility and
  benefits appropriately followed.

  •      Responsible for ensuring appropriate structure,
  standards and Policies and Procedures followed.

  	
   

  	
  For Benefit Interpretations MG must:

  •      Comply with PacifiCare’s Turn Around Times.

  •      Develop and document program to perform benefit
  interpretations function meeting all regulatory and PacifiCare standards.

  	
   

  	
   

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function.

  •      Annual onsite assessment to determine ability
  to perform function.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Appeals

  	
   

  	
  Delegated

  	
   

  	
  Responsible for handling all member and provider
  appeals.

  	
   

  	
  •      Develop and document program to support
  cooperation with PacifiCare in handling appeals

  •      Notify PacifiCare of all member and provider
  appeals coming through MG.

  	
   

  	
  PacifiCare will provide the MG a quarterly report to
  show number of appeals and overturn rate for specific MG.

  	
   

  	
  •      Pre-delegation onsite assessment to determine
  ability to perform function.

  •      Annual onsite assessment to determine ability
  to perform function.

  



 


54

















 


PacifiCare’s
responsibilities relating to Medical Management and those responsibilities,
which PacifiCare has delegated to the Medical Group, are outlined above.


 


The
Medical Group agrees to be accountable for all responsibilities delegated by
PacifiCare and will not further delegate any such responsibilities without the
prior written approval by PacifiCare.


 


PacifiCare
will perform audits annually and as needed to evaluate the group’s delegated
status.  In the event there are
deficiencies PacifiCare will perform audits annually and as needed to evaluate
the group’s delegated status.  In the
event there are deficiencies identified in the audit, PacifiCare will provide a
specific corrective action plan.  If the
group is not able to comply with the corrective action plan within the
specified time frame, PacifiCare may revoke the group’s delegated status.


 


55

















 


	
   

  	
  PACIFICARE OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Brian Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/17/01

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL GROUP

  Northwest Orange Bounty Medical Group

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Pratibha Patel

  	
   

  
	
   

  	
   

  	
  PRATIBHA PATEL, MD

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  PRESIDENT

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/2/01

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	 
	
   

  	
   

  	
  /s/ James P. Agronick

  	
  , CEO

  
	 
	
   

  	
   

  	
  PREMIER PHYSICIAN
  SERVICES

  
	 
	
   

  	
   

  	
  4/2/01

  
					



 


56

















 


PACIFICARE OF CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES AGREEMENT

(SPLIT CAPITATION)


 


EXHIBIT 3


PRODUCT ATTACHMENTS


VERIFICATION OF RECEIPT OF PROVIDER MANUAL,


FORM SUBSCRIBER AGREEMENT AND EVIDENCE OF COVERAGE


(This Exhibit 3 is an integral part of this Agreement)


 


MEDICAL GROUP
NAME: Northwest Orange County Medical Group


 


VERIFICATION OF
RECEIPT OF PROVIDER MANUAL, SUBSCRIBER AGREEMENT AND EVIDENCE OF COVERAGE:


 


A copy of the
PacifiCare Provider Policies and Procedures Manual and standard form Subscriber
Agreement and Evidence of Coverage for each of the Managed Care Plans specified
below has been provided to Medical Group by PacifiCare prior to the execution
of this Agreement:


 


	
  By:

  	
  /s/ Pratibha Patel

  	
   

  	
  /s/ James P. Agronick 

  
	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  PRESIDENT

  	
   

  	
  CEO, PREMIER PHYS SVCS.

  
	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  4/2/01

  	
   

  	
  4/2/01

  



 


ATTACHMENTS:


 


The following
attachments, when initialed by PacifiCare and Medical Group, are an integral
part of this Agreement:


 


 


	
   

  	
   

  	
  PacifiCare

  	
   

  	
  Medical
  Group

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PacifiCare Commercial Health Plan

  	
   

  	
  /s/ BJ

  	
   

  	
  PP /s/ JPA

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PacifiCare
  Commercial POS Health Plan

  	
   

  	
  /s/ BJ

  	
   

  	
  PP /s/ JPA

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Secure Horizons
  Health Plan

  	
   

  	
  /s/ BJ

  	
   

  	
  PP /s/ JPA

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Division of
  Financial Responsibility

  	
   

  	
  /s/ BJ

  	
   

  	
  PP /s/ JPA

  	
   

  



 


57

















 


PACIFICARE OF CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES AGREEMENT

(SPLIT CAPITATION)


 


EXHIBIT 4


INCENTIVE PROGRAMS

(This Exhibit 4 is an integral part of this Agreement)


 


58

















 


PRODUCT ATTACHMENT
A


 


PACIFICARE
COMMERCIAL HEALTH PLAN


 


This Product
Attachment A, along with the Base Agreement, sets forth the specific terms and
conditions which are applicable to the PacifiCare Commercial Health Plan, as
defined below.


 


ARTICLE 1

DEFINITIONS


 


The following
terms shall have the meaning attributed below for purposes of the PacifiCare
Commercial Health Plan, as described in this Product Attachment A.  Capitalized terms not otherwise defined
herein shall have the meaning assigned to them in the Base Agreement.


 


1.1           Commercial
Plan Premium is the Premium received by PacifiCare each month for
PacifiCare Commercial Plan Members, excluding amounts to pay broker and agent
commissions/compensation, Premium taxes and Premiums for Supplemental Benefits.


 


1.2           OPM
Agreement is the agreement between PacifiCare and the Federal Office of
Personnel Management for the provision of Covered Services to persons enrolled
in the PacifiCare Commercial Plan through their participation in the health
benefits programs for Federal employees and their dependents.


 


1.3           PacifiCare
Commercial Plan is any and all of the various Managed Care Plans sold by
PacifiCare to individuals (excluding individuals eligible for the PacifiCare
Medicaid Plan and the Secure Horizons Health Plan) and employer groups,
associations with employer group participation and unions which purchase
benefits for their employees and their dependents.


 


1.4           Commercial
Plan Members are Medical Group Members enrolled in the PacifiCare Commercial
Plan.


 


1.5           Supplemental
Benefits are benefits offered under the PacifiCare Commercial Plan which
require separate Premium, in addition to the Commercial Plan Premium, as
consideration for the additional benefits.


 


ARTICLE 2

DUTIES OF MEDICAL GROUP


 


2.1           Provision
of Covered Services.  Medical Group
and its Participating Providers shall provide Covered Services to Commercial
Plan Members pursuant to the terms of the Base Agreement and this Product
Attachment A.


 


2.2           Compliance
with OPM Agreement.  Medical Group
shall comply with all requirements in the OPM Agreement which are applicable to
Medical Group as a subcontractor of PacifiCare as a result of this
Agreement.  Without limiting the
foregoing, Medical Group shall ensure that all provisions of the OPM Agreement
which are applicable to Medical Group’s Participating


 


60

















 


Providers are included in Medical Group’s subcontracts with its
Participating Providers.  A copy of the
OPM Agreement shall be provided to Medical Group concurrent with the execution
of this Agreement.


 


2.3           Compliance
with Subscriber Agreements for PacifiCare Commercial Plan.  Medical Group and its Participating
Providers shall comply with all requirements in Subscriber Agreements for the
PacifiCare Commercial Plan which are applicable to Medical Group.  PacifiCare shall make good faith efforts to
notify Medical Group of any such requirements that are not otherwise reflected
in this Agreement.


 


ARTICLE 3

COMPENSATION


 


3.1           Capitation
Payments for Commercial Plan Members. 
Effective January 1, 2001, Capitation Payments for Commercial Plan
Members shall equal *** per Member per month, which amount shall be adjusted
monthly to reflect the age/gender and play type for eligible Medical Group
Members, subject to the adjustments set forth in Article 5 of the Base
Agreement.  Effective January 1, 2002,
Capitation Payments for Commercial Plan Members shall equal *** per Member per
month, which amount shall be adjusted monthly to reflect the age/gender and
play type for eligible Medical Group Members, subject to the adjustments set
forth in Article 5 of the Base Agreement. 
Age/gender and plan type adjustment will be made by multiplying the
capitation rate above by age/gender and plan type factors as set forth in
Exhibit 5, as modified from time to time per the term of Section 7.8.4 entitled
“Amendment to Managed Care Plans.”


 


3.1.1        Premium Adjustments.  The Commercial Plan Premium and benefits may
be amended for each Subscriber Agreement upon the annual renewal date of each
Subscriber Agreement at the sole discretion of PacifiCare.


 


3.1.2        Adjustment for ISL Premium, In
calculating Capitation Payments due to Medical Group, PacifiCare shall deduct
the ISL Premium amount set forth herein from the amounts otherwise due to
Medical Group, unless PacifiCare has approved of Medical Group’s opting out of
PacifiCare’s ISL Program.


 


3.1.3        Adjustment for Experience-Rated Managed Care
Plans.  Capitation Payments for
Experience Rated Plans shall be calculated utilizing the following definitions
and methodology:


 


(i)            An “Experience-Rated
Plan” is a non-federally-qualified plan in which the Subscriber Group’s premium
is partially deferred or adjusted to reflect the actual medical costs incurred
by Commercial Plan Members.


 


(ii)           The “Net Actuarial
Experience Rate” shall mean a rate calculated by the same method used to
determine premium for federally-qualified plans, except that trended claims and
utilization data may be considered to determine expected medical costs and
PacifiCare’s administrative retention may be adjusted to


 


61

















 


reflect actuarial risk
taken by the Subscriber Group instead of PacifiCare.


 


(iii)          For Experience-Rated
Plans, Capitation Payments shall be calculated as a percent of the Net
Actuarial Experience Rate rather than based on a percent of the Commercial Plan
Premium.  The Net Actuarial Experience
Rate, like the Commercial Plan Premium, shall exclude broker and agent
commissions, premium taxes and premiums for Supplemental Benefits.


 


3.2           ISL
Program.  The ISL Deductible, ISL
Premium and ISL Coinsurance for the Commercial Plan shall initially be:


 


(i)            ISL Deductible shall
be zero dollars ($0.00) per Commercial Plan Member per calendar year.


 


(ii)           ISL Premium shall be
zero percent (0%) of the Commercial Plan Premium.


 


(iii)          ISL Coinsurance shall be
zero percent (0%) of Cost of Care in excess of the ISL Deductible.


 


If PacifiCare has
approved of Medical Group opting out of the ISL Program, the above amounts and
percentages will reflect “zero.” In such event, Medical Group shall be required
to obtain ISL coverage from a third-party insurance carrier in accordance with
Section 5.5.3 of the Base Agreement.


 


3.3           Commercial
Hospital Incentive Program.  Medical
Group and Hospital shall establish and maintain an annual Commercial Hospital
Incentive Program for the PacifiCare Commercial Plan (the “CHIP”).  The CHIP shall be designed to provide an
incentive for efficient and effective use of Hospital Services, and shall be
consistent with this Agreement and with State and Federal Law.  A copy of the CHIP is included in the
Exhibits and incorporated herein. 
Medical Group shall provide PacifiCare with a copy of any and all
revisions to the CHIP, which shall be deemed incorporated into this Agreement,
copies of any and all reports and payment schedules prepared by Medical Group
or Hospital relating to the CHIP and evidence of stop-loss reinsurance obtained
pertaining to the CHIP (which insurance must be approved, in writing, by
PacifiCare).  PacifiCare reserves the
right to require that the CHIP be modified from time to time to comply with
this Agreement and State and Federal Law. 
[Without limiting the foregoing, the CHIP shall provide that in the
event of a deficit under the CHIP which exceeds any established withhold,
Medical Group shall not be responsible for reimbursing Hospital or PacifiCare
for such deficit nor shall PacifiCare offset such deficit against Medical
Group’s Capitation Payments due under this Agreement.]


 


If PacifiCare provides
reinsurance protection for the CHIP, such reinsurance shall be obtained in
accordance with PacifiCare’s Reinsurance Program then in effect and elections
for such Reinsurance Program shall be made by Hospital, in writing, with written
notice to Medical Group.  Hospital shall
not change its Reinsurance Program elections without the written consent of
Medical Group.  Reinsurance Premiums
shall be paid by Hospital and PacifiCare may deduct such Reinsurance Premiums
from Hospital’s Capitation Payments.


 


62

















 


3.4           Commercial
Plan Pharmacy Incentive Program. 
PacifiCare shall establish and administer an annual Pharmacy Incentive
Program for the PacifiCare Commercial Plan (the “PIP”).  The PIP is designed to provide an incentive
for the efficient and effective use of Outpatient Pharmacy Supplemental
Benefits for Commercial Plan Members. 
The PIP shall be calculated as follows:


 


3.4.1        Outpatient Pharmacy
Supplemental Benefits shall be the benefits made available by PacifiCare
under the PacifiCare Supplemental Pharmacy Benefit, as defined in the
applicable Subscriber Agreement.


 


3.4.2        PIP Budget shall
equal eighty percent (80%) of the premium received by PacifiCare for Outpatient
Pharmacy Supplemental Benefits for Commercial Plan Members plus thirty one
cents ($0.31) per Commercial Plan Member per month, which amount is established
as a credit for rebates received from pharmaceutical manufacturers.  This credit may or may not reflect the total
pharmaceutical manufacturer rebate revenues received by PacifiCare.  The PIP Budget shall be retained by
PacifiCare for purposes of administering the PIP.


 


3.4.3        PIP Expense shall
equal the expense incurred for the provision of Outpatient Pharmacy Supplemental
Benefits during the applicable period.


 


3.4.4        PIP Surplus.  In the event the PIP Expense is less than
the PIP Budget, fifty percent (50%) of the surplus shall be allocated to
Medical Group.


 


3.4.5        PIP Deficit.  In the event that the PIP Expense is greater
than the PIP Budget, fifty percent (50%) of the deficit shall be allocated to
Medical Group.


 


63

















 


IN WITNESS
WHEREOF, the parties hereto have executed this Product Attachment A.


 


	
   

  	
  PACIFICARE OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Brian Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/17/01

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL GROUP

  Northwest Orange County Medical Group

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Pratihba Patel

  	
   

  
	
   

  	
   

  	
  PRATIHBA PATEL, MD

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Title:

  	
  PRESIDENT

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/2/01

  	
   

  
	
   

  
	
   

  
	
   

  	
   

  	
  /s/ James P. Agronick

  	
  , CEO

  
	
   

  	
   

  	
  PREMIER PHYSICIAN
  SERVICES

  
	
   

  	
   

  	
  4/2/01

  



 


64

















 


PRODUCT ATTACHMENT B


 


PACIFICARE COMMERCIAL POINT-OF-SERVICE PLAN


 


This Product Attachment
B, along with Product Attachment A and the Base Agreement, sets forth the terms
and conditions which are applicable to the PacifiCare Commercial
Point-of-Service Plan, as defined below.


 


ARTICLE 1


DEFINITIONS


 


The following terms shall
have the meaning attributed below for purposes of the PacifiCare Commercial
Point-of-Service Plan, as described in this Product Attachment B.  Capitalized terms not otherwise defined
herein shall have the meaning assigned to them in the Base Agreement.


 


1.1           In-Network
Services are Covered Services which are (a) provided or arranged by Medical
Group pursuant to the PacifiCare Commercial Plan; (b) received from a
non-contracting Provider following an authorization from Medical Group; (c)
Emergency Services and (d) Urgently Needed Services.


 


1.2           Out-of-Network
Services are Covered Services, excluding Emergency Services and Urgently
Needed Services, which are received without the prior authorization of Medical
Group.


 


1.3           PacifiCare
Commercial Point-of-Service (“POS”) Plan is any PacifiCare Commercial Plan,
as defined in Product Attachment A, under which Members are entitled to
coverage for both In-Network Services and Out-of-Network Services.


 


1.4           Commercial
POS Plan Members are Medical Group Members enrolled in the PacifiCare
Commercial POS Plan.


 


1.5           POS
Plan Premium is the sum of the In-Network Premium and the Out-of-Network
Premium, as defined below:


 


1.5.1        In-Network Premium is the Commercial
Plan Premium, as defined in Product Attachment A, billed or accounted for by
PacifiCare for coverage of In-Network Services under the PacifiCare Commercial
POS Plan.


 


1.5.2        Out-of-Network Premium is the Commercial
Plan Premium, as defined in Product Attachment A, billed or accounted for by
PacifiCare (or an insurance company or self-insured employer which has assumed
the risk for the Out-of-Network Services), for coverage of Out-of-Network
Services under the PacifiCare Commercial POS Plan.


 


ARTICLE 2


DUTIES OF MEDICAL GROUP


 


2.1           Covered Services.  Medical Group and its Participating
Providers shall provide or arrange


 


65

















 


Covered Services
to Commercial POS Plan Members under same terms and conditions as Commercial
Plan Members.


 


2.2           Reciprocity;
Reimbursement for Out-of-Network Services. 
If any of Medical Group’s Participating Providers provides Out-of-Network
Services to a Commercial POS Plan Member, such Medical Group Participating
Provider shall bill PacifiCare or the payor responsible for payment for
Out-of-Network Services for such services and agrees to accept full payment at
the Cost of Care.  Neither Medical Group
nor its Participating Providers shall encourage Members to receive Covered
Services from non-Participating Providers. 
Medical Group shall include the requirements of this Section in all
subcontracts with its Participating Providers.


 


ARTICLE 3


COMPENSATION


 


3.1           Capitation
Payments for Commercial POS Plan Members. 
For Commercial POS Plan Members, PacifiCare will pay Medical Group ***
of the Capitation Payment for Commercial Plan Members, subject to the
adjustments set forth in Article 5 of the Base Agreement and the
adjustments set forth below in this Section. 
Capitation Payments for Commercial POS Plan Members will be based on a
percentage of the In-Network Premium only. 
The payment described in this Section is payment in full for In-Network
Services, except for Copayments, coordination of benefits, third party
recoveries and payments under the PacifiCare POS Control Program set forth
below.


 


3.1.1        Adjustment for ISL Premium.  In calculating Capitation Payments due to
the Medical Group for Commercial POS Plan Members, PacifiCare shall deduct
eighty percent (80%) of the ISL Premium amount set forth in Section 3.2 of
Product Attachment A from the amounts otherwise due to Medical Group, unless
PacifiCare has approved of Medical Group opting out of PacifiCare’s ISL
Program.


 


3.2           Commercial
POS Control Program.  PacifiCare
shall establish and administer an annual Control Program for the PacifiCare
Commercial Point-of-Service Plan (“Commercial POS Control Program”).  The Commercial POS Control Program is
designed to provide an incentive to control Out-of-Network Services, and shall
be calculated in accordance with the following provisions.


 


3.2.1        Definitions.  The following terms shall have the meaning attributed below for
purposes of the Commercial POS Control Program.


 


(i)            POS
Plan Budget shall equal eighteen percent (18%) of In-Network Premium plus
eighteen percent (18%) of Out-of-Network Premium, less PacifiCare Commercial
POS Control Program Reinsurance Premium, if any.


 


(ii)           Out-of-Network
Costs shall mean the following:


 


(a)           Claims
paid for Out-of-Network Services incurred during the current period, calculated
at the actual amount paid; plus,


 


66

















 


(b)           Claims
paid for Out-of-Network Services incurred but not included in prior period
Commercial POS Control Program calculations, calculated at the actual amount
paid; minus,


 


(c)           Amounts
pursuant to the Commercial POS Control Program Reinsurance, if any; minus,


 


(d)           Any
and all amounts from third-party liability and coordination of benefit
recoveries for Out-of-Network Services that are received during the period of
calculation.


 


(iii)          Budget Surplus.  The amount, if any, by which the POS Plan
Budget exceeds the Out-of-Network Costs for any calendar year.


 


(iv)          Budget
Deficit.  The amount, if any, by
which the Out-of-Network Costs exceed the POS Plan Budget for any calendar
year.


 


(v)           Capitation
Restoration Amount.  The difference
between (a) the amount Medical Group or Hospital would have received if Medical
Group’s Capitation Payments for Commercial POS Plan Members had been determined
by multiplying the percentage set forth in Section 3.1 of Product
Attachment A by the In-Network Premium and (b) the actual Capitation Payments
to Medical Group or Hospital for Commercial POS Plan Members for the relevant
contract year.  The Capitation
Restoration Amount shall be calculated separately for Medical Group and
Hospital.


 


3.2.2        Documentation.  PacifiCare shall provide Medical Group with a list of Out-of-Network
claim payments in support of computation and accuracy of Out-of-Network Costs,
third party liability and coordination of benefit recoveries, assumptions and
data supporting the POS Plan Budget, the Budget Surplus, and the Budget Deficit
and the Capitation Restoration Amount.


 


3.2.3        Budget Surplus Reconciliation.  Medical Group and Hospital shall each
receive fifty percent (50%) of the Budget Surplus, until such time as either
Hospital or Medical Group has received the applicable Capitation Restoration
Amount.  Additional Budget Surplus
amounts shall be paid to the party whose capitation has yet to be restored
until that party has received the applicable Capitation Restoration Amount.  If the Budget Surplus exceeds the Capitation
Restoration Amount for both Hospital and Medical Group, then PacifiCare,
Hospital and Medical Group shall each be entitled to one-third of the remaining
Budget Surplus.


 


3.2.4        Budget Deficit Reconciliation.  In the event of a Budget Deficit, neither
Medical Group nor Hospital shall be responsible for making any payments under
the PacifiCare POS Control Program. 
However, fifty percent (50%) of the Budget Deficit amount shall be
considered a Medical Group obligation for purposes of offsetting surpluses
under other incentive programs under the Agreement.


 


67

















 


3.3           Adjustment
of Rates.  Capitation Payments for
Commercial POS Plan Members and the POS Plan Budget may be prospectively
adjusted on an annual basis to reflect actual experience under the Commercial
POS Plan; provided, however, that in no event shall the amount of any increase
or decrease to such Capitation Payments be greater than ten (10) percentage
points in any given year.


 


68

















 


IN WITNESS WHEREOF, the
parties hereto have executed this Product Attachment B.


 


	
   

  	
  PACIFICARE OF
  CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Brian Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/17/01

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL GROUP

  
	
   

  	
  Northwest Orange County
  Medical Group

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Pratihba Patel

  	
   

  
	
   

  	
   

  	
  PRATIHBA PATEL, MD

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  PRESIDENT

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/2/01

  	
   

  
	
   

  
	
   

  	
   

  
	
   

  	
   

  	
  /s/ James P. Agronick

  	
  , CEO

  
	
   

  	
   

  	
  PREMIER PHYSICIAN
  SERVICES

  
	
   

  	
   

  	
  4/2/01

  
					



 


69

















 


PRODUCT ATTACHMENT C


 


SECURE HORIZONS HEALTH PLAN


 


This Product Attachment
C, along with the Base Agreement, sets forth the terms and conditions which are
applicable to the Secure Horizons Health Plan, as defined below.


 


ARTICLE 1


DEFINITIONS


 


The following terms shall
have the meaning attributed below for purposes of the Secure Horizons Health
Plan, as described in this Product Attachment C.  Capitalized terms not otherwise defined herein shall have the
meaning assigned to them in the Base Agreement.


 


1.1           HCFA
is the Health Care Financing Administration, an administrative agency of the
United States Government, responsible for administering the Medicare program.


 


1.2           HCFA
Agreement is the Medicare + Choice contract between PacifiCare and HCFA.


 


1.3           Medicare
is the Hospital Insurance Plan (Part A) and the Supplementary Medical Insurance
Plan (Part B) provided under Title XVIII of the Social Security Act, as
amended.


 


1.4           Monthly
HCFA Payment is the revenue received by PacifiCare each month from HCFA, as
determined by HCFA, for providing Covered Services to Secure Horizons Members.


 


1.5           Secure
Horizons Health Plan is the prepaid health plan operated by PacifiCare
pursuant to the HCFA Agreement which provides Covered Services to individuals
(including retirees) eligible to receive Medicare benefits.


 


1.6           Secure
Horizons Members are Medical Group Members enrolled in the Secure Horizons
Health Plan.


 


1.7           Secure
Horizons Revenue is the Monthly HCFA Payment for Medical Group Members
enrolled in the Secure Horizons Health Plan, less payments for broker and
agent commissions/compensation (when applicable), premium taxes and amounts
used to fund the Market Specific Benefit Program (as defined below).


 


ARTICLE 2


DUTIES OF MEDICAL GROUP


 


2.1           Compliance
with HCFA Agreement and Federal Medicare Law.  Medical Group shall comply with all requirements in the HCFA
Agreement which are applicable to Medical Group as a subcontractor of
PacifiCare as a result of this Agreement. 
Without limiting the foregoing, Medical Group shall ensure that all
provisions of the HCFA Agreement which are applicable to Medical Group’s
Participating Providers as a subcontractor of PacifiCare are included in
Medical Group’s subcontracts with its Participating Providers.  A copy of the


 


70

















 


HCFA Agreement
shall be made available to Medical Group concurrent with the execution of this
Agreement.  Medical Group and its
Participating Providers shall comply with Title XVIII of the Social Security
Act and the regulations adopted thereunder by HCFA for the Medicare program.


 


2.2           Medicare
Participation Standards.  Medical
Group shall require that all of its Participating Providers who provide
services to Secure Horizons Members meet the standards for participation and
all applicable requirements for providers of health care services under the
Medicare program.  In addition, Medical
Group shall require that all facilities and offices utilized by Medical Group
and its Participating Providers to provide or arrange Covered Services to
Secure Horizons Members shall comply with facility standards established by
HCFA.


 


2.3           Specific
Provisions Pertaining to Benefits, Coverage and Beneficiary Protections.  Without limiting any of Medical Group’s
other obligations under this Agreement, Medical Group specifically agrees to
comply with the following policies and procedures:


 


(i)            PacifiCare’s
policies pertaining to the collection of copayments which prohibit the
collection of copayments for routine injections, routine immunizations, flu
immunizations, and the administration of pneumococcal/pneumonia vaccine.


 


(ii)           PacifiCare’s
policies pertaining to pre-certification which provide that Secure Horizons
Members may directly access a provider for mammography and influenza
vaccinations and women’s health specialists for routine and preventative health
care.


 


(iii)          PacifiCare’s policies pertaining to complex
and serious conditions which provide for procedures to identify, assess and
establish treatment plans for persons with complex or serious medical
conditions.


 


(iv)          PacifiCare’s
policies pertaining to enrollment and assessment of new Secure Horizons Members
including requirements to conduct a health assessment of all new Secure
Horizons Members within ninety (90) days of the effective date of their
enrollment.


 


2.4           Confidentiality
of Medical Records.  Medical Group
shall establish and maintain procedures and controls so that no information
contained in its records or obtained from HCFA or from others in carrying out
the terms of this Agreement shall be used by or disclosed by it, its agents,
officers, or employees except as provided in Section 1106 of the Social
Security Act, as amended, and regulations prescribed thereunder.


 


2.5           Submission
of Data.  Medical Group shall
cooperate with PacifiCare in submitting to the Secretary of Health and Human
Services statistical data pertaining to Covered Services provided by Medical
Group, enrollment and disenrollment data and any other reports the Secretary
may reasonably require to carry out its functions under the Medicare + Choice program.


 


2.6           Advance
Directives.  Medical Group shall
document all Secure Horizons Member patient records with respect to the
existence of an Advance Directive in compliance with the Patient


 


71

















 


Self-Determination
Act (Section 4751 of the Omnibus Reconciliation Act of 1990), as amended,
and other appropriate laws.  For
purposes of this Agreement, an Advance Directive is a Member’s written
instructions, recognized under State law, relating to the provision of health
care when the Member is not competent to make health care decisions as
determined under State law.  Examples of
Advance Directives are living wills and durable powers of attorney for health
care.


 


2.7           Non-Discrimination.  Medical Group understands that HCFA requires
compliance with the provisions of this Section as a condition for
participation in the Secure Horizons Health Plan.  Medical Group and its Participating Providers shall not
unlawfully discriminate against any of their employees or applicants for
employment or against any Members on the basis of race, color, creed, national
origin, ancestry, religion, sex, marital status, age (except as provided by
law), sexual orientation, gender identity, or physical or mental handicap,
including HIV status.  Medical Group and
its Participating Providers shall ensure that the evaluation and treatment of
their employees and applicants for employment and of Members are free of such
discrimination.  Medical Group and its
Participating Providers shall comply with Title VI of the Civil Rights Act of
1964, as amended (42 U.S.C. Section 2000d et. seq.), Section 504 of
the Rehabilitation Act of 1973, as amended (29 U.S.C. Section 794) and the
regulations thereunder, Title IX of the Education Amendments of 1972, as amended
(20 U.S.C. Section 1681 et. seq.), the Age Discrimination Act of 1975, as
amended (42 U.S.C. Section 6101 et. seq.), Section 654 of the Omnibus
Budget Reconciliation Act of 1981, as amended (42 U.S.C. Section 9849),
the Americans With Disabilities Act (P.L. 101-365) and all implementing
regulations, guidelines and standards as are now or may be lawfully adopted
under the above statutes.


 


2.8           Termination
of HCFA Agreement.  In the event the
HCFA Agreement is terminated or not renewed, the provisions of this Agreement
relating to the Secure Horizons Health Plan shall automatically terminate
unless otherwise agreed by HCFA and PacifiCare.


 


ARTICLE 3


COMPENSATION


 


3.1           Capitation
Payments for Secure Horizons Members. 
Capitation Payments for Secure Horizons Members shall be *** of the
Secure Horizons Revenue per Secure Horizons Member per month, plus zero dollars
($0.00) per month for each Secure Horizons Member for whom PacifiCare has
received a monthly member premium, subject to the adjustments set forth in
Article 5 of the Base Agreement and the adjustments set forth below in
this Section.


 


3.1.1        Adjustment for ISL Premium.  In calculating Capitation Payments due to
Medical Group, PacifiCare shall deduct the ISL Premium amount set forth herein
from the amounts otherwise due to Medical Group, unless PacifiCare has approved
of Medical Group opting out of PacifiCare’s ISL Program.


 


3.2           ISL
Program.  The ISL Deductible, ISL
Premium and ISL Coinsurance for the Secure Horizons Plan shall initially be:


 


72

















 


(i)            ISL
Deductible shall be zero dollars ($0.00) per Secure Horizons Member per
calendar year.


 


(ii)           ISL Premium shall be
zero percent (0%) of the Secure Horizons Revenue.


 


(iii)          ISL Coinsurance shall be
zero percent (0%) of the Cost of Care in excess of the ISL Deductible.


 


If PacifiCare has
approved of Medical Group opting out of the ISL Program, the above amounts and
percentages will reflect “zero.” In such event, Medical Group shall be required
to obtain ISL coverage from a third-party insurance carrier in accordance with
Section 5.5.3 of the Base Agreement.


 


3.3           Secure
Horizons Hospital Incentive Program. 
Medical Group and Hospital shall establish and administer an annual
Secure Horizons Hospital Incentive Program for the Secure Horizons Plan (the
“SHIP”).  The SHIP shall be designed to
provide an incentive for efficient and effective use of Hospital Services, and
shall be consistent with this Agreement and with State and Federal Law.  A copy of the SHIP is included in the
Exhibits and incorporated herein. 
Medical Group shall provide PacifiCare with a copy of any and all
revisions to the SHIP, which shall be deemed incorporated into this Agreement;
copies of any and all reports and payment schedules prepared by Medical Group
or Hospital relating to the SHIP and evidence of stop-loss reinsurance obtained
pertaining to the SHIP (which insurance must be approved, in writing, by
PacifiCare).  PacifiCare reserves the
right to require that the SHIP be modified from time to time to comply with
this Agreement and State and Federal Law. 
Without limiting the foregoing, the SHIP shall provide that in the event
of a deficit under the SHIP which exceeds any established withhold, Medical
Group shall not be responsible for reimbursing Hospital or PacifiCare for such
deficit nor shall PacifiCare offset such deficit against Medical Group’s
Capitation Payments due under this Agreement.


 


If PacifiCare
provides reinsurance protection for the SHIP, such reinsurance shall be obtained
in accordance with PacifiCare’s Reinsurance Program then in effect and
elections for such Reinsurance Program shall be made by Hospital, in writing,
with written notice to Medical Group. 
Hospital shall not change its Reinsurance Program elections without the
written consent of Medical Group. 
Reinsurance Premiums shall be paid by Hospital and PacifiCare may deduct
such Reinsurance Premiums from Hospital’s Capitation Payments.


 


3.4           Market-Specific
Benefit Program.  PacifiCare may
establish, at its sole discretion, an annual Market-Specific Benefit Program
(the “MSBP”).  The MSBP is designed to
provide an incentive to control costs for certain additional benefits (the
“MSBP Benefits”) offered to Secure Horizons Members, as defined in the
applicable Subscriber Agreement, for the purpose of enhancing the marketability
of the Secure Horizons Health Plan.  The
MSBP may include the following additional benefits and may be amended from time
to time by PacifiCare to reflect changes in the benefits:


 


Dental Benefits


Immunosuppressive
Drugs


Outpatient
Pharmacy Benefits


 


73

















 


Respite Care


 


PacifiCare shall
retain *** of the Monthly HCFA Payment (the “MSBP Budget”) and add to it ***
per Secure Horizons Plan Member per month, which amount is established as a
credit for rebates received from pharmaceutical manufacturers.  This credit may or may not reflect the total
pharmaceutical manufacturer rebate revenues received by PacifiCare for purposes
of funding and administering the MSBP. 
The MSBP shall be calculated as follows:


 


3.4.1        MSBP Benefits shall be the additional
benefits listed above in this Section and made available under the Secure
Horizons Health Plan as defined in the applicable Subscriber Agreement.


 


3.4.2        MSBP Expense shall equal the expense
incurred for the provision of MSBP Benefits during the applicable period.


 


3.4.3        MSBP Surplus.  In the event the MSBP Expense is less than the MSBP Budget, fifty
percent (50%) of the surplus shall be allocated to Medical Group.


 


3.4.4        MSBP Deficit.  In the event the MSBP Expense is greater than the MSBP Budget,
fifty percent (50%) of the deficit, limited to five percent (5%) of the MSBP
Budget, shall be allocated to Medical Group.


 


3.4.5        Settlements.  The calculations in this Section and settlements shall be
performed in accordance with the procedures specified in Article 5 of the
Base Agreement.


 


3.5           Collection
of Charges From Third Parties When Medicare Is Not the Primary Payor.  Medical Group shall accept Capitation
Payments from PacifiCare as payment in full for Covered Services provided to
Secure Horizons Members; provided, however, when Medicare is not the primary
payor for Covered Services, such as when the Secure Horizons Member is entitled
to payment from another third party or for payment for a workers’ compensation
claim, or from other primary insurance coverage maintained by Secure Horizons
Member, Medical Group shall make no demand upon PacifiCare for reimbursement
under the Individual Stop-Loss Program until all primary sources of payment
have been pursued and it is determined that full payment cannot be obtained
within ten (10) months from the date of the provision of Covered Services.


 


74

















 


IN WITNESS WHEREOF, the
parties hereto have executed this Product Attachment C.


 


	
   

  	
  PACIFICARE OF
  CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  Brian
  Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice
  President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/17/01

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL GROUP

  
	
   

  	
  Northwest Orange County
  Medical Group

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Pratihba Patel

  	
   

  
	
   

  	
   

  	
  PRATIHBA PATEL, MD

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  PRESIDENT

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  4/2/01

  	
   

  
	
   

  
	
   

  	
   

  
	
   

  	
   

  	
  /s/ James P. Agronick

  	
  , CEO

  
	
   

  	
   

  	
  PREMIER PHYSICIAN
  SERVICES

  
	
   

  	
   

  	
  4/2/01

  



 


75

















 


PACIFICARE OF
CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES AGREEMENT


(SPLIT CAPITATION)


 


EXHIBIT 5


CALCULATION OF FIXED CAPITATION RATE


AGE/GENDER AND BENEFIT PLAN ADJUSTED


(This Exhibit 5 is an integral part of this Agreement)


 


 


76

















 


PacifiCare
of California - Commercial


 


Northwest
Orange County


 


Calculation of Fixed Rate Capitation - Age/Sex & Benefit
Adjusted


 




	
  Base Rate

  	
   

  	
  ***

  
	
  Age/Sex Plan Factor

  	
   

  	
  ***

  
	
  Expected Cap Yield

  	
   

  	
  ***

  






 


A. Rate Grid


 


	
  Age Sex

  Category

  	
   

  	
  OV Copay

  Plan Factor

  Age/Sex Factor

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Child 0

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Child 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Child 2-9

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Female 18-19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 20-24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 25-29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 30-34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 35-39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 40-44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 45-49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 50-54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 55-59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 60-64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 65 plus

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Male 18-19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 20-24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 25-29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 30-34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 35-39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 40-44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 45-49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 50-54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 55-59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 60-64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 65 plus

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


 

















 


PacifiCare
of California - Commercial


 


Northwest
Orange County


 


Calculation of Fixed Rate Capitation - Age/Sex & Benefit
Adjusted


 




	
  Base Rate

  	
   

  	
  ***

  
	
  Age/Sex Plan Factor

  	
   

  	
  ***

  
	
  Expected Cap Yield

  	
   

  	
  ***

  






 


A. Rate Grid


 


	
  Age Sex

  Category

  	
   

  	
  OV Copay

  Plan Factor

  Age/Sex Factor

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Child 0

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Child 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Child 2-9

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Female 18-19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 20-24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 25-29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 30-34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 35-39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 40-44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 45-49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 50-54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 55-59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 60-64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Female 65 plus

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Male 18-19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 20-24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 25-29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 30-34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 35-39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 40-44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 45-49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 50-54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 55-59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 60-64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Male 65 plus

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


 


 


 

















 


 


DIVISION OF
FINANCIAL RESPONSIBILITY


 


The following matrix
outlines the division of financial responsibility between PacifiCare, Medical
Group and Hospital, the intent being to clarify Covered Services categories in
order to provide for accurate administration. The matrix serves as a model
under which broad Covered Service categories suggest the appropriate financial
responsibility for Covered Services not specifically listed. The applicable
Subscriber Agreement and Evidence of Coverage should be consulted for an
accurate and complete description of Covered Services and the Provider Manual
for administrative clarification. Member benefit information should be verified
prior to the provision of services.


 

















 


DIVISION
OF FINANCIAL RESPONSIBILITY


CALIFORNIA


Commercial Risk Services
Agreement


(IPA Capitated, Hospital
Capitated)


 


	
  List of Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  AIDS

  	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Allergy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Serum (is not covered by all
  plans; those with coverage are noted in back of eligibility list)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Ambulance, Air or Ground

  	
  •  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Amniocentesis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Anesthetics, Administration of (Anesthesiology)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Apnea Monitor (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Artificial Insemination

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Artificial Limbs (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Biofeedback

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Blood & Blood Products (Including Professional Component)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Autologous Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical Dependency Rehabilitation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemotherapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chiropractic (requires P.M.G. referral)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Circumcision

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Colostomy Supplies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Contact Lenses

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Intraocular lens (surgically
  implanted)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Incident to Cataract Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Cosmetic Surgery (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Dental Services (for repair of accident/injury only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Detox

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
									



 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Durable Medical Equipment (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Hearing Aids

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Custom Made

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Custom fitted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Emergency Room
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Emergency Room
  Physicians – In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Initial
  Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Consults

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Employment
  Physical

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Endoscopic
  Studies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  With Biopsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Without
  Biopsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Experimental
  Procedures

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family Planning
  (e.g.: Abortions, Amniocentesis, Artificial Insemination, Contraceptive
  Devices, Genetic Testing, Infertility Treatment, Tubal Ligation, Vasectomy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diaphragms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Oral
  Contraceptives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Invitro
  Fertilization

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Reversal of
  Sterilization 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Fetal Monitoring

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  (diagnostic)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Genetic Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Health Education

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Health
  Evaluation (Physical)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hearing Aids

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hearing
  Screening

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hemodialysis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 


 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Home Health Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Includes IV)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospice Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospital Based Physicians (Inpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pulmonary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgeon

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospitalization,
  Inpatient Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Supplies and
  Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Immunization and
  Inoculations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  As Medically
  indicated

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  For
  work/travel

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Infertility
  (diagnosis and treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Injections and
  Injected Substances

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (outpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Insulin &
  Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratory
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Lithotripsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mammography

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Marriage
  Counseling

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Medication

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Intravenous (as outpatient or
  home health)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  O.P. covered injectables

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  O.P. non-injectables

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Nuclear Medicine
  Diagnostics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Nuclear Medicine
  Treatment/Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component (inpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component (outpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Nutritional/Dietetic
  Counseling

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  O.B.
  Complications (In Area)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PMG Referred

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Emergent
  Diagnostics (OB Unit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  ER Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Office Visit
  Supplies, Splints, Bandages, custom fitted appliances, etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Organ
  Transplants (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  O.P. Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Interpretative
  MD’s)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component – other

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (i.e., Surgeon,
  Assistant Surgeon, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Outpatient
  Surgery/Facility Based Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Emergency
  Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pulmonary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgeon

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Outpatient Diagnostic Services – Facility and Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (including but not limited to those listed below)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Cat Scan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  2 D Echo

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  EKG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  ENG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Treadmills 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Pediatric
  Services (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physical Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physician Visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  To Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  To S.N.F.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  To Patients
  Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physician Office
  Visits/Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Podiatry
  Services (requires P.M.G. referral)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Pregnancy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Prosthetic
  Devices

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgically
  Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiation
  Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component (inpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component (outpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiology
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  O.P. Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Reconstructive
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Prosthetics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Refractions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Rehabilitation (Short Term, i.e.: P.T., O.T., Speech, Cardiac Therapy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Skilled Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Social Services – Medical

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Specialist Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Surgical Supplies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  IPA

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TMJ

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Dental
  Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diagnosis and
  Medically Necessary Correction

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Transfusions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  From Blood
  Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Autologous
  Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Tissue
  Plasminogen Activator (TPA)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision Screening

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Implanted
  lenses (cataract surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Lenses and
  Frames incident to cataract surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Non-cataract
  related lenses and frames

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Medically
  necessary care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Refractions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 

















 


DIVISION
OF FINANCIAL RESPONSIBILITY


CALIFORNIA


Secure Horizons Risk
Services Agreement


(IPA Capitated, Hospital
Capitated)


 


	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  AIDS

  	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Allergy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Serum (is not covered by all
  plans; those with coverage are noted in back of in back of eligibility list)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Ambulance, Air or Ground

  	
  •  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Amniocentesis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Anesthetics, Administration of (Anesthesiology)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Apnea Monitor (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Artificial Insemination

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Artificial Limbs (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Biofeedback

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Blood  & Blood Products (Including
  Professional Component)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  From Blood
  Bank 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Autologous
  Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency Rehabilitation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemotherapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chiropractic
  (requires P.M.G. referral) 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Circumcision

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Colostomy
  Supplies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Contact Lenses

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Intraocular
  lens (surgically implanted)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Incident to
  Cataract Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Cosmetic Surgery
  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Dental Services
  (for repair of accident/injury only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Detox

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
									



 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Durable Medical Equipment (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Hearing Aids

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Custom made

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Custom fitted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Emergency Room
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Emergency Room
  Physicians - In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Initial
  Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Consults

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Employment
  Physical

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Endoscopic
  Studies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  With Biopsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Without
  Biopsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Experimental
  Procedures

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family Planning
  (e.g.: Abortions, Amniocentesis, Artificial Insemination, Contraceptive
  Devices, Genetic Testing, Infertility Treatment, Tubal Ligation, Vasectomy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diaphragms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Oral
  Contraceptives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Invitro
  Fertilization 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Reversal of
  Sterilization

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Fetal Monitoring

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  (diagnostic)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Genetic Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Health Education

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Health
  Evaluation (Physical)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hearing Aids

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hearing
  Screening

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hemodialysis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












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


 

















 


DIVISION
OF FINANCIAL RESPONSIBILITY


CALIFORNIA


Martin Luther Risk
Services Agreement


(IPA Capitated,
Hospital Capitated)


 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Home Health Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (includes IV)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospice Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospital Based Physicians (Inpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pulmonary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgeon

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospitalization,
  Inpatient Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Supplies and
  Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Immunization and
  Inoculations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  As Medically
  indicated

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  For
  work/travel

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Infertility
  (diagnosis and treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Injections and
  Injected Substances (outpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Insulin &
  Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratory
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Lithotripsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mammography

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Marriage
  Counselling

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












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


 

















 


DIVISION
OF FINANCIAL RESPONSIBILITY


CALIFORNIA


Secure Horizons Risk
Services Agreement


(IPA Capitated, Hospital
Capitated)


 


	
  List of Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Medication

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Intravenous (as
  outpatient or home health)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  O. P. covered injectables

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  O. P. non-injectables

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Nuclear Medicine
  Diagnostics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Nuclear Medicine
  Treatment / Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component  (inpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component  (outpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Nutritional/Dietetic
  Counseling

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  O. B.
  Complications  (In Area)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  Diagnostic Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PMG Referred

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Emergent
  Diagnostics (OB Unit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  ER Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Office Visit
  Supplies, Splints, Bandages, custom fitted appliances, etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Organ
  Transplants  (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  O. P. Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Interpretative
  MD’s)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component - other

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (i.e., Surgeon,
  Assistant Surgeon, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Outpatient
  Surgery/Facility Based Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Emergency
  Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Pulmonary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgeon

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Outpatient Diagnostic Services - Facility and Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (including but not limited to those listed below)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Cat Scan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  2 D Echo

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  EKG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  ENG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Treadmills

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Pediatric
  Services  (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physical Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physician visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  To Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  To S.N.F.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  To Patients
  Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physician Office
  Visits/ Consultations 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Podiatry
  Services (requires P.M.G. referral)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Pregnancy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Prosthetic
  Devices

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgically
  Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiation
  Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component  (inpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component  (outpatient)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiology
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  O.P. Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Reconstructive
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Prosthetics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Refractions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 

















 


	
   

  	
   

  	
  Responsible
  Party

  
	
  List of
  Benefits

  	
   

  	
  IPA

  	
   

  	
  Hospital

  	
   

  	
  PacifiCare

  100%

  
	
  Rehabilitation (Short Term, i.e.: P.T., O.T., Speech, Cardiac Therapy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Skilled Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Social Services - Medical

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Specialist
  Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Surgical Supplies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  IPA

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TMJ

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Dental
  Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Diagnosis and
  Medically Necessary Correction

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Transfusions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  From Blood
  Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Autologous
  Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Tissue
  Plasminogen Activator (TPA)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision Screening

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Implanted
  lenses (cataract surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Lenses and
  Frames incident to cataract surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Non-cataract
  related lenses and frames

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Medically
  necessary care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Refractions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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