Exhibit 10.140


 


 


AMENDMENT


to the


PARTICIPATING PHYSICIAN GROUP AGREEMENT


between


HEALTH NET, Inc. Affiliates


and


SIERRA MEDICAL GROUP


 


The Participating Physician Group Agreement
(“Agreement”) dated January 1, 1998 between Sierra Medical Group a Participating
Physician Group (“PPG”) and Health Net, Inc. Affiliates (“HNI”) as subsequently
amended on November 1, 2000 and the amendment executed on February 28, 2001, is
hereby amended effective January 1, 2003.


 


HNI
and PPG hereby agree to amend the Agreement as follows:


 


1.                                       Addendum
A, Benefit Programs and Affiliates, is hereby deleted in its entirety and
replaced with a new Addendum A. Benefit Programs and Affiliates attached hereto
and incorporated herein.


 


2.                                       Addendum C, Medicare Health Maintenance
Organization (HMO) Benefit Programs is hereby deleted in its entirety and
replaced with a new Addendum C. 
Medicare Health Maintenance Organization (HMO) Benefit Programs attached
hereto and incorporated herein.


 


Except
as so amended, all other provisions of the Agreement shall remain unchanged and
in effect.


 


IN WITNESS WHEREOF, the parties hereto have executed this
Amendment by their officers duly authorized, to be effective on the date and
year first written above.


 


 


	
  Sierra
  Medical Group

  	
   

  	
  Health
  Net, Inc. Affiliates

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  /s/ Peter G. Goll

  	
   

  	
   

  	
  /s/ Jenni Vargas

  	
   

  
	
  Signature

  	
   

  	
  Signature

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Peter G.
  Goll

  	
   

  	
  Jenni Vargas

  
	
  Print Name

  	
   

  	
  Network
  Management and Development

  
	
  Officer

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Senior Vice
  President

  	
   

  	
   

  
	
  Title

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  1-17-03

  	
   

  	
   

  	
  1-27-03

  	
   

  
	
  Date

  	
   

  	
  Date

  
									



 












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


 


1

















 


ADDENDUM A


 


BENEFIT PROGRAMS AND AFFILIATES


 


I.                                         BENEFIT
PROGRAMS


 


Benefit
Program participation included under this Agreement is as follows:


 


	
  BENEFIT PROGRAM

  	
   

  	
  ADDENDUM

  	
   

  	
  PPG

  PARTICIPATION

  Yes/No

  
	
  Standard HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Flex Funded HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Small Group HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Individual HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  AIM

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Medicare COB

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Commercial POS

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Medicare HMO

  	
   

  	
  C

  	
   

  	
  YES

  
	
  Medicare POS

  	
   

  	
  C

  	
   

  	
  NO

  
	
  PPO EPO POS (out-of-network)

  	
   

  	
  D

  	
   

  	
  YES

  
	
  Medi-Cal

  	
   

  	
  F

  	
   

  	
  NO

  
	
  TRICARE

  	
   

  	
  G

  	
   

  	
  YES

  
	
  Occupational Medicine

  	
   

  	
  H

  	
   

  	
  YES

  
	
  Healthy Families

  	
   

  	
  I

  	
   

  	
  YES

  
	
  Financial Solvency Requirements

  	
   

  	
  J

  	
   

  	
  NO

  



 


II.                                     AFFILIATES


 


Upon execution of this Agreement, the Affiliates primarily using this
Agreement include, but are not limited to, the following Health Net of
California, Inc; Health Net Life Insurance Company; Health Net Federal Services
Inc; Employer and Occupational Services Group (EOS); Foundation Integrated Risk
Management Solution, Inc., and Foundation Health Systems Life and Health
Insurance Company.  The Affiliates are
defined in Section 1.1 of this Agreement.


 


Notwithstanding the foregoing, PPG agrees that any other Affiliate of
HNI not listed above may access the rates set forth in this Agreement and
Addenda.  This would include Members of
non-California based Affiliates who may receive Contracted Services from PPG.


 


2

















 


ADDENDUM C


 


MEDICARE HEALTH MAINTENANCE ORGANIZATION
(HMO) BENEFIT PROGRAMS


 


PPG understands and agrees that the obligations of HNI set forth in
this Addendum are only the obligations of Health Net of California.  A California Health Plan, (hereafter “HMO”)
and not the obligations of HNI or any other Affiliate of HNI PPG shall be
compensated according to this Addendum C and this Addendum shall be applicable
to only those Medicare HMO Members.


 


A.                                    DEFINITIONS.  For purposes of this Addendum C, the definitions included herein
shall have the meaning required by law to applicable Medicare Benefit Programs.


 


1.                                      Downstream Providers.  A Participating Provider who or which is
contracted with Provider to render services to Members.


 


2.                                      Centers for Medicare & Medicaid Services (CMS).  The
Centers for Medicare and Medicaid Services which is the agency of the federal
government responsible for administration of the Medicare Benefit program.


 


3.                                      In-Network Services.  Covered Services provided or arranged for
through a Member’s selected or assigned PCP or PPG.


 


4.                                      Medicare – Choice (M–C) Organization or M+CO.  A health plan Provider or Downstream
Provider sponsored organization who has entered into an agreement with CMS to
provide Medicare beneficiaries with health care options.


 


5.                                      Medicare Enrollment Area.  The area approved by CMS and the State
regulatory agency as the area in which HMO may market and enroll Medicare HMO
Members.  At any given time during the
term of the Agreement, the Medicare Enrollment Area consists of the list of zip
codes currently approved by CMS and/or the State regulatory agency as the
Medicare Enrollment Area.  (This is not
the area for which PPG shall be responsible for “in-area” services.


 


6.                                      Medicare
HMO Member.  An
individual who has enrolled in or elected coverage in Health Net Seniority
Plus, an M–C Organization.


 


7.                                      Monthly
Revenue.  The amount
equal to the applicable CMS payment.


 


8.                                      Medicare Regulations.  PPG shall assume the financial
responsibility for any failure to comply with Medicare Regulations, including,
but not limited to, failure to provide records when requested and failure to
provide or document Notice(s) of Non-Coverage to Members.


 


B.                                    MEDICARE
HMO BENEFIT PROGRAMS.


 


1.                                      HMO Benefit Program.  The Medicare HMO Benefit Program shall apply
to Medicare HMO Members; any per Member per month (“PMPM”) or any percent of
Monthly Revenue calculation under Addendum C shall be based on Medicare HMO
Members.


 


2.                                      Capitation: PPG Capitated Services.


 


2.1                               Compensation for PPG Capitated Services.  As compensation for rendering PPG Capitated
Services as defined herein.  HMO shall
pay PPG Capitation at *** of Monthly Revenue as set forth below for each
Medicare HMO Member eligible to receive such services from PPG during any
particular month.  Capitation shall be
computed on the basis of the most current information available and shall be
paid by HMO by wire transfer on or before the fifteenth (15th) day
of each month or the first business day following the fifteenth if the
fifteenth is a holiday or on a weekend or within two (2) days of CMS’s payment
to HMO, whichever is later.  Each
Capitation payment shall be accompanied by a remittance summary.  The remittance summary identifies the total
Capitation payable and those Medicare HMO Members for whom Capitation is being
paid.  In the event of a Capitation
error, resulting in an overpayment or underpayment to PPG.  HMO shall adjust subsequent Capitation to
offset such error.


 


3

















 


2.2                               Professional
Stop Loss Program.


 


PPG elects not to participate in the Professional Stop Loss
Program.  PPG shall provide HMO with
proof of Professional Stop Loss coverage.


 


2.3                               Compensation
to Other Providers of PPG Capitated Services.  PPG shall compensate all providers of PPG Capitated Services to
Medicare HMO Members assigned to PPG. 
In the event that PPG does not process and pay eligible claims submitted
to PPG for Capitated Services within applicable time limits.  HMO may pay such claims at the lesser of
HMO’s contract rate with such provider, if any, the PPG’s subcontract terms, or
the provider’s billed charges.  HMO
shall deduct any such claim amounts paid from PPG’s Capitation, as set forth in
the Operations Manual.


 


3.                                      Shared
Risk Program.


 


3.1                               Shared
Risk Budget.  As a contingency
for any PPG liability under the Shared Risk Program.  HMO shall deduct four percent (4%) of PPG’s Capitation and place
such amount in the Withhold Fund as described in the Agreement.  Each month, HMO shall fund the Shared Risk
Budget for each eligible Medicare HMO Member at forty-seven percent (47%) of
Monthly Revenue.


 


3.2                               Shared
Risk Budget Surplus.  In the
event of a Shared Risk Budget surplus, PPG’s share of the surplus shall be
limited to the lesser of (a) *** of the Shared Risk Budget surplus, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.


 


3.3                               Shared
Risk Budget Deficit.  In the
event of a Shared Risk Budget deficit, PPG’s share of the deficit shall be
limited to the lesser of (a) *** of the Shared Risk Budget deficit, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.  Subject to Section 4.3. of the Agreement,
any amounts payable by PPG shall be offset against the Withhold Fund and any
other amount payable by HMO.


 


In the event a
deficit remains in the Shared Risk Program after such offset, such deficit
shall be carried forward to be applied against future years Shared Risk Program
surpluses and withhold funds.


 


3.4                               Shared
Risk Reinsurance.  PPG shall
participate in the Shared Risk Reinsurance program.  The cost to the PPG for the Shared Risk Reinsurance program shall
be calculated as follows.


 


(a)                                  Out-of-Area
Emergency and Urgently Needed services: *** of the applicable Medicare HMO
Member’s CMS payment and county premium, if any.


 


Out-of-Area Emergency and Urgently Needed services are reimbursed at
*** of cost, and the remaining *** of the cost shall be charged against the
Shared Risk Budget.


 


(b)                                 In-Area
Shared Risk services *** of the applicable Medicare HMO Member’s CMS payment
and county premium, if any.


 


The cost of In-Area Shared Risk services utilized by a Medicare HMO
Member in a Reconciliation Period shall be charged against the Shared Risk
Budget as follows: *** of any amount over ***.


 


4.                                      Pharmacy
Budget.  Each month, HMO shall
fund the Pharmacy Budget as set forth in this Addendum C for applicable
Medicare HMO Members.


 


C.                                    ADMINISTRATION
OF SHARED RISK BUDGET FOR MEDICARE HMO.


 


1.                                      Shared
Risk Administration.  Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claims to the corresponding Shared
Risk Budget.


 


HMO shall perform both an interim and final settlement.  In the event any amounts remain in the
Withhold Fund following the reconciliation of any shared risk program, those
excess funds shall be paid to PPG by April 30 of the


 


4

















 


following year.  In the event that such claims are less than
the Shared Risk Budget for the Interim Period. 
PPG’s share of the settlement shall be seventy-five percent (75%),
subject to Section 4.3 of the Agreement. 
Shared Risk Claims with dates of service within the Reconciliation
Period and paid by March 31 of the following year shall be used in the
calculation.  Shared Risk Services
incurred within the Reconciliation Period but paid after March 31 of the
following year will be included in the next Reconciliation Period calculation.


 


2.                                      Withhold
Fund and Determination of Maximum Downside Shared Risk Deficits.  Notwithstanding any provision in the
Agreement or in any Addendum hereto to the contrary, PPG’s total downside
liability for all Shared Risk Budget deficits shall not exceed twenty percent
(20%) of PPG’s gross annual Capitation. 
Any and all Withhold Fund amounts, as set forth herein shall be applied
to offset such total downside liability.


 


3.                                      Pharmacy
Reconciliation For Medicare HMO Members  [This section does not apply to all group members]  For each Reconciliation Period, HMO shall
calculate pharmacy claims subject to this Program as as outlined in the Operations
Manual.  HMO shall compare such claims
to the corresponding Pharmacy Budget. 
In the event pharmacy claims are less than the Pharmacy Budget, PPG’s
share of the Pharmacy Budget surplus shall be fifty percent (50%).  In the event pharmacy claims exceed the
Pharmacy Budget, PPG’s share of the Pharmacy Budget deficit shall be fifty
percent (50%).  HMO shall perform an
interim and final settlement for the Pharmacy Risk Sharing Program.  The timing of these settlements shall
correspond to the interim and final settlements of other shared risk
programs.  Subject to Section 4.3 of the
Agreement any Pharmacy Budget deficit shall be offset against any amounts
payable by HMO or any amounts remaining in the Withhold Fund, or shall be
offset against Capitation.  In the event
the Withhold Fund eliminates the Pharmacy Budget deficit, any amounts remaining
in the Withhold Fund shall be paid to PPG within one hundred twenty (120)
calendar days after the end of the Reconciliation Period.


 


D.                                    Immunizations.


 


1.                                      Immunizations:  PPG assumes financial responsibility for
immunization under the capitation rate set forth in this Addendum.  New immunizations approved by American
Academy of Pediatrics and the Advisory Committee on Immunization Practices
(ACIP) of the US Public Health Service, after the effective date of the
Agreement shall be reimbursed by HMO at rates that are negotiated in good faith
based on experiential data which shall be manually agreed upon by HMO and
PPG.  In the event HMO and PPG cannot
agree upon such rates.  PPG shall be
reimbursed in accordance with Addendum E.


 


E.                                      OTHER
SERVICES.


 


1.                                      Contracted
Services.  PPG and Member
Physicians shall render Contracted Services which are not PPG Capitated
Services to Members covered under this Addendum C and shall be compensated on a
fee-for-service basis at the rates set forth in Addendum E.  PPG shall claims in accordance with the
terms of the Agreement.


 


F.                                      ACCESS:  RECORDS AND FACILITIES


 


PPG agrees:


 


1.                                       To
pay for emergency and urgently needed services consistent with federal
regulations, if such services are PPG’s liability.


2.                                       To
pay for renal dialysis services for Members temporarily outside the service
area.  If such services are PPG’s
liability.


3.                                       To
direct access to mammography screening and influenza vaccinations.


4.                                       To
direct access to in-network women’s health specialist for women for routine and
preventative services.


5.                                       To
have approved procedures to certify, assess and establish a treatment plan for
Members with complex or serious medical conditions.


 


G.                                    MEMBER
PROTECTIONS/ACCESS:  BENEFITS &
COVERAGE


 


PPG agrees:


 


1.                                      To
not collect any co-payment or other cost sharing for influenza vaccine and
pneumococcal vaccines


 


5

















 


2.                                      To
provide access to benefits in a manner described by CMS.


3.                                      To
protect Members who are hospitalized from loss of benefits through the date of
discharge or through the period of time CMS premiums are paid.


4.                                      To
work with HMO in conducting a health assessment of all new Members within ninety
(90) days of the effective date of enrollment.


 


H.                                    COMPLIANCE


 


PPG agrees:


 


1.                                      The
PPG must notify any Participation Provider being terminated, in writing of the
reason(s) for denial, suspension or termination determinations.


2.                                      To
comply with all applicable HMO procedures and the Operations Manual including
but not limited to the accountability provisions.


3.                                      To
comply with and require that all Downstream Providers comply with applicable
state and Federal laws and regulations including Medicare laws and regulations
and CMS instructions.


4.                                      To
not employ or contract with individuals excluded from participation in Medicare
under Section 1128 or 1128A of the Social Security Act.


5.                                      To
adhere to Medicare’s appeals, expedited appeals and expedited review procedures
for HMO Members, including gathering and forwarding information on appeals to
HMO, as necessary.


 


I.                                         ADOPTION
OF MEDICARE RISK PROGRAM CONTRACT REQUIREMENTS


 


PPG agrees:


 


1.                                      That
all contracts with Participating Providers must be signed and dated.


 


J.                                      DELEGATION


 


PPG agrees:


 


1.                                      To
maintain delegated functions consistent with HMO’s requirements and to be
compliant with M-C’s regulations and HMO’s policy and procedures as set forth
in the HMO Seniority Plus Participating Provider Group Operations Manual.


 


2.                                      To
comply with any applicable delegation requirements between HWO and PPG.


 


K.                                    PAYMENT
AND FEDERAL FUNDS


 


PPG agrees:


 


1.                                      To
pay claims promptly according to CMS standards and comply with all payment
provisions of state and federal law. 
CMS requires non-contracted provider claims to be paid within thirty
(30) days of receipt and contracted provider claims to be paid within sixty
(60) days of receipt


 


2.                                      That
Member’s health services are being paid for with Federal funds, and as such,
payments for such services are subject to laws applicable to individuals or
entities receiving Federal funds.


 


L.                                     REPORTING
AND DISCLOSURE


 


PPG agrees:


 


1.                                      To
submit to HMO all data, including medical records, necessary to characterize
the content and purpose of each encounter with Member.


 


2.                                      To
submit and certify the completeness and truthfulness of all encounter data.


 


6

















 


M.                                  PRIVATE
FEE FOR SERVICE


 


PPG agrees:


 


1.                                      That
contracts with private Fee-for-Service providers must specify uniform
Fee-for-Service payment rates.


 


2.                                      That
PPG cannot charge more than cost sharing and balanced billing amounts permitted
under the applicable HMO plan.  HMO must
specify cost sharing amounts, and balance billing may not exceed fifteen
percent (15%) of uniform payment rate.


 


7

















 


ADDENDUM C.1


 


PHARMACY SHARED RISK BUDGETS


 


For purposes of calculating PPG’s Pharmacy Budget, the specific amounts
set forth below as a percent of the applicable CMS payment and the county
premium, if any, are applicable.  In
January, 2003 and thereafter on an annual basis, these amounts shall be
revised, forwarded to PPG, and incorporated into the Agreement by reference


 


	
  Effective:

  County

  	
   

  	
  1/1/2002
  to 2/28/2002

  Percent

  	
   

  	
  3/1/2002
  to 12/31/2002

  Percent

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Alameda

  	
   

  	
  0.00

  	
  %

  	
  1.44

  	
  %

  
	
  Contra Costa

  	
   

  	
  0.00

  	
  %

  	
  1.73

  	
  %

  
	
  Kern

  	
   

  	
  2.93

  	
  %

  	
  2.93

  	
  %

  
	
  Los Angeles

  	
   

  	
  5.74

  	
  %

  	
  5.74

  	
  %

  
	
  Orange

  	
   

  	
  8.82

  	
  %

  	
  8.82

  	
  %

  
	
  Placer

  	
   

  	
  2.33

  	
  %

  	
  2.33

  	
  %

  
	
  Riverside

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Sacramento

  	
   

  	
  2.35

  	
  %

  	
  2.35

  	
  %

  
	
  San Bemardino

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  San Diego

  	
   

  	
  3.03

  	
  %

  	
  3.03

  	
  %

  
	
  San Francisco

  	
   

  	
  1.70

  	
  %

  	
  1.70

  	
  %

  
	
  San Mateo

  	
   

  	
  1.89

  	
  %

  	
  1.89

  	
  %

  
	
  Santa Barbara

  	
   

  	
  2.35

  	
  %

  	
  2.35

  	
  %

  
	
  Santa Clara

  	
   

  	
  1.93

  	
  %

  	
  1.93

  	
  %

  
	
  Yolo

  	
   

  	
  2.13

  	
  %

  	
  2.13

  	
  %

  



 


8

















 


ADDENDUM C.2


DIVISION OF FINANCIAL RESPONSIBILITY


MATRIX OF HMO AND PPG CAPITATED SERVICES


MEDICARE BENEFIT PROGRAM


 


The following matrix outlines the division of financial responsibility
between HMO, PPG and Hospital.  The
matrix is intended only as a summary guide. 
The applicable Subscriber’s Certificate should be consulted for an
accurate and complete description of Covered Services and the PPG Operations
Manual for clarification.


 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Facility
  Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AIDS -
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMBULANCE

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In Area (30 Mile Radius)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out-of-Area

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anologous/Homologous

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Blood Bank

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Storage and Collection of Blood

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Inpatient Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Inpatient Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Outpatient Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Outpatient Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMOTHERAPY

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Drugs, including Epogen, Neupogen and adjunctive therapies

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHIROPRACTIC (Medicare
  Approved)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CONSULTATIONS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COSMETIC SURGERY

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  (Medically Necessary)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CRITICAL CARE VISITS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


R: Reinsurance
purchased by PPG from HMO.  Claims shall
be submitted to and processed by Health Net’s Claims Dept.


 


9

















 


	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  DENTAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (When a covered benefit)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DIAGNOSTIC TESTING
  – Outpatient Facility & Professional

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DURABLE MEDICAL EQUIPMENT

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Surgically Implanted

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ADMISSIONS
  – In-Area

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ADMISSIONS
  - Out-of-Area

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ROOM VISITS
  - In-Area

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ROOM VISITS
  – Out-of-Area

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EXTENDED CARE/SKILLED NURSING FACILITY

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  GROWTH HORMONES

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING AIDS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Epogen, Neupogen

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOME HEALTH

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOME VISITS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPICE

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITAL BASED PHYSICIANS
  – Inpatient, Ambulatory Surgery or Emergency Room Admissions

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Technical Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT APNEA MONITOR

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INJECTABLES SELF ADMINISTERED

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


R: Reinsurance
purchased by PPG from HMO.  Claims shall
be submitted to and processed by Health Net’s Claims Dept.


 


10

















 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IVF & GIFT

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MATERNITY –
  Deliveries and Non-Deliveries

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MEDICAL ADMISSIONS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH -
  Inpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH -
  Outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OFFICE VISITS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PATIENT EDUCATION

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PATHOLOGY –
  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Technical Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PATHOLOGY – Office

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PATHOLOGY –
  Outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Technical Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PERIODIC EXAMS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PRE ADMISSION –
  Outpatient Laboratory, X-ray

  (within 72 hrs or related admission)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PROSTHETIC/ORTHOTIC DEVICES
  

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Surgically Implanted

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY –
  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Technical Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY – Office

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY –
  Outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Technical Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


R: Reinsurance
purchased by PPG from HMO.  Claims shall
be submitted to and processed by Health Net’s Claims Dept.


 


11

















 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  SPEECH AND HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES- Medical,
  Surgical, Office

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Related to a Hospital Stay:

  Surgical Supplies, Equipment, etc...

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Related to an Outpatient Office Visit: Splints, Casts, Bandages, etc...

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SUPPLIES, DIABETIC 

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Chem, Strips, Lancer, Needles, Syringes
  Glucometer

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGERY -
  Inpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGERY - Office

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGERY –
  Outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  THERAPEUTIC INJECTIONS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  THERAPY: Physical, Occupational, Speech
  

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Inpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Outpatient Office

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSPLANTS
  (Non-experimental) 

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •

  	
  Covered Immunosupressives

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •

  	
  Facility Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •

  	
  Organ Procurement

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •

  	
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSPLANT EVALUATIONS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •

  	
  Facility

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •

  	
  Professional

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE VISITS
  – In-Area

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE VISITS
  - Out-of-Area

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION CARE

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Exams and Medically Necessary Care

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Implanted Lenses (Cataract Surgery)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Lenses and Frames (Non-Cataract)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


R: Reinsurance
purchased by PPG from HMO.  Claims shall
be submitted to and processed by Health Net’s Claims Dept.


 


12