Document:

Provider Group Agreement

 Exhibit 10.20 
 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

WhiteGlove House Call Health, Inc 
 Effective Date: 07/15/2009 
 July 1,2009 

Robert Fabbio 
 WhiteGlove House Call Health,
Inc. 
 5300 Bee Cave Road, Building One, Suite 100 
 Austin, TX 78746 
 Dear M. Fabbio: 
 Effective July 15, 2009, Aetna Health Inc. and WhiteGlove House Call Health, Inc. entered into an Agreement to provide health care services to Members. After execution of the Agreement, an issue was
identified regarding missing language in the WhiteGlove Service and Compensation Schedule, which requires formal clarification. 
  

			
	 Service or Language as Indicated in the Executed
Agreement
	  	 Clarification/Modification

	 Missing definition for the Aetna Market Fee
 Schedule
	  	“Aetna Market Fee Schedule” (AMFS) is the fee schedule that is geographically based and dependent upon contracted location where service is performed. The fee
schedule is updated annually.

 This letter serves as an Amendment to the executed Agreement, effective July 15, 2009, clarifying
that the language above will be added to the WhiteGlove Service and Compensation Schedule to reflect the intent of both Parties during the negotiation. Attached is an updated WhiteGlove Service and Compensation Schedule. 

All other terms and provisions of the Agreement not amended hereby shall remain in full force and effect. In the event of any inconsistency between the
terms of this Amendment and the Agreement, the terms of this Amendment shall govern and control. 
  

									
	PROVIDER	 		 	COMPANY
					
	By:	 	 /s/Robert Fabbio
	 		 	By:	  	 /s/ Dave Roberts

					
		 	(Signature)	 		 		  	(Signature)
					
	Printed Name:	 	Robert Fabbio	 		 	Printed Name:	  	Dave Roberts
					
	Title:	 	CEO	 		 	Title:	  	Regional Network Head
					
	Date: 7/7/09	 		 		 	Date:	  	7-15-09
					
	Tax I.D. Number:	 	20-8913858	 		 		  	

 WhiteGlove House Call Health, Inc. 

 

 WHITEGLOVE 

SERVICES AND COMPENSATION SCHEDULE 
 COMPENSATION: 
 Payment Details: 

 

					
	 Service
	  	 Billing Codes
	  	Rates
			
	Initial Patient Visit (to be billed only once every six months for a Member)	  	 CPT4 Codes:

99214
	  	[****]
			
	Subsequent Patient Visit	  	 CPT4 Codes:

99212
	  	[****]
			
	Strep A Assay W/optic	  	 CPT4 Codes:

87880
	  	[****]
			
	Immunology	  	 CPT4 Codes:

86308
	  	[****]
			
	Urinalysis	  	 CTP4 Codes:

81025
	  	[****]
			
	Remove Impacted Ear Wax	  	 CPT4 Codes:

69210
	  	[****]
			
	Routine Venipuncture Of Finger/he	  	 CPT4 Codes:

36415
	  	[****]
			
	Non-automated, Without Micro	  	 CPT4 Codes:

81002
	  	[****]
			
	Influenza Assay W/optic	  	 CPT4 Codes:

87804
	  	[****]
			
	Assay, Glucose, Blood Quant	  	 CPT4 Codes:

82947
	  	[****]
			
	Antibody	  	 CPT4 Codes:

86677
	  	[****]
			
	Drainage Of Skin Abscess	  	 CPT4 Codes:

10060
	  	[****]
			
	11750 Blood From Under Nail	  	 CPT4 Codes:

11740
	  	[****]
			
	Electrocardiogram, Complete	  	 CPT4 Codes:

93000
	  	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
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 WhiteGlove House Call Health, Inc. 

 

					
			
	Td Adsorb-individual 7 Yrs/o	  	 CPT4 Codes:

90718
	  	[****]
			
	Pneumococcal Vaccine	  	 CPT4 Codes:

90732
	  	[****]
			
	Flu Virus Vacc-split 3 Yr & Above	  	 CPT4 Codes:

90658
	  	[****]
			
	Immunization Admin, Single	  	 CPT4 Codes:

90471
	  	[****]
			
	Tetanus, Diphtheria Toxoi	  	 CPT4 Codes:

90715
	  	[****]
			
	Immunization Admin - under 8 Y	  	 CPT4 Codes:

90465
	  	[****]
			
	Influenza Virus Vaccine	  	 CPT4 Codes:

90655
	  	[****]
			
	Influenza Virus Vaccine	  	 CPT4 Codes:

90656
	  	[****]
			
	Dtap Vaccine, Im	  	 CPT4 Codes:

90700
	  	[****]
			
	Dt Immunization, Im	  	 CPT4 Codes:

90702
	  	[****]
			
	Tetanus Toxoid Absorbed For	  	 CPT4 Codes:

90703
	  	[****]
			
	Tetanus And Diphtheria	  	 CPT4 Codes:

90714
	  	[****]
			
	Flu Vaccine, Nasal	  	 CTP4 Codes:

90660
	  	[****]
			
	Ther/proph/diag Inj,Sc/im	  	 CTP4 Codes:

96372
	  	[****]
			
	Pen G Benzath To 1200000/4mx	  	 HCPC Codes:

J0570
	  	[****]
			
	B-12 Cyanoc Upto 1000mcg/5mx	  	 HCPC Codes:

J3420
	  	[****]
			
	Dexamethasone Sodium Phos1mg	  	 HCPC Codes:

J1100
	  	[****]
			
	Diphenhydr Hel Upto 50mg/6mx	  	 HCPC Codes:

J1200
	  	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
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 WhiteGlove House Call Health, Inc. 

 

					
	Ketorolac Trom Per 15mg/8mx	 	 HCPC Codes:

J1885
	 	[****]
			
	Metoclopra Hcl Upto 10mg/4mx	 	 HCPC Codes:

J2765
	 	[****]
			
	Odansetro Hcl Per 1mg/32 Mx	 	 HCPC Codes:

J2405
	 	[****]
			
	Orphenad Citr Upto 60mg/2 Mx	 	 HCPC Codes:

J2360
	 	[****]
			
	Ceftriaxon Sod Per 250mg/8mx	 	 HCPC Codes:

J0696
	 	[****]
			
	Medrxyprogester Inj 150 Mg	 	 HCPC Codes:

J1055
	 	[****]
			
	 Methylpr Sod Upto

125mg/12mx
	 	 HCPC Codes:

J2930
	 	[****]
			
	Fluorescein Angioscopy	 	 CPT4 Codes:

92230
	 	[****]
			
	 Remove Foreign Body From

Eye
	 	 CPT4 Codes:

65205
	 	[****]
			
	 Remove Foreign Body From

Eye
	 	 CPT4 Codes:

65220
	 	[****]
			
	Control Of Nosebleed	 	 CPT4 Codes:

30901
	 	[****]
			
	Airway Inhalation Treatm2	 	 CPT4 Codes:

94640
	 	[****]
			
	Aerosol Or Vapor Inhalat3	 	 CPT4 Codes:

94664
	 	[****]
			
	Ipratropium Brom Inh Sol/mg	 	 HCPC Codes:

J7644
	 	[****]
			
	Application Long Leg Splint	 	 CPT4 Codes:

29505
	 	[****]
			
	Application Lower Leg Splint	 	 CPT4 Codes:

29515
	 	[****]
			
	Apply Forearm Splint	 	 CPT4 Codes:

29125
	 	[****]
			
	Apply Long Arm Splint	 	 CPT4 Codes:

29105
	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 4 of 8

 WhiteGlove House Call Health, Inc. 

 

					
	Application Of Finger Splint	 	 CPT4 Codes:

29130
	 	[****]
			
	Removal Of Nail Plate	 	 CPT4 Codes:

11730
	 	[****]
			
	Removal Of Nail Bed	 	 CPT4 Codes:

11750
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16020
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16025
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16030
	 	[****]
			
	Wound(s) Care Non-select	 	 CPT4 Codes:

97602
	 	[****]
			
	Remove Foreign Body	 	 CPT4 Codes:

10120
	 	[****]
			
	Destruction Eg, Laser Surger	 	 CPT4 Codes:

17110
	 	[****]
			
	Bx Skin &/ Subq Tissue; 1 Le	 	 CPT4 Codes:

11100
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12001
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12002
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12004
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12011
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12013
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12014
	 	[****]
			
	Intrmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12031
	 	[****]
			
	Intrmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12032
	 	[****]

 [****] Certain information on this page has
been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 5 of 8

 WhiteGlove House Call Health, Inc. 

 

					
	 Intmd Wnd Repair S/tr/ext
	 	 CPT4 Codes:

12034
	 	[****]
			
	 Intmd Wnd Repair N-hf/genit
	 	 CPT4 Codes:

12041
	 	[****]
			
	 Intmd Wnd Repair N-hg/genit
	 	 CPT4 Codes:

12042
	 	[****]
			
	 Intmd Wnd Repair N-hg/genit
	 	 CPT4 Codes:

12044
	 	[****]
			
	 Intmd Wnd Repair Face/mm
	 	 CPT4 Codes:

12051
	 	[****]
			
	 Intmd Wnd Repair Face/mm
	 	 CPT4 Codes:

12052
	 	[****]
			
	 Intmd Wnd Repair Face/mm
	 	 CPT4 Codes:

12053
	 	[****]
			
	 Supplies/special Equipment
	 	 CPT4 Codes:

99070
	 	[****]
			
	 All Services not otherwise

identified
	 		 	[****]

 SERVICES: 

Participating Group Provider will provide services in the Member’s home or work that are within the scope of and appropriate to the Participating
Group Provider’s license and certification to practice. Participating Group Provider will provide, as appropriate, the generic medicines outlined in Attachment A – Generics Provided by WhiteGlove. In addition Participating Group Provider
may draw blood for lab tests; deliver lab tests to Company designated participating laboratories; inform Member’s Primary Care Physician of lab and other results and services provided; and provide instruction to Member and/or caregiver.

 Participating Group Provider may also provide at Participating Group Provider’s discretion and upon approval by Member selected supplies
such as food items, beverages and over-the-counter remedies that are not considered Covered Services. 
 Participating Group Provider will
provide follow-up calls or visits by Participating Group Provider or Participating Group Provider’s representative to ascertain a Member’s medical progress, share lab results or other services commonly provided by medical professionals.

 COMPENSATION TERMS AND CONDITIONS: 
 Definitions 
 “Aetna Market Fee Schedule” (AMFS) is the fee schedule that
is geographically based and dependent upon contracted location where service is performed. The fee schedule is updated annually. 
 [****]
Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

  
 Page 6 of 8

 WhiteGlove House Call Health, Inc. 

 

 General 
 a) Rates are inclusive of any applicable Member Copayment, Coinsurance or Deductible. Procedures and/or services provided by WhiteGlove in accordance with this Agreement but not specifically listed above
will not be reimbursed. No additional charges are allowed regardless of the time spent at the Member’s home, for travel, administrative services, lab draws, generic medications outlined in Attachment A, miscellaneous supplies that are not
considered Covered Services, weekend, evening or holiday differentials. Company will pay the lesser of the contracted rate or eligible billed charges. 
 Billing 
  

	b)	Participating Group Provider must designate the codes set forth in this Compensation Schedule when billing. 

Coding 
  

	c)	Company utilizes nationally recognized coding structures including, but not limited to, Revenue Codes as described by the Uniform Billing Code, AMA Current Procedural
Terminology (CPT4), CMS Common Procedure Coding System (HCPCS), Diagnosis Related Groups (DRG), ICD-9 Diagnosis and Procedure codes, National Drug Codes (NDC) and the American Society of Anesthesiologists (ASA) relative values for the basic coding,
and description for the services provided. As changes are made to nationally recognized codes, Company will update internal systems to accommodate new codes. Such changes will only be made when there is no material change in the procedure itself.
Until updates are complete, the procedure will be paid according to the standards and coding set for the prior period. 

 Company will comply and utilize nationally recognized coding structures as directed under applicable Federal laws and regulations, including, without limitation, the Health Insurance Portability and
Accountability Act (HIPAA). 

  
 Page 7 of 8

 WhiteGlove House Call Health, Inc. 

 

 Attachment A-Generics 

Provided by WhiteGlove 
  

					
	Acyclovir	  	Diltiazem	  	Metoclopramide
	Albuterol nebulizer soln	  	Doxazosin	  	Metoprolol Tartrate
	Albuterol	  	Doxepin HCL	  	Metronidazole
	Alendronate	  	Doxycycline Hyclate	  	Nadolol
	Allopurinol	  	Enalapril	  	Naproxen
	Amiloride-HCTZ	  	Enalapril-HCTZ	  	Neomycin/Polymyxin/Dexamethasone
	Amitriptyline	  	Erythromycin EC	  	Nortriptyline
	Amoxicillin	  	EST Estrogen/Methyl Testost	  	Nystatin
	Amoxil	  	Estradiol	  	Nystatin/Triamcin
	Antipyrine/Benzocaine otic	  	Estropipate	  	Oxybutynin
	Atenolol	  	Famotidine	  	Paroxetine
	Atenolol-Chlorthalidone	  	Fluconazole	  	Penicillin
	Atropine Sulfate	  	Fluocinolone Acet	  	Phenazopyridine
	Bacitracin	  	Fluocinonide cream	  	Pilocarpine
	Baclofen	  	Fluoxetine	  	Pindolol
	Belladonna Alkaloid/PB	  	Fluphenazine	  	Piroxicam
	Benazepril	  	Furosemide	  	Polymyxin Sulfate/TMP
	Benzonatate	  	Gentamicin	  	Pravastatin
	Benzoyl Peroxide	  	Glimepiride	  	Prazosin HCL
	Benztropine	  	Glipizide	  	Prednisone
	Betamethasone Dipropionate	  	Glyburide	  	Prochlorperazine
	Betamethasone Valerate	  	Guanfacine	  	Promethazine DM Syrup
	Bisoprolol-HCTZ	  	Haloperidol	  	Propranolol
	Bumetanide	  	Hydralazine	  	Ranitidine
	Buspirone	  	Hydrochlorothiazide (HCTZ)	  	Salsalate
	Captopril	  	Hydrocortisone	  	Selenium Sulfide
	Carbamazepine	  	Ibuprofen	  	Silver Sulfadiazine
	Carvedilol	  	Indapamide	  	SMZ-TMP
	Cephalexin	  	Indomethacin	  	Sotalol HCL
	Ceron DM syrup	  	Ipratropium Nebulizer Soln	  	Spironolactone
	Chlorhexidine Gluconate	  	Isoniazid	  	Sprintec 28-day tab
	Chlorpropamide	  	Isosorbide Mononitrate	  	Sulfacet Sodium
	Chlorthalidone	  	Lactulose syrup	  	Tamoxifen
	Cimetidine	  	Levobunolol	  	Terazosin
	Ciprofloxacin	  	Levothyroxine	  	Terbinafine
	Citalopram	  	Lidocaine	  	Tetracycline
	Clomiphene	  	Lisinopril	  	Thioridazine
	Clonidine	  	Lisinopril-HCTZ	  	Thiothixene
	Colchicine	  	Lithium Carbonate	  	Timolol Maleate
	C-Phen drops	  	Loratadine	  	Tobramycin
	Cyclobenzaprine	  	Lovastatin	  	Trazodone
	Cytra2	  	Medroxyprogesterone Acetate	  	Triamcinolone
	Dex PC syrup	  	Megestrol	  	Triamterene-HCTZ
	Dexamethasone	  	Meloxicam	  	Trihexyphenidyl
	Diclofenac DR	  	Metformin	  	Tri-Sprintec
	Dicyclomine	  	Methyldopa	  	Verapamil
	Digoxin	  	Methylpred	  	Warfarin

  
 Page 8 of 8

 WhiteGlove House Call Health, Inc. 

 

 PROVIDER GROUP AGREEMENT 

TABLE OF CONTENTS 
  

							
	 1.0        DEFINITIONS
	  	 	3	  
		
	 2.0        GROUP AND PARTICIPATING GROUP PROVIDER SERVICES AND
OBLIGATIONS
	  	 	6	  
			
	 2.1
	 	PROVISION OF SERVICES	  	 	6	  
	 2.2
	 	NON-DISCRIMINATION	  	 	6	  
	 2.3
	 	GROUP AND PARTICIPATING GROUP PROVIDER REPRESENTATIONS	  	 	7	  
	 2.4
	 	PARTICIPATING GROUP PROVIDERS	  	 	8	  
	 2.5
	 	GROUP CAPACITY	  	 	8	  
	 2.6
	 	GROUP PROVIDERS’ INFORMATION	  	 	8	  
	 2.7
	 	ADMINISTRATIVE OBLIGATIONS OF PRIMARY CARE PROVIDERS	  	 	9	  
	 2.8
	 	ADMINISTRATIVE OBLIGATIONS OF PARTICIPATING GROUP PROVIDERS OTHER
THAN PRIMARY CARE PROVIDERS	  	 	9	  
	 2.9
	 	GROUP AND PARTICIPATING GROUP PROVIDERS’
INSURANCE	  	 	9	  
	 2.10
	 	PRODUCT PARTICIPATION	  	 	9	  
	 2.11
	 	CONSENTS TO RELEASE MEDICAL INFORMATION	  	 	10	  
	 2.12
	 	ENCOUNTER DATA	  	 	10	  
		
	 3.0        COMPANY OBLIGATIONS
	  	 	10	  
			
	 3.1
	 	COMPANY’S COVENANTS	  	 	10	  
	 3.2
	 	COMPANY REPRESENTATIONS	  	 	10	  
	 3.3
	 	COMPANY’S INSURANCE	  	 	11	  
		
	 4.0        CLAIMS SUBMISSIONS, COMPENSATION AND MEMBER
BILLING
	  	 	11	  
			
	 4.1
	 	CLAIM SUBMISSION AND PAYMENT	  	 	11	  
	 4.2
	 	COORDINATION OF BENEFITS	  	 	15	  
	 4.3
	 	MEMBER BILLING	  	 	15	  
		
	 5.0        COMPLIANCE WITH POLICIES
	  	 	16	  
			
	 5.1
	 	POLICIES	  	 	16	  
	 5.2
	 	NOTICES AND REPORTING	  	 	16	  
	 5.3
	 	INFORMATION AND RECORDS	  	 	16	  
	 5.4
	 	QUALITY, ACCREDITATION AND REVIEW ACTIVITIES	  	 	17	  
	 5.5
	 	PROPRIETARY INFORMATION	  	 	17	  
		
	 6.0        TERM AND TERMINATION
	  	 	18	  
			
	 6.1
	 	TERM	  	 	18	  
	 6.2
	 	TERMINATION WITHOUT CAUSE	  	 	18	  
	 6.3
	 	TERMINATION FOR BREACH	  	 	18	  
	 6.4
	 	IMMEDIATE TERMINATION OR SUSPENSION	  	 	18	  
	 6.5
	 	OBLIGATIONS FOLLOWING TERMINATION	  	 	19	  
	 6.6
	 	OBLIGATIONS DURING DISPUTE RESOLUTION PROCEEDINGS	  	 	20	  
		
	 7.0        RELATIONSHIP OF THE PARTIES
	  	 	20	  
			
	 7.1
	 	INDEPENDENT CONTRACTOR STATUS	  	 	20	  
	 7.2
	 	USE OF NAME	  	 	20	  
	 7.3
	 	INTERFERENCE WITH CONTRACTUAL RELATIONS	  	 	20	  
		
	 8.0        DISPUTE RESOLUTION
	  	 	21	  
			
	 8.1
	 	MEMBER GRIEVANCE DISPUTE RESOLUTION	  	 	21	  
	 8.2
	 	PHYSICIAN DISPUTE RESOLUTION	  	 	21	  

  
 Page 1 of 45

 WhiteGlove House Call Health, Inc. 

 

							
	 8.3
	 	ARBITRATION	  	 	21	  
	 8.4
	 	ARBITRATION SOLELY BETWEEN PARTIES: NO CONSOLIDATION OR
CLASS ACTION	  	 	21	  
		
	 9.0        MISCELLANEOUS
	  	 	22	  
			
	 9.1
	 	AMENDMENTS	  	 	22	  
	 9.2
	 	WAIVER	  	 	22	  
	 9.3
	 	GOVERNING LAW	  	 	22	  
	 9.4
	 	LIABILITY	  	 	22	  
	 9.5
	 	SEVERABILITY	  	 	22	  
	 9.6
	 	SUCCESSORS; ASSIGNMENT	  	 	22	  
	 9.7
	 	HEADINGS	  	 	22	  
	 9.8
	 	NOTICES	  	 	22	  
	 9.9
	 	REMEDIES	  	 	23	  
	 9.10
	 	FORCE MAJEURE	  	 	23	  
	 9.11
	 	NON-EXCLUSIVITY	  	 	23	  
	 9.12
	 	SURVIVAL	  	 	23	  
	 9.13
	 	ENTIRE AGREEMENT	  	 	24	  

  
 Page 2 of 45

 WhiteGlove House Call Health, Inc. 

 

 PROVIDER GROUP AGREEMENT 

This Provider Group Agreement (“Agreement”) is made and entered into as of July 15, 2009 (“Effective Date”) by
and between Aetna Health Inc., a Texas corporation, on behalf of itself and its Affiliates (hereinafter “Company”) and WhiteGlove House Call Health, Inc. (hereinafter “Group”). 

WHEREAS, Company offers, issues and administers Full Risk Plans and Plans for Plan Sponsors that provide access to health care
services to Members; and 
 WHEREAS, Company contracts with certain health care providers and facilities to provide
access to such health care services to Members; and 
 WHEREAS, Participating Group Providers provide health care
services to patients within the scope of their licensure or accreditation; and 
 WHEREAS, Company and Group mutually
desire to enter into an arrangement whereby Group and Participating Group Providers will become Participating Providers and Participating Group Providers will render health care services to Members; and 

WHEREAS, in return for the provision of health care services and other obligations assumed by Participating Group Providers under
this Agreement, Company will pay Group’s claims for Covered Services under the terms of this Agreement. 
 NOW,
THEREFORE, in consideration of the foregoing and of the mutual covenants, promises and undertakings in this Agreement, the sufficiency of which is hereby acknowledged, and intending to be legally bound, the parties agree as follows: 

 

	1.0	DEFINITIONS 

 When used in this Agreement,
all capitalized terms shall have the following meanings: 
  

	1.1	AAA. Defined in Section 8.3 of this Agreement. 

  

	1.2	Affiliate. Any corporation, partnership or other legal entity (including any Plan) directly or indirectly owned or controlled by or which owns or controls, or
which is under common ownership or control with Company. 

  

	1.3	Agreement. Defined in first paragraph of this Agreement. 

  

	1.4	Clean Claim. A clean claim is a claim that contains the information that is required by applicable Texas law and regulations adopted by the Commissioner of
Insurance, and is submitted consistent with Aetna’s established processing procedures to the extent Aetna establishes the information and processing procedure requirements consistent with applicable Texas law and regulations.

  

	1.5	Coinsurance. The percentage of the lesser of: (a) the rates established under this Agreement; or (b) Participating Group Provider’s usual,
customary and reasonable billed charges, which a Member is required to pay for Covered Services under a Plan. 

  

	1.6	Company. Defined in first paragraph of this Agreement. 

  

	1.7	 Confidential Information. Any information that identifies a Member and is related to the Member’s participation in a Plan, the
Member’s physical or mental health or condition, the provision of health care to the Member or payment for the provision of health care to the Member. Confidential Information includes, without limitation, “individually identifiable health
information,” as defined in 45 C.F.R. §160.103 and “non-public personal information” as defined in laws or regulations promulgated under the Gramm-Leach-

  
 Page 3 of 45

 WhiteGlove House Call Health, Inc. 

 

	 	 
Bliley Act of 1999, and vendor cost information that Provider uses to price percentage of billed charge services subject to “Cost Plus Services” markup. 

 

	1.8	Copayment. A charge required under a Plan that must be paid by a Member at the time of the provision of Covered Services, or at such other time as determined by
Participating Group Provider. 

  

	1.9	Cost Plus Services. Those healthcare services that are paid for under the Plan based on a percentage markup over the Provider’s documented cost.

  

	1.10	Covered Services. Those health care services that are paid for under the applicable Plan and that are not otherwise excluded or limited. The Parties agree that
Company is obligated to pay for only those Covered Services that are determined to be medically necessary, as determined in accordance with the Member’s applicable Plan. 

 

	1.11	Covering Physician. A Participating Provider designated by a Participating Group Provider to provide Covered Services to Members when a Participating Group
Provider is unavailable (e.g. out of the office or on vacation). 

  

	1.12	Deductible. An amount that a Member must pay for Covered Services during a specified coverage period in accordance with the Member’s Plan before benefits
will be paid. 

  

	1.13	Effective Date. Defined in first paragraph of this Agreement. 

  

	1.14	Emergency Services. Those services necessary to treat a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain)
such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or, with respect to a pregnant
woman, her pregnancy or health or the health of her fetus) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part; or such other definition as may be required by applicable
law. 

  

	1.15	Full Risk Plan. A Plan where Company is the underwriter, in full, of the Plan (i.e. fully-insured Plans). 

 

	1.16	Government Programs. Defined in Section 2.3.3 of this Agreement. 

 

	1.17	Group. Defined in first paragraph of this Agreement. 

  

	1.18	Group Provider. A duly licensed and qualified physician or nurse practitioner who is employed by, or who is a partner or shareholder, of Group.

  

	1.19	Information. Defined in Section 5.3.2 of this Agreement. 

  

	1.20	Initial Term. Defined in Section 6.1 of this Agreement. 

  

	1.21	License. Defined in Section 3.2 of this Agreement. 

  

	1.22	Material Change. Any change in Policies that could reasonably be expected, in Company’s determination, to have a material adverse impact on
(i) Group’s reimbursement for Provider Services or (ii) administration of Group’s practice. 

  

	1.23	 Medically Necessary or Medical Necessity. Health care services that a physician, exercising prudent clinical judgment, would provide to a
patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in
terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease, and (c) not primarily for the convenience of the patient, physician or other health care provider, and not more
costly than an alternative service or 

  
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sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease. For these
purposes “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise
consistent with physician specialty society recommendations and the views of Providers practicing in relevant clinical areas and any other relevant factors. 

 

	1.24	Member. An individual covered by or enrolled in a Plan. 

  

	1.25	Participating Provider. Any physician, hospital, hospital-based physician, skilled nursing facility, or other individual or entity involved in the delivery of
health care or ancillary services who or which has entered into and continues to have a current valid contract with Company to provide Covered Services to Members, and, where applicable, has been credentialed by Company or its designee consistent
with Company’s credentialing policies. Certain categories of Participating Providers may be referred to herein more specifically as, e.g., “Participating Physicians” or “Participating Hospitals.” 

 

	1.26	Participating Group Provider. A Group Physician or Nurse Practitioner who has been accepted as a Participating Provider by Company. 

 

	1.27	Party. Company or Group and Participating Group Providers, as applicable. 

 

	1.28	Provider Services. Defined in Section 2.1 of this Agreement. 

  

	1.29	Plan. A Member’s health care benefits as set forth in the Member’s Summary Plan Description, Certificate of Coverage or other applicable coverage
document. 

  

	1.30	Plan Sponsor. An employer, insurer, third party administrator, labor union, organization or other person or entity which has contracted with Company to offer,
issue and/or administer a Plan that is not a Full Risk Plan and has agreed to be responsible for funding benefit payments for Covered Services provided to Members under the terms of a Plan. 

 

	1.31	Policies. The policies and procedures promulgated by Company which relate to this Agreement, including, but not limited to: (a) quality
improvement/management; (b) utilization management, including, but not limited to, precertification of elective admissions and procedures, concurrent review of services and referral processes or protocols; (c) pre-admission testing
guidelines; (d) claims payment review; (e) member grievances; (f) Physician credentialing; (g) electronic submission of claims and other data required by Company; and (h) any applicable Participation Criteria as set forth in
the Participation Criteria Schedules. Policies also include those policies and procedures set forth in the Company’s manuals, Health Care Professional Toolkit or their successors (as modified from time to time); Clinical Policy Bulletins made
available via Company’s internet web site; and other policies and procedures, whether made available via a password-protected web site for Participating Physicians (when available), by letter, newsletter, electronic mail or other media.
“Precertification” when used in this Agreement means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the Company’s clinical criteria for coverage.
Precertification does not mean verification which is defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. 

 

	1.32	Primary Care Physician. A Participating Physician whose area of practice and training is family practice, general medicine, internal medicine or pediatrics, or
who is otherwise designated as a Primary Care Physician by Company, and who has agreed to provide primary care services and to coordinate and manage all Covered Services for Members who have selected or been assigned to such Participating Physician,
if the applicable Plan provides for a Primary Care Physician. 

  

	1.33	 Proprietary Information. Any and all information, whether prepared by a Party, its advisors or otherwise, relating to such Party or the
development, execution or performance of this Agreement whether furnished prior to or after the Effective Date. Proprietary Information includes but is not limited to, with respect to

  
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Company, the development of a pricing structure, (whether written or oral) all financial information, rate schedules and financial terms which relate to Group and which are furnished or disclosed
to Group by Company. Notwithstanding the foregoing, the following shall not constitute Proprietary Information: 

  

	 	(a)	information which was known to a receiving Party (a “Recipient”) prior to receipt from the other Party (a “Disclosing Party”) (as evidenced by the
written records of a Recipient); 

  

	 	(b)	information which was previously available to the public prior to a Recipient’s receipt thereof from a Disclosing Party; 

 

	 	(c)	information which subsequently became available to the public through no fault or omission on the part of a Recipient, including without limitation, the
Recipient’s officers, directors, trustees, employees, agents, contractors and other representatives; 

  

	 	(d)	information which is furnished to a Recipient by a third party which a Recipient confirms, after due inquiry, has no confidentiality obligation, directly or indirectly,
to a Disclosing Party; or 

  

	 	(e)	information which is approved in writing in advance for disclosure or other use by a Disclosing Party. 

 

	1.34	Records. Defined in Section 5.3.2 of this Agreement. 

  

	1.35	Rules. Defined in Section 8.3 of this Agreement. 

  

	1.36	Specialty Program. A Company established program for a targeted group of Members with certain types of illnesses, conditions, cost or risk factors (e.g., organ
transplants, women’s health, other disease management programs, etc). 

  

	1.37	Specialty Program Providers. Those hospitals, Participating Physicians and other providers that have been identified or designated by Company to provide
transplant services and other Covered Services associated with a Specialty Program. Certain categories of Specialty Program Providers may be referred to herein more specifically as, e.g. “Specialty Program Physician”.

  

	2.0	GROUP AND PARTICIPATING GROUP PROVIDER SERVICES AND OBLIGATIONS 

  

	2.1	Provision of Services. 

Group shall provide to Members, through Participating Group Providers, those Covered Services which are within the scope of the respective
Participating Group Provider’s license and certification to practice (“Provider Services”). Unless otherwise permitted by applicable law or regulation, Participating Group Providers may not provide any Covered Services to Members
unless and until Participating Group Providers have been fully credentialed and approved by the applicable peer review committee. 
  

	2.2	Non-Discrimination 

  

	 	2.2.1.	Equitable Treatment of Members. Group and Participating Group Providers agree to provide Provider Services to Members with the same degree of care and skill as
customarily provided to Participating Group Providers’ patients who are not Members, according to generally accepted standards of physician and/or nurse practitioner practice. Group, Participating Group Providers and Company agree that Members
and non-Members should be treated equitably; to that end, Group and Participating Group Providers agree not to discriminate against Members on the basis of race, gender, creed, ancestry, lawful occupation, age, religion, marital status, sexual
orientation, mental or physical disability, color, national origin, place of residence, health status, source of payment for services, cost or extent of Provider Services required, or any other grounds prohibited by law or this Agreement. Company
acknowledges Participating Group Providers’ practice is to require electronic payments from Members. 

  

	 	2.2.2	 Affirmative Action. Company is a Federal contractor and an Equal Opportunity Employer which maintains an Affirmative Action Program. To the
extent applicable to Group and Participating Group Providers. Group and Participating Group Providers, on behalf of themselves and any subcontractors, agree to comply with the following, as amended from time to time: Executive Order

  
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11246, the Vietnam Era Veterans Readjustment Act of 1974, the Drug Free Workplace Act of 1988, Section 503 of the Rehabilitation Act of 1973, Title VI of the Civil Rights Act of 1964, the
Age Discrimination Act of 1975, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) administrative simplification rules at 45 CFR parts 160, 162, and 164, the Americans with Disabilities Act of 1990, Federal laws,
rules and regulations designed to prevent or ameliorate fraud, waste and abuse, including, but not limited to, applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. 3729 etc. seq.), and the anti-kickback statue (Section
1128B(b) of the Social Security Act), and any similar laws, regulations or other legal mandates applicable to recipients of federal funds and/or transactions under or otherwise subject to any government contract of Company.

  

	2.3	Group and Participating Group Provider Representations. 

  

	 	2.3.1	General Representations. Group represents, Warrants and covenants, as applicable, that: (a) it and Participating Group Providers have, and shall maintain
throughout the term of this Agreement all appropriate license(s) and certification(s) mandated by governmental regulatory agencies, which for cash Participating Group Provider shall include, without limitation, DEA certification and an unrestricted
license to practice medicine in the state(s) in which such Participating Group Provider maintains offices and provides Provider Services to Members; (b) each Participating Group Provider is board certified or board eligible in the Specialty for
which they provide Provider Services; (c) it and Participating Group Providers are, and will remain throughout the term of this Agreement, in compliance with all applicable Federal and state laws and regulations related to this Agreement and
the services to be provided under this Agreement, including, without limitation, statutes and regulations related to fraud, abuse, discrimination, disabilities, confidentiality, self-referral, false claims and prohibition of kickbacks; (d) each
Participating Group Provider, if applicable, has and shall maintain throughout the term of this Agreement unrestricted hospital privileges at a Participating Hospital; (e) it is legally authorized to negotiate on behalf of Participating Group
Providers and to bind those Participating Group Providers to abide by the terms of this Agreement, as amended from time to time; (f) this Agreement has been executed by its duly authorized representative; and (g) executing this Agreement
and performing its obligations hereunder shall not cause Group nor Participating Group Providers to violate any term or covenant of any other agreement or arrangement now existing or subsequently executed. 

 

	 	2.3.2	Qualified Personnel. Group also represents that Group and Participating Group Providers have established an ongoing quality assurance/assessment program which
includes, but is not limited to, credentialing of employees and subcontractors. Group shall supply to Company the relevant documentation, including, but not limited to, internal quality assurance/assessment protocols, state licenses and
certifications, Federal agency certifications and/or registrations upon request. Group further represents that all personnel employed by, associated or contracted with Group and Participating Group Providers who treat Members: (a) are and shall
remain throughout the term of this Agreement appropriately licensed and/or certified and supervised (when and as required by state law), and qualified by education, training and experience to perform their professional duties; and (b) shall act
within the scope of their licensure or certification, as the case may be. Company may audit Group and Participating Group Providers compliance with this section upon prior written notice. 

 

	 	2.3.3	 Government Program Representations. Company has or may seek a contract to serve Medicare, Medicaid, CHIP, and/or Tricare beneficiaries
(“Government Programs”). To the extent Company participates in such Government Programs, Group and Participating Group Providers agree, on behalf of themselves and any subcontractors of Group or Participating Group Providers, to be bound
by all rules and regulations of, and all requirements applicable to, Government Programs. Group and Participating Group Providers acknowledges and agrees that all provisions of this Agreement shall apply equally to any employees, independent
contractors and subcontractors of Group and Participating Group Providers who provide or may provide Covered Services to Members of Government Programs, and Group and Participating Group Providers represents and warrants that Group and Participating
Group Providers shall take all steps necessary to cause such employees, independent contractors and subcontractors to comply with the Agreement and all applicable laws, 

  
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rules and regulations and perform all requirements applicable to Government Programs. With respect to Members of Government Programs, Group and Participating Group Providers acknowledge that
compensation under this Agreement for such Members constitutes receipt of Federal funds. Group and Participating Group Providers agree that all services and other activities performed by Group and Participating Group Providers under this Agreement
will be consistent and comply with Company’s obligations under its contract(s) with the Centers for Medicare and Medicaid Services (“CMS”), and any applicable state regulatory agency, to offer Medicare/Medicaid Plans. Group and
Participating Group Providers further agree to allow CMS, any applicable state regulatory agency, and Company to monitor Group and Participating Group Providers’ performance under this Agreement on an ongoing basis in accordance with
Medicare/Medicaid laws, rules and regulations. Group and Participating Group Providers acknowledge and agree that Company may only delegate its activities and responsibilities under its contract(s) with CMS and any applicable regulatory agency, to
offer Medicare/Medicaid Plans in a manner consistent with Medicare/Medicaid laws, rules and regulations, and that if any such activity or responsibility is delegated by Company to Group and Participating Group Providers, the activity or
responsibility may be revoked if CMS or Company determine that Group and Participating Group Providers have not performed satisfactorily. 
 If Company designates Group and Participating Group Providers to participate in a Government Program Pursuant to Section 2.10 below. Group and Participating Group Providers may opt out of
participation of that Government Program. Group and Participating Group Providers shall have thirty (30) days from receipt of Company’s notice of designation, to notify Company in writing if Group and Participating Group Providers elects
not to participate in that Government Program. 
  

	2.4	Participating Group Providers. 

 Notwithstanding any contrary interpretation of this Agreement or of any contracts between Group and Participating Group Providers, Group acknowledges and agrees that all provisions of this Agreement
applicable to Group shall apply with equal force to Participating Group Providers, unless clearly applicable only to Group. Group agrees that it is Group’s responsibility to assure that the obligations of Participating Group Providers under
this Agreement are fully satisfied, that Group will take all steps necessary to cause Participating Group Providers to comply with and perform the terms and conditions of this Agreement, and that Group’s failure to do so shall constitute a
material breach of this Agreement by Group. Group agrees, and shall require Participating Group Providers to agree, that in the event of any inconsistency between this Agreement and any contracts entered into between Group and Participating Group
Providers, the terms of this Agreement shall control. Upon request by Company, Group shall provide copies of its template contracts with Participating Group Providers, if any, to Company. Group agrees that each Participating Group Provider shall
execute an individual provider addendum with Company. 
  

	2.5	Group Capacity. 

 Group
shall provide, at the earliest possible time, notice to Company of any significant changes in the capacity of Group to provide or arrange for the provision of Covered Services to Members as contemplated by this Agreement, including, but not limited
to, any reduction in the number of Participating Group Providers. If Company determines at any time that Members’ access to Participating Group Providers is unacceptable due to any reduction in the number of Participating Group Providers, or
any change in the types or geographic mix of Participating Group Providers that limits Participating Group Providers’ availability to Members or ability for Members to access Participating Group Providers’ services, Company may request
that Group take corrective action acceptable to Company within thirty (30) days. If Group fails to take such corrective action within such thirty (30) day period, Company may terminate this Agreement as provided in Section 6.3.

  

	2.6	Group Providers’ Information. 

 Group shall provide to Company a complete list of Participating Group Providers, including names, office addresses, office hours, telephone and facsimile numbers, and area of practice or specialty. Group
shall notify Company in writing within ten (10) business days of its acquiring knowledge of any change in this information. Group shall provide to Company at least sixty (60) days prior notice (or, if Group does not receive at least sixty
(60) days notice, then such notice as Group actually receives) of the termination of Group’s relationship with a Participating Group Provider. Group Shall obtain a completed credentialing

  
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application to become a Participating Group Provider from each Group Physician, and shall, at Company’s request, make available to Company any credentialing material held by or accessible to
Group. Group shall obtain all necessary releases from Group Providers to permit Group to release said credentialing files to Company, and Company shall be entitled to presume that such releases have been obtained. 

 

	2.7	Administrative Obligations of Primary Care Physicians. 

 Each Participating Group Provider who is a Primary Care Physician shall comply with the following: 
  

	 	2.7.1	Coordination of Care. A Primary Care Physician shall arrange and coordinate the overall provision of Covered Services to Members under the terms and conditions
of the Member’s applicable Plan. A Primary Care Physician shall provide or arrange for the provision of Covered Services, including, without limitation, urgently needed services or Emergency Services, regardless of whether a Participating Group
Provider has previously seen or treated the Member. 

  

	 	2.7.2	Referrals. To the extent required by the terms of the applicable Plan, Participating Group Providers who are Primary Care Physicians shall refer or admit Members
only to Participating Providers for Covered Services, and shall furnish such Participating Provider with complete information on treatment procedures and diagnostic tests performed prior to such referral or admission. In addition, to the extent
possible, Participating Group Physicians shall refer Members with out of network benefits to Participating Providers. 

  

	2.8	Administrative Obligations of Participating Group Providers Other than Primary Care Physicians. 

A Participating Group Provider who is not a Primary Care Physician shall (a) render services to Members only in the Member’s
home or work; (b) promptly submit, upon a Member’s request, a report on the treatment of each Member to the Member’s Primary Care Physician and (c) refer or admit Members only to Participating Providers for Covered Services, if
applicable. 
  

	2.9	Group and Participating Group Providers’ Insurance. 

  

	 	2.9.1	Group’s Insurance. During the term of this Agreement, Group agrees to procure and maintain such policies of general and professional liability and other
insurance, or a comparable program of self insurance, at minimum levels required by state law or, in the absence of a state law specifying a minimum limit, an amount customarily maintained by Group in the state or region in which the Group operates.
Such insurance coverage shall cover the acts and omissions of Group and Participating Group Providers as well as those Group and Participating Group Providers’ agents and employees. Group agrees to deliver certificates of insurance or other
documentation as appropriate to show evidence of such coverage to Company upon request. Group agrees to make best efforts to provide to Company at least thirty (30) days advance notice, and in any event will provide notice as soon as reasonably
practicable, of any cancellation or material modification of these policies. 

  

	 	2.9.2	Participating Group Providers’ Insurance. During the term of this Agreement, each Participating Group Provider agrees to procure and maintain such policies
of general and professional liability and other insurance, or a comparable program of self-insurance, at minimum levels required by state law or, in the absence of a state law specifying a minimum limit, an amount customarily maintained by
Participating Group Provider in the state or region in which the Participating Group Provider operates, Such insurance coverage shall cover the acts and omissions of Participating Group Provider as well as Participating Group Provider’s agents
and employees. Participating Group Provider agrees to deliver certificates of insurance or other documentation as appropriate to show evidence of such coverage to Company upon request. Participating Group Provider agrees to make best efforts to
provide to Company at least thirty (30) days advance notice, and in any event will provide notice as soon as reasonably practicable, of any cancellation or material modification of said policies. 

 

	2.10	Product Participation. 

Group and Participating Group Providers agree to participate in the Plans and other health benefit products as described in the Product
Participation Schedule. Company reserves the right upon ninety (90) days prior 

  
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 notice, to introduce, modify and designate Groups’ and Participating Group
Providers’ participation in new Plans, Specialty Programs and products during the term of this Agreement and will provide Group with written notice of such Plans, Specialty Programs and products and the associated compensation. 

Nothing in this Agreement shall require that Company identify, designate or include Group and Participating Group Providers as a preferred
participant in any specific Plan, Specialty Program or product; provided, however, Group and Participating Group Providers shall accept compensation in accordance with this Agreement for the provision of any Covered Services to Members under a Plan,
Specialty Program or product in which Group and Participating Group Providers have agreed to participate in this Agreement. 

Company may sell, lease, transfer or otherwise convey to payers (other than Plan Sponsors) which do not compete with Company’s
product offerings (e.g., workers’ compensation or automobile insurers) in the geographic area where Group provides Covered Services, the benefits of this Agreement, including, without limitation, the Services and Compensation Schedule,
under terms and conditions which will be communicated to Group in each such case. For those programs and products which are not health benefit products (e.g., worker’s compensation or auto insurance), Group shall have thirty (30) days from
receipt of the Company’s notice to notify Company in writing if Group elects not to participate in these products(s). 
  

	2.11	Consents to Release Medical Information. 

 Group and Participating Group Providers covenant that it will obtain from Members to whom Participating Group Provider provides Covered Services, any necessary consents or authorizations to the release of
Information and Records to Company, Plan Sponsors, their agents and representatives. In performing this covenant, Group and Participating Group Providers shall comply with any applicable Federal or state law or regulation or this Agreement.

  

	2.12	Encounter Data. 

 Group
and Participating Group Providers agree to provide Company with encounter data by type of Provider Service rendered to Members in the form and manner as specified by Company. There shall be no restrictions on Company’s use of such encounter
data. Furthermore, Company is under no obligation to return such encounter data to Group or Participating Group Providers. 
  

	3.0	COMPANY OBLIGATIONS 

  

	3.1	Company’s Covenants. 

Company or Plan Sponsors shall provide the following: a means for Members to identify themselves to Participating Group Providers (e.g.,
identification cards), an explanation of Group’s payments, a general description of products (e.g., Quick Reference Card), a listing of Participating Providers, and timely notification of Material Changes in this information. Company shall
provide Group and Participating Group Providers with a means to check Member eligibility. Provider may check eligibility via Electronic Data Interchange through either vendors or on Aetna’s website (when available) or by calling the phone
number on the Member’s identification card. Company shall include Group and Participating Group Providers in the Participating Provider directory or directories for the Plans, Specialty Programs and products in which Group and Participating
Group Providers are Participating Providers, including when Group and Participating Group Providers are designated as preferred participant, and shall make these directories available to Members. Company reserves the right to determine the content
of Physician directories. 
  

	3.2	Company Representations. 

Company represents and warrants that: (a) it, where applicable, is licensed to offer, issue and administer Plans in the service areas
covered by this Agreement by the applicable regulatory authority (“License”); (b) it will not lose such License involuntarily during the course of this Agreement; (c) it is, and will remain throughout the term of this Agreement,
substantially in compliance with all applicable Federal and state laws and regulations related to this Agreement and the services to be provided under this Agreement; including without limitation, any applicable prompt payment statutes and
regulations or capital reserve requirements; provided however, that for the purposes of (b) and (c), Group and Participating Group Providers will have no basis for termination to the extent that such action does not impact the obligations of
Company under this 

  
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Agreement; (d) this Agreement has been executed by its duly authorized representative; and (e) executing this Agreement and performing its obligations under this Agreement shall not
cause Company to violate any term or covenant of any other agreement or arrangement now existing or subsequently executed. 
  

	3.3	Company’s Insurance. 

Company at its sole cost and expense agrees to procure and maintain such policies of general and/or professional liability and other
insurance (or maintain a self-insurance program) as shall be necessary to insure Company and its employees against any claim or claims for damages arising by reason of personal injuries or death occasioned directly or indirectly in connection with
the performance of any service by Company under this Agreement and the administration of Plans. 
  

	4.0	CLAIMS SUBMISSIONS, COMPENSATION AND MEMBER BILLING 

  

	4.1	Claim Submission and Payment. 

  

	 	4.1.1	Obligation to Submit Claims. Group agrees to submit Clean Claims for non-capitated services to Company for Provider Services rendered to Members by Participating
Group Providers. With respect to Government Programs, Group agrees to submit claim and risk adjustment data related to a Member enrolled in a Government Program in the form and manner as specified by Company, Group certifies that any such data is
accurate, complete and truthful. Group and Participating Group Providers will make best commercial efforts to submit a minimum of eighty-five percent (85%) of its Member claims electronically to Company. Group and Participating Group Providers
represent that, where necessary, they have obtained signed assignments of benefits authorizing payment for Providers Services to be made directly to Group. For claims Group submits electronically, Group shall not submit a claim to Company in paper
form unless Company fails to pay or otherwise respond to electronic claims submission in accordance with the time frames required under this Agreement or applicable law or regulation. Group agrees that Company, or the applicable Plan Sponsor, will
not be obligated to make payments for billings received more than one hundred and twenty (120) days from (a) the date of service or, (b) the date of receipt of the primary payer’s explanation of benefits when Company is the
secondary payer. This limit is ninety-five (95) days for Medicaid and CHIP plans. Except for Medicaid and CHIP plans, this limitation will be waived in the event Group provides notice to Company, along with appropriate evidence, of extraordinary
circumstances outside the control of Group that resulted in the delayed submission. In addition, unless Group notifies Company of any payment disputes within one hundred eighty (180) days, or such longer time as required by applicable state law
or regulation, of receipt of payment from Company, such payment will be considered full and final payment for the related claims. Except as otherwise required under applicable Federal, or state law or regulation, or a Plan, if Group does not bill
Company or plan Sponsors, or disputes any payment, timely as provided in this Section 4.1.1, Group’s claim for payment will be deemed waived and Group will not seek payment form Plan Sponsors, Company or Members. Group shall pay on a timely
basis all employees, independent contractors and subcontractors who render Covered Services to Members of Company’s Medicare/Medicaid Plans for which Group is financially responsible pursuant to this Agreement. 

Group agrees to permit rebundling to the primary procedure those services considered part of, incidental to, or inclusive of primary
procedure and to allow Company to make other adjustments for inappropriate billing or coding (e.g., duplicative procedures or claim submissions, mutually exclusive procedures, gender/procedure mismatches, age/procedure mismatches). To the extent
Group is billing on a CMS 1500, as of the Effective Date, in performing rebundling and making adjustments for inappropriate billing or coding, Company utilizes a commercial software package (as modified by Company for all Participating Providers in
the ordinary course of Company’s business) which commercial software package relies upon Medicare/Medicaid and other industry standards in the development of its rebundling logic. 

 

	 	4.1.2	Company Obligation to Pay Covered Services. Company agrees to: (a) pay Group for Covered Services rendered to members of Full Risk Plans. and
(b) notify Plan Sponsors to forward payment to 

  
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 Company for payment to Group Covered Services rendered to a Plan Sponsor’s Members
by Participating Group Providers. Such payment shall be made as follows: (a) for capitated services Group shall be paid according to the Physician Compensation Model as described in the Services and Compensation Schedule; (b) for
non-capitated services: the lesser of (i) Participating Group Provider’s usual, customary and reasonable (ucr) billed charges; (ii) the rates set forth in the Services and Compensation Schedule; or (iii) the fee schedule
then in effect as applicable to such Member’s Plans. Payment for such non-capitated services shall be made within thirty (30) days (or such shorter time as required by applicable law or regulation) of actual receipt by Company of a Clean
Claim. Except for capitated services, in the event Company fails to pay Clean Claims within forty-five (45) days (or such shorter time as required by applicable law or regulation) of receipt, Company shall pay a penalty as required by applicable law
or regulation. In relation to Full Risk Plans, if applicable law or regulation does not require a penalty for Company’s failure to pay a clean claim within the time period required by applicable law or regulation, then Group and Participating
Group Providers shall not be entitled to billed charges or any penalty. Group and Participating Group Providers shall not be entitled to billed charges or any penalty for claims submitted in relation to Plan Sponsor Plans. (Plan Sponsor Plans are
not Full Risk Plans.) The receipt date for claims will be determined in accordance with applicable law or regulation. 
 Except
as otherwise required under applicable Federal, or state law or regulation, or a Plan, if Company pays a claim and afterwards either– 
  

	 	4.1.2.1	Company discovers a possible underpayment to Group within the time period for Group to dispute payments stated in Section 4.1.1, or 

 

	 	4.1.2.2	Group discovers a possible underpayment to Group and gives prompt notice to Company within the time period for Group to dispute payments stated in section 4.1.1 above,
then Company shall review the claim within forty-five (45) days of Company’s discovery or Participating Group Provider or Group’s notice, and shall pay any eligible unpaid portion of the claim. In relation to Full Risk Plans. If
applicable law or regulation does not require a penalty for Company’s failure to pay a clean claim within the time period required by applicable law or regulation, then Group and Participating Group Provider shall not be entitled to billed
charges or any penalty for a possible underpayment. Group and Participating Group Provider shall not be entitled to billed charges or any penalty for possible underpayment for claims submitted in relation to Plan Sponsor Plans. (Plan Sponsor Plans
are not Full Risk Plans.) When required, Company shall comply with all applicable statutes and rules pertaining to prompt payment of clean claims, including Texas Insurance Code Sections 1301.101-1301.109, Sections 1301.131-1301.138, Sections
843.336–843.353, and 28 Texas Administrative Code Sections 21.2801-21.2826, with respect to payment to a Participating Provider for Covered Services that are rendered to Members. 

In accordance with applicable law and regulation; including but not limited to Texas Insurance Code Section 1301.136 and Sec.
843.321: 
  

	 	(1)	Group may request a description and copy of the coding guidelines, including any underlying bundling, recoding, or other payment process and fee schedules applicable to
specific procedures that the Group will receive under the contract; 

  

	 	(2)	Company or Company’s agent will provide the coding guidelines and fee schedules not later than the 30th day after the date the Company receives the request;

  

	 	(3)	Company or Company’s agent will provide notice of changes to the coding guidelines and fee schedules that will result in a change of payment to Group not later
than the 90th day before the date the changes take effect and will not make retroactive revisions to the coding guidelines and fee schedules; 

  

	 	(4)	The contract may be terminated by Group on or before the 30th day after the date Group receives information requested under this subsection without penalty or
discrimination in participation in other health care products or plans; 

  
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	 	(5)	Group shall only use or disclose the information for the purpose of practice management, billing activities, and other business operations; and disclose the information
to a governmental agency involved in the regulation of health care or insurance; 

  

	 	(6)	Company shall, on request of Group, provide the name, edition, and model version of the software that Company uses to determine bundling and unbundling of claims.

 Group and Participating Group Providers will make best commercial efforts to utilize online
explanation of benefits or electronic remittance of advice (or combination thereof) and electronic funds transfer in lieu of receiving paper equivalents. While Company may pay claims on behalf of Plan Sponsors, Group, Participating Group Providers
and Company acknowledge that Company has no legal responsibility for the payment of such claims for Covered Services rendered to a Plan Sponsor’s Members; provided, however, that Company agrees to reasonably assist Group as appropriate in
collecting any such payments. Where there is a Plan Sponsor, Company shall have no obligation to pay Group and Participating Group Providers in the event the Plan Sponsor or member fails to pay Group or Participating Group Providers. Company
represents that it exercises commercially reasonable due diligence prior to entering into agreements with Plan Sponsors. Company represents that its agreements with Plan Sponsors require that such Plan Sponsor make funds available to allow Company
to reimburse participating providers for Covered Services provided to Members enrolled in the applicable self-funded plan. In the event that a Plan Sponsor fails to make funds available to Company to pay for Covered Services, Company will act
promptly in accordance with its policies to and its relationship with that Plan Sponsor, unless prohibited from doing so by applicable law or order of court. Except as otherwise required under applicable Federal, or state law or regulation, or a
Plan, Company may, from time to time, notify Group of overpayments to Group and Group agrees to the return of any such overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by a Participating Group Provider
to a patient who was not a Member) within forty-five (45) days. In the event Group and Participating Group Providers fail to return overpayments within forty-five (45) days of receipt, upon written notice from Company of such event, Group
and Participating Group Providers shall pay a contracted penalty of 1.0% per month simple interest on the eligible, unrepaid portion of such overpayment, beginning on the forty-sixth (46th) day after receipt of notice of such overpayment(s). If the
overpayment request is mailed, the Group and Participating Group Provider’s receipt date will be the fifth
(5th) calendar day following the postmark date,
Company shall not be entitled to collect any other penalty, charge or fee, for Group and Participating Group Provider’s failure to return overpayment of claims under any Full Risk Plans, Company shall not be entitled to the contracted penalty
for overpayments submitted in relation to Plan Sponsor Plans. In the event Company is unable to secure the return of any such payment within such reasonable time, Company reserves the right to offset such payment against any other monies due to
Group under this Agreement provided Company has delivered to Group at least ten (10) days prior written notice and Group has otherwise failed to return such payment to Company. To the extent, if any, that the compensation under certain Plans is
in the form of capitation payments or a case-based rate methodology, Group acknowledges the financial risks to Group of this arrangement and has made an independent analysis of the adequacy of this arrangement. Group, therefore, agrees and covenants
not to bring any action asserting the inadequacy of these arrangements or that Group was in any way improperly induced by Company to accept the rate of payment, including but not limited to, causes of actions for damages, rescission or termination
alleging fraud or negligent misrepresentation or improper inducement. Company may propose changes in the capitation rate or the Services and Compensation Schedule upon ninety (90) days written notice to Group. If Group is compensated in the
form of capitation payments, said payments shall begin and selection of a primary care physician by a member shall be in accordance with applicable state law. Furthermore, to the extent that the compensation under certain Plans is in the form of
capitation payments or a case-based methodology and Participating Group Provider utilizes the services of a Covering Physician, Group agrees to hold Company. Affiliates, Sponsors, Members and Payers harmless against any and all claims by such
Covering Physician related to or arising out of Payment for Covered Services rendered to Members Group understands that if Company makes payment to such Covering Physician under the circumstances described above, Company may offset future capitation
or case-rate payments by the amount paid to such Covering Physician. Notwithstanding anything in this Agreement to the contrary, during such time as Physician is a member of a Group, Physician agrees to seek compensation solely

  
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from Group for those Covered Services provided to Members and for which Group is compensated by Company on behalf of Group, and Group and Participating Group Providers shall in no event bill
Company, applicable Affiliates Plan Sponsors or Members for any such Covered Services (except for the collection of Copayments, Coinsurance, Deductibles in accordance with Section 4.3.1). 

If capitation applies, Company will comply with the requirements described in Texas Insurance Code Sections 843.315 and 843.316.

 In accordance with Texas Insurance Code Sections 843.323 and 1301.0641, Company’s clearinghouse may not refuse to
process or pay an electronically submitted clean claim because the claim is submitted together with or in a batch submission with a claim that is not a clean claim. 
  

	 	4.1.3	Group’s Payment to Participating Group Providers. Group shall be financially responsible for payment to all Participating Group Providers who render Covered
Services to Members. Group shall require all Participating Group Providers who render such services to look solely to Group for payment. In addition, Group shall be financially responsible for payment to any other Providers who render Covered
Services to Members when Group has been compensated on a capitated basis, if any, for such services. Group shall pay on a timely basis all Participating Group Providers and other Providers who render Covered Services for which Group is financially
responsible hereunder. Company shall forward any claims it receives for payment for such services to Group. Company reserves the right to pay, or to instruct Payers to pay, any Participating Physician or other provider for Covered Services for which
Group is financially responsible and for which a valid, undisputed invoice, or portion thereof, is outstanding for more than fourteen (14) days beyond its due date, except that Company need not wait fourteen (14) days if Group has engaged
in a pattern of late payments in the past. Company may deduct any such payments from any and all amounts due and payable to Group hereunder. 

  

	 	4.1.4	Utilization Management. Company utilizes systems of utilization review/quality improvement/peer review to promote adherence to accepted medical treatment
standards and to encourage Participating Providers to minimize unnecessary medical costs consistent with sound medical judgment. To further this end, Participating Group Providers agree, consistent with sound medical judgment:

  

	 	(a)	To participate, as requested, and to abide by Company’s utilization review, patient management quality improvement programs, and all other related programs (as
modified from time to time) and decisions with respect to all Members to other providers. 

  

	 	(b)	To comply with Company’s pre-certification and utilization management requirements for all elective admissions and other Covered Services.

  

	 	(c)	To regularly interact and cooperate with Company’s nurse case managers, medical directors, and other related Company staff. 

 

	 	(d)	If applicable, to utilize Participating Group and Participating Group Providers to the fullest extent possible, consistent with sound medical judgment.

  

	 	(e)	To abide by all Company’s credentialing criteria and procedures, including site visits, if applicable, and medical chart reviews, and to submit to these processes
biannually, annually, or otherwise, when applicable. 

  

	 	(f)	If applicable, to obtain advance authorization from Company prior to any non-emergency admission. In cases where a Member requires an emergency hospital admission,
Group and Participating Group Providers shall notify as soon as is reasonable, but in no event later than the next business day. Both of these requirements shall be in accordance with Company’s Policies than in effect at the time the services
were rendered. Failure to notify Company shall result in denial of payment. 

  
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 Except when a Member requires Emergency Services, Group and Participating Group
Providers agree to comply with any applicable precertification and/or referral requirements under the Member’s Plan prior to the provision of Provider Services. Group and Participating Group Providers agree to notify Company of all admissions
of Members, and of all services for which Company requires notice, upon admission or prior to the provision of such services. For those Members who require services under a Specialty Program, Group and Participating Group Providers agree to work
with Company in transferring the Member’s care to a Specialty Program Provider. Provider may find the majority of such policies in the Health Care Professional Toolkit, and on Company’s website, as they may be revised from time to time.

  

	4.2	Coordination of Benefits. 

Group and Participating Group Providers shall retain in his/her records updated information for a Member concerning other health benefit
plan coverage and to provide the information to Company on the form described by applicable law or regulation, and if a form is not described by applicable law or regulation, in the manner specified by Company. Except as otherwise required under
applicable Federal, state law or regulation or a Plan, (a) when Company and Group agree that Company or a Plan Sponsor, as the case may be, is the primary payer under applicable coordination of benefit principles. Company or such Plan Sponsor
agrees to pay in accordance with this Agreement, and (b) when Company or a Plan Sponsor is secondary under said principles, and payment from the primary payer is less than the compensation payable under this Agreement without coordination of
benefits, then Company or Plan Sponsor will pay Group the amount of the difference between the amount paid by the primary payer and the compensation payable under this Agreement, absent other sources of payment; provided, however, that if payment
from this primary payer is greater than or equal to the compensation payable under this Agreement without coordination of benefits, neither Company, Plan Sponsor nor the applicable Member (in accordance with Section 4.3.2 below) shall have any
obligation to Group. Notwithstanding anything to the contrary in this section, in no event shall Group collect more than Medicare allows if Medicare is the primary payer. Medicaid is never the primary payer. 

 

	4.3	Member Billing. 

  

	 	4.3.1	Permitted Billing of Members. Group may bill or charge Members only in the following circumstances: (a) applicable Copayments, Coinsurance and/or
Deductibles not collected at the time that Covered Services are rendered; (b) individuals were not Members at the time that services were rendered; (c) a Plan Sponsor becomes insolvent or otherwise fails to pay Group in accordance with
applicable Federal law or regulation (e.g., ERISA) provided that Group has first exhausted all reasonable efforts to obtain payment from the Plan Sponsor, however, this Section 4.3.1 (b) is not applicable to Medicaid Members; and
(d) services that are not Covered Services only if: (i) the Member’s Plan provides and/or Company confirms that the specific services are not covered; (ii) the Member was advised in writing prior to the services being rendered
that the specific services may not be Covered Services; and (iii) the Member agreed in writing to pay for such services after being so advised. Group acknowledges that Company’s denial or adjustment of payment to Group based on
Company’s performance of utilization management as described in Section 4.1.4 or otherwise is not a denial of Covered Services under this Agreement or under the terms of a Plan, except as required under applicable law or regulation, or if
Company confirms otherwise under this Section 4.3. Group may bill or charge individuals who were not Members at the time that services were rendered. 

  

	 	4.3.2	 Holding Members Harmless. Group and Participating Group Providers hereby agree that in no event, including, but not limited to the failure,
denial or reduction of payment by Company, insolvency of Company or breach of this Agreement, shall Group or Participating Group Providers bill, charge, collect a deposit from, seek remuneration or reimbursement from, or have any recourse
(i) against Members or persons acting on their behalf (other than Company) or (ii) any settlement fund or other res controlled by or on behalf of, or for the benefit of, a Member for Covered Services. This provision shall not prohibit
collection of Copayments, Coinsurance, Deductibles or other supplemental charges made in accordance with the terms of the applicable Plan. Group and Participating Group Providers further agree that this Section 4.3.2: (a) shall survive the
expiration or termination of this Agreement regardless of the cause giving rise to termination and shall be construed for the benefit of Members; 

  
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and (b) supersedes any oral or written contrary agreement or waiver now existing or hereafter entered into between Group and Participating Group Providers and Members or persons acting on
their behalf. 
 Any modifications, additions, deletions to the provisions of this clause shall become effective on a date no
earlier than ninety (90) days after notice to Group of any such modification, addition, or deletion to the provisions of this clause, and no earlier than fifteen (15) days after the Commissioner of Insurance has received written notice of
such proposed changes. 
 To protect Members, Group and Participating Group Providers agree not to seek or accept or rely upon
waivers of the Member protections provided by this Section 4.3. 
  

	5.0	COMPLIANCE WITH POLICIES 

  

	5.1	Policies. 

 Group and
Participating Group Providers agree to accept and comply with Policies of which Group knows or reasonably should have known (e.g., Clinical Policy Bulletins or other Policies made available to Group and Participating Group Providers). Group and
Participating Group Providers will utilize the electronic real time HIPAA compliant transactions, including but not limited to, eligibility, precertification and claim status inquiry transactions. Provider may find the majority of such policies in
the Health Care Professional Toolkit, and on Company’s website, as they may be revised from time to time. Company may at any time modify Policies. Company will provide ninety (90) days prior notice by letter, newsletter, electronic mail or
other media, of Material Changes. If Group objects to the Material Change, the Group shall provide written notice to Company and may request that the Parties negotiate in good faith an appropriate amendment to this Agreement. if the parties are
unable to negotiate any such amendment not more than thirty (30) calendar days after receipt of a Material Change and Group provides notice of termination of this Agreement not more than thirty (30) calendar days after a Material Change,
then this Agreement shall terminate coincident with the effective date of the Material Change. In the event that Group reasonably believes that a Material Change is likely to have a material adverse financial impact upon Group, Group agrees to
notify Company, specifying the specific bases demonstrating a likely material adverse financial impact, and the Parties will negotiate in good faith an appropriate amendment, if any, to this Agreement. Group and Participating Group Providers agree
that noncompliance with any requirements of this Section 5.1 or any Policies will relieve Company or Plan Sponsors and Members from any financial liability for the applicable portion of the Provider Services. In addition, Group and
Participating Group Providers shall participate in Company’s preventive care program or implement an effective preventive care program consistent with Company’s criteria and policies, for which Group and Participating Group Providers shall
be compensated in accordance with the rates set forth in the Services and Compensation Schedule. 
  

	5.2	Notices and Reporting. 

To the extent neither prohibited by law nor violative of applicable privilege, Group and Participating Group Providers agree to provide
notice to Company, and shall provide all information reasonably requested by Company regarding the nature, circumstances, and disposition, of (a) any litigation brought against Group and Participating Group Providers or any of its employees or
affiliated providers which is related to the provision of health care services and could have a material impact on the Provider Services provided to Members; (b) comply with any Company requirements regarding reporting of self-referrals, loss
of licensure or accreditation, and claims by governmental agencies or individual regarding fraud, abuse , self-referral, false claims, or kickbacks; and (c) any material change in services provided by Group and Participating Group Providers or
licensure status related to these services. Group agrees to use best efforts to provide Company with prior notice of, and in any event will provide notice as soon as reasonably practicable notice of, any actions taken by or against Group or
Participating Group Providers described in this Section 5.2. 
  

	5.3	Information and Records. 

  

	 	5.3.1	 Maintenance of Information and Records. Group and Participating Group Providers agree (a) to maintain Information and Records (as such
terms are defined in Section 5.3.2) in a current, detailed, organized and comprehensive manner and in accordance with customary medical practice, applicable 

  
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Federal and state laws, and accreditation standards; (b) that all Member medical records and Confidential Information shall be treated as confidential and in accordance with applicable laws;
(c) to maintain such Information and Records for the longer of six (6) years after the last date Provider Services were provided to Member, or the period required by applicable law. This Section 5.3.1 shall survive the termination of
this Agreement, regardless of the cause of the termination. 

  

	 	5.3.2	Access to Information and Records. Group and Participating Group Providers agree that (a) Company (including Company’s authorized designee) and Plan
Sponsors shall have access to all data and information obtained, created or collected by Group and Participating Group Providers related to Members and necessary for the evaluation of and payment of claims, including without limitation Confidential
Information (“Information”); (b) Company (including Company’s authorized designee), Plan Sponsors and Federal, state, and local governmental authorities and their agents having jurisdiction, upon request, shall have access to all
books, records and other papers (including, but not limited to, contracts, medical and financial records and physician incentive plan information) and information relating to this Agreement and to those services rendered by Participating Group
Providers to Members (“Records”); (c) consistent with the consents and authorizations required by Section 2.11 hereof, Company or its agents or designees shall have access to medical records for the purpose of assessing quality
of care, conducting medical evaluations and audits, and performing utilization management functions; (d) as required by Texas law, Company conducts quality assessment through a panel of at least three (3) Participating Providers;
(c) applicable Federal and state authorities and their agents shall have access to medical records for assessing the quality of care or investigating Member grievances or complaints; and (f) Members shall have access to their health information
as required by 45 C.F.R § 164.524 and applicable state law, be provided with an accounting of disclosures of information when and as required by 45 C.F.R § 164.528 and applicable state law, and have the opportunity to amend or correct the
information as required by 45 C.F.R. § 164.526 and applicable state law. Group and Participating Group Provider agree to supply copies of Information and Records within fourteen (14) days of the receipt of a request, where practicable, and
in no event later than the date required by any applicable law or regulatory authority, Subject to the provisions of this section as well as other provisions of this Agreement, Company confirms that, as between Company and Group and Participating
Group Providers, Group and Participating Group Providers owns Group and Participating Group Providers’ medical records. This Section 5.3.2 shall survive the termination of this Agreement, regardless of the cause of termination.

  

	 	5.3.3	Government Requirements Regarding Records for Medicare Members. In addition to the requirements of Sections 5.3.1 and 5.3.2, with respect to Medicare Plans,
Group and Participating Group Providers agree to maintain Information and Records (as those terms are defined in Section 5.3) for the longer of: (i) ten (10) years from the end of the final contract period of any government contract of Company, (ii)
the date the U.S. Department of Health and Human Services (“HHS”), the U.S. Comptroller General, or their designees complete an audit, or (iii) the period required by applicable laws, rules or regulations. Group and Participating Group
Providers further agree that, with respect to Medicare Plans, Company and Federal, state and local government authorities having jurisdiction, or their designees, upon request, shall have access to all Information and Records, and that this right of
inspection, evaluation and audit of Information and Records shall continue for the longer of (i) ten (10) years from the end of the final contract period of any government contract of Company. (ii) the date HHS, the U.S. Comptroller General, or
their designee complete an audit, or (iii) the period required by applicable laws, rules or regulations. This Section 5.3.3 shall survive the termination of this Agreement, regardless of the cause of termination. 

 

	5.4	Quality, Accreditation and Review Activities. 

 Group and Participating Group Providers agree to cooperate with any Company quality activities or review of Company or a Plan conducted by the National Committee for Quality Assurance (NCQA) or a Federal
or state agency with authority over Company and/or the Plan, as applicable. 
  

	5.5	Proprietary Information. 

  

  
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	 	5.5.1	Rights and Responsibilities. Each Party agrees that the Proprietary Information of the other Party is the exclusive property of such Party and that each Party
has no right, title or interest in the Proprietary Information. Each Party agrees to keep the Proprietary Information and this Agreement strictly confidential and agrees not to disclose any Proprietary Information or the contents of this Agreement
to any third party without the other Party’s consent, except (i) to governmental authorities having jurisdiction, (ii) in the case of Company’s disclosure to Members, Plan Sponsors, consultants or vendors under contract with Company,
and (iii) in the case of Participating Group Providers’ disclosure to Members for the purposes of advising Members of potential treatment options and costs. Except as otherwise required under applicable Federal or state law, each Party
agrees to not use any Proprietary Information of the other Party, and at the request of the other Party to this Agreement, return any Proprietary Information upon termination of this Agreement for whatever reason. Notwithstanding the foregoing,
Participating Group Providers are encouraged to discuss Company’s provider payment methodology with patients, including descriptions of the methodology under which the Group or Participating Group Providers are paid. In addition, Participating
Group Providers may freely communicate with patients about their treatment options, regardless of benefit coverage limitations. This Section 5.5.1 shall survive the termination of this Agreement for one (1) year, regardless of the cause of
termination. 

  

	6.0	TERM AND TERMINATION 

Prior to termination initiated by Company and in accordance with applicable State law, Company shall provide a written explanation of the
reason(s) for termination, and upon request before the effective date, Group or Participating Group Providers shall be entitled to a review by an advisory panel. 
  

	6.1	Term. 

 This Agreement
shall be effective for an initial term (“Initial Term”) of one years(s) from the Effective Date, and thereafter shall automatically continue for additional terms of one (1) year each, unless and until terminated in accordance with
this Article 6.0. 
  

	6.2	Termination without Cause. 

This Agreement may be terminated by either Party with at least ninety (90) days prior written notice to the other Party; and in
accordance with such procedures as are applicable at the time of such termination. 
  

	6.3	Termination for Breach. 

This Agreement may be terminated at any time by either Party upon at least ninety (90) days prior written notice of such termination
to the other Party upon material default or substantial breach by the other Party of one or more of its obligations under this Agreement, unless such material default or substantial breach is cured within ninety (90) days of the notice of
termination; provided, however, if such material default or substantial breach is incapable of being cured within such ninety (90) day period, any termination pursuant to this Section 6.3 will be ineffective for the period reasonably
necessary to cure such breach if the breaching party has taken all steps reasonably capable of being performed within such ninety (90) day period. Furthermore, Company may terminate the status of any Participating Group Provider as a
Participating Provider for default or breach of said Participating Group Provider’s obligations hereunder upon at least ninety (90) days notice to said Participating Group Provider, unless such default or breach is cured within the notice
period. Notwithstanding the foregoing, the effective date of such termination may be extended pursuant to Section 6.6 herein. 
  

	6.4	Immediate Termination or Suspension. 

 Company may immediately terminate this Agreement or, where applicable, the status of any Participating Group Provider as a Participating Provider, at Company’s discretion at any time, due to any of
the following events: (a) the suspension, withdrawal, expiration, revocation or non-renewal of any Federal, state or local license, certificate or other legal credential authorizing Group and/or Participating Group Providers to practice
medicine: (b) a suspension or revocation of a Participating Group Provider’s DEA certification or other right to prescribe controlled substances; (c) an indictment, arrest or conviction of a felony or for any criminal charge related
to or in any way impairing Group’s and Participating Group Provider’s ability to provide Provider Services to Members; (d) the loss or material limitation of Group’s or Participating Group 

 

  
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Provider’s insurance under Section 2.5 of this Agreement; (e) the debarment or suspension of Group or Participating Group Providers from participation in any governmental sponsored program,
including, but not limited to, Medicare or Medicaid; (f) the listing of Group or Participating Group Providers in the Healthcare Integrity and Protection Data Bank (“HIPDB”); (g) change of control of Group to an entity directly in
competition with Company; (h) any false statement or material omission of Participating Group Provider in the participation application and/or confidential information forms and all other requested information, as determined by Company in its sole
discretion; (i) any adverse action with respect to Participating Group Provider’s hospital staff privileges; or (j) a determination by Company that Group or Participating Group, Provider’s continued participation in provider networks could
result in harm to Members. To protect the interests of patients, including Members, Group and/or Participating Group Providers will provide immediate notice to Company of any of the events described in this Section 6.4, including notification of
impending bankruptcy. 
  

	6.5	Obligations Following Termination. 

 Following the effective date of any expiration or termination of this Agreement or any Plan, Group and Participating Group Providers and Company will cooperate as provided in this Section 6.5. This
Section 6.5 shall survive the termination of this Agreement, regardless of the cause of termination. 
  

	 	6.5.1	Upon Termination. Upon expiration or termination of this Agreement for any reason, other than termination by Company in accordance with Section 6.4 above, Group
and Participating Group Providers agree to provide Provider Services at Company’s discretion to: (a) any Member under a Participating Group Providers, care, who at the time of the expiration or termination is a registered bed patient at a
Participating Facility until such Member’s discharge or Company’s orderly transition of such Member’s care to another provider; and (b) any Member within the six month timeframe of a Period of Time Payment, upon request of such
Member or the applicable Plan Sponsor. 

 If applicable, Company shall reimburse Group and
Participating Group Providers for Covered Services to any Member of special circumstance, such as a person who has a disability, acute condition, or life-threatening illness or is past the twenty-fourth week of pregnancy. “Special
circumstances” means a condition such that Group or Participating Group Providers reasonably believes that discontinuing care by Group and Participating Group Providers could cause harm to the patient. The special circumstance shall be
identified by Group and Participating Group Providers, who must request that the Member be permitted to continue treatment under Group and Participating Group Provider’s care and agree not to seek payment from the patient of any amounts for
which the Member would not be responsible if Group and Participating Group Providers were still a Participating Provider. This subsection does not extend the obligation of Company to reimburse the terminated Group and Participating Group Provider
for ongoing treatment of a Member beyond the 90th day
after the effective date of termination, or beyond nine months in the case of a Member who at the time of the termination has been diagnosed with a terminal illness, except that the obligation to reimburse a Member who at the time of the termination
is past the 24th week of pregnancy, extends through
delivery of the child, immediate postpartum care, and the follow-up checkup within the first six weeks of delivery. 
 The terms
of this Agreement, including the Services and Compensation Schedule shall apply to all services under this Section 6.5.1 
  

	 	6.5.2	Upon Insolvency or Cessation of Operations. If this Agreement terminates as a result of insolvency or cessation of operations of Company, and as to Members of
HMOs that become insolvent or cease operations, then in addition to other obligations set forth in this section, Group and Participating Group Providers shall continue to provide Provider Services to; (a) all Members for the six month period
for which the Period of Time Payment has been paid; and (b) Members confined in an inpatient facility on the date of insolvency or other cessation of operations until medically appropriate discharge. This provision shall be construed to be for
the benefit of Members. No modification of this provision shall be effective without the prior written approval of the applicable regulatory agencies. 

  

	 	6.5.3	 Obligation to Cooperate. Upon notice of expiration or termination of this Agreement or of a Plan, Group and Participating Group Providers, if
applicable, shall cooperate with Company and comply 

  
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with Policies in the transfer of Members to other providers. Upon notice of expiration or termination of this Agreement or of a Plan, Group and Participating Group Providers, upon the direction
of Company and in accordance with applicable state law, shall provide reasonable advance notice to Members currently under treatment by Group and Participating Group Providers of the impending termination. 

 

	6.5.4	Obligation to Notify Members. Upon notice of termination of this Agreement or of a Plan, Company shall provide reasonable advance notice of the impending
termination to Members of Plans currently under the treatment of Group and/or Participating Group Provider, or in the event of immediate termination, as soon as practicable after termination. 

 

	6.6	Obligations During Dispute Resolution Proceedings. 

 In the event of any dispute between the Parties in which a Party has provided notice of termination under Section 6.3 and the dispute is required to be resolved or is submitted for resolution under
Article 8.0 below, the termination of this Agreement shall be stayed and the Parties shall continue to perform under the terms of this Agreement until the final resolution of the dispute. 

 

	7.0	RELATIONSHIP OF THE PARTIES 

  

	7.1	Independent Contractor Status. 

 The relationship between Company and Group, as well as their respective employees and other agents, is that of independent contractors, and neither shall be considered an agent or representative of the
other Party for any purpose, nor shall either hold itself out to be an agent or representative of the other for any purpose. Company and Group will each be solely liable for its own activities and those of its employees and other agents, and neither
Company nor Group will be liable in any way for the activities of the other Party or the other Party’s or employees or other agents arising out of or in connection with: (a) any failure to perform any of the agreements, terms, covenants or
conditions of this Agreement; (b) any negligent act or omission or other misconduct; (c) the failure to comply with any applicable laws, rules or regulations; or (d) any accident, injury or damage. Group and Participating Group
Providers acknowledge that all Member care and related decisions are the responsibility of Participating Group Providers and that Policies do not dictate or control a Participating Group Providers’ clinical decisions with respect to the care of
Members. In particular, medical necessity decisions are for compensation purposes only, and do not direct or limit the advice or care which Group or Participating Group Provider can or should provide in Physician’s sole medical judgment. Group
agrees to indemnify and hold harmless the Company from any and all claims, liabilities and third party causes of action arising out of the Participating Group Providers’ provision of care to Members. Notwithstanding anything else in this
section or this Agreement to the contrary, nothing shall require Group and Participating Group Providers to indemnify and hold harmless the Company from any and all claims, liabilities and third party causes of action arising out of the
Company’s administration of Plans. This provision shall survive the expiration or termination of this Agreement, regardless of the reason for termination. 
  

	7.2	Use of Name. 

 Group and
Participating Group Providers consent to the use of Group’s and Participating Group Provider’s names and other identifying and descriptive material in provider directories of Company in all formats, including, but not limited to,
electronic media. Except as set forth in the preceding sentence, neither Party may use the names, logos, trademarks or service marks of the other Party in marketing materials or otherwise, except upon receipt of such Party’s prior written
consent, which shall not be unreasonably withheld. Company shall use best efforts to expedite such approvals. 
  

	7.3	Interference with Contractual Relations. 

 Group and Participating Group Providers shall not engage in activities that will cause Company to lose existing or potential Members, including but not limited to: (a) advising Company customers.
Plan Sponsors or other entities currently under contract with Company to cancel, or not renew said contracts; (b) impeding or otherwise interfering with negotiations which Company is conducting for the provision of health benefits or Plans; or
(c) using or disclosing to any third party membership lists acquired during the term of this 

  
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 Agreement for the purpose of soliciting individuals who were or are Members or otherwise
to compete with Company. Nothing in this Section 7.3 is intended or shall be deemed to restrict (i) any communication between a Participating Group provider and a Member, or a party designated by a member, determined by participating Group
provider to be necessary or appropriate for the diagnosis and care of the Member and otherwise in accordance with Section 5.51; or (ii) notification of participation status with other HMOs or insures. This section shall continue to be in
effect for a period of one (1) year after the expiration or termination of this Agreement. 
  

	8.0	DISPUTE RESOLUTION 

  

	8.1	Member Grievance Dispute Resolution. 

 Group and Participating Group providers agree to (a) cooperate with and participate in Company’s applicable appeal, grievance and external review procedures (including, but not limited to,
medical necessity appeals and expedited appeals procedures) for Members, (b) provide Company with the information necessary to resolve same, and (c) abide by decisions of the applicable appeals, grievance and review committees. As required
by State law, Group and Participating Group Provider’s, if applicable, shall post in Physician’s office a notice to Members on the process for resolving complaints with Company including the Department of Insurance toll-free number for
filing complaints. Company shall not terminate or refuse to renew this Agreement or otherwise retaliate against Group or Participating Group Provider because Group and Participating Group Provider reasonably filed a complaint or an appeal on behalf
of a Member. 
  

	8.2	Physician Dispute Resolution. 

 Company shall provide an internal mechanism under which Group any raise issues, concerns, controversies or claims regarding the obligations of the Parties under this Agreement. Group shall exhaust this
internal mechanism for any contractual disputes prior to instituting any arbitration or other permitted legal proceeding. Discussions and negotiations held pursuant to this Section 8.2 shall be treated as inadmissible compromise and settlement
negotiations for purposes of applicable rules of evidence. 
  

	8.3	Arbitration. 

 Any
controversy or claim arising out of or relating to this Agreement including the breach, termination, or validity of this Agreement, except for temporary, preliminary, or permanent injunctive relief or any other form of equitable relief, shall be
settled by binding arbitration administered by the American Arbitration Association (“AAA”) and conducted by three (3) arbitrators in accordance with the AAA’s Commercial Arbitration Rules (“Rules”). Except as modified
by this Section 8.3, the arbitration shall be governed by the Federal Arbitration Act, 9 U.S.C. §§ 1-16, to the exclusion of state laws inconsistent with the Federal Arbitration Act, 9 U.S.C. §§1-16 or that would produce a
different result, and judgment on the award rendered by the arbitrator may be entered by any court having jurisdiction of the claim or controversy at issue. Except as may be required by law or to the extent necessary in connection with a judicial
challenge, or enforcement of an award, neither a party nor the arbitrator may disclose the existence, content, record or results of an arbitration. Fourteen (14) calendar days before the hearing, the parties will exchange and provide to the
arbitrator (a) a list of witnesses they intend to call (including any experts) with a short description of the anticipated direct testimony of each witness and an estimate of the length thereof, and (b) premarked copies of all exhibits
they intend to use at the hearing. At the request of a party in any arbitration in which any disclosed claim or counterclaim exceeds $250,000, the Arbitrator may also order pre-hearing discovery by desposition upon good cause shown. Such depositions
shall be limited to a maximum of three (3) per Party and shall be limited to a maximum of six (6) hours’ duration each. The arbitrator may award only monetary damages in accordance with this Agreement. 

 

	8.4	Arbitration Solely Between Parties; No Consolidation or Class Action. 

 Any arbitration or other proceeding related to a dispute arising under this Agreement shall be conducted solely between the parties. Neither Party shall request, nor consent to any request, that their
dispute be joined or consolidated for any purpose, including without limitation any class action or similar procedural device, with any other proceeding between such Party and any third party. 

  
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	9.0	MISCELLANEOUS 

  

	9.1	Amendments. 

 This
Agreement constitutes the entire understanding of the Parties hereto and no changes, amendments or alterations shall be effective unless signed and agreed to by duly authorized representatives of both Parties, except as expressly provided herein.
Notwithstanding the foregoing, at Company’s discretion, Company may amend this Agreement upon written notice, by letter, newsletter, electronic mail or other media, to comply with applicable law or regulation, or any order or directive of any
governmental agency. 
  

	9.2	Waiver. 

 The waiver by
either Party of breach or violation of any provision of this Agreement shall not operate as or be construed to be a waiver of any subsequent breach of this Agreement. To be effective, all waivers must be in writing and signed by an authorized
officer of the Party to be charged. Group waives any claims or cause of action for fraud in the inducement or execution related hereto. 
  

	9.3	Governing law. 

 Unless
otherwise provided for, this Agreement shall be governed in all respects by the laws of the State of Texas which exist not only at the time of this Agreement, but also includes any recodification and amendments to existing law as well as the future
enactment of any new statutes and regulations by the State of Texas. The effective date of any recodification, any amendments to existing law as well as the future enactment of any new statutes and regulations by the State of Texas is the date
stated by the Legislature, unless the Legislature specifies that the effective date of any such change in law or regulation to be the renewal date of this Agreement. 
  

	9.4	Liability. 

Notwithstanding Section 9.3, either Party’s liability, if any, for damages to the other party for any cause whatsoever arising
out of or related to this Agreement, and regardless of the form of the action, shall be limited to the damaged Party’s actual damages. Neither Party shall be liable for any indirect, incidental, punitive, exemplary, special or consequential
damages of any kind whatsoever sustained as a result of a breach of this Agreement or any action, inaction, alleged tortious conduct, or delay by the other Party. 
  

	9.5	Severability. 

 Any
determination that any provision of this Agreement or any application thereof is invalid, illegal or unenforceable in any respect in any instance shall not affect the validity, legality and enforceability of such provision in any other instance, or
the validity, legality or enforceability of any other provision of this Agreement. Neither Party shall assert or claim that this Agreement or any provision hereof is void or voidable if such Party performs under this Agreement without prompt and
timely written objection. 
  

	9.6	Successors; Assignment. 

This Agreement relates solely to the provision of Provider Services by Group and Participating Group Providers and does not apply to any
other organization which succeeds to Group assets, by merger, acquisition or otherwise, or is an affiliate of Group. Neither Party may assign its rights or delegate its duties and obligations under this Agreement without the prior written consent of
the other Party, which consent may not be unreasonably withheld. However, Company may assign its rights or delegate its duties and obligations to an Affiliate or successor in interest so long as any such assignment or delegation will not have a
material impact upon the rights, duties and obligations of Group. 
  

	9.7	Headings. 

 The headings
contained in this Agreement are included for purposes of convenience only, and shall not affect in any way the meaning or interpretation of any of the terms or provisions of this Agreement. 

 

	9.8	Notices. 

 Except for
notices pursuant to section 5.2, 6.0,8.0, 9.1, 9.6, and 9.8, a Party may provide notices pursuant to this Agreement by electronic means if the Party receiving notice has a fax number, e-mail address, or both listed below. 

 

  
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 Company fax number: ADD 
 Provider fax number: 
 Company e-mail addresses: 

Physician e-mail addresses: 
 All notices given
pursuant to sections 5.2, 6.0, 8.0, 9.1, 9.6, and 9.8 shall be effective only if given in writing and sent by overnight delivery service with proof of receipt, or by United States certified mail return receipt requested, to the addresses listed
below. If a Party does not provide all other notices pursuant to this Agreement by electronic means, then the Party shall give all other notices by United States mail to the other Party’s address listed below. 

To Group at: 
 WhiteGlove House Call Health

 Attn: CFO 
 5300 Bee Cave Road,
Building One, Suite 100 
 Austin, TX 78746 
 and to Company at: 
  

			
	Aetna	 	Aetna
	Provider Contract Management	 	Provider Contract Management
	Network Operations – Southwest. Region	 	Network Operations–Southwest Region
	Post Office Box 569440	 	2777 Stemmons Freeway, #400
	Dallas, TX 75356-9440	 	Dallas, TX 75207

 A Party may add,
change or delete its addresses for notice by electronic means, and may change its address for notice by delivery and United States mail, by notice in conformity with this section 9.8. 

 

	9.9	Remedies. 

Notwithstanding Section 8.3 and 9.3, the Parties agree that each has the right to seek any and all remedies at law or equity in the
event of breach or threatened breach of Section(s) 5.5, 6.6, and 7.3. 
  

	9.10	Force Majeure. 

 If either
Party shall be delayed or interrupted in the performance or completion of its obligations hereunder by any act, neglect or default of the other Party, or by an embargo, war, act of terror, riot, incendiary, fire, flood, earthquake, epidemic or other
calamity, or other act of God or of the public enemy, governmental act (including, but not restricted to, any government priority, preference, requisition, allocation, interference, restraint or seizure, or the necessity of complying with any
governmental order, directive, ruling or request) then the time of completion specified herein shall be extended for a period equivalent to the time lost as a result thereof. This Section 9.10 shall not apply to either Party’s obligations
to pay any amounts owing to the other Party, nor to any strike or labor dispute involving such Party or the other Party. 
  

	9.11	Non-Exclusivity. 

 Except
as otherwise provided for in the attached Addendum, this Agreement is not exclusive, and nothing herein shall preclude either Party from contracting with any other person or entity for any purpose. Company makes no representation or guarantee as to
the number of Members who may select or be assigned to Group and Participating Group Providers. 
  

	9.12	Survival. 

 In addition to
those provisions which by their terms survive expiration or termination of this Agreement (e.g., 4.3.2 and 5.3.1), Sections 1.0, 5.3.2, 5.5, 6.5, 7.3, 8.0 and 9.0 shall survive expiration or termination of this Agreement, regardless of the cause
giving rise to expiration or termination of this Agreement. 

  
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	9.13	Entire Agreement. 

 This
Agreement, including the Product Participation Schedule, Participation Criteria Schedules, Services and Compensation Schedule, if applicable and any additional attached schedules and Addendum, constitute the complete and sole contract between the
Parties regarding the subject matter described above and supersedes any and all prior or contemporaneous oral or written representations, communications, proposals or agreements not expressly included in this Agreement and may not be contradicted or
varied by evidence of prior, contemporaneous or subsequent oral representations, communications, proposals, agreements, prior course of dealings or discussions of the Parties. There are no oral agreements between the Parties. Group represents that
Group has not relied on any data, financial analysis, reports, notes, proposals, conclusions or projections, whether made orally or in writing, made by Company or any of its representatives, agents, employees or advisors, in connection with
negotiation, acceptance, execution or delivery of the Agreement by Group. 
  

	9.14	Delegation. 

 To the
extent Company delegates certain functions to Group such delegation shall be governed by a separate delegation agreement which shall be subject to the applicable requirements of Texas Insurance Code, Chapter 1272. 

IN WITNESS WHEREOF, the undersigned parties have executed this Agreement by their duly authorized officers, intending to be
legally bound hereby. 
  

									
	GROUP	 		 		 	COMPANY	 	
					
	By:	 	 /s/ ROBERT FABBIO
	 		 	By:	 	 /s/ Dave Roberts

					
	Printed Name:	 	 ROBERT FABBIO
	 		 	Printed Name:	 	 Dave Roberts

					
	Title:	 	 CEO
	 		 	Title:	 	 Regional Network Head

					
	Date:	 	 6/4/09
	 		 	Date:	 	 7-15-09

 REIMBURSEMENT ADDRESS: 
 WHITEGLOVE HOUSE CALL HEALTH 

5300 BEE CAVE ROAD, BUILDING ONE, SUITE 100 
 AUSTIN, TX 78746 
 MAIN TELEPHONE NUMBER: 512-329-8081 

CHIEF EXECUTIVE OFFICER: 512-329-8081 

CHIEF FINANCIAL OFFICER: 512-329-8081 

BUSINESS OFFICE MANAGER: 512-329-8081 

FEDERAL TAX I.D. NUMBER: 20-8913858 

  
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 ADDENDUM TO THE AGREEMENT 
 This Addendum which is attached to the Agreement contains the following provisions which Company and Group wish to include in the Agreement: 
 1) GEOGRAPHIC SCOPE: The Parties agree that Group will serve the greater Austin, Dallas-Fort Worth, Houston, and San Antonio markets (“Initial Service Areas”) for one year from the effective
date of the Agreement, unless terminated for any reason by either party with 90 days prior written notice. If the Agreement continues after the initial year period, the Parties agree to make Group available as a network provider in all other Texas
cities that Company and Group serve. 
 2) EFFECTIVE DATE: The Parties agree to use their best efforts to implement Group in the Initial Service
Areas as soon as possible but not until such time as Company has determined to its satisfaction that all regulatory, credentialing, operational and other requirements necessary to ensure a successful implementation have been met. 

3) JOINT MARKETING: The Parties agree to use best-efforts to work together to put together a marketing and roll-out plan within 30 days from the
execution of the Agreement to promote Group’s services to Company’s members in those areas described in the Geographic Scope provision above. 
 4) EXCLUSIVITY: So long as the Agreement is not terminated between the Parties, Group will agree to not participate in any other new payor’s networks in the Dallas-Fort Worth and Houston markets for
six (6) months from the Effective Date of the Agreement. In addition, Group agrees that it will extend the aforementioned exclusivity to other Texas cities outside of the geographic scope defined above for six (6) months, if Company is the
first payor to add Group to its network in other Texas cities that Group serves. Group also agrees that it will extend the aforementioned exclusivity to other cities outside of Texas for six (6) months, if Company is the first payor to add
Group to its network in cities outside of Texas that Group serves. This exclusivity provision will end twenty-four (24) months after the Effective Date of the Agreement. 
 5) CREDENTIALING: The Parties agree that all physicians and nurse practitioners of Group will be required to meet Company’s credentialing standards before they are allowed to provide covered services
to individuals enrolled or covered in a healthcare benefit plan underwritten or administered by Company (“Member”). Company will use its best efforts to expedite the credentialing process. 

6) PAYMENT TERMS AND CONDITIONS: 

(A) Period of Time Payment: 
 Notwithstanding the terms and conditions contained in the Services and Compensation Schedule, the Parties agree that in relation to the first visit for a Member, Company will pay Group [****]. For all
subsequent Group visits during the six month period after the date of the first visit, Group will file an electronic claim for each visit using CPT code 99212 and other CPT Codes as applicable for services and supplies provided by [****] Group
visits described above include generic prescription medications as more fully described in Attachment A, “Generics Provided by WhiteGlove.” 
 After the initial six (6) month period described above in paragraph A has elapsed, if a Member should again utilize Group’s services, Group will bill Company, and Company will pay for Group
visits during the next six month period in accordance with the reimbursement methodology set forth in paragraph A above regarding the initial visit and subsequent visits. This same reimbursement methodology will be followed by the parties for each
subsequent six month period in which a Member utilizes Group’s services. In the event Company overpays Group during a six month period in which a Member has utilized Group’s services, Group agrees to immediately refund such payments, as
applicable. 
 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has
been requested with respect to the omitted portions. 

  
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 (B) Services Included with Group’s Gold Membership: The Parties agree that
each Company Member will receive the services Group provides under its Group Gold membership program. Each Company Member shall receive the following Group services beginning on the date the Company Member receives an initial visit from a Group
representative for routine medical care: 
  

	 	•	 	 Affordable routine medical care, at work or home, 7 days a week, between 8am to 8pm. This includes face to face medical care, lab draws and generic
prescription medications described in Attachment A. 

  

	 	•	 	 Group may also provide at Group’s discretion and upon approval by Members selected services that are not Covered Benefits such as food items,
beverages and over-the-counter remedies. Group hereby agrees to indemnify and hold Company harmless from any and all claims, liabilities and third party causes of action associated with the provision of services that are not Covered Benefits.

  

	 	•	 	 Secure web access through Group’s systems to medical records, lab results, medical expenses, treatment records, and other information collected by
Group with Company Member’s authorization. Group shall comply with all state and federal laws related to the HIPAA Privacy rule regarding the maintenance of any such records. 

 

	 	•	 	 Follow-up calls or visits by Group to ascertain a Member’s medical progress, share lab results or other services commonly provided by medical
professionals. 

 (C) Services Excluded from with Group’s Gold Membership: 

 

	 	•	 	 Members shall pay Group their applicable in-network cost-sharing (specialist copays/deductibles/coinsurance). 

 

	 	•	 	 Labs services provided by Company participating labs will be paid in accordance with the agreement between Company and such participating lab.

  

	 	•	 	 Brand medications or other medications not listed in Attachment A not provided by Group or obtained by Group or the Member from a Company participating
pharmacy will be paid to the participating pharmacy in accordance with the agreement between Company and such participating pharmacy. 

 (D) Diagnostics: 
 Group shall send all lab specimens to the participating
lab of Company’s choice, initially Quest Diagnostics. Group shall direct or refer Members to specified participating providers for any appropriate services not provided by Group. 
 In the event of a conflict between the Agreement and this Addendum, the parties agree that this Addendum shall prevail and supercede the terms of such Agreement. In the event of a conflict between the
Agreement and applicable Federal and/or State law, the parties acknowledge that such Federal and/or State law shall prevail and supercede the terms of this Agreement. 

  
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 MEDICARE PROVIDER AMENDMENT 

Provider agrees to comply with all applicable Medicare laws, rules and regulations, including, without limitation, instructions issued by the Centers for
Medicare and Medicaid Services (“CMS”). Specifically, the following provisions are now part of the Agreement: 
  

	1.	Provider agrees to provide services to those persons who meet all eligibility requirements of the federal Medicare program and who have enrolled in Company’s
Medicare Plans (“Medicare Members”). 

  

	2.	Provider agrees to comply with all Medicare laws, rules and regulations, as well as Company requirements designed to ensure Company’s compliance with such laws,
rules and regulations, including, without limitation, laws, rules and regulations relating to the protection of Medicare Member privacy and confidentiality and the accuracy of Medicare Member health records. Provider agrees that all services and
other activities performed by Provider under the Agreement will be consistent and comply with Company’s obligations under its contract(s) with the Centers for Medicare and Medicaid Services (CMS) to offer Medicare Plans. Upon request, Provider
shall immediately provide to Company any information required by Company to meet its reporting obligations to CMS, including, where applicable, physician incentive plan information. Provider agrees to allow CMS and Company to monitor Provider’s
performance under this Agreement on an ongoing basis, in accordance with Medicare laws, rules and regulations. 

  

	3.	Provider acknowledges and agrees that all provisions of this Amendment and of the Agreement shall apply equally to any employees, independent contractors and
subcontractors of Provider who provide or may provide Covered Services to Medicare Members, and Provider represents and warrants that Provider shall take all steps necessary to cause such employees, independent contractors and subcontractors to
comply with this Amendment and the Agreement and all applicable laws and regulations, and perform all requirements applicable to Medicare programs. 

  

	4.	Except as set forth in the next sentence, Company agrees to pay Provider for Covered Services rendered to Medicare Members within forty-five (45) calendar days of
actual receipt by Company of a Clean Claim. Payments for non-capitated Covered Services rendered to Medicare Members are subject to any and all valid and applicable Medicare laws related to claims payment. With respect to Medicare Members, Provider
acknowledges that compensation under the Agreement for such Members constitutes receipt of federal funds. 

Provider shall pay on a timely basis all employees, independent contractors and subcontractors who render Covered Services to Medicare
Members for which Provider is financially responsible pursuant to the Agreement. 
  

	5.	Provider agrees to cooperate with and participate in internal and external review procedures necessary to process Medicare appeals and grievances.

  

	6.	For purposes of this Section 6, “risk adjustment date” shall have the meaning set forth in 42 C.F.R. Section 422.310(a), as may be amended from time
to time. Company is required to obtain risk adjustment data from Provider for Medicare Members, and Provider agrees to provide complete and accurate risk adjustment data to Company for Medicare Members that conforms to all standards and requirements
set forth in applicable laws, rules and regulations and/or CMS instructions that apply to risk adjustment data. Provider certifies, based on best knowledge, information and belief, that any risk adjustment data that Provider submits to Company for
Medicare Members is accurate, complete and truthful. Provider agrees to immediately notify Company if any risk adjustment data that was submitted to Company for Medicare Members is erroneous, and follow procedures established by Company to correct
erroneous risk adjustment data to ensure Company’s compliance with applicable laws, rules and regulations and CMS instructions. 

 Provider further agrees to maintain accurate, legible and complete medical record documentation for all risk adjustment data submitted to Company for Medicare Members in a format that meets all standards
and requirements set forth in applicable laws, rules, regulations and/or CMS instructions, and allows any federal 

  
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 governmental authorities with jurisdiction or their designees (“Government
Officials”) to: (1) confirm that the appropriate diagnoses codes and level of specificity are documented ; (2) verify the date of service is documented and within the risk adjustment data collection period; and (3) confirm that
the appropriate provider’s signature and credentials are present (“Medical Records”). 
 Provider agrees to
provide Company and Government Officials, or their designees, with medical records and any other information or documentation required by Government Officials for the validation of risk adjustment data (“Audit Data”). Provider agrees to
provide Company with Audit Data within the timeframe established by Company to ensure Company’s compliance with deadlines imposed by Government Officials for the submission of Audit Data. In the event that CMS conducts a review that includes
the validation of risk adjustment data submitted by Provider, Company will submit to Provider a copy of the CMS written notice of such review, along with a written request from Company for Audit Data. 

 

	7.	With respect to any Plan offered by Company to Medicare Members, Provider agrees to provide Company and federal, state and local governmental authorities having
jurisdiction, or their designees, upon request, access to all books, records and other papers (including, but not limited to, medical and financial records and contracts) and information relating to the Agreement and to those Covered Services
rendered by Provider and its employees, independent contractors and subcontractors to Medicare Members (“Information and Records”), and that this right of inspection, evaluation and audit will continue for the longer of: (i) a period
of ten (10) years from the end of the contract period of any government contract of Company, (ii) the date that the U.S. Department of Health and Human Services (HHS), the Comptroller General or their designees complete an audit, or
(iii) the period required under applicable laws, rules or regulations. With respect to any Plan offered by Company to Medicare Members, Provider also agrees to maintain Information and Records for the longer of: (i) ten (10) years
from the end of the contract period of any government contract of Company, (ii) the date HHS, the Comptroller General or their designees complete an audit, or (iii) the period required by applicable laws, rules or regulations. This
Section 7 shall survive the termination of the Agreement, regardless of the cause of the termination. 

  

	8.	Provider agrees to comply with the following, as applicable and as amended from time to time: Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973,
the Age Discrimination Act of 1975, HIPAA administrative simplification rules at 45 C.F.R. parts 160, 162, and 164, the Americans with Disabilities Act, Federal laws and regulations designed to prevent or ameliorate fraud, waste, and abuse,
including, but not limited to, applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. §§ 3729 et.seq.), and the anti-kickback statute (section 1128B(b) of the Social Security Act), and any other laws
applicable to recipients of Federal funds. 

  

	9.	In no event, including without limitation, non-payment by Company, insolvency of Company or breach of the Agreement or this Amendment, shall Provider bill, charge,
collect a deposit from, seek remuneration or reimbursement from, or have any recourse against a Medicare Member or persons (other than the Company) acting on a Medicare Member’s behalf for services covered by the Agreement. This provision shall
not prohibit collection of deductibles, coinsurance or copayments from Medicare Members in accordance with the terms of the Medicare Member’s agreement with Company. 

Provider further agrees that; (a) this provision shall survive termination of the Agreement and this Amendment regardless of the
cause giving rise to termination and shall be construed for the benefit of Medicare Members, and (b) this provision supersedes any oral or written agreement to the contrary now existing or hereafter entered into between Provider and a Medicare
Member or persons acting on a Medicare Member’s behalf. 
 No modification of this provision shall be effective without the
prior written approval of the appropriate state and/or federal regulatory entities. 
  

	10.	In the event of Company’s insolvency or other cessation of operations, Provider shall continue to provide Covered Services to (i) Medicare Members through the
period for which premium has been paid to Company, and (ii) those Medicare Members who are confined in an inpatient facility on the date of insolvency or other cessation of operations until medically appropriate discharge.

  
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	11.	Provider acknowledges that Company may only delegate activities or functions to Provider in a manner consistent with Medicare laws, rules and regulations. Provider
acknowledges and agrees that if any of Company’s activities or responsibilities under Company’s contract with CMS to offer Medicare Plans is delegated by Company to Provider, such activity or responsibility may be revoked if CMS or Company
determines that Provider has not performed satisfactorily. 

 Capitalized terms not otherwise defined herein shall have the
meaning given such terms in the Agreement. All terms of the Agreement not amended herein remain in full force and effect. If the terms of this Amendment conflict with any term of Agreement, the terms of this Amendment shall prevail. 

  
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 PRODUCT PARTICIPATION SCHEDULE 

Participation under this Physician Group Agreement will include the Aetna Products indicated below. Compensation for these products will be according to
the Services and Compensation Schedule attached to this Agreement. 
  

	•	 	 Gated Health Benefit Product – Commercial health benefit plan which contains a Primary Care Physician as a component of the Plan design
regardless of whether (i) selection of a Primary Care Physician is mandatory or voluntary under the terms of the Plan; or, (ii) an individual Member has selected a Primary Care Physician, Gated Health Benefit Products include but are not
limited to: HMO, QPOS, Elect Choice, Managed Choice POS, Aetna Choice POS II, and Aetna Select. 

  

	•	 	 Non-Gated Health Benefit Product – Commercial health benefit plan which does not allow for the designation and/or use of a Primary Care
Physician in the administration of the benefit Plan. Non-Gated Health Benefit Products include but are not limited to: Open Choice PPO and National Advantage. 

Many member ID cards include the National Advantage logo (NAP) in conjunction with Gated and non-Gated Health Benefit Products. In
those circumstances the rate applicable to other product (not NAP) on the ID card will apply. 
  

	•	 	 Government Programs – All plans offered by Company under any government contract serving Medicare, Medicaid and Children’s Health
Insurance Program beneficiaries. Government Programs include, but are not limited to: all Aetna Medicare Advantage HMO, PPO, POS and network-based private fee-for-service plans. 

Compensation for Government Programs may vary based upon the applicable products as specified in the Service and Compensation Schedule.

 As of the effective date of this Agreement, and until such time the Parties amend the Agreement otherwise, Group does
not participate in Medicaid, Children’s Health Insurance Program and Tricare. 
  

	•	 	 Non-Health Benefit Products – Including but not limited to: Aetna Workers’ Comp Access. 

As of the effective date of this Agreement, and until such time the Parties amend the Agreement otherwise, Group does not participate
in the Aetna Workers’ Comp Access product. 

  
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 SPECIALIST PHYSICIAN 

PARTICIPATION CRITERIA SCHEDULE 
  

	I.	BUSINESS CRITERIA 

  

	 	A.	Applicability 

  

	 	1.	These criteria shall apply to each applicant for participation and each Specialist Physician participating in Plans for the duration of the Agreement and shall be
enforced at the sole discretion of Company. 

  

	 	2.	The applicant must be certified by a Board recognized by the American Board of Medical Specialties or the American Osteopathic Association, unless the applicant meets
an exception under the Company’s Policy. All exceptions must be approved by the Aetna Medical Director or designee. 

  

	 	3.	If Specialist Physician is part of a group practice, all specialist physicians in the group must satisfy these Participation Criteria. If any physician in the group
does not satisfy these criteria, the group cannot participate. If a solo practitioner, the Specialist must continue to satisfy the participation criteria through the duration of the agreement. 

 

	 	4.	Each applicant must fully complete the participation application form and execute an individual provider addendum with Company. Each applicant and participating
Specialist Physician shall periodically supply to Company all requested information, including the confidential information forms. 

  

	 	C.	Coverage 

  

	 	1.	When applicable to the relevant Specialty, as determined by Company at its sole discretion, Specialist Physician shall ensure that twenty-four (24) hours-a-day
coverage for Members is arranged with another Company Participating Specialist Physician, except as otherwise provided in subsection 2 of this section. 

  

	 	2.	Inpatient coverage must be arranged with a Participating Physician who has privileges at the same hospital as the covering physician. 

 

	 	D.	Access 

  

	 	1.	Specialist Physician shall have a reliable twenty-four (24) hours, seven (7) days-a-week answering service or machine with a beeper or paging system. A recorded
message or answering service which refers Members to the emergency room is not acceptable. 

  

	 	2.	Group shall be available seven days a week from 8:00 am to 8:00 pm for scheduling appointments. 

 

	 	E.	Sanctions 

  

	 	1.	Specialist Physician must not have been indicted, arrested for, charged with or convicted (e.g., finding of guilt by a judge or jury, a plea of guilty or nolo
contendere, participation in a first offender program or any other such program which may be available as an alternative to proceeding with prosecution, whether or not the record has been closed or expunged) of a) any felony or b) any criminal
charge related to, or in any way impairing, Specialist’s practice of medicine. 

  
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	 	2.	A Specialist must have an unrestricted DEA certification, and where applicable, a state-mandated controlled drug certification. 

 

	 	3.	A Specialist shall not be: 

  

	 	(a)	suspended or debarred from participation in the Medicare or Medicaid programs; or 

	 	(b)	sanctioned by the Department of Health and Human Services Office of the Inspector General (DHHS-OIG); OR 

	 	(c)	debarred by the Office or Personnel Management (OPM). 

  

	 	II.	PROFESSIONAL COMPETENCE AND CONDUCT CRITERIA 

  

	 	A.	Professional Liability Claims History 

  

	 	1.	Specialist Physician must not have a history of professional liability claims, including, but not limited to, lawsuits, arbitration, mediation, settlements or
judgments, which in the view of the applicable peer review committee may raise concerns about possible future substandard professional performance, competence or conduct. 

 

	 	B.	History of Unprofessional Conduct/Unacceptable Business Practices 

  

	 	1.	Specialist Physician must not have engaged in any unprofessional conduct, unacceptable business practices or any other act or omission which in the view of the
applicable peer review committee may raise concerns about possible future substandard professional performance, competence or conduct. 

  

	 	C.	History of Involuntary Termination or Restrictions 

  

	 	1.	Specialist Physician must not have a history of involuntary termination (or voluntary termination during or in anticipation of an investigation or dismissal) of
employment or any other sort of engagement as a health care professional, reduction or restriction of duties or privileges, or of a contract to provide health care services, which in the view of the applicable peer review committee may raise
concerns about possible future substandard professional performance, competence or conduct. 

  

	 	D.	References 

  

	 	1.	Each applicant for participation must supply references as requested by the applicable Company peer review committee. 

 

	 	2.	The applicable Company peer review committee shall have the right to act on any reference or information received from a Specialist Physician’s colleagues.
Specialist Physician waives any and all rights to bring any legal action relating to such information or the collection or use thereof against Company, any Affiliates or related companies or any director, officer, employee or agent thereof, or any
person or entity providing a reference or information at the request of the applicable Company peer review committee. 

  
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 WhiteGlove House Call Health, Inc. 

 

 PROVIDER 
 PARTICIPATION CRITERIA SCHEDULE 
 FOR CERTIFIED NURSE PRACTITIONERS WITH
ADVANCED PRACTICE 
 REGISTERED NURSE STATUS 

 

	I.	BUSINESS CRITERIA 

  

	 	A.	Applicability 

  

	 	1.	 These criteria shall apply to each applicant for participation and each Nurse Practitioner participating in Plans for the duration of the Agreement and
shall be enforced at the sole discretion of Company1.

  

	 	2.	A Nurse Practitioner must (1) be a registered nurse, (2) have a minimum of a master’s degree in nursing, (3) have received post-graduate or graduate
education designed to prepare the provider in the specialty area for which the provider is applying and (4) be approved to practice as an independent provider as an advanced practice registered nurse by the Texas Board of Nursing.

  

	 	3.	The applicant must be certified by a nationally recognized professional organization authorized to certify the provider in his or her specialty area, unless the
applicant meets an exception under the Company’s Policy. All exceptions must be approved by the Company Medical Director. 

  

	 	4.	If Nurse Practitioner is part of a group practice, all providers and physicians in the group must satisfy these Participation Criteria. If any provider or physician in
the group does not satisfy these criteria the group cannot participate. In cases of sole practitioners, the Nurse Practitioner must continue to meet the participation criteria through the duration of the Agreement. 

 

	 	5.	Each applicant must fully complete the participation application form and execute an individual provider addendum with Company. Each applicant and participating Nurse
Practitioner shall periodically supply to Company all requested information, including the confidential information forms. 

  

	 	6.	Nurse Practitioner must be authorized by an Aetna Participating Physician to provide care within the scope of Texas Occupations Code, Chapter 157 as amended from time
to time. If Nurse Practitioner’s authorizing physician ceases to be an Aetna Participating Physician, or if Nurse Practitioner ceases to have an authorizing physician, then Nurse Practitioner shall immediately suspend providing care under this
Agreement. If the suspension continues for sixty (60) days, then Company may terminate this Agreement by notice to Nurse Practitioner. 

  

	 	C.	Coverage 

  

	 	1.	When applicable to the relevant Specialty, as determined by Company in its sole discretion, Nurse Practitioner shall ensure that twenty-four (24) hours-a-day
coverage for Members is arranged with another Company Participating Nurse Practitioner or Physician, except as otherwise provided in subsection 2 of this section. 

 

	 	2.	Inpatient coverage must be arranged with a Participating Provider or Participating Physician who has privileges at the same hospital as the covered provider or
physician. 

  

	 	D.	Access 

  

	 	1.	Nurse Practitioner shall have a reliable twenty-four (24) hours, seven (7) days-a-week answering 

 

	1 	 “Company” is defined in the opening paragraph of the Agreement. 

  
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 WhiteGlove House Call Health, Inc. 

 

	 	 
service or machine with a beeper or paging system. A recorded message or answering service which refers Members to the emergency room is not acceptable. 

 

	 	2.	Group shall be available seven days a week from 8:00 am to 8:00 pm for scheduling appointments. 

 

	 	E.	Sanctions 

  

	 	1.	Nurse Practitioner must not have been indicated, arrested for or charged with, or convicted (i.e., finding of guilt by a judge or jury, a plea of guilty or nolo
contendere, participation in a first offender program or any other such program which may be available as an alternative to proceeding with prosecution, whether or not the record has been closed or expunged) or a.) any felony or (b.) any criminal
charge related to, or in any way impairing Nurse Practitioner’s practice of medicine. 

  

	 	2.	A Nurse Practitioner must have an unrestricted DEA certification, and, where applicable, a state-mandated controlled drug certification. 

 

	 	3.	A Nurse Practitioner shall not be: 

  

	 	(a)	suspended or debarred from participation in the Medicare or Medicaid programs; or 

 

	 	(b)	sanctioned by the Department of Health and Human Services Office of the Inspector General (DHHS-OIG); or 

 

	 	(c)	debarred by the Office of Personnel Management (OPM). 

  

	II.	PROFESSIONAL CRITERIA 

  

	 	A.	Professional Liability Claims History 

  

	 	1.	Nurse Practitioner must not have a history of professional liability claims, including, but not limited to, lawsuits, arbitration, mediation, settlements or judgments,
which in the view of the applicable peer review committee may raise concerns about possible future substandard professional performance, competence or conduct. 

 

	 	B.	History of Unprofessional Conduct/Unacceptable Business Practices 

  

	 	1.	Nurse Practitioner must not have engaged in any unprofessional conduct, unacceptable business practices or any other act or omission which in the view of the applicable
peer review committee may raise concerns about possible future substandard professional performance, competence or conduct. 

  

	 	C.	History of Involuntary Termination or Restriction 

  

	 	1.	Nurse Practitioner must not have a history of involuntary termination (or voluntary termination during or in anticipation of an investigation or dismissal) of
employment or any other sort of engagement as a health care professional, or reduction or restriction of duties or previleges, or of a contract to provide health care services, which in the view of the applicable peer review committee may raise
concerns about possible future substandard professional performance, competence or conduct. 

  
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 WhiteGlove House Call Health, Inc. 

 

	E.	References 

  

	 	1.	Each applicant for participation must supply references as requested by the applicable Company peer review committee. 

 

	 	2.	The applicable Company peer review committee shall have the right to act on any reference or information received from a Nurse Practitioner’s colleagues. Nurse
Practitioner waives any and all rights to bring any legal action relating to such information or the collection or use thereof against Company, any Affiliates or related companies or any director, officer, employee or agent thereof, or any person or
entity providing a reference or information at the request of the applicable Company peer review committee. 

  
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 WhiteGlove House Call Health, Inc. 

 

 INDIVIDUAL PROVIDER ADDENDUM 

The undersigned health care provider (“Provider”), a member of WhiteGlove House Call Health, Inc. (“Entity”), has and
does hereby designate Entity as his/her attorney-in-fact for the purposes of negotiating, consenting to and executing the Physician Group Agreement (the “Agreement”), between Aetna Health Inc., a Texas corporation (“Company”) and
Entity and any documents related to amendments to the Agreement. Terms capitalized herein but not otherwise defined shall have the meanings ascribed to them in the Agreement. 
 Provider hereby acknowledges that Provider has reviewed the Agreement (a copy of which has been made available to Provider by Entity), under which Entity, on behalf of Provider, agrees to provide Covered
Services to Members enrolled in the Plans. Plans include any health benefit product or plan issued, administered, or serviced by Company or one of its Affiliates, including, but not limited to, HMO, preferred provider organization, indemnity,
Medicaid, Medicare and Worker’s Compensation. Provider hereby agrees to be bound by the terms and conditions of the Agreement, including, without limitation, compliance with the Participation Criteria applicable to Provider and all applicable
Company rules, policies and procedures. 
 Provider hereby agrees to seek compensation solely from Entity for services rendered
to Members under the terms of the Agreement, and shall in no event bill Company, its Affiliates, Payors, or Members for any such services (except for any Copayments, Coinsurance or Deductibles Members may be required to pay for certain Covered
Services). Provider further agrees that if the Member is enrolled in an HMO, then in no event, including but not limited to non-payment by the HMO, insolvency of the HMO or breach by the HMO of the Agreement, shall Provider bill, charge, collect a
deposit from, seek remuneration or reimbursement from, or have any recourse against a Member or persons acting on Member’s behalf for Covered Services. This provision shall not prohibit collection of Copayments, Coinsurance of Deductibles.
Provider further agrees that this provision shall be construed for the benefit of Members, shall supersede any oral or written agreement to the contrary now existing or hereafter entered into between Provider or Entity and a Member or any person
acting on behalf of a Member, and shall survive the termination of the Agreement, regardless of the cause giving rise to termination. 
 Provider hereby agrees that in the event: (i) Provider ceases to be a member of Entity; (ii) the Agreement expires or is terminated for any reason; (iii) the Entity is dissolved;
(iv) a voluntary or involuntary bankruptcy or a proposed settlement of outstanding debts under applicable reorganization or insolvency laws is filed by or against Entity, a receiver is appointed or Entity makes an assignment for the benefit of
creditors; or (v) the Entity otherwise ceases to exist, either voluntarily or involuntarily (each, a “ Triggering Event”), the terms of the Agreement shall, at Company’s option, survive with respect to Provider for the first nine
(9) months after such Triggering Event, in which case Provider shall continue to provide services to Members in accordance with the terms of the Agreement during said nine (9) month period. Provider agrees to take any and all actions necessary
to effectuate the intent of this paragraph, including executing an individual agreement for participation in Company’s provider network if so requested by Company. 
 IN WITNESS WHEREOF, the undersigned has executed this Individual Provider Addendum as of this      day of
            , 20    , intending to be legally bound hereby. 

 

			
	PROVIDER:	 	  

	PRINTED NAME:	 	  

  
 Page 36 of 45

 WhiteGlove House Call Health, Inc. 

 

 SERVICE AREA SCHEDULE 
 Provider’s services will be provided in all counties or other applicable service areas listed in the table below. 
 *Please indicate zip codes for those counties in which only partial coverage is available. In the absence of delineation of non-covered zip codes, it will be determined by Company that the entire
county is eligible for service. 
 Contracted rates apply to all eligible services rendered to Members in accordance with Company’s
policies and procedures, regardless of whether the counties or zip codes are listed on the table below. 
  

					
	 County
	 	 Zip codes covered/included
	 	 Zip codes excluded

	 Travis
	 	All	 	None
			
	 Hays
	 	All	 	None
			
	 Williamson
	 	All	 	None
			
	 Comal
	 	All	 	None
			
	 Bexar
	 	All	 	None
			
	 Dallas
	 	All	 	None
			
	 Tarrant
	 	All	 	None
			
	 Denton
	 	All	 	None
			
	 Collin
	 	All	 	None
			
	 Rockwall
	 	All	 	None
			
	 Harris
	 	All	 	None

  
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 WhiteGlove House Call Health, Inc. 

 

 Service and Billing Location Form 

Listed below is each participating provider* with the corresponding physical location, billing address and telephone numbers: 

*Upon written notice from Provider, Company may agree to add new or relocating facilities, locations or providers to existing Agreement upon
completion of applicable credentialing and satisfaction of all other requirements of Company. Other demographic information may be revised upon written notice from Provider. 

Provider Name: WhiteGlove House Call Health, Inc. 
  

							
	 Service Location Name
	 	 Billing Name

		 		 	 Electronic Billing Name 
 (as it appears on the submission)
	 	
				
	 Street
	 	 5300 Bee Cave Road
	 	Address	 	5300 Bee Cave Road
				
	 Suite #
	 	 Building One, Suite 100
	 	Suite #	 	Building One, Suite 100
				
	 City
	 	 Austin
	 	City	 	Austin
				
	 State, Zip
	 	 TX 78746
	 	State, Zip	 	TX 78746
				
	 Phone #
	 	 512-329-8081
	 	Phone #	 	512-329-8081
				
	 Fax #
	 		 	Fax #	 	
				
	 Email Address
	 		 	Email Address	 	
				
	 Tax ID#
	 	 20-8913858
	 	NPI	 	NPI Type:

 Company Use Only: PIN#
9477173 PVN# tbd 
  

							
	 Service Location Name
	 	 Billing Name

		 		 	 Electronic Billing Name

(as it appears on the submission)
	 	
				
	 Street
	 	 15950 N, Dallas Pkwy Tower II
	 	 Address
	 	 5300 Bee Cave Road

				
	 Suite #
	 	 Suite 457
	 	 Suite #
	 	 Building One, Suite 100

				
	 City
	 	 Dallas
	 	 City
	 	 Austin

				
	 State, Zip
	 	 TX 75248
	 	 State, Zip
	 	 TX 78746

				
	 Phone #
	 	 512-329-8081
	 	 Phone #
	 	 512-329-8081

				
	 Fax #
	 		 	 Fax #
	 	
				
	 Email Address
	 		 	 Email Address
	 	
	 Tax ID#
	 	 20-8913858
	 	 NPI
	 	 NPI Type:

 Company Use Only: PIN# 9477173 PVN# tbd 
  

							
	 Service Location Name
	 	 Billing Name

				
		 		 	 Electronic Billing Name

(as it appears on the submission)
	 	
				
	Street	 	9901 IH 10 West	 	Address	 	5300 Bee Cave Road
				
	Suite #	 	Suite 8053	 	Suite #	 	Building One, Suite 100
				
	City	 	San Antonio	 	City	 	Austin
				
	State, Zip	 	TX 78230	 	State, Zip	 	TX 78746
				
	Phone #	 	512-329-8081	 	Phone #	 	512-329-8081
				
	Fax #	 		 	Fax #	 	
				
	Email Address	 		 	Email Address	 	
				
	Tax ID#	 	20-8913858	 	NPI	 	NPI Type:

 Company Use Only: PIN#
9477173 PVN# tbd 

  
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 WhiteGlove House Call Health, Inc. 

 

 WHITEGLOVE 
 SERVICES AND COMPENSATION SCHEDULE 
 COMPENSATION: 

Payment Details: 
  

					
	 Service
	 	 Billing Codes
	 	 Rates

	Initial Patient Visit (to be billed only once every six months for a Member)	 	 CPT4 Codes:

99214
	 	[****]
			
	Subsequent Patient Visit	 	 CPT4 Codes:

99212
	 	[****]
			
	Strep A Assay W/optic	 	 CPT4 Codes:

87880
	 	[****]
			
	Immunology	 	 CPT4 Codes:

86308
	 	[****]
			
	Urinalysis	 	 CPT4 Codes:

81025
	 	[****]
			
	Remove Impacted Ear Wax	 	 CPT4 Codes:

69210
	 	[****]
			
	Routine Venipuncture Of Finger/he	 	 CPT4 Codes:

36415
	 	[****]
			
	Non-automated, Without Micro	 	 CPT4 Codes:

81002
	 	[****]
			
	Influenza Assay W/optic	 	 CPT4 Codes:

87804
	 	[****]
			
	Assay, Glucose, Blood Quant	 	 CPT4 Codes:

82947
	 	[****]
			
	Antibody	 	 CPT4 Codes:

86677
	 	[****]
			
	Drainage Of Skin Abscess	 	 CPT4 Codes:

10060
	 	[****]
			
	11750 Blood From Under Nail	 	 CPT4 Codes:

11740
	 	[****]
			
	Electrocardiogram, Complete	 	 CPT4 Codes:

93000
	 	[****]
			
	Td Adsorb-individual 7 Yrs/0	 	CPT4 Codes:	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 39 of 45

 WhiteGlove House Call Health, Inc. 

 

					
			
	 	 	90718	 	 
			
	Pneumococcal Vaccine	 	 CPT4 Codes:

90732
	 	[****]
			
	Flu Virus Vacc-split 3Yr & Above	 	 CPT4 Codes:

90658
	 	[****]
			
	Immunization Admin, Single	 	 CPT4 Codes:

90471
	 	[****]
			
	Tetanus, Diphtheria Toxoi	 	 CPT4 Codes:

90715
	 	[****]
			
	Immunization Admin-under 8 Y	 	 CPT4 Codes:

90465
	 	[****]
			
	Influenza Virus Vaccine	 	 CPT4 Codes:

90655
	 	[****]
			
	Influenza Virus Vaccine	 	 CPT4 Codes:

90656
	 	[****]
			
	Dtap Vaccine, Im	 	 CPT4 Codes:

90700
	 	[****]
			
	Dt Immunization, Im	 	 CPT4 Codes:

90702
	 	[****]
			
	Tetanus Toxoid Absorbed For	 	 CPT4 Codes:

90703
	 	[****]
			
	Tetanus And Diphtheria	 	 CPT4 Codes:

90714
	 	[****]
			
	Flu Vaccine, Nasal	 	 CPT4 Codes:

90660
	 	[****]
			
	Ther/proph/diag Inj, Sc/im	 	 CPT4 Codes:

96372
	 	[****]
			
	Pen G Benzath To 1200000/4mx	 	 HCPC Codes:

J0570
	 	[****]
			
	B-12 Cyanoc Upto 1000mcg/5mx	 	 HCPC Codes:

J3420
	 	[****]
			
	Dexamethasone Sodium Phos 1mg	 	 HCPC Codes:

J1100
	 	[****]
			
	Diphenhydr Hcl Upto 50mg/6mx	 	 HCPC Codes:

J1200
	 	[****]
			
	Ketorolac Trom Per 15mg/8mx	 	HCPC Codes:	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 40 of 45

 WhiteGlove House Call Health, Inc. 

 

					
			
		 	J1885	 	
			
	Metoclopra Hcl Upto 10mg/4mx	 	 HCPC Codes:

J2765
	 	[****]
			
	Odansetro Hcl Per 1mg/32 Mx	 	 HCPC Codes:

J2405
	 	[****]
			
	Orphenad Citr Upto 60mg/2 Mx	 	 HCPC Codes:

J2360
	 	[****]
			
	Ceftriaxon Sod Per 250mg/8mx	 	 HCPC Codes:

J0696
	 	[****]
			
	Medrxyprogester Inj 150 Mg	 	 HCPC Codes:

J1055
	 	[****]
			
	Methylpr Sod Upto 125mg/12mx	 	 HCPC Codes:

J2930
	 	[****]
			
	Fluorescein Angioscopy	 	 CPT4 Codes:

92230
	 	[****]
			
	Remove Foreign Body From Eye	 	 CPT4 Codes:

65205
	 	[****]
			
	Remove Foreign Body From Eye	 	 CPT4 Codes:

65220
	 	[****]
			
	Control Of Nosebleed	 	 CPT4 Codes:

30901
	 	[****]
			
	Airway Inhalation Treatm2	 	 CPT4 Codes:

94640
	 	[****]
			
	Aerosol Or Vapor Inhalat3	 	 CPT4 Codes:

94664
	 	[****]
			
	Ipratropium Brom Inh Sol/mg	 	 HCPC Codes:

J7644
	 	[****]
			
	Application Long Leg Splint	 	 CPT4 Codes:

29505
	 	[****]
			
	Application Lower Leg Splint	 	 CPT4 Codes:

29515
	 	[****]
			
	Apply Forearm Splint	 	 CPT4 Codes:

29125
	 	[****]
			
	Apply Long Arm Splint	 	 CPT4 Codes:

29105
	 	[****]
			
	Application Of Finger Splint	 	CPT4 Codes:	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 41 of 45

 WhiteGlove House Call Health, Inc. 

 

					
			
		 	29130	 	
			
	Removal Of Nail Plate	 	 CPT4 Codes:

11730
	 	[****]
			
	Removal Of Nail Bed	 	 CPT4 Codes:

11750
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16020
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16025
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16030
	 	[****]
			
	Wound(s) Care Non-select	 	 CPT4 Codes:

97602
	 	[****]
			
	Remove Foreign Body	 	 CPT4 Codes:

10120
	 	[****]
			
	Destruction Eg, Laser Surger	 	 CPT4 Codes:

17110
	 	[****]
			
	Bx Skin &/ Subq Tissue; 1 Le	 	 CPT4 Codes:

11100
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12001
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12002
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12004
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12011
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12013
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12014
	 	[****]
			
	Intmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12031
	 	[****]
			
	Intmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12032
	 	[****]
			
	Intmd Wnd Repair S/tr/ext	 	CPT4 Codes:	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 42 of 45

 WhiteGlove House Call Health, Inc. 

 

					
			
		 	12034	 	
			
	Intmd Wnd Repair N-hf/genit	 	 CPT4 Codes:

12041
	 	[****]
			
	Intmd Wnd Repair N-hg/genit	 	 CPT4 Codes:

12042
	 	[****]
			
	Intmd Wnd Repair N-hg/genit	 	 CPT4 Codes:

12044
	 	[****]
			
	Intmd Wnd Repair Face/mm	 	 CPT4 Codes:

12051
	 	[****]
			
	Intmd Wnd Repair Face/mm	 	 CPT4 Codes:

12052
	 	[****]
			
	Intmd Wnd Repair Face/mm	 	 CPT4 Codes:

12053
	 	[****]
			
	Supplies/special Equipment	 	 CPT4 Codes:

99070
	 	[****]
			
	All Services not otherwise identified	 		 	[****]

 SERVICES: 

Participating Group Provider will provide services in the Member’s home or work that are within the scope of and appropriate to the Participating
Group Provider’s license and certification to practice. Participating Group Provider will provide, as appropriate, the generic medicines outlined in Attachment. A – Generics Provided by WhiteGlove. In addition Participating Group Provider
may draw blood for lab tests; deliver lab tests to Company designated participating laboratories; Inform Member’s Primary Care Physician of lab and other results and services provided; and provide instruction to Member and/or caregiver.

 Participating Group Provider may also provide at Participating Group Provider’s discretion and upon approval by Member selected supplies
such as food items, beverages and over-the-counter remedies that are not considered Covered Services. 
 Participating Group Provider will
provide follow-up calls or visits by Participating Group Provider or Participating Group Provider’s representative to ascertain a Member’s medical progress, share lab results or other services commonly provided by medical professionals.

 COMPENSATION TERMS AND CONDITIONS: 
 General 
 a) Rates are inclusive of any applicable Member Copayment, Coinsurance or
Deductible. Procedures and/or services provided by WhiteGlove in accordance with this Agreement but not specifically listed above will not be reimbursed. No additional charges are allowed regardless of the time spent at the Member’s home, for
travel, 
 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been
requested with respect to the omitted portions. 

  
 Page 43 of 45

 WhiteGlove House Call Health, Inc. 

 

 administrative services, lab draws, generic medications outlined in Attachment A, miscellaneous supplies
that are not considered Covered Services, weekend, evening or holiday differentials. Company will pay the lesser of the contracted rate or eligible billed charges. 
 Billing 
  

	b)	Participating Group Provider must designate the codes set forth in this Compensation Schedule when billing. 

Coding 
  

	c)	Company utilizes nationally recognized coding structures including, but not limited to, Revenue Codes as described by the Uniform Billing Code, AMA Current Procedural
Terminology (CPT4), CMS Common Procedure Coding System (HCPCS), Diagnosis Related Groups (DRG), ICD-9 Diagnosis and Procedure codes, National Drug Codes (NDC) and the American Society of Anesthesiologists (ASA) relative values for the basic coding,
and description for the services provided. As changes are made to nationally recognized codes, Company will update internal systems to accommodate new codes. Such changes will only be made when there is no material change in the procedure itself.
Until updates are complete, the procedure will be paid according to the standards and coding set for the prior period. 

 Company will comply and utilize nationally recognized coding structures as directed under applicable Federal laws and regulations, including, without limitation, the Health Insurance Portability and
Accountability Act (HIPAA). 

  
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 WhiteGlove House Call Health, Inc. 

 

					
		 	 Attachment A-Generics
 Provided by WhiteGlove
	 	
	Acyclovir	 	Diltiazem	 	Metoclopramide
	Albuterol nebulizer soln	 	Doxazosin	 	Metoprolol Tartrate
	Albuterol	 	Doxepin HCL	 	Metronidazole
	Alendronate	 	Doxycycline Hyclate	 	Nadolol
	Allopurinol	 	Enalapril	 	Naproxen
	Amiloride-HCTZ	 	Enalapril-HCTZ	 	Neomycin/Polymyxin/Dexamethasone
	Amitriptyline	 	Erythromycin EC	 	Nortriptyline
	Amoxicillin	 	EST Estrogen/Methyl Testost	 	Nystatin
	Amoxil	 	Estradiol	 	Nystatin/Triamcin
	Antipyrine/Benzocaine otic	 	Estropipate	 	Oxybutynin
	Atenolol	 	Famotidine	 	Paroxetine
	Atenolol-Chiorthalidone	 	Fluconazole	 	Penicillin
	Atropine Sulfate	 	Flucinolone Acet	 	Phenazopyridine
	Bacitracin	 	Fluocinonide cream	 	Pilocarpine
	Baclofen	 	Fluoxetine	 	Pindolol
	Belladonna Alkaloid/PB	 	Fluphenazine	 	Piroxicam
	Benazepril	 	Furosemide	 	Polymyxin Sulfate/TMP
	Benzonatate	 	Gentamicin	 	Pravastatin
	Benzoyl Peroxide	 	Glimepiride	 	Prazosin HCL
	Benztropine	 	Glipizide	 	Prednisone
	Betamethasone Dipropionate	 	Glyburide	 	Prochlorperazine
	Betamethasone Valerate	 	Guanfacine	 	Promethazine DM Syrup
	Bisoprolol-HCTZ	 	Haloperidol	 	Propranolol
	Bumetanide	 	Hydralazine	 	Ranitidine
	Buspirone	 	Hydrochlorothiazide (HCTZ)	 	Salsalate
	Captopril	 	Hydrocortisone	 	Selenium Sulfide
	Carbamazepine	 	Ibuprofen	 	Silver Sulfadiazine
	Carvedilol	 	Indapamide	 	SMZ-TMP
	Cephalexin	 	Indomethacin	 	Sotalol HCL
	Ceron DM syrup	 	Ipratropium Nebulizer Soln	 	Spironolactone
	Chlorhexidine Gluconate	 	Isoniazid	 	Sprintec 2B-day tab
	Chlorpropamide	 	Isosorbide Mononitrate	 	Sulfacet Sodium
	Chlorthalidone	 	Lactulose syrup	 	Tamoxifen
	Cimetidine	 	Levobunolol	 	Terazosin
	Ciprofloxacin	 	Levothyroxine	 	Terbinafine
	Citalopram	 	Lidocaine	 	Tetracycline
	Clomiphene	 	Lisinopril	 	Thioridazine
	Clonidine	 	Lisinopril-HCTZ	 	Thiothixene
	Colchicine	 	Lithium Carbonate	 	Timolol Maleate
	C-Phen drops	 	Loratadine	 	Tobramycin
	Cyclobenzaprine	 	Lovastatin	 	Trazodone
	Cytra2	 	Medroxyprogesterone Acetate	 	Triamcinolone
	Dex PC syrup	 	Megestrol	 	Triamterene-HCTZ
	Dexamethasone	 	Meloxicam	 	Trihexyphenidyl
	Diclofenac DR	 	Metformin	 	Tri-Sprintec
	Dicyclomine	 	Methyldopa	 	Verapamil
	Digoxin	 	Methylpred	 	Warfarin

  
 Page 45 of 45

 

 

 January 27, 2010 
 WhiteGlove House Call Health, Inc 
 Attn: Suzanne Lawlor / Office Manager 

5300 Bee Caves Road, Bldg. 1, Suite 100 
 Austin,
TX 78746 
 Dear Suzanne: 
 Thank you
for continued participation in Aetna. 
 Attached is your countersigned Amendment. We are pleased that your organization will continue to be a
part of our network. The effective date of this new amendment is October 1, 2009. 
 Should you have any further questions, or need
additional information, please contact our Provider Service Center at 1-800-624-0756 for HMO-based benefits plans or 1-888-MD Aetna (632-3862) for indemnity or PPO-based benefits plans. 
 Thank you for your participation, and we look forward to our continued successful working relationship with you. 
 Sincerely, 
 /s/ Melissa Rodriguez 
 Melissa Rodriguez 
 Contract Negotiator 
 Enclosures: Amendment 

 WhiteGlove House Call Health, Inc. 

Effective Date: 10/01/2009 
  

 AMENDMENT 
 This Amendment (the “Amendment”) is made as of October 1, 2009 (the “Effective Date”), between Aetna Health Inc., a Texas corporation, on behalf of itself and its Affiliates
(hereinafter referred to as “Company”) and WhiteGlove House Call Health, Inc. (hereinafter referred to as “Group”). 

WHEREAS, Company and Group have entered into a Physician Group Agreement (“Agreement”) to provide health care services to members
enrolled in coverage plans issued or administered by Company; and 
 WHEREAS, the Parties “(as that term is defined in the
Agreement)” wish to amend the Agreement as of the Effective Date to add a reimbursement rate for the administration of the H1N1 vaccine as provided herein. 
 NOW, THEREFORE, in consideration of the mutual promises and undertakings contained herein, the parties agree to be legally bound as follows: 

 

	1.	The WhiteGlove Services and Compensation Schedule attached to the Agreement is deleted and replaced in its entirety by the attached WhiteGlove Services and Compensation
Schedule annexed hereto. 

  

	2.	All other terms and provisions of the Agreement not amended hereby shall remain in full force and effect. In the event of any inconsistency between the terms of this
Amendment and the Agreement, the terms of this Amendment shall govern and control. 

  

	3.	This Amendment may be signed in several counterparts, each of which will be deemed an original; however, all shall constitute one and the same Amendment.

 IN WITNESS WHEREOF, this Amendment has been duly executed by the authorized representatives of Company and Provider as
of the Effective Date. 
 Accepted By: 
  

									
	GROUP	 		 	COMPANY Aetna Health Inc., a Texas corporation
					
	By:	 	 /s/ William J. Kerley
	 		 	By:	 	 /s/ C. Carleton King

		 	(Signature)	 		 		 	(Signature)

									
					
	Printed Name:	 	 William J. Kerley
	 		 	Printed Name:	 	 C. Carleton King

	Title:	 	 CFO
	 		 	Title:	 	 President, Health Care Delivery-SE & SW

	Date:	 	 12-8-2009
	 		 	Date:	 	 12/21/09

	Tax I.D. Number:	 	 20-8913858
	 		 		 	

  
 Page 1 of 8

 WhiteGlove House Call Health, Inc. 

 

 WHITEGLOVE 
 SERVICES AND COMPENSATION SCHEDULE 
 COMPENSATION: 

Payment Details: 
  

					
	 Service
	 	 Billing Codes
	 	 Rates

			
	 Initial Patient Visit (to be billed
 only once every six months for a Member)
	 	 CPT4 Codes:

99214
	 	[****]
			
	Subsequent Patient Visit	 	 CPT4 Codes:

99212
	 	[****]
			
	Strep A Assay W/optic	 	 CPT4 Codes:

87880
	 	[****]
			
	Immunology	 	 CPT4 Codes:

86308
	 	[****]
			
	Urinalysis	 	 CPT4 Codes:

81025
	 	[****]
			
	Remove Impacted Ear Wax	 	 CPT4 Codes:

69210
	 	[****]
			
	Routine Venipuncture Of Finger/he	 	 CPT4 Codes:

36415
	 	[****]
			
	Non-automated, Without Micro	 	 CPT4 Codes:

81002
	 	[****]
			
	Influenza Assay W/optic	 	 CPT4 Codes:

87804
	 	[****]
			
	Assay, Glucose, Blood Quant	 	 CPT4 Codes:

82947
	 	[****]
			
	Antibody	 	 CPT4 Codes:

86677
	 	[****]
			
	Drainage Of Skin Abscess	 	 CPT4 Codes:

10060
	 	[****]
			
	11750 Blood From Under Nail	 	 CPT4 Codes:

11740
	 	[****]
			
	Electrocardiogram, Complete	 	 CPT4 Codes:

93000
	 	[****]

 [****] Certain information on this page has
been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 2 of 8

 WhiteGlove House Call Health, Inc. 

 

					
			
	Td Adsorb-individual 7 Yrs/o	 	 CPT4 Codes:

90718
	 	[****]
			
	Pneumococcal Vaccine	 	 CPT4 Codes:

90732
	 	[****]
			
	Flu Virus Vacc-split 3 Yr & Above	 	 CPT4 Codes:

90658
	 	[****]
			
	Immunization Admin, Single	 	 CPT4 Codes:

90471
	 	[****]
			
	Tetanus, Diphtheria Toxoi	 	 CPT4 Codes:

90715
	 	[****]
			
	Immunization Admin-under 8 Y	 	 CPT4 Codes:

90465
	 	[****]
			
	Influenza Virus Vaccine	 	 CPT4 Codes:

90655
	 	[****]
			
	Influenza Virus Vaccine	 	 CPT4 Codes:

90656
	 	[****]
			
	Dtap Vaccine, Im	 	 CPT4 Codes:

90700
	 	[****]
			
	Dt Immunization, Im	 	 CPT4 Codes:

90702
	 	[****]
			
	Tetanus Toxoid Absorbed For	 	 CPT4 Codes:

90703
	 	[****]
			
	Tetanus And Diphtheria	 	 CPT4 Codes:

90714
	 	[****]
			
	Flu Vaccine, Nasal	 	 CPT4 Codes:

90660
	 	[****]
			
	Ther/proph/diag Inj, Sc/im	 	 CPT4 Codes:

96372
	 	[****]
			
	Pen G Benzath To 1200000/4mx	 	 HCPC Codes:

J0570
	 	[****]
			
	B-12 Cyanoc Upto 1000mcg/5mx	 	 HCPC Codes:

J3420
	 	[****]
			
	Dexamethasone Sodium Phos1mg	 	 HCPC Codes:

J1100
	 	[****]
			
	Diphenhydr Hcl Upto 50mg/6mx	 	 HCPC Codes:

J1200
	 	[****]

 [****] Certain information on this page has
been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 3 of 8

 WhiteGlove House Call Health, Inc. 

 

					
			
	Ketorolac Trom Per 15mg/8mx	 	 HCPC Codes:

J1885
	 	[****]
			
	Metoclopra Hcl Upto 10mg/4mx	 	 HCPC Codes:

J2765
	 	[****]
			
	Odansetro Hcl Per 1mg/32 Mx	 	 HCPC Codes:

J2405
	 	[****]
			
	Orphenad Citr Upto 60mg/2 Mx	 	 HCPC Codes:

J2360
	 	[****]
			
	Ceftriaxon Sod Per 250mg/8mx	 	 HCPC Codes:

J0696
	 	[****]
			
	Medrxyprogester Inj 150 Mg	 	 HCPC Codes:

J1055
	 	[****]
			
	Methylpr Sod Upto 125mg/12mx	 	 HCPC Codes:

J2930
	 	[****]
			
	Fluorescein Angioscopy	 	 CPT4 Codes:

92230
	 	[****]
			
	Remove Foreign Body From Eye	 	 CPT4 Codes:

65205
	 	[****]
			
	Remove Foreign Body From Eye	 	 CPT4 Codes:

65220
	 	[****]
			
	Control Of Nosebleed	 	 CPT4 Codes:

30901
	 	[****]
			
	Airway Inhalation Treatm2	 	 CPT4 Codes:

94640
	 	[****]
			
	Aerosol Or Vapor Inhalat3	 	 CPT4 Codes:

94664
	 	[****]
			
	Ipratropium Brom Inh Sol/mg	 	 HCPC Codes:

J7644
	 	[****]
			
	Application Long Leg Splint	 	 CPT4 Codes:

29505
	 	[****]
			
	Application Lower Leg Splint	 	 CPT4 Codes:

29515
	 	[****]
			
	Apply Forearm Splint	 	 CPT4 Codes:

29125
	 	[****]
			
	Apply Long Arm Splint	 	 CPT4 Codes:

29105
	 	[****]

 [****] Certain information on this page has
been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 4 of 8

 WhiteGlove House Call Health, Inc. 

 

					
	Application Of Finger Splint	 	 CPT4 Codes:

29130
	 	[****]
			
	Removal Of Nail Plate	 	 CPT4 Codes:

11730
	 	[****]
			
	Removal Of Nail Bed	 	 CPT4 Codes:

11750
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16020
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16025
	 	[****]
			
	Dressings And/or Debridement	 	 CPT4 Codes:

16030
	 	[****]
			
	Wound(s) Care Non-select	 	 CPT4 Codes:

97602
	 	[****]
			
	Remove Foreign Body	 	 CPT4 Codes:

10120
	 	[****]
			
	Destruction Eg, Laser Surger	 	 CPT4 Codes:

17110
	 	[****]
			
	Bx Skin &/ Subq Tissue; 1 Le	 	 CPT4 Codes:

11100
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12001
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12002
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12004
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12011
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12013
	 	[****]
			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12014
	 	[****]
			
	Intmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12031
	 	[****]
			
	Intmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12032
	 	[****]

 [****] Certain information on this page has
been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 5 of 8

 WhiteGlove House Call Health, Inc. 

 

					
	Intmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12034
	 	[****]
			
	Intmd Wnd Repair N-hf/genit	 	 CPT4 Codes:

12041
	 	[****]
			
	Intmd Wnd Repair N-hg/genit	 	 CPT4 Codes:

12042
	 	[****]
			
	Intmd Wnd Repair N-hg/genit	 	 CPT4 Codes:

12044
	 	[****]
			
	Intmd Wnd Repair Face/mm	 	 CPT4 Codes:

12051
	 	[****]
			
	Intmd Wnd Repair Face/mm	 	 CPT4 Codes:

12052
	 	[****]
			
	Intmd Wnd Repair Face/mm	 	 CPT4 Codes:

12053
	 	[****]
			
	Supplies/special Equipment	 	 CPT4 Codes:

99070
	 	[****]
			
	Immune Admin H1n1 Im/nasal	 	 CPT4 Codes:

90470
	 	[****]
			
	All Services not otherwise identified	 		 	[****]

 SERVICES: 

Participating Group Provider will provide services in the Member’s home or work that are within the scope of and appropriate to the Participating
Group Provider’s license and certification to practice. Participating Group Provider will provide, as appropriate, the generic medicines outlined in Attachment A – Generics Provided by WhiteGlove. In addition Participating Group Provider
may draw blood for lab tests; deliver lab tests to Company designated participating laboratories; inform Member’s Primary Care Physician of lab and other results and services provided; and provide instruction to Member and/or caregiver.

 Participating Group Provider may also provide at Participating Group Provider’s discretion and upon approval by Member selected supplies
such as food items, beverages and over-the-counter remedies that are not considered Covered Services. 
 Participating Group Provider will
provide follow-up calls or visits by Participating Group Provider or Participating Group Provider’s representative to ascertain a Member’s medical progress, share lab results or other services commonly provided by medical professionals.

 COMPENSATION TERMS AND CONDITIONS: 
 Definitions 
 [****] Certain information on this page has been omitted and filed separately
with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

  
 Page 6 of 8

 WhiteGlove House Call Health, Inc. 

 

 “Aetna Market Fee Schedule” (AMFS) is the fee schedule that is geographically based and
dependent upon contracted location where service is performed. The fee schedule is updated annually. 
 General 

a) Rates are inclusive of any applicable Member Copayment, Coinsurance or Deductible. Procedures and/or services provided by WhiteGlove in accordance with
this Agreement but not specifically listed above will not be reimbursed. No additional charges are allowed regardless of the time spent at the Member’s home, for travel, administrative services, lab draws, generic medications outlined in
Attachment A, miscellaneous supplies that are not considered Covered Services, weekend, evening or holiday differentials. Company will pay the lesser of the contracted rate or eligible billed charges. 

Billing 
  

	b)	Participating Group Provider must designate the codes set forth in this Compensation Schedule when billing. 

Coding 
  

	c)	Company utilizes nationally recognized coding structures including, but not limited to, Revenue Codes as described by the Uniform Billing Code, AMA Current Procedural
Terminology (CPT4), CMS Common Procedure Coding System (HCPCS), Diagnosis Related Groups (DRG), ICD-9 Diagnosis and Procedure codes, National Drug Codes (NDC) and the American Society of Anesthesiologists (ASA) relative values for the basic coding,
and description for the services provided. As changes are made to nationally recognized codes, Company will update internal systems to accommodate new codes. Such changes will only be made when there is no material change in the procedure itself.
Until updates are complete, the procedure will be paid according to the standards and coding set for the prior period. 

 Company will comply and utilize nationally recognized coding structures as directed under applicable Federal laws and regulations, including, without limitation, the Health Insurance Portability and
Accountability Act (HIPAA). 
 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential
treatment has been requested with respect to the omitted portions. 

  
 Page 7 of 8

 WhiteGlove House Call Health, Inc. 

 

 Attachment A-Generics 

Provided by WhiteGlove 
  

					
	Acyclovir	  	Diltiazem	  	Metoclopramide
	Albuterol nebulizer soln	  	Doxazosin	  	Metoprolol Tartrate
	Albuterol	  	Doxepin HCL	  	Metronidazole
	Alendronate	  	Doxycycline Hyclate	  	Nadolol
	Allopurinol	  	Enalapril	  	Naproxen
	Amiloride-HCTZ	  	Enalapril-HCTZ	  	Neomycin/Polymyxin/Dexamethasone
	Amitriptyline	  	Erythromycin EC	  	Nortriptyline
	Amoxicillin	  	EST Estrogen/Methyl Testost	  	Nystatin
	Amoxil	  	Estradiol	  	Nystatin/Triamcin
	Antipyrine/Benzocaine otic	  	Estropipate	  	Oxybutynin
	Atenolol	  	Famotidine	  	Paroxetine
	Atenolol-Chlorthalidone	  	Fluconazole	  	Penicillin
	Atropine-Sulfate	  	Fluocinolone Acet	  	Phenazopyridine
	Bacitracin	  	Fluocinonide cream	  	Pilocarpine
	Baclofen	  	Fluoxetine	  	Pindolol
	Belladonna Alkaloid/PB	  	Fluphenazine	  	Piroxicam
	Benazepril	  	Furosemide	  	Polymyxin Sulfate/TMP
	Benzonatate	  	Gentamicin	  	Pravastatin
	Benzoyl Peroxide	  	Glimepiride	  	Prazosin HCL
	Benztropine	  	Glipizide	  	Prednisone
	Betamethasone Dipropionate	  	Glyburide	  	Prochlorperazine
	Betamethasone Valerate	  	Guanfacine	  	Promethazine DM Syrup
	Bisoprolol-HCTZ	  	Haloperidol	  	Propranolol
	Bumetanide	  	Hydralazine	  	Ranitidine
	Buspirone	  	Hydrochlorothiazide (HCTZ)	  	Salsalate
	Captopril	  	Hydrocortisone	  	Selenium Sulfide
	Carbamazepine	  	Ibuprofen	  	Silver Sulfadiazine
	Carvedilol	  	Indapamide	  	SMZ-TMP
	Cephalexin	  	Indomethacin	  	Sotalol HCL
	Ceron DM syrup	  	Ipratropium Nebulizer Soln	  	Spironolactone
	Chlorhexidine Gluconate	  	Isoniazid	  	Sprintec 28-day tab
	Chlorpropamide	  	Isosorbide Mononitrate	  	Sulfacet Sodium
	Chlorthalidone	  	Lactulose syrup	  	Tamoxifen
	Cimetidine	  	Levobunolol	  	Terazosin
	Ciprofloxacin	  	Levothyroxine	  	Terbinafine
	Citalopram	  	Lidocaine	  	Tetracycline
	Clomiphene	  	Lisinopril	  	Thioridazine
	Clonidine	  	Lisinopril-HCTZ	  	Thiothixene
	Colchicine	  	Lithium Carbonate	  	Timolol Maleate
	C-Phen drops	  	Loratadine	  	Tobramycin
	Cyclobenzaprine	  	Lovastatin	  	Trazodone
	Cytra2	  	Medroxyprogesterone Acetate	  	Triamcinolone
	Dex PC syrup	  	Megestrol	  	Triamterene-HCTZ
	Dexamethasone	  	Meloxicam	  	Trihexyphenidyl
	Diclofenac DR	  	Metformin	  	Tri-Sprintec
	Dicyclomine	  	Methyldopa	  	Verapamil
	Digoxin	  	Methylpred	  	Warfarin

  
 Page 8 of 8

 

 

 January 27, 2010 
 WhiteGlove House Call Health, Inc. 
 Attn: Suzanne Lawlor / Office Manager 

5300 Bee Caves Road, Bldg. 1, Suite 100 
 Austin,
TX 78746 
 Dear Suzanne: 
 Thank you
for continued participation in Aetna. 
 Attached is your countersigned Amendment. We are pleased that your organization will continue to be a
part of our network. The effective date of this new amendment is December 11, 2009. 
 Should you have any further questions, or
need additional information, please contact our Provider Service Center at 1-800-624-0756 for HMO-based benefits plans or 1-888-MD Aetna (632-3862) for indemnity or PPO-based benefits plans. 
 Thank you for your participation, and we look forward to our continued successful working relationship with you. 
 Sincerely, 
 /s/ Melissa Rodriguez 
 Melissa Rodriguez 
 Contract Negotiator 
 Enclosures: Amendment 

 WhiteGlove House Call Health, Inc. 

Effective Date: 12/11/2009 
  

 AMENDMENT 
 This Amendment is made as of December 11, 2009 (Effective Date), between Aetna Health Inc., a Texas corporation, on behalf of itself and its Affiliates (hereinafter referred to as
“Company”) and WhiteGlove House Call Health, Inc., (hereinafter referred to as “Groupr”). 
 WHEREAS, the parties
have entered into a Provider Group Agreement (“Agreement”) to provide health care services to Members; 
 WHEREAS, the parties wish to
amend the Agreement to exclude Group’s participation in Company’s Government Programs; and 
 NOW, THEREFORE, in consideration
of the mutual promises and undertakings contained herein, the parties agree to be legally bound as follows: 
  

	1.	The Product Participation Schedule of the Agreement is hereby deleted and replaced in its entirety with the attached Product Participation Schedule.

  

	2.	All other terms and provisions of the Agreement not amended hereby shall remain in full force and effect. In the event of any inconsistency between the terms of
this Amendment and the Agreement, the terms of this Amendment shall govern and control. 

 IN WITNESS WHEREOF, the parties
have caused this Amendment to be executed below. 
 Accepted By: 

 

									
	GROUP WhiteGlove House Call Health, Inc.	 		 	COMPANY Aetna Health Inc., a Texas corporation
					
	By:	 	 /s/ William J. Kerley
	 		 	By:	 	 /s/ C. Carleton King

		 	(Signature)	 		 		 	(Signature)
					
	Printed Name:	 	 William J. Kerley
	 		 	Printed Name:	 	 C. Carleton King

					
	Title:	 	 CFO
	 		 	Title:	 	 President, Health Care Delivery-SE & SW

					
	Date:	 	 12-8-2009
	 		 	Date:	 	 12/21/09

					
	Tax I.D. Number:	 	 20-8913858
	 		 		 	

  
 Page 1 of 2

 WhiteGlove House Call Health, Inc. 

Effective Date: 12/11/2009 
  

 PRODUCT PARTICIPATION SCHEDULE 

Participation under this Provider Group Agreement will include the Aetna Products indicated below. Compensation for these products will be according to
the Services and Compensation Schedule attached to this Agreement. 
  

	•	 	 Gated Health Benefit Product – Commercial health benefit plan which contains a Primary Care Physician as a component of the Plan design
regardless of whether (i) selection of a Primary Care Physician is mandatory or voluntary under the terms of the Plan; or, (ii) an individual Member has selected a Primary Care Physician. Gated Health Benefit Products include but are not
limited to: HMO, QPOS, Elect Choice, Managed Choice POS, Aetna Choice POS II, and Aetna Select. 

  

	•	 	 Non-Gated Health Benefit Product – Commercial health benefit plan which does not allow for the designation and/or use of a Primary Care
Physician in the administration of the benefit Plan. Non-Gated Health Benefit Products include but are not limited to: Open Choice PPO and National Advantage. 

Many member ID cards include the National Advantage logo (NAP) in conjunction with Gated and non-Gated Health Benefit Products. In
those circumstances the rate applicable to other product (not NAP) on the ID card will apply. 
  

	•	 	 Government Programs – All plans offered by Company under any government contract serving Medicare, Medicaid and Children’s Health
Insurance Program beneficiaries. Government Programs include, but are not limited to: all Aetna Medicare Advantage HMO, PPO, POS and network-based private fee-for-service plans. 

As of the effective date of this Amendment, Group does not participate in any Government Program plan offerings by Company; however,
Group participation status with Government Programs may change in accordance with the ‘Product Participation’ section of this Agreement. 
  

	•	 	 Non-Health Benefit Products – Including but not limited to: Aetna Workers’ Comp Access. 

As of the effective date of this Agreement, and until such time the Parties amend the Agreement otherwise, Group does not participate
in the Aetna Workers’ Comp Access product. 

  
 Page 2 of 2

 WhiteGlove House Call Health, Inc. 

Effective Date: 11/01/2010 
  

 AMENDMENT 
 This Amendment is made as of November 1, 2010 (Effective Date), between Aetna Health Inc., a Texas corporation, on behalf of itself and its Affiliates (hereinafter referred to as “Company”)
and WhiteGlove House Call Health, Inc., a Texas corporation (hereinafter referred to as “Group”). 
 WHEREAS, the parties have
entered into a Physician Group Agreement (“Agreement”) to provide health care services to Members 
 WHEREAS, the parties wish
to amend the Agreement to amend Group’s participation status such that Group shall participate in all Full Risk Plans and only specific agreed upon Plan Sponsor Plans; and 
 WHEREAS, the parties have agreed to provide transitional benefits for no more than six (6) months to Members of non Full Risk Plans who have obtained health care services from Group prior to
the effective date of this Amendment, as more fully described in Paragraph 3 below; 
 NOW, THEREFORE, in consideration of the mutual
promises and undertakings contained herein, the parties agree to be legally bound as follows: 
  

	1.	Group’s participation status is hereby amended, such that Group shall participate in all Full Risk Plans and only specific agreed upon Plan Sponsor Plans,
as defined in Paragraph 3 below. 

  

	2.	Section 1.24 Member is hereby deleted and replaced in its entirety with the following: 

1.24 Member. An individual covered by or enrolled in a Full Risk Plan or Plan Sponsor Plan. 

 

	3.	Section 1.30 Plan Sponsor is hereby deleted and replaced in its entirety with the following: 

1.30 Plan Sponsor. An employer, insurer, third party administrator, labor union, organization or other person or entity which has
contracted with Company to offer, issue and/or administer a Plan that is not a Full Risk Plan and has agreed to be responsible for funding benefit payments for Covered Services provided to Members under the terms of a Plan. As of the effective date
of this Amendment, the following are considered Plan Sponsors: Dallas Area Rapid Transport and Parkland Health & Hospital System. 
  

	4.	“Section 6.5.1.1 Transitional Benefit Obligations for non- Full Risk Plan Members No Longer Covered Under This Agreement” is hereby added to the Agreement and
made a part hereof: 

 6.5.1.1 Transitional Benefit Obligations for non- Full Risk Plan Members No Longer
Covered Under This Agreement. Upon the effective date of this Amendment, for non- Full Risk Plan Members, excluding Members of Dallas Area Rapid Transport and Parkland Health & Hospital System, Group and Participating Group Providers
shall continue to provide health care services to non- Full Risk Plan Members no longer covered under this Agreement so long as such Member obtained health care services from Group prior to the effective date of this Amendment. Group shall be
obligated to provide health care services for six months following the date of the first visit prior to the effective date of this Amendment in which the non- Full Risk Plan Member initially obtained health care services. 

 

	5.	The WhiteGlove Services and Compensation Schedule of the Agreement only applies to the following Plan Sponsors: Dallas Area Rapid Transport and Parkland
Health & Hospital System. The attached Capitation Services and Compensation Schedule is hereby added to the Agreement and made a part hereof and shall apply to all Company Full Risk Plan Members. 

 

	6.	All other terms and provisions of the Agreement not amended hereby shall remain in full force and effect. In the event of any inconsistency between the terms of this
Amendment and the Agreement, the terms of this Amendment shall govern and control. 

  
 Page 1 of 12

 WhiteGlove House Call Health, Inc. 

Effective Date: 11/01/2010 
  

 IN WITNESS WHEREOF, the parties have caused this Amendment to be executed below. 

Accepted By: 
  

									
	GROUP	 		 		 	COMPANY	 	Aetna Health Inc., a Texas corporation
					
	By:	 	 /s/ ROBERT FABBIO
	 		 	By:	 	 /s/ C. Carleton King

		 	(Signature)	 		 		 	(Signature)
	Printed Name:	 	ROBERT FABBIO	 		 	Printed Name:	 	C. Carleton King
	Title:	 	CEO	 		 	Title:	 	Head of Natl Networks and Contracting Services
	Date:	 	9/28/10	 		 	Date:	 	10-6-10
	Tax I.D. Number:	 	20-8913858	 		 		 	

  
 Page 2 of 12

 WhiteGlove House Call Health, Inc. 

Effective Date: 11/01/2010 
  

 CAPITATED 
 SERVICES AND COMPENSATION SCHEDULE 
  

	I.	General Terms and Conditions. 

  

	 	A.	Terms. 

  

	 	1.	Billable Services. Covered Services which are paid on a fee-for-service basis rather than included in capitation pursuant to a capitation arrangement. Under this
Agreement there are no Group billable services for Company Full Risk Plan Members. 

  

	 	2.	Capitation. A fixed amount, paid monthly by the Company for each Member. Capitation constitutes payment for the services as outlined in section 6 of the Addendum
to the Agreement. Capitation will include only Full Risk Plan Membership. Capitation payments shall be calculated using the prior month membership. The first capitation payment shall be made December 2010 (for the month of November with accurate
November counts) and monthly thereafter. 

  

	 	3.	Member Co-payments. Co-payments are specified in Members’ Plan documents and are the Member’s obligation. The Member’s Co-payment shall be the
specialist physician copay. 

  

	 	B.	Conditions. 

  

	 	1.	Company utilizes nationally recognized coding structures including, but not limited to, Revenue Codes as described by the Uniform Billing Code, AMA Current Procedural
Terminology (CPT4), CMS Common Procedure Coding System (HCPCS), Diagnosis Related Groups (DRG), ICD-9 (ICD-10 or successor standard) Diagnosis and Procedure Codes, National Drug Codes (NDC) and the American Society of Anesthesiologists (ASA)
relative values for the basic coding, and description for the services provided. As changes are made to nationally recognized codes, Company will update internal systems to accommodate new codes. Such updates may include changes to Service
Groupings. Such changes will only be made when there is no material change in the procedure itself. Until updates are complete, the procedure will be paid according to the standards and coding set for the prior period. 

Company will comply and utilize nationally recognized coding structures as directed under applicable Federal laws and regulations,
including, without limitation, the Health Insurance Portability and Accountability Act (HIPAA). 
 The use of ICD-10 coding
shall not impact the aggregate rates and compensation intended by the parties as set forth in this Services and Compensation Schedule. Consequently, in the event that use of ICD-10 codes result in aggregate payments that would differ from the
aggregate payments that would have resulted based on ICD-9 coding (excluding utilization and validated case mix severity changes), the rates set forth in this Services and Compensation Schedule will be reviewed by Company periodically and adjusted
at least annually in order to reflect what would have been paid had ICD-9 coding been utilized for determination of the payments. 

  
 Page 3 of 12

 WhiteGlove House Call Health, Inc. 

Effective Date: 11/01/2010 
  

	II.	Full Risk Plans. 

  

	 	1.	Compensation for the Full Risk Plan products is as follows: 

																													
	 Capitation Rate For
	  	$	0.08	  	  	$	0.15	  	  	$	0.225	  	  	$	0.30	  	  	$	0.375	  	  	$	0.45	  	  	$	0.525	  
	 Full Risk Plan Member per Month Visit Range per Quarter
	  	 
 
 	Less than
600
visits	  
  
  	  	 
 
 	601 visits
through 1,200
visits	  
  
  	  	 
 
 	1,201 visits
through 1,800
visits	  
  
  	  	 
 
 	1,801 visits
through 2,400
visits	  
  
  	  	 
 
 	2,401 visits
through 3,000
visits	  
  
  	  	 
 
 	3,001 visits
through 3,600
visits	  
  
  	  	 
 
 	3,601 visits
through 4,200
visits	  
  
  

 In the event visits exceed [****] visits per quarter, the per member per month capitation rate shall increase by [****] pmpm for each incremental increase of [****] per quarter in the same pattern as the
rates outlined above. 
 The parties shall review the number of visits provided within a quarter within sixty (60) days of
the close each quarter. In the event the capitation rate for any quarter requires adjustment due to the actual number of visits provided, Company shall reimburse Group any underpayments and Group shall reimburse Company any overpayments. 

 

	2.	Retroactive Adjustments for Capitation Payments. Payments to Group in accordance with this Agreement shall not be subject to retroactive adjustments resulting
from additions and deletions of Full Risk Plan Members because Capitation Payments are made after the end of each month pursuant to section A.2 above. 

  

	3.	Per Visit Rate 

Recognizing Group’s desire to receive a capitation payment in lieu of fee for service payments the parties have agreed to prospective
capitation payments as outline above. Recognizing Company’s desire to ensure that services are provided for the capitation rate, the parties agree to a minimum [****] rate and a maximum [****]. The actual per visit rate shall be calculated
during the quarterly review of the capitation rate and [****]. 
 In the event the calculated per visit rate is less than [****]
Company shall reimburse Group the difference between the calculated visit rate and [****]. 
 In the event the calculated per
visit rate is greater than [****] Group shall reimburse Company the difference between the calculated rate and [****]. 
  

	4.	Performance Guarantee 

The parties enter into this Agreement with the intent of providing Full Risk Plan Members alternatives to primary care physician, urgent
care center, freestanding emergency center and hospital emergency departments for routine care. The parties agree to the following performance parameters. 
  

	 	(i)	Reduction in freestanding emergency center and hospital emergency department visits by Members who have used Group’s services. 

 

	 	(a)	Company shall identify all Full Risk Plan Members who have obtained services, within three hundred and sixty five days of the date Company runs its report from Group
(the “Group Members”), and have one or more visits to a freestanding emergency center or a hospital emergency department and the related diagnoses for such visits. 

 

	 	(b)	Company shall identify those diagnoses that require services that could have been provided by Group as an alternative to the freestanding emergency center or hospital
emergency department. 

  

	 	(c)	In the event the number of claims with a diagnoses related to a service that could have been provided by Group is greater than ten percent of the overall number of
freestanding emergency center and hospital emergency department claims for Group Members, Group shall refund to Aetna the at risk capitation payment amount identified below. 

 [****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

  
 Page 4 of 12

 WhiteGlove House Call Health, Inc. 

Effective Date: 11/01/2010 
  

 (ii) Group services are accessed by Full Risk Plan Members when access to a Primary Care
Physician is unlikely and the Full Risk Plan Members alternative would be to go to an Urgent Care Center or hospital emergency department. 
 (a) Group shall capture the days and times when a Full Risk Plan Member obtains services from Group 
 (b) Group shall provide an annual report, twelve (12) months following the Effective Date (and annually thereafter), identifying the percentage of Full Risk Plan Members accessing Group’s
services between the hours of 8:00 a.m. and 10:00 a.m. and after 3:00 p.m. Monday through Friday and 8:00 a.m. through 8:00 p.m. Saturday and Sunday and such percentage shall be in excess of fifty-five percent of the overall visits. 

(iii) Full Risk Plan Members use Group services in lieu of obtaining services at an emergency room. 

(a) Group shall survey Full Risk Plan Members and ask the following question: “Would you have gone to the ER, if WhiteGlove were not
available today?” 
 (b) Group shall provide an annual report, twelve (12) months following the Effective Date (and
annually thereafter), identifying the percentage of Full Risk Members responding affirmatively and such percentage shall be in excess of forty five percent for those Full Risk Members obtaining services from Group when the Full Risk Plan
Member’s primary care physician is not available. 
 The above performance measures shall be measured annually, twelve
(12) months following the Effective Date (and annually thereafter). In the event Group does not meet all the goals established for the above three performance measures, Group shall repay Company [****]. 

[****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect
to the omitted portions. 

  
 Page 5 of 12

 WhiteGlove House Call Health, Inc. 

 

 WHITEGLOVE 
 SERVICES AND COMPENSATION SCHEDULE 
 (DART/PARKLAND CUSTOMER SPECIFIC
NETWORK ONLY) 
 COMPENSATION: 
 Payment Details: 
  

					
	 Service
	 	 Billing Codes
	 	 Rates

	Initial Patient Visit (to be billed only once every six months for a Member)	 	 CPT4 Codes:

99214
	 	[****]
			
	Subsequent Patient Visit	 	 CPT4 Codes:

99212
	 	[****]
			
	Strep A Assay W/optic	 	 CPT4 Codes:

87880
	 	[****]
			
	Immunology	 	 CPT4 Codes:

86308
	 	[****]
			
	Urinalysis	 	 CPT4 Codes:

81025
	 	[****]
			
	Remove Impacted Ear Wax	 	 CPT4 Codes:

69210
	 	[****]
			
	Routine Venipuncture Of Finger/he	 	 CPT4 Codes:

36415
	 	[****]
			
	Non-automated, Without Micro	 	 CPT4 Codes:

81002
	 	[****]
			
	Influenza Assay W/optic	 	 CPT4 Codes:

87804
	 	[****]
			
	Assay, Glucose, Blood Quant	 	 CPT4 Codes:

82947
	 	[****]
			
	Antibody	 	 CPT4 Codes:

86677
	 	[****]
			
	Drainage Of Skin Abscess	 	 CPT4 Codes:

10060
	 	[****]
			
	11750 Blood From Under Nail	 	 CPT4 Codes:

11740
	 	[****]
			
	Electrocardiogram, Complete	 	 CPT4 Codes:

93000
	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 6 of 12

 WhiteGlove House Call Health, Inc. 

 

					
	Td Adsorb-individual 7 Yrs/o	 	 CPT4 Codes:

90718
	 	[****]
			
	Pneumococcal Vaccine	 	 CPT4 Codes:

90732
	 	[****]
			
	Flu Virus Vacc-split 3 Yr & Above	 	 CPT4 Codes:

90658
	 	[****]
			
	Immunization Admin, Single	 	 CPT4 Codes:

90471
	 	[****]
			
	Tetanus, Diphtheria Toxoi	 	 CPT4 Codes:

90715
	 	[****]
			
	Immunization Admin-under 8 Y	 	 CPT4 Codes:

90465
	 	[****]
			
	Influenza Virus Vaccine	 	 CPT4 Codes:

90655
	 	[****]
			
	Influenza Virus Vaccine	 	 CPT4 Codes:

90656
	 	[****]
			
	Dtap Vaccine, Im	 	 CPT4 Codes:

90700
	 	[****]
			
	Dt Immunization, Im	 	 CPT4 Codes:

90702
	 	[****]
			
	Tetanus Toxoid Absorbed For	 	 CPT4 Codes:

90703
	 	[****]
			
	Tetanus And Diphtheria	 	 CPT4 Codes:

90714
	 	[****]
			
	Flu Vaccine, Nasal	 	 CPT4 Codes:

90660
	 	[****]
			
	Ther/proph/diag Inj, Sc/im	 	 CPT4 Codes:

96372
	 	[****]
			
	Pen G Benzath To 1200000/4mx	 	 HCPC Codes:

J0570
	 	[****]
			
	B-12 Cyanoc Upto 1000mcg/5mx	 	 HCPC Codes:

J3420
	 	[****]
			
	Dexamethasone Sodium Phos1mg	 	 HCPC Codes:

J1100
	 	[****]
			
	Diphenhydr Hcl Upto 50mg/6mx	 	 HCPC Codes:

J1200
	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 7 of 12

 WhiteGlove House Call Health, Inc. 

 

					
	Ketorolac Trom Per 15mg/8mx	 	 HCPC Codes:

J1885
	 	[****]
			
	Metoclopra Hcl Upto 10mg/4mx	 	 HCPC Codes:

J2765
	 	[****]
			
	Odansetro Hcl Per 1mg/32 Mx	 	 HCPC Codes:

J2405
	 	[****]
			
	Orphenad Citr Upto 60mg/2Mx	 	 HCPC Codes:

J2360
	 	[****]
			
	Ceftriaxon Sod Per 250mg/8mx	 	 HCPC Codes:

J0696
	 	[****]
			
	Medrxyprogester Inj 150 Mg	 	 HCPC Codes:

J1055
	 	[****]
			
	Methylpr Sod Upto 125mg/12mx	 	 HCPC Codes:

J2930
	 	[****]
			
	Fluorescein Angioscopy	 	 CPT4 Codes:

92230
	 	[****]
			
	Remove Foreign Body From Eye	 	 CPT4 Codes:

65205
	 	[****]
			
	Remove Foreign Body From Eye	 	 CPT4 Codes:

65220
	 	[****]
			
	Control Of Nosebleed	 	 CPT4 Codes:

30901
	 	[****]
			
	Airway Inhalation Treatm2	 	 CPT4 Codes:

94640
	 	[****]
			
	Aerosol Or Vapour Inhalat3	 	 CPT4 Codes:

94664
	 	[****]
			
	Ipratropium Brom Inh Sol/mg	 	 HCPC Codes:

J7644
	 	[****]
			
	Application Long Leg Splint	 	 CPT4 Codes:

29505
	 	[****]
			
	Application Lower Leg Splint	 	 CPT4 Codes:

29515
	 	[****]
			
	Apply Forearm Splint	 	 CPT4 Codes:

29125
	 	[****]
			
	Apply Long Arm Splint	 	 CPT4 Codes:

29105
	 	[****]

 [****] Certain information on this page has been
omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted portions. 
  

  
 Page 8 of 12

 WhiteGlove House Call Health, Inc. 

 

					
			
	Application Of Finger Splint	 	 CPT4 Codes:

29130
	 	 [****]

			
	Removal Of Nail Plate	 	 CPT4 Codes:

11730
	 	 [****]

			
	Removal Of Nail Bed	 	 CPT4 Codes:

11750
	 	 [****]

			
	Dressings And/or Debridement	 	 CPT4 Codes:

16020
	 	 [****]

			
	Dressings And/or Debridement	 	 CPT4 Codes:

16025
	 	 [****]

			
	Dressings And/or Debridement	 	 CPT4 Codes:

16030
	 	 [****]

			
	Wound(s) Care Non-Select	 	 CPT4 Codes:

97602
	 	 [****]

			
	Remove Foreign Body	 	 CPT4 Codes:

10120
	 	 [****]

			
	Destruction Eg, Laser Surger	 	 CPT4 Codes:

17110
	 	 [****]

			
	Bx Skin &/Subq Tissue; 1 Le	 	 CPT4 Codes:

11100
	 	 [****]

			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12001
	 	 [****]

			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12002
	 	 [****]

			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12004
	 	 [****]

			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12011
	 	 [****]

			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12013
	 	 [****]

			
	Repair Superficial Wound(s)	 	 CPT4 Codes:

12014
	 	 [****]

			
	Intmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12031
	 	 [****]

			
	Intmd Wnd Repair S/tr/ext	 	 CPT4 Codes:

12032
	 	 [****]

[****] Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect
to the omitted portions. 
  

  
 Page 9 of 12

 WhiteGlove House Call Health, Inc. 

 

					
			
	Intmd Wnd Repair S/tr/ext	  	 CPT4 Codes:

12034
	  	[****]
			
	Intmd Wnd Repair N-hf/genit	  	 CPT4 Codes:

12041
	  	[****]
			
	Intmd Wnd Repair N-hg/genit	  	 CPT4 Codes:

12042
	  	[****]
			
	Intmd Wnd Repair N-hg/genit	  	 CPT4 Codes:

12044
	  	[****]
			
	Intmd Wnd Repair Face/mm	  	 CPT4 Codes:

12051
	  	[****]
			
	Intmd Wnd Repair Face/mm	  	 CPT4 Codes:

12052
	  	[****]
			
	Intmd Wnd Repair Face/mm	  	 CPT4 Codes:

12053
	  	[****]
			
	Supplies/special Equipment	  	 CPT4 Codes:

99070
	  	[****]
			
	Immune Admin H1n1 Im/nasal	  	 CPT4 Codes:

90470
	  	[****]
			
	All Services not otherwise identified	  		  	[****]

 SERVICES: 

Participating Group Provider will provide services in the Member’s home or work that are within the scope of and appropriate to the Participating
Group Provider’s license and certification to practice. Participating Group Provider will provide, as appropriate, the generic medicines outlined in Attachment A – Generics Provided by WhiteGlove. In addition Participating Group Provider
may draw blood for lab tests; deliver lab tests to Company designated participating laboratories; inform Member’s Primary Care Physician of lab and other results and services provided; and provide instruction to Member and/or caregiver.

 Participating Group Provider may also provide at Participating Group Provider’s discretion and upon approval by Member selected supplies
such as food items, beverages and over-the-counter remedies that are not considered Covered Services. 
 Participating Group Provider will
provide follow-up calls or visits by Participating Group Provider or Participating Group Provider’s representative to ascertain a Member’s medical progress, share lab results or other services commonly provided by medical professionals.

 COMPENSATION TERMS AND CONDITIONS: 
 Definitions 
 [****] Certain information on this page has been omitted and filed separately
with the Commission. Confidential treatment has been requested with respect to the omitted portions. 

  
 Page 10 of 12

 WhiteGlove House Call Health, Inc. 

 

 “Aetna Market Fee Schedule” (AMFS) is the fee schedule that is
geographically based and dependent upon contracted location where service is performed. The fee schedule is updated annually. 
 General

 a) Rates are inclusive of any applicable Member Copayment, Coinsurance or Deductible. Procedures and/or services provided by WhiteGlove in
accordance with this Agreement but not specifically listed above will not be reimbursed. No additional charges are allowed regardless of the time spent at the Member’s home, for travel, administrative services, lab draws, generic medications
outlined in Attachment A, miscellaneous supplies that are not considered Covered Services, weekend, evening or holiday differentials. Company will pay the lesser of the contracted rate or eligible billed charges. 

Billing 
  

	b)	Participating Group Provider must designate the codes set forth in this Compensation Schedule when billing. 

Coding 
  

	c)	Company utilizes nationally recognized coding structures including, but not limited to, Revenue Codes as described by the Uniform Billing Code, AMA Current Procedural
Terminology (CPT4), CMS Common Procedure Coding System (HCPCS), Diagnosis Related Groups (DRG), ICD-9 Diagnosis and Procedure codes, National Drug Codes (NDC) and the American Society of Anesthesiologists (ASA) relative values for the basic coding,
and description for the services provided. As changes are made to nationally recognized codes, Company will update internal systems to accommodate new codes. Such changes will only be made when there is no material change in the procedure itself.
Until updates are complete, the procedure will be paid according to the standards and coding set for the prior period. 

 Company will comply and utilize nationally recognized coding structures as directed under applicable Federal laws and regulations, including, without limitation, the Health Insurance Portability and
Accountability Act (HIPAA). 

  
 Page 11 of 12

 WhiteGlove House Call Health, Inc. 

 

 Attachment A-Generics 

Provided by WhiteGlove 
  

					
	Acyclovir	  	Diltiazem	  	Metoclopramide
	Albuterol nebulizer soln	  	Doxazosin	  	Metoprolol Tartrate
	Albuterol	  	Doxepin HCL	  	Metronidazole
	Alendronate	  	Doxycycline Hyclate	  	Nadolol
	Allopurinol	  	Enalapril	  	Naproxen
	Amiloride-HCTZ	  	Enalapril-HCTZ	  	Neomycin/Polymyxin/Dexamethasone
	Amitriptyline	  	Erythromycin EC	  	Nortriptyline
	Amoxicillin	  	EST Estrogen/Methyl Testost	  	Nystatin
	Amoxil	  	Estradiol	  	Nystatin/Triamcin
	Antipyrine/Benzocaine otic	  	Estropipate	  	Oxybutynin
	Atenolol	  	Famotidine	  	Paroxetine
	Atenolol-Chlorthalidone	  	Fluconazole	  	Penicillin
	Atropine Sulfate	  	Fluocinolone Acet	  	Phenazopyridine
	Bacitracin	  	Fluocinonide cream	  	Pilocarpine
	Baclofen	  	Fluoxetine	  	Pindolol
	Belladonna Alkaloid/PB	  	Fluphenazine	  	Piroxicam
	Benazepril	  	Furosemide	  	Polymyxin Sulfate/TMP
	Benzonatate	  	Gentamicin	  	Pravastatin
	Benzoyl Peroxide	  	Glimepiride	  	Prazosin HCL
	Benztropine	  	Glipizide	  	Prednisone
	Betamethasone Dipropionate	  	Glyburide	  	Prochlorperazine
	Betamethasone Valerate	  	Guanfacine	  	Promethazine DM Syrup
	Bisoprolol-HCTZ	  	Haloperidol	  	Propranolol
	Bumetanide	  	Hydralazine	  	Ranitidine
	Buspirone	  	Hydrochlorothiazide (HCTZ)	  	Salsalate
	Captopril	  	Hydrocortisone	  	Selenium Sulfide
	Carbamazepine	  	Ibuprofen	  	Silver Sulfadiazine
	Carvedilol	  	Indapamide	  	SMZ-TMP
	Cephalexin	  	Indomethacin	  	Sotalol HCL
	Ceron DM syrup	  	Ipratropium Nebulizer Soln	  	Spironolactone
	Chlorhexidine Gluconate	  	Isoniazid	  	Sprintec 28-day tab
	Chlorpropamide	  	Isosorbide Mononitrate	  	Sulfacet Sodium
	Chlorthalidone	  	Lactulose syrup	  	Tamoxifen
	Cimetidine	  	Levobunolol	  	Terazosin
	Ciprofloxacin	  	Levothyroxine	  	Terbinafine
	Citalopram	  	Lidocaine	  	Tetracycline
	Clomiphene	  	Lisinopril	  	Thioridazine
	Clonidine	  	Lisinopril-HCTZ	  	Thiothixene
	Colchicine	  	Lithium Carbonate	  	Timolol Maleate
	C-Phen drops	  	Loratadine	  	Tobramycin
	Cyclobenzaprine	  	Lovastatin	  	Trazodone
	Cytra2	  	Medroxyprogesterone Acetate	  	Triamcinolone
	Dex PC syrup	  	Megestrol	  	Triamterene-HCTZ
	Dexamethasone	  	Meloxicam	  	Trihexyphenidyl
	Diclofenac DR	  	Metformin	  	Tri-Sprintec
	Dicyclomine	  	Methyldopa	  	Verapamil
	Digoxin	  	Methylpred	  	Warfarin

  
 Page 12 of 12Medical Group Participation Agreement

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Exhibit 10.21 
 Medical Group Participation Agreement 
 This Agreement is entered into by and between
United HealthCare Insurance Company, contracting on behalf of itself, United HealthCare of Texas, inc., PacifiCare of Texas, Inc., Evercare of Texas, LLC, and the other entities that are United’s Affiliates (collectively referred to as
“United”) and WhiteGlove House Call Health, Inc. (“Medical Group”). 
 This Agreement is effective on the later of the
following dates (the “Effective Date”): 
 i)
                     or 
 ii) the first day of the first calendar month that begins at least 30 days after the date when this Agreement has been executed by all parties. 
 Through contracts with physicians and other providers of health care services, United maintains one or more networks of providers that are available to Customers. Medical Group is a provider of health
care services. 
 United wishes to arrange to make Medical Group’s services available to Customers. Medical Group wishes to provide such
services, under the terms and conditions set forth in this Agreement. 
 The parties therefore enter into this Agreement. 

Article I. 

Definitions 
 The
following terms when used in this Agreement have the meanings set forth below: 
 1.1 “Benefit Plan” means a certificate of
coverage, summary plan description, or other document or agreement, whether delivered in paper, electronic, or other format, under which a Payer is obligated to provide coverage of Covered Services for a Customer. 

1.2 “Covered Service” is a health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to
the terms of the Customer’s Benefit Plan with that Payer. 
 1.3 “Customary Charge” is the fee for health care services
charged by Medical Group that does not exceed the fee Medical Group would ordinarily charge another person regardless of whether the person is a Customer. 
 1.4 “Customer” is a person eligible and enrolled to receive coverage from a Payer for Covered Services. 
 1.5 “Medical Group Physician” is a Doctor of Medicine (“M.D.”), or a Doctor of Osteopathy (“D.O.”), duly licensed and qualified under the laws of the jurisdiction in
which Covered Services are provided, who practices as a shareholder, partner, or employee of Medical Group, or who practices as a subcontractor of Medical Group. However, a subcontractor of Medical Group is a Medical Group Physician only with regard
to services rendered to patients of Medical Group and billed under Medical Group’s tax identification number. Additionally, a subcontractor is not a Medical Group Physician with regard to any services rendered in a physician’s office other
than those locations listed in Appendix 1. 
 1.6 “Medical Group Non-Physician Provider” is a surgical assistant, physician
assistant, nurse practitioner, physical therapist, occupational therapist, speech therapist, mental health provider, or licensed social worker, who is duly authorized under the laws of the jurisdiction in which Covered Services are provided, and who
renders Covered Services as an employee or subcontractor of Medical Group. However, a subcontractor of Medical Group is a Medical Group Non-Physician Provider only with regard to services rendered to patients of Medical Group and billed under
Medical Group’s tax identification number. Additionally, a subcontractor is not a Medical Group Non-Physician Provider with regard to any services rendered in a physician’s office other than those locations listed in Appendix 1.

 1.7 “Medical Group Professional” is a Medical Group Physician or a Medical Group
Non-Physician Provider. 
 1.8 “Payment Policies” are the guidelines adopted by United for calculating payment of claims under
this Agreement. The Payment Policies may change from time to time as discussed in section 7.4 of this Agreement. 
 1.9 “Payer”
is an entity obligated to a Customer to provide reimbursement for Covered Services under the Customer’s Benefit Plan, and authorized by United to access Medical Group’s services under this Agreement. 

1.10 “Protocols” are the programs, protocols and administrative procedures adopted by United or a Payer to be followed by Medical Group
in providing services and doing business with United and Payers under this Agreement. These Protocols may include, among other things, credentialing and recredentialing processes, utilization management and care management processes, quality
improvement, peer review, Customer grievance, concurrent review, or other similar United or Payer programs. The Protocols may change from time to time as discussed in section 5.4 of this Agreement. 

1.11 “United’s Affiliates” are those entities controlling, controlled by, or under common control with United HealthCare Insurance
Company. 
 Article II. 
 Representations and Warranties 
 2.1 Representations and Warranties of Medical
Group. Medical Group, by virtue of its execution and delivery of this Agreement, represents and warrants as follows: 
 (a) Medical Group is
a duly organized and validly existing legal entity in good standing under the laws of its jurisdiction of organization. 
 (b) Medical Group has
all requisite corporate power and authority to conduct its business as presently conducted, and to execute, deliver and perform its obligations under this Agreement. The execution, delivery and performance of this Agreement by Medical Group have
been duly and validly authorized by all action necessary under its organizational documents and applicable corporate law. 
 (c) The execution,
delivery and performance of this Agreement by Medical Group do not and will not violate or conflict with (i) the organizational documents of Medical Group, (ii) any material agreement or instrument to which Medical Group is a party or by
which Medical Group or any material part of its property is bound, or (iii) applicable law. Medical Group has the unqualified authority to bind, and does bind, itself and Medical Group Professionals to all of the terms and conditions of this
Agreement, including any Appendices, Attachments and Exhibits, as applicable. 
 (d) Medical Group has obtained and holds all registrations,
permits, licenses, and other approvals and consents, and has made all filings, that it is required to obtain from or make with all governmental entities under applicable law in order to conduct its business as presently conducted and to enter into
and perform its obligations under this Agreement. 
 (e) Medical Group has been given an opportunity to review the Protocols and Payment
Policies and acknowledges that it is bound by the Protocols and that claims under this Agreement will be paid in accordance with the Payment Policies. 
 (f) Each submission of a claim by Medical Group pursuant to this Agreement shall be deemed to constitute the representation and warranty by it to United that (i) the representations and warranties of
it set forth in this section 2.1 and elsewhere in this Agreement are true and correct as of the date the claim is submitted, (ii) it has complied with the requirements of this Agreement with respect to the Covered Services involved and the
submission of such claim, (iii) the charge amount set forth on the claim is the Customary Charge and (iv) the claim is a valid claim. 

 2.2 Representations and Warranties of United. United, by virtue of its execution and delivery of
this Agreement, represents and warrants as follows: 
 (a) United is a duly organized and validly existing legal entity in good standing under
the laws of its jurisdiction of organization. 
 (b) United has all requisite corporate power and authority to conduct its business as presently
conducted, and to execute, deliver and perform its obligations under this Agreement. The execution, delivery and performance of this Agreement by United have been duly and validly authorized by all action necessary under its organizational documents
and applicable corporate law. 
 (c) The execution, delivery and performance of this Agreement by United do not and will not violate or conflict
with (i) the organizational documents of United, (ii) any material agreement or instrument to which United is a party or by which United or any material part of its property is bound, or (iii) applicable law. 

(d) United has obtained and holds all registrations, permits, licenses, and other approvals and consents, and has made all filings, that it is required
to obtain from or make with all governmental entities under applicable law in order to conduct its business as presently conducted and to enter into and perform its obligations under this Agreement. 

Article III. 
 Applicability of this Agreement 
 3.1 Medical Group’s Services. This
Agreement applies to Medical Group’s practice locations set forth in Appendix 1. In the event Medical Group begins providing services at other locations (either by opening such locations itself, or by acquiring, merging or coming under common
ownership and control with an existing provider of services that was not already under contract with United or one of United’s Affiliates to participate in a network of health care providers), such additional locations will become subject to
this Agreement 30 days after United receives the notice required under section 5.7(v) of this Agreement. 
 Medical Group may transfer all or
some of its assets to another entity, if the result of such transfer would be that all or some of the Covered Services subject to this Agreement will be rendered by the other entity rather than by Medical Group, but only if Medical Group requests
that United approve the assignment of this Agreement as it relates to those Covered Services and only if the other entity agrees to assume this Agreement. This paragraph does not limit United’s right under section 10.4 of this Agreement to
elect whether to approve the assignment of this Agreement. 
 3.2 Payers and Benefit Plan types. United may allow Payers to access
Medical Group’s services under this Agreement for the Benefit Plan types described in Appendix 2. Appendix 2 may be modified by United upon 30 days written or electronic notice. 
 3.3 Services not covered under a Benefit Plan. This Agreement does not apply to services not covered under the applicable Benefit Plan. Medical Group may seek and collect payment from a Customer
for such services, provided that the Medical Group first obtain the Customer’s written consent. 
 This section does not authorize Medical
Group to bill or collect from Customers for Covered Services for which claims are denied or otherwise not paid. That issue is addressed in sections 7.5 and 7.8 of this Agreement. 
 3.4 Patients who are not Customers. This Agreement does not apply to services rendered to patients who are not Customers at the time the services were rendered. Section 7.6 of this Agreement
addresses circumstances in which claims for services rendered to such persons are inadvertently paid by a Payer. 
 3.5 Health Care.
Medical Group acknowledges that this Agreement and Customer Benefit Plans do not dictate the health care provided by Medical Group or Medical Group Professionals, or govern Medical Group’s or Medical Group Professional’s determination of
what care to provide its patients, even if those patients are Customers. The decision regarding what care is to be provided remains with Medical Group Professionals and with Customers, and not with United or any Payer. 

 3.6 Communication with Customers. Nothing in this Agreement is intended to limit Medical
Group’s or Medical Group Professional’s right or ability to communicate fully with a Customer regarding the Customer’s health condition and treatment options. Medical Group and Medical Group Professionals are free to discuss all
treatment options without regard to whether or not a given option is a Covered Service. Medical Group and Medical Group Professionals are free to discuss with a Customer any financial incentives Medical Group may have under this Agreement, including
describing at a general level the payment methodologies contained in this Agreement. 
 Article IV. 

Participation of Medical Group Professionals in United’s Network 

4.1 Medical Group Professionals as Participating Providers. Except as described under section 4.2, all Medical Group Professionals will
participate in United’s network. Medical Group has the authority to bind, and will bind, all new Medical Group Professionals to the obligations of this Agreement. 
 4.2 Medical Group Professionals who are not Participating Providers. The following Medical Group Professionals are not participating providers in United’s network: 

i) A Medical Group Physician (or a Medical Group Non-Physician Provider, in the event such provider is of a provider type that United credentials) who
has been denied participation in United’s credentialing program, whose credentialing application has not been submitted, or whose credentialing application remains pending; or 
 ii) A Medical Group Professional who has been terminated from participation in United’s network pursuant to section 4.5 of this Agreement. 
 4.3 Credentialing. Medical Group and Medical Group Physicians will participate in and cooperate with United’s credentialing program. Medical Group Non-Physician Providers will participate in
and cooperate with United’s credentialing program to the extent such Medical Group Non-Physician Providers are subject to credentialing by United. 
 4.4 New Medical Group Professionals. Medical Group will notify United at least 30 days before a physician becomes a Medical Group Physician. In the event that the Medical Group’s agreement
with the new Medical Group Physician provides for a starting date that would make it impossible for Medical Group to provide 30 days advance notice to United, then Medical Group will give notice to United within five business days after reaching
agreement with the new Medical Group Physician. In either case, the new Medical Group Physician will submit and complete a credentialing application to United within 30 days of the new Medical Group Physician’s agreement to join Medical Group,
unless the new Medical Group Physician already has been credentialed by United and is already a participant in United’s network. The requirements of this section 4.4 also apply to new Medical Group Non-Physician Providers who are subject to
credentialing by United. 
 4.5 Termination of a Medical Group Professional from United’s Network. United may terminate a Medical
Group Professional’s participation in United’s network, without terminating this Agreement, immediately upon becoming aware of any of the following: 
 i) material breach of this Agreement that is not cured by Medical Group Professional within 30 days after United provided notice to Medical Group of the breach; 

ii) the suspension, revocation, condition, limitation, qualification or other material restriction on a Medical Group Professional’s licenses,
certifications and permits by any government agency under which the Medical Group Professional is authorized to provide health care services; 

iii) the suspension, revocation, condition, limitation, qualification or other material restriction of a Medical Group Physician’s staff privileges
at any licensed hospital, nursing home or other facility at which the Medical Group Physician has staff privileges during the term of this Agreement; 

 iv) an indictment, arrest or conviction for a felony, or for any criminal charge related to the practice of
Medical Group Professional’s profession; 
 v) a sanction imposed by any governmental agency or authority, including Medicare or Medicaid;
or 
 vi) pursuant to United’s Credentialing Plan. 
 United will notify Medical Group of the Medical Group Professional’s termination according to the notice provision set forth in section 10.8 of this Agreement. 

4.6 Covered Services by Medical Group Professionals who are not Participating Providers. Medical Group will staff its service locations so that
Covered Services can appropriately be rendered to Customers by Medical Group Professionals who participate in United’s network. A Medical Group Professional who does not participate in United’s network, pursuant to section 4.2 of this
Agreement, will not render Covered Services to a Customer. 
 In the event Covered Services are rendered by a Medical Group Professional who
does not participate in United’s network, Medical Group and the Medical Group Professional will not submit a claim or other request for payment to United or Payer, and will not seek or accept payment from the Customer. 

Article V. 

Duties of Medical Group 
 5.1 Provide Covered Services. Medical Group will provide Covered Services to Customers. 

5.2 Nondiscrimination. Medical Group will not discriminate against any patient, with regard to quality of service or accessibility of services, on
the basis that the patient is a Customer. Medical Group will not require a Customer to pay a “membership fee” or other fee in order to access Medical Group for Covered Services (except for copayments, coinsurance and/or deductibles
provided for under Customer’s Benefit Plan) and will not discriminate against any Customer based on the failure to pay such a fee. 

5.3 Accessibility. Medical Group will provide or arrange for the provision of advice and assistance to Customers in emergency situations 24 hours
a day, seven days a week. 
 5.4 Cooperation with Protocols. Medical Group will cooperate with and be bound by United’s and
Payers’ Protocols. The Protocols include but are not limited to all of the following: 
  

	l.	Medical Group will use reasonable commercial efforts to direct Customers only to other providers that participate in United’s network, except as otherwise
authorized by United or Payer. 

  

	2.	If the Customer’s Benefit Plan requires the Customer to receive certain Covered Services from or upon referral by a primary care physician, all referral physicians
must adhere to the following additional protocols when those Covered Services are provided: 

  

	 	a.	Notify Customer’s primary care physician of referrals to other participating or nonparticipating providers. 

 

	 	b.	Covered Services must be provided pursuant to the terms and limitations of the referral notification issued by or on behalf of the Customer’s primary care
physician. 

  

	 	c.	If the Medical Group Physician providing the Covered Services is a referral physician, the Medical Group Physician must also notify the Customer’s primary care
physician of all admissions in accordance with the required time frames. 

  

	3.	Medical Group will provide notification for certain Covered Services, accept and return telephone calls from United staff, and respond to United requests for clinical
information, as required by United or Payer as described in the Protocols. 

 The Protocols will be made available to Medical Group online or upon request. Some or all Protocols also
may be disseminated in the form of an administrative manual or guide or in other communications. See Appendix 4 for additional information on the Protocols applicable to Customers enrolled in certain Benefit Plans. 

United may change the Protocols from time to time. United will use reasonable commercial efforts to inform Medical Group at least 30 days in advance of
any material changes to the Protocols. United may implement changes in the Protocols without Medical Group’s consent if such change is applicable to all or substantially all of the medical groups in United’s network located in the same
state as Medical Group and that practice the same specialty as Medical Group. Otherwise, changes to the Protocols proposed by United to be applicable to Medical Group are subject to the terms of section 10.2 of this Agreement that are applicable to
amendments. 
 5.5 Licensure. Medical Group and Medical Group Professionals will maintain, without material restriction, such licensure,
registration, and permits as are necessary to enable Medical Group and Medical Group Professionals to lawfully perform this Agreement. 
 5.6
Liability Insurance. Medical Group will assure that Medical Group and all Medical Group Professionals are covered by liability insurance. Except to the extent coverage is a state mandated placement, the liability coverage must be placed with
responsible, financially sound insurance carriers authorized or approved to write coverage in the state in which the Covered Services are provided. The liability insurance shall be, at a minimum, of the types and in the amounts set forth below.
Medical malpractice insurance shall be either occurrence or claims made with an extended period reporting option. Prior to the Effective Date of this Agreement and within 10 days of each policy renewal thereafter, Medical Group shall submit to
United in writing evidence of insurance coverage. 
  

			
	 TYPE OF INSURANCE
	  	 MINIMUM LIMITS

	Medical malpractice and/or professional liability insurance	  	Five Hundred Thousand Dollars ($500,000.00) per occurrence and 1 Million Dollars aggregate ($1,000,000.00), if Medical Group insures all Medical Group Professionals in a single
policy. This insurance requirement will also be satisfied if the Medical Group insures each Medical Group Professional separately, and the coverage for each Medical Group Professional is at least One Million Dollars ($1,000,000.00) per occurrence
and 3 Million Dollars ($3,000,000.00) aggregate.
		
	Commercial general and/or umbrella liability insurance	  	One Million Dollars ($1,000,000.00) per occurrence and aggregate.

 In lieu of purchasing the insurance coverage required in this section, Medical Group may, with the prior written approval of United, self-insure its medical malpractice and/or professional liability, as
well as its commercial general liability. Medical Group shall maintain a separate reserve for its self-insurance. If Medical Group will use the self-insurance option described in this paragraph, Medical Group will provide to United, prior to the
Effective Date, a statement verified by an independent auditor or actuary that its reserve funding levels and process of funding appears adequate to meet the requirements of this section and fairly represents the financial condition of the fund.
Medical Group will provide a similar statement during the term of this Agreement upon United’s request, which will be made no more frequently than annually. Medical Group will assure that its self-insurance fund will comply with applicable laws
and regulations. 
 5.7 Notice. Medical Group will give notice to United within 10 days after any event that causes Medical Group to be
out of compliance with section 5.5 or 5.6 of this Agreement, or of any change in Medical Group’s name, ownership, control, or Taxpayer Identification Number. This section does not apply to changes of ownership or control that result in Medical
Group being owned or controlled by an entity with which it was already affiliated prior to the change. In addition, Medical Group will give written notice to United within 10 days after it learns of any of the following: 

	 	i)	any suspension, revocation, condition, limitation, qualification or other material restriction on a Medical Group Professional’s licenses, certifications and
permits by any government agency under which a Medical Group Professional is authorized to provide health care services; 

  

	 	ii)	any suspension, revocation, condition, limitation, qualification or other material restriction of a Medical Group staff privileges at any licensed hospital, nursing
home or other facility at which a Medical Group Physician has staff privileges during the term of this Agreement; 

  

	 	iii)	indictment, arrest or conviction of a Medical Group Professional for a felony or for any criminal charge related to the practice of the Medical Group
Professional’s profession; 

  

	 	iv)	The departure of any Medical Group Professional from Medical Group; or 

  

	 	v)	any changes to the information contained in Appendix 1. 

 5.8 Customer consent to release of Medical Record Information. Medical Group will obtain any Customer consent required in order to authorize Medical Group to provide access to requested information
or records as contemplated in section 5.9 of this Agreement, including copies of the Medical Group’s medical records relating to the care provided to Customer. 
 5.9 Maintenance of and Access to Records. Medical Group will maintain adequate medical, financial and administrative records related to Covered Services rendered by Medical Group under this
Agreement, including claims records, for at least 6 years following the end of the calendar year during which the Covered Services are provided, unless a longer retention period is required by applicable law. Medical Group will provide access to
these records as follows: 
  

	 	i)	to United or its designees, in connection with United’s utilization management/care management, quality assurance and improvement and for claims and other
administrative obligations, including reviewing Medical Group’s compliance with the terms and provisions of this Agreement and appropriate billing practice. Medical Group will provide access during ordinary business hours fourteen days after a
request is made, except in cases of a United audit involving a fraud investigation or the health and safety of a Customer (in which case, access shall be given within 48 hours after the request) or of an expedited Customer appeal or grievance enable
United to reasonably meet the timelines for determining the appeal or grievance); and 

  

	 	ii)	to agencies of the government, in accordance with applicable law, to the extent such access is necessary to comply with regulatory requirements applicable to Medical
Group, United, or Payers. 

 Medical Group will cooperate with United on a timely basis in connection with any such audit
including, among other things, in the scheduling of and participation in an audit exit interview within 30 days of United’s request. 

Upon invoice from Medical Group, United will pay for copies of records requested by United in cases where United requests the records more than once and
the records are requested for some other purpose than claims processing, coverage determinations, or other routine health benefits administration. Payment will be made at a rate of 10 cents per page, not to exceed a total of 25 dollars per record,
unless a different rate is specified under state law. 
 5.10 Access to Data. Medical Group represents that in conducting its operations,
it collects and reviews certain quality data relating to care rendered by Medical Group that is reported in a manner which has been validated by a third party as having a clear, evidence-based link to quality or safety (e.g., AHRQ standards) or
which has been created by employer coalitions as proxies for quality (e.g., Leapfrog standards). 
 United recognizes that Medical Group has the
sole discretion to select the metrics which it will track from time to time and that Medical Group’s primary goal in so tracking is to advance the quality of patient care. If the information that Medical Group chooses to report on is available
in the public domain in a format that includes all data elements required by United, United will obtain quality information directly from the source to whom Medical Group reported. If the Medical Group does not report metrics in the public domain,
on a quarterly basis, Medical 

 
Group will share these metrics with United as tracked against a database of all commercial patients (including patients who are not United customers). United may publish this data to entities to
which United renders services or seeks to render services, and to Customers. 
 5.11 Compliance with law. Medical Group will comply with
applicable regulatory requirements, including but not limited to those relating to confidentiality of Customer medical information. 
 5.12
Electronic connectivity. When made available by United, Medical Group will do business with United electronically. Medical Group will use www.unitehealthcareonline.com to check eligibility status, claims status, and submit requests for
claims adjustments for Customers enrolled in products supported by www.unitedhealthcareonline.com. Medical Group agrees to use www.unitedhealthcareonline.com for additional functionalities (for instance, notification of admission)
after United informs Medical Group that such functionalities have become available for the applicable Customer. 
 5.13 Employees and
subcontractors. Medical Group will assure that its employees, affiliates and any individuals or entities subcontracted by Medical Group to render services in connection with this Agreement adhere to the requirements of this Agreement. The use of
employees, affiliates or subcontractors to render services in connection with this Agreement will not limit Medical Group’s obligations and accountability under this Agreement with regard to such services. 

For laboratory services, Medical Group will only be reimbursed for services that Medical Group is certified through the Clinical Laboratory Improvement
Amendments (CLIA) to perform, and Medical Group must not bill Customers for any laboratory services for which Medical Group lacks CLIA certification. 
 Article VI. 
 Duties of United and Payers 

6.1 Payment of Claims. As described in further detail in Article VII of this Agreement, Payers will pay Medical Group for rendering Covered
Services to Customers. 
 6.2 Liability Insurance. United will procure and maintain professional and general liability insurance and
other insurance, as United reasonably determines may be necessary, to protect United and United’s employees against claims, liabilities, damages or judgments that arise out of services provided by United or United’s employees under this
Agreement. 
 6.3 Licensure. United will maintain, without material restriction, such licensure, registration, and permits as are
necessary to enable United to lawfully perform this Agreement. 
 6.4 Notice. United will give written notice to Medical Group within 10
days after any event that causes United to be out of compliance with section 6.2 or 6.3 of this Agreement, or of any change in United’s name, ownership, control, or Taxpayer Identification Number. This section does not apply to changes of
ownership or control that result in United being owned or controlled by an entity with which it was already affiliated prior to the change. 

6.5 Compliance with law. United will comply with applicable regulatory requirements, including but not limited to those relating to
confidentiality of Customer medical information and those relating to prompt payment of claims to the extent those requirements are applicable. 

6.6 Electronic connectivity. United will do business with Medical Group electronically by providing eligibility status, claims status, and
accepting requests for claim adjustments, for those products supported online. United will communicate enhancements in online functionality as they become available, as described in Section 5.12, and will make information available as to which
products are supported online. 
 6.7 Employees and subcontractors. United will assure that its employees, affiliates and any individuals
or entities subcontracted by United to render services in connection with this Agreement adhere to the requirements of this Agreement. The use of employees, affiliates or subcontractors to render services in connection with this Agreement will not
limit United’s obligations and accountability under this Agreement with regard to such services. 

 Article VII. 
 Submission, Processing, and Payment of Claims 
 7.1 Form and content of
claims. Medical Group must submit claims for Covered Services in a manner and format prescribed by United, as further described in the Protocols. Unless otherwise directed by United, Medical Group shall submit claims using current CMS 1500 form
or its successor for paper claims and HIPAA standard professional or institutional claim formats for electronic claims, as applicable, with applicable coding including, but not limited to, ICD, CPT, Revenue and HCPCS coding. Medical Group will
submit claims only for services performed by Medical Group or Medical Group staff. Pass through billing is not payable under this Agreement. 

7.2 Electronic riling of claims. Within one year after the Effective Date of this Agreement, Medical Group will use electronic submission for all
of its claims under this Agreement that United is able to accept electronically. 
 7.3 Time to file claims. All information necessary to
process a claim must be received by United no more than 90 days from the date that Covered Services are rendered. In the event United requests additional information in order to process the claim, Medical Group will provide such additional
information within 90 days of United’s request. If Payer is not the primary payer, and Medical Group is pursuing payment from the primary payer, the 90 days filing limit will begin on the date Medical Group receives the claim response from the
primary payer. 
 7.4 Payment of claims. Payer will pay claims for Covered Services according to the lesser of Medical Group’s
Customary Charge or the applicable fee schedule (as further described in Appendix 3 to this Agreement), and in accordance with Payment Policies. 
 Claims for Covered Services subject to coordination of benefits will paid in accordance with the Customer’s Benefit Plan and applicable law. 
 The obligation for payment under this Agreement is solely that of Payer, and not that of United unless United is the Payer. 
 Ordinarily, fee amounts listed in Appendix 3 are based upon primary fee sources. United reserves the right to use gap-fill fee sources where primary fee sources are not available. 

United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association, price
changes for immunizations and injectable medications, and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry, such as those maintained by the
Centers for Medicaid and Medicare Services (for example HCPCS, etc.). 
 Ordinarily, United’s fee schedule is updated using similar
methodologies for similar services. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates within 90 days from the date of publication. 

United will give Medical Group 90 days written or electronic notice of non-routine fee schedule changes which will substantially alter the overall
methodology or reimbursement level of the fee schedule. In the event such changes will reduce Medical Groups overall reimbursement under this Agreement, Medical Group may terminate this Agreement by giving 60 days written notice to United, provided
that the notice is given by Medical Group within 30 days after the notice of the fee schedule change. 
 United will make its Payment Policies
available to Medical Group online or upon request. United may change its Payment Policies from time to time. 
 7.5 Denial of Claims for Not
Following Protocols, Not Filing Timely, or Lack of Medical Necessity. Payment may be denied in whole or in part if Medical Group does not comply with a Protocol or does not file a timely claim under section 7.3 of this Agreement. Payment may
also be denied for services provided that are determined by United to be medically unnecessary, and Medical Group may not bill the Customer for such services unless the 

 
Customer has, with knowledge of United’s determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. 

In the event that payment of a claim is denied for lack of notification or for untimely filing, the denial will be reversed if Medical Group appeals
within 12 months after the date of denial and can show all of the following: 
  

	 	i)	that, at the time the Protocols required notification or at the time the claim was due, Medical Group did not know and was unable to reasonably determine that the
patient was a Customer, 

  

	 	ii)	that Medical Group took reasonable steps to learn that the patient was a Customer, and 

 

	 	iii)	that Medical Group promptly provided notification, or filed the claim, after learning that the patient was a Customer. 

7.6 Retroactive Correction of Information Regarding Whether Patient Is a Customer. Prior to rendering services, Medical Group will ask the patient
to present his or her Customer identification card. In addition, Medical Group may contact United to obtain the most current information on the patient as a Customer. 
 However, Medical Group acknowledges that such information provided by United is subject to change retroactively, under the following circumstances: (1) if United has not yet received information that
an individual is no longer a Customer; (2) if the individual’s Benefit Plan is terminated retroactively for any reason including, but not limited to, non-payment of premium; (3) as a result of the Customer’s final decision
regarding continuation of coverage pursuant to state and federal laws; or (4) if eligibility information United receives is later proven to be false. 
 If Medical Group provides health care services to an individual, and it is determined that the individual was not a Customer at the time the health care services were provided, those services shall not be
eligible for payment under this Agreement and any claims payments made with regard to such services may be recovered as overpayments under the process described in section 7.10 of this Agreement. Medical Group may then directly bill the individual,
or other responsible party, for such services. 
 7.7 Payment under this Agreement is Payment in Full. Payment as provided under section
7.4 of this Agreement, together with any co-payment, deductible or coinsurance for which the Customer is responsible under the Benefit Plan, is payment in full for a Covered Service. Medical Group will not seek to recover, and will not accept any
payment from Customer, United, Payer or anyone acting in their behalf, in excess of payment in full as provided in this section 7.7, regardless of whether such amount is less than Medical Group’s billed charge or Customary Charge. 

7.8 Customer “Hold Harmless.” Medical Group will not bill or collect payment from the Customer, or seek to impose a lien, for the
difference between the amount paid under this Agreement and Medical Group’s billed charge or Customary Charge, or for any amounts denied or not paid under this Agreement due to: 

 

	 	i)	Medical Group’s failure to comply with the Protocols, 

  

	 	ii)	Medical Group’s failure to file a timely claim, 

  

	 	iii)	Payer’s Payment Policies, 

  

	 	iv)	inaccurate or incorrect claim processing, 

  

	 	v)	insolvency or other failure by Payer to maintain its obligation to fund claims payments, if Payer is United, or is an entity required by applicable law to assure that
its Customers not be billed in such circumstances, or 

  

	 	vi)	a denial based on medical necessity or prior authorization, except as permitted under section 7.5. 

 This obligation to refrain from billing Customers applies even in those cases in which Medical Group
believes that United or Payer has made an incorrect determination. In such cases, Medical Group may pursue remedies under this Agreement against United or Payer, as applicable, but must still hold the Customer harmless. 

In the event of a default by a Payer other than those Payers covered by the above clause v), Medical Group may seek payment directly from the Payer or
from Customers covered by that Payer. However, Medical Group may do so only if it first inquires in writing to United as to whether the Payer has defaulted and, in the event that United confirms that Payer has defaulted (which confirmation will not
be unreasonably withheld), Medical Group then gives United 15 days prior written notice of Medical Group’s intent to seek payment from Payer or Customers. For purposes of this paragraph, a default is a systematic failure by a Payer to fund
claims payments related to Customers covered through that Payer; a default does not occur in the case of a dispute as to whether certain claims should be paid or the amounts that should be paid for certain claims. 

This section 7.8 and section 7.7 will survive the termination of this Agreement, with regard to Covered Services rendered prior to when the termination
takes effect. 
 7.9 Consequences for Failure to Adhere to Customer Protection Requirements. If Medical Group collects payment from,
brings a collection action against, or asserts a lien against a Customer for Covered Services rendered (other than for the applicable copayment, deductible or coinsurance), contrary to section 7.7 or 7.8 of this Agreement, Medical Group shall be in
breach of this Agreement. This section 7.9 will apply regardless of whether Customer or anyone purporting to act on Customer’s behalf has executed a waiver or other document of any kind purporting to allow Medical Group to collect such payment
from Customer. 
 In the event of such a breach, Payer may deduct, from any amounts otherwise due Medical Group, the amount wrongfully collected
from Customers, and may also deduct an amount equal to any costs or expenses incurred by the Customer, United or Payer in defending the Customer from such action and otherwise enforcing sections 7.7 through 7.9 of this Agreement. Any amounts
deducted by Payer in accordance with this provision shall be used to reimburse the Customer and to satisfy any costs incurred. The remedy contained in this paragraph does not preclude United from invoking any other remedy for breach that may be
available under this Agreement. 
 7.10 Correction of overpayments or underpayments of claims. In the event that either Party believes
that a claim has not been paid correctly, or that funds were paid beyond or outside of what is provided for under this Agreement, either party may seek correction of the payment except that Medical Group may not seek correction of a payment more
than 12 months after it was made. 
 Medical Group will repay overpayments within 30 days of notice of the overpayment. Medical Group will
promptly report any credit balance that it maintains with regard to any claim overpayment under this Agreement, and will return such overpayment to United within 30 days after posting it as a credit balance. 

Medical Group agrees that recovery of overpayments may be accomplished by offsets against future payments. 

7.11 Claims Payment Issues Arising from Departure of Medical Group Professionals from Medical Group. In the event a Medical Group Professional
departs from Medical Group and uncertainty arises as to whether Medical Group or some other entity is entitled to receive payment for certain services rendered by such former Medical Group Professional, the parties will cooperate with each other in
good faith in an attempt to resolve the situation appropriately. 
 In the event that Medical Group’s failure to give timely notice under
section 5.7 (iv) of this Agreement resulted in claims payments being made incorrectly to Medical Group, Medical Group shall promptly call the situation to United’s attention and return such payments to United. In the event Medical Group
fails to do so, United may hold Medical Group liable for any attorneys fees, costs, or administrative expenses incurred by United as a result. 

In the event that both Medical Group and some other entity assert a right to payment for the same service rendered by the former Medical Group
Professional, United may refrain from paying either entity until the payment obligation is clarified. Provided that United act in good faith, Medical Group will waive any right to receive interest or penalties Linder any applicable law relating to
the prompt payment of claims. 

 Article VIII. 
 Dispute Resolution 
 The parties will work together in good faith to resolve any and
all disputes between them (hereinafter referred to as “Disputes”) including but not limited to all questions of arbitrability, the existence, validity, scope or termination of the Agreement or any term thereof. 

If the parties are unable to resolve any such Dispute within 60 days following the date one party sent written notice of the Dispute to the other party,
and if either party wishes to pursue the Dispute, it shall thereafter be submitted to binding arbitration in accordance with the Commercial Dispute Procedures of the American Arbitration Association, as they may be amended from time to time (see ).
Unless otherwise agreed to in writing by the parties, the party wishing to pursue the Dispute must initiate the arbitration within one year after the date on which notice of the Dispute was given or shall be deemed to have waived its right to pursue
the dispute in any forum. 
 Any arbitration proceeding under this Agreement shall be conducted in Travis County, TX. The arbitrator(s) may
construe or interpret but shall not vary or ignore the terms of this Agreement and shall be bound by controlling law. The arbitrator(s) shall have no authority to award punitive, exemplary, indirect or special damages, except in connection with a
statutory claim that explicitly provides for such relief. 
 The parties expressly intend that any dispute relating to the business relationship
between them be resolved on an individual basis so that no other dispute with any third party(ies) may be consolidated or joined with our dispute. The parties agree that any arbitration ruling by an arbitrator allowing class action arbitration or
requiring consolidated arbitration involving any third party(ies) would be contrary to their intent and would require immediate judicial review of such ruling. 
 If the Dispute pertains to a matter which is generally administered by certain United procedures, such as a credentialing or quality improvement plan, the policies and procedures set forth in that plan
must be fully exhausted by Medical Group before Medical Group may invoke any right to arbitration under this Article VIII. 
 The decision of
the arbitrator(s) on the points in dispute will be binding, and judgment on the award may be entered in any court having jurisdiction thereof. The parties acknowledge that because this Agreement affects interstate commerce the Federal Arbitration
Act applies. 
 In the event that any portion of this Article or any part of this Agreement is deemed to be unlawful, invalid or unenforceable,
such unlawfulness, invalidity or unenforceability shall not serve to invalidate any other part of this Article or Agreement. In the event any court determines that this arbitration procedure is not binding or otherwise allows litigation involving a
Dispute to proceed, the parties hereby waive any and all right to trial by jury in, or with respect to, such litigation. Such litigation would instead proceed with the judge as the finder of fact. 

In the event a party wishes to terminate this Agreement based on an assertion of uncured material breach, and the other party disputes whether grounds
for such a termination exist, the matter will be resolved through arbitration under this Article VIII. While such arbitration remains pending, the termination for breach will not take effect. 
 This Article VIII governs any dispute between the parties arising before or after execution of this Agreement and shall survive any termination of the Agreement. 

Article IX. 

Term and Termination 
 9.1 Term. This Agreement shall take effect on the Effective Date. This Agreement shall have an initial term of one year and renew automatically for renewal terms of one year, until terminated
pursuant to section 9.2. 
 9.2 Termination. This Agreement may be terminated under any of the following circumstances: 

 

	 	i)	by mutual written agreement of the parties, 

	 	ii)	by either party, upon at least 90 days prior written notice, effective at the end of the initial term or effective at the end of any renewal term;

  

	 	iii)	by either party upon 60 days written notice in the event of a material breach of this Agreement by the other party, except that such a termination will not take effect
if the breach is cured within 60 days after notice of the termination; moreover, such termination may be deferred as further described in Article VIII of this Agreement; 

 

	 	iv)	by either party upon 10 days written notice in the event the other party loses licensure or other governmental authorization necessary to perform this Agreement, or
fails to have insurance as required under section 5.6 or section 6.2 of this Agreement; or 

  

	 	v)	by Medical Group, as described in section 7.4 of this Agreement in the event of a non-routine fee schedule change. 

9.3 Ongoing Services to Certain Customers After Termination Takes Effect. In the event a Customer is receiving any of the Covered Services listed
below, as of the date the termination takes effect, Medical Group will continue to render those Covered Services to that Customer and this Agreement will continue to apply to those Covered Services, after the termination takes effect, for the length
of time indicated below: 
  

			
	Inpatient Covered Services	  	30 days or until discharge, whichever comes first
		
	Pregnancy, Third Trimester - Low Risk	  	Through postpartum follow up visit
		
	Pregnancy, First, Second or Third Trimester - Moderate Risk and High Risk	  	Through postpartum follow up visit
		
	Non-surgical Cancer Treatment	  	30 days or a complete cycle of radiation or chemotherapy, whichever is greater
		
	End Stage Kidney Disease and Dialysis	  	30 days
		
	Symptomatic AIDS undergoing active treatment	  	30 days
		
	Circumstances where Payer is required by applicable law to provide transition coverage of services rendered by Medical Group after Medical Group leaves the provider network accessed
by Payer.	  	As applicable

 Article X. 

Miscellaneous Provisions 
 10.1 Entire Agreement. This Agreement is the entire agreement between the parties with regard to the subject matter herein, and supersedes any prior written or unwritten agreements between the
parties or their affiliates with regard to the same subject matter. 
 10.2 Amendment. This Agreement may only be amended in a writing
signed by both parties, except as provided in section 7.4 and subject to Medical Group’s termination rights described in section 9.2(v). Additionally, this Agreement may be unilaterally amended by United upon written notice to Medical Group in
order to comply with applicable regulatory requirements. United will provide at least 30 days notice of any such regulatory amendment, unless a shorter notice is necessary in order to accomplish compliance. 

10.3 Nonwaiver. The waiver by either party of any breach of any provision of this Agreement shall not operate as a waiver of any subsequent breach
of the same or any other provision. 
 10.4 Assignment. This Agreement may not be assigned by either party without the written consent of
the other party, except that this Agreement may be assigned by United to any of United’s Affiliates. 
 This Agreement may be assigned by
Medical Group to an entity affiliated with Medical Group common ownership, upon 30 days written notice to United. However no such assignment is permitted without United’s prior written consent if the impact of the assignment would be to cause
additional locations to become subject to this Agreement 

 
without United’s consent; circumstances in which additional locations would be made subject to this Agreement are governed by section 3.1 of this Agreement rather than by this section 10.4.

 10.5 Relationship of the Parties. The sole relationship between the parties to this Agreement is that of independent contractors. This
Agreement does not create a joint venture, partnership, agency, employment or other relationship between the parties. 
 10.6 No Third-Party
Beneficiaries. United and Medical Group are the only entities with rights and remedies under the Agreement. 
 10.7 Delegation.
United may delegate (but not assign) certain of its administrative duties under this Agreement to one or more other entities. No such delegation will relieve United of its obligations under this Agreement. 

10.8 Notice. Any notice required to be given under this Agreement shall be in writing, except in cases in which this Agreement specifically
permits electronic notice, or as otherwise permitted or required in the Protocols. All written or electronic notices shall be deemed to have been given when delivered in person, by electronic communication, by facsimile or, if delivered by
first-class United States mail, on the date mailed, proper postage prepaid and properly addressed to the appropriate party at the address set forth on the signature portion of this Agreement or to another more recent address of which the sending
party has received written notice. Notwithstanding the previous sentence, all notices of termination of this Agreement by either party must be sent by certified mail, return receipt requested. Each party shall provide the other with proper
addresses, facsimile numbers and electronic mail addresses of all designees that should receive certain notices or communication instead of that party. 
 10.9 Confidentiality. Neither party will disclose to a Customer, other health care providers, or other third parties any of the following information (except as required by an agency of the
government): 
  

	 	i)	any proprietary business information, not available to the general public, obtained by the party from the other party; 

 

	 	ii)	the specific reimbursement amounts provided for under this Agreement, except for purposes of administration of benefits. 

At least 48 hours before either party issues a press release, advertisement, or other media statement about the business relationship between the
parties, that party will give the other party a copy of the material the party intends to issue. 
 10.10 Governing Law. This Agreement
will governed by and construed in accordance with the laws of the state in which Medical Group renders Covered Services, and any other applicable law. 
 10.11 Regulatory Appendices. One or more regulatory appendix may be attached to this Agreement, setting forth additional provisions included in this Agreement in order to satisfy regulatory
requirements under applicable law. These regulatory appendices, and any attachments to them, are expressly incorporated into this Agreement and are binding on the parties to this Agreement. the event of any inconsistent or contrary language between
a regulatory appendix and any other part of this Agreement, including but not limited to appendices, amendments and exhibits, the provisions of the regulatory appendix will control, to the extent it is applicable. 

10.12 Severability. Any provision of this Agreement that is unlawful, invalid or unenforceable in any situation in any jurisdiction shall not
affect the validity or enforceability of the remaining provisions of this Agreement or the lawfulness validity or enforceability of the offending provision in any other situation or jurisdiction. 

10.13 Survival. Sections 5.9, 7.7, 7.8, Article VIII and sections 9.3 and 10.9 (for the last paragraph) of this Agreement will survive the
termination of this Agreement. 

 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES.

  

					
	WhiteGlove House Call Health, Inc.	 		 	
			
	Signature	 	Street	 	
			
	Print Name	 	City:	 	Austin
			
	Title	 	State	 	TX             , Zip Code 78746
			
	D/B/A	 	Phone	 	
			
	Date	 	Email	 	

 United HealthCare Insurance Company, on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of
Texas, Inc., Evercare of Texas, LLC, and its other affiliates, as signed by its authorized representative: 
  

			
	Signature	 	Signature
		
	Print Name	 	Print Name
		
	Title	 	Title
		
	Date
                                    	 	Date
                                    

Address to be used for giving notice to United under the Agreement 

 

			
	Street	  	
	City	  	State        Zip

Month and year in which Agreement is first effective
                                         
            

 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES.

  

					
	WhiteGlove House Call Health, Inc.	 		 	
			
	Signature	 	Street	 	
			
	Print Name	 	City:	 	Austin
			
	Title	 	State	 	TX             , Zip Code 78746
			
	D/B/A	 	Phone	 	
			
	Date	 	Email	 	

 United HealthCare Insurance Company, on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of
Texas, Inc., Evercare of Texas, LLC, and its other affiliates, as signed by its authorized representative: 
  

			
	Signature	 	Signature
		
	Print Name	 	Print Name
		
	Title	 	Title
		
	Date
                                        
	 	Date
                                        

 Address to be used for giving notice to United under the Agreement 

 

			
	Street	  	
	City	  	State        Zip

Month and year in which Agreement is first effective
                                         
            

 Attachments 
     X     Appendix 1: Medical Group Practice Locations 
     X     Appendix 2: Benefit Plan Descriptions 
     X     Appendix 3: Fee Schedule Sample 

    X     Appendix 4: PacifiCare Protocols 
     X     State Regulatory Requirements Appendix (list all states as applicable) 

Texas 

           Medicare Advantage Regulatory Requirements Appendix 

           Medicaid Regulatory Requirements Appendix 

    X     Other All Payer Appendix 

 Appendix 1 
 Medical Group Practice Locations 
 Medical Group attests that this Appendix identifies all
services and locations covered under this Agreement. 
 IMPORTANT NOTE: Medical Group acknowledges its obligation under Section 5.7 to
promptly report any change in Medical Group’s name or Taxpayer Identification Number. Failure to do so may result in denial of claims or incorrect payment. 
 BILLING ADDRESS 
 Practice Name: WhiteGlove House Call Health, Inc. 

Street Address: 5300 Bee Caves Rd., Bldg-1, Suite 100 
 City: Austin State: Texas Zip: 78746 
 Tax ID Number (TIN): 20-8913858 

National Provider ID (NPI): 1609041003 

PRACTICE LOCATIONS (complete one for each service location) 
  

					
	 Clinic Name
	  	 Clinic Name
	  	 Clinic Name

			
	Street Address	  	Street Address	  	Street Address
	5300 Bee Caves Rd, Bldg 1, Ste 100	  		  	
	City	  	City	  	City
	Austin	  		  	
	State and Zip Code	  	State and Zip Code	  	State and Zip Code
	TX 78746	  		  	
	Phone Number	  	Phone Number	  	Phone Number
	512-329-8081	  		  	
	TIN (if different from above)	  	TIN (if different from above)	  	TIN (if different from above)
			
	National Provider ID (NPI)	  	National Provider ID (NPI)	  	National Provider ID (NPI)
			
	 Clinic Name
	  	 Clinic Name
	  	 Clinic Name

			
	Street Address	  	Street Address	  	Street Address
			
	City	  	City	  	City
			
	State and Zip Code	  	State and Zip Code	  	State and Zip Code
			
	Phone Number	  	Phone Number	  	Phone Number
			
	TIN (if different from above)	  	TIN (if different from above)	  	TIN (if different from above)
			
	National Provider ID (NPI)	  	National Provider ID (NPI)	  	National Provider ID (NPI)

 Appendix 2 
 Benefit Plan Descriptions 
 Medical Group will participate in the network of physicians and
other health care professionals and providers established by United (“Participating Providers”) for the Benefit Plan types described below: 
  

	•	 	 Benefit Plans where Customers are offered a network of Participating Providers and must select a Primary Physician. Such Benefit Plans may or may not
include an out-of-network benefit. 

  

	•	 	 Benefit Plans where Customers are offered a network of Participating Providers but are not required to select a primary physician. Such Benefit Plans
may or may not include an out-of-network benefit. 

  

	•	 	 Benefit Plans where Customers are not offered a network of Participating Providers from which they may receive Covered Services.

 Notwithstanding the above, this Agreement does not apply to the following: 

 

	•	 	 Capitation arrangements are when all of the following apply: 

 

	 	(i)	Medical Group (directly or through an IPA or other provider organization in which Medical Group is a participant) is part of a network for a United Affiliate; and

  

	 	(ii)	As part of that network, Medical Group arranges directly with the United Affiliate, or an IPA or another medical group or an other provider organization, for certain
designated services to be provided to members who are assigned to Medical Group or to the IPA or the other medical group or other provider organization (as the case may be) and who are covered by that United Affiliate’s Benefit Plans, and under
which either: 

  

	 	(a)	Medical Group is capitated or otherwise has financial responsibility; or 

  

	 	(b)	Medical Group is paid on a fee-for-service basis directly by the IPA or by the other medical group or other provider organization which has financial responsibility for
the service, at a rate agreed upon by Medical Group with that IPA or other medical group or other provider organization; and 

  

	 	(iii)	Medical Group provides those designated services to one of those assigned members. 

In such cases, the obligation for payment will be solely that of the medical group, IPA or other provider organization that has financial
responsibility for the service, and not that of United or the United Affiliate. 
 It is not a capitation arrangement when:

  

	 	(1)	Another medical group or an IPA or other provider organization is not affiliated with Medical Group, and is capitated by a United Affiliate for designated Covered
Services rendered to assigned Customers covered by a Benefit Plan issued by that United Affiliate; and 

  

	 	(2)	Medical Group provides those designated Covered Services to one of those assigned Customers, without having a contract or other arrangement with the other medical group
or the IPA or other provider organization for the terms under which those designated Covered Services are provided. 

 In such cases, this Agreement will apply and the medical group or IPA or other provider organization that has responsibility for the Covered Service will be considered the Payer. 

Note: Although the above capitation arrangements are excluded from this Agreement, there can be a separate agreement providing for Medical
Group’s participation in a network for such capitation arrangements. 

	•	 	 Medicare Benefit Plans that (A) are sponsored, issued or administered by any Payer and (B) replace, either partially or in its entirety, the
original Medicare coverage (Medicare Part A and Medicare Part B) issued to beneficiaries by the Centers for Medicare and Medicaid Services (“CMS”). Note: Although Medicare Benefit Plans, as described above, are excluded from this
Agreement, there can be a separate agreement between Carrier and Medical Group or Medical Group’s affiliates providing for Medical Group’s participation in a network for certain of those Medicare Benefit Plans.

  

	•	 	 Benefit Plans for Medicaid Customers. Note: Although Medicaid Benefit Plans are excluded from this Agreement, there can be a separate agreement between
the parties or between United Affiliates and the affiliates of Medical Group or other entity authorized to contract on behalf of Medical Group (such as an IPA agreement) providing for Medical Group’s participation in a network for those Benefit
Plans. 

  

	•	 	 Medicaid Benefit Plans marketed under the name UnitedHealthcare - Texas Star, as indicated by a reference to UnitedHealthcare - Texas Star on the face
of the valid identification card of any Customer eligible and enrolled in such a Benefit Plan. Note: Although Medicaid UnitedHealthcare - Texas Star Benefit Plans are excluded from this Agreement, there can be a separate agreement between United or
between United’s and Facility’s affiliates or other entity authorized to contract on behalf of Facility (such as an IPA agreement) providing for Facility participation in a network for those Benefit Plans. 

 

	•	 	 Medicare Advantage Private Fee-For-Service plans. 

  

	•	 	 Benefit Plans for Medicare Select 

  

	•	 	 Benefit Plans for workers’ compensation benefit programs. 

 Appendix 3 
 Fee Schedule Sample: Options PPO 
 Representative Options PPO Fee Schedule Sample for:
81349/81350 
 The provisions of this fee schedule apply to Covered Services by Medical Group to Customers covered by Benefit Plans marketed
under the name “Options PPO” and Benefit Plans where Customers are not offered a network of participating physicians and other health care professionals from which they may receive Covered Services. This fee schedule does not apply to
Covered Services rendered by Medical Group to Customers covered by Benefit Plans sponsored, issued or administered by a subsidiary of either PacifiCare Health Plan Administrators, Inc. or PacifiCare Health Systems, LLC. 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the Customer is responsible to pay under the Customer’s Benefit Plan will be subtracted from the listed amount in determining the
amount to be paid by the Payer. The actual payment amount is also subject to matters described in this Agreement, such as the Payment Policies. This information is subject to the confidentiality provisions of this Agreement. 

 Appendix 3 
 Fee Schedule Sample: Products other than Options PPO 
 Representative All-Payer Fee
Schedule Sample(s) for: 81349/81350 
 Unless another fee schedule to this Agreement applies specifically to a particular Benefit Plan as it
covers a particular Customer, the provisions of this fee schedule apply to Covered Services rendered by Medical Group to Customers covered by Benefit Plans sponsored, issued or administered by all Payers. 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the Customer is responsible to pay under the Customer’s Benefit Plan will be subtracted from the listed amount in determining the
amount to be paid by the Payer. The actual payment amount is also subject to matters described in this Agreement, such as the Payment Policies. This information is subject to the confidentiality provisions of this Agreement. 

 Appendix 4 
 PacifiCare Protocols 
 For Customers enrolled in Benefit Plans issued or administered by a
subsidiary of either PacifiCare Health Plan Administrators Inc. or PacifiCare Health Systems, LLC (“PacifiCare Customers”), Medical Group will be subject to the Protocols described in or made available through the PacifiCare Provider
Policy and Procedure Manual (“PacifiCare Manual”). When this Agreement refers to the Administrative Manual or Guide, it is also referring to the PacifiCare Manual. The PacifiCare Manual will be made available to Medical Group on line or
upon request. In the event of any conflict between this Agreement or the “UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide” or other UnitedHealthcare administrative protocols, and
the PacifiCare Manual, in connection with any matter pertaining to a PacifiCare Customer, the PacifiCare Manual will govern, unless applicable statutes and regulations dictate otherwise. United may make changes to the Administrative Manual or Guide
or PacifiCare Manual or other administrative protocols upon 30 days’ electronic or written notice to Medical Group. 

 For reference purposes, the following fee schedules will be used to pay claims under this agreement:

  

					
	 PRODUCTS:
	  	 FEE SCHEDULES:
	  	 PROVIDER DESCRIPTION

			
	Commercial - Options PPO	  	 *  See All Payer Appendix
	  	 Austin/San Antonio Market

Service Delivery Area

			
	Commercial - All Other	  	 *  See All Payer Appendix
	  	 Austin/San Antonio Market

Service Delivery Area

 All Payer Appendix 

Provider Participation Agreement 
 APPLICABILITY 
 Unless another appendix to this Agreement applies specifically to a
particular Benefit Plan as it covers a particular Customer, the provisions of this Appendix apply to Covered Services rendered by Provider to Customers covered by Benefit Plans sponsored, issued or administered by all Payers. 

The terms and conditions of this Appendix, including but not limited to the contracted rates for reimbursement set forth herein, will remain in effect
for the initial term of the Agreement and for all subsequent renewals. 
 SECTION 1 

Definitions 
 Covered
Service: A health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to the terms of the Customer’s Benefit Plan with that Payer. 
 Customary Charge: The fee for health care services charged by Ancillary Provider that does not exceed the fee Ancillary Provider would ordinarily charge another person regardless of whether the
person is a Customer. 
 Customer Expenses: Copayments, deductibles or coinsurance that are the financial responsibility of the Customer
according to the Customer’s Benefit Plan. 
 Encounter Rate: The payment made to Medical Group for Covered Services rendered to a
Customer during an encounter. Unless otherwise specified in this Appendix, such payment shall be considered payment in full, less any applicable Customer Expenses, for all Covered Services rendered to the Customer by the Medical Group. Payor shall
pay Medical Group for covered Health Services rendered to Customers the lesser of (1) Medical Group’s Customary Charge, less any applicable Member Expense or (2) the applicable Case Rate less any applicable Member Expense. 

 SECTION 2 
 Payment 
 For Covered Services rendered by Provider to a Customer, Provider shall be paid
by Payer the lesser of (1) Provider’s Customary Charges, less an applicable Customer Expenses, or (2) the contract rate set forth in Section 2 of this Appendix, less any applicable Customer Expenses. Payment under this Appendix
is subject to the requirements set forth in the Agreement regarding timely submission of a complete claim and compliance with applicable Protocols. 
  

							
	 Covered Services
	  	 PAYMENT

METHOD
	  	RATE	 
	 All Covered Services*
	  	Encounter Rate*	  	 	[****]	  

  

	*	The Encounter Rate Payment includes payment in full for all services and supplies billed during an entire patient encounter. 

The Encounter Rate will be paid, less any applicable Customer Expenses, for all Covered Services rendered to the Customer by the Medical Group, only once
every six months from the initial date of service to the Customer, or first date of service after a six month period has expired, whichever is later. All other services to be billed to $.01. 

SECTION 3 

Miscellaneous Provisions 

The rates established by the Agreement are all-inclusive and represent the entire payment for all Covered Services to the Customer. No additional
payments shall be made for any services or items covered under the Customer’s Benefit Plan and billed for separately by Provider. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Market Standard Specifications 
 Austin Market(s) 
 Specifications as of: 07/01/2009 

Report Date: 06/22/2009* 

AUSTN 81349 
  

									
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIATION THERAPY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)- Jan 2008 Conv Fctr	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Representative Fee Schedule Sample for Family Practice: AUSTN 81349 

Fee amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17000
	  	00	 	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	 69210
	  	00	 	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 84443
	  	00	 	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 87880
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	 90658
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99222
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99238
	  	00	 	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99385
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 JO696
	  	00	 	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Market Standard Specifications 
 Austin Market(s) 
 Specifications as of: 07/01/2009 

Report Date: 06/22/2009* 

AUSTN 81350 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIATION THERAPY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)- Jan 2008 Conv Fctr	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Representative Fee Schedule Sample for Family Practice: AUSTN 81350 

Fee amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17000
	  	00	 	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	 69210
	  	00	 	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 84443
	  	00	 	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 87880
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	 90658
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99222
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99238
	  	00	 	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99385
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 JO696
	  	00	 	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Options PPO 
 Market Standard Specifications 
 Austin Market(s) 

Specifications as of: 07/01/2009 
 Report Date: 06/22/2009* 
 AUSTN 81349 

 

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

									
	 Type Of Service
	 	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - INTEGUMENTARY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - RESPIRATORY
	 	 2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - CARDIOVASCULAR
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - DIGESTIVE
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - URINARY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MALE GENITAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY- FEMALE GENITAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - ENDOCRINE
	 	 2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr
	  	[****]
	 SURGERY - NERVOUS
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - AUDITORY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - BONE DENSITY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - CT
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRI
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRA
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - PET SCANS
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIATION THERAPY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - ULTRASOUND
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 LAB - PATHOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OFFICE LAB
	 	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	 	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - OTHER
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHEMO ADMIN
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OBSTETRICS - GLOBAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 IMMUNIZATIONS
	 	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	 	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	 	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	 	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	 	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	 	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	 	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	 	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	 	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	 	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Options PPO 
 Representative Fee Schedule Sample for Family Practice : AUSTN 81349 
 Fee
amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 

Site of Service - Linked Schedule ID: AUSTN 81350 
  

											
	 CPT
	  	Mod	  	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17000	  	00	  	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	20610	  	00	  	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	36415	  	00	  	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	59400	  	00	  	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	69210	  	00	  	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	71020	  	00	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	26	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	TC	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	80050	  	TC	  	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	80061	  	00	  	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	84443	  	00	  	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	85025	  	00	  	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	87880	  	00	  	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	90471	  	00	  	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	90658	  	00	  	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	90669	  	00	  	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	93000	  	00	  	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	93307	  	00	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	26	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	TC	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	97110	  	00	  	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	97140	  	00	  	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	99202	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99203	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99204	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99205	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99211	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99212	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99213	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99214	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99215	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99222	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99223	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99232	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99233	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99238	  	00	  	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99243	  	00	  	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99244	  	00	  	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99283	  	00	  	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99284	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99285	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99385	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99391	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99392	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99393	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99394	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99395	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99396	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	JO696	  	00	  	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 
 [****]

 [****] 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Options PPO 
 Market Standard Specifications 
 Austin Market(s) 

Specifications as of: 07/01/2009 
 Report Date: 06/22/2009* 
 AUSTN 81350 

 

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY- FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 [****] 

[****] 
 [****] 

[****] 
 [****] 

Anesthesia Rounding Option: Proration 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Options PPO 
 Representative Fee Schedule Sample for Family Practice: AUSTN 81350 
 Fee
amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 

Site of Service - Linked Schedule ID: AUSTN 81349 
  

											
	 CPT
	  	Mod	  	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17000	  	00	  	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	20610	  	00	  	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	36415	  	00	  	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	59400	  	00	  	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	69210	  	00	  	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	71020	  	00	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	26	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	TC	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	80050	  	TC	  	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	80061	  	00	  	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	84443	  	00	  	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	85025	  	00	  	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	87880	  	00	  	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	90471	  	00	  	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	90658	  	00	  	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	90669	  	00	  	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	93000	  	00	  	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	93307	  	00	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	26	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	TC	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	97110	  	00	  	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	97140	  	00	  	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	99202	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99203	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99204	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99205	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99211	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99212	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99213	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99214	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99215	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99222	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99223	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99232	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99233	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99238	  	00	  	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99243	  	00	  	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99244	  	00	  	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99283	  	00	  	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99284	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99285	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99385	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99391	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99392	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99393	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99394	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99395	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99396	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	JO696	  	00	  	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Texas Regulatory Requirements Appendix 

In addition to our understandings in the agreement between you and us, there are certain additional items that Texas laws and regulations require to be
part of our contract. This appendix sets forth those items and is made part of the agreement between you and us. 
 These requirements apply to
all products or benefit contract sponsored, issued or administered by or accessed through us, to the extent such products are regulated under Texas laws applicable to HMOs, managed care, insurance and/or preferred provider organizations; provided,
however, that the requirements in this appendix will not apply to the extent they are preempted by the Medicare Modernization Act or other applicable law. 
 We each agree to be bound by the terms and conditions contained in this appendix. In the event of a conflict or inconsistency between this appendix and any term or condition contained in the agreement,
this appendix shall control, except with regard to benefit contracts outside the scope of this appendix. 
 This appendix will be deemed to be
updated to incorporate any changes to the laws and regulations referenced in this appendix, including any changes to definitions referenced herein, effective as of the date of such changes. 
 For the purposes of this appendix, “enrollee” means our customers who are enrolled in a benefit contract insured or administered by us or by a participating entity. 

Provisions for fully insured benefit contracts regulated under Texas HMO law: 
 1. Payment. Any financial incentive used or payment made directly or indirectly to you under any provision of this agreement between you and us is not made as an inducement to reduce or limit the
provision of medically necessary services to any enrollee. 
 2. Prompt Payment of Clean Claims. We or a participating entity will make
payment to you pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date we receive an electronic clean claim and not later than 45 days from the
date we receive a non-electronic clean claim, we or a participating entity will either: pay the total amount of the claim in accordance with this agreement; pay the portion of the claim that is not in dispute and notify you in writing why the
remaining portion of the claim is not being paid; pay the total amount of the claim in accordance with this agreement but notify you that the claim is subject to audit; request additional information from you within 30 days of receipt of a clean
claim, and then pay or deny the claim within the time required by law after we receive that information or you fail to timely provide it; or notify you in writing why we or the participating entity will not pay the claim. 

If you submit claims that are not clean: 
  

	•	 	 We will notify you within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a clean claim;

  

	•	 	 You may be asked for additional information so that your claim may be adjudicated; or 

 

	•	 	 Your claim may be denied and you will be notified of the denial and the reason for it; or 

 

	•	 	 We may in our discretion pay or have the claim paid by the other applicable participating entity based on the information that you gave in addition to
the information we have. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where you can contact us with questions regarding claims you have submitted, information
regarding any entity to whom we may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of claims or services. 

 We or a participating entity may not refuse to process or pay an electronically submitted clean claim,
because the claim is submitted together with or in a batch submission with a claim that is not a clean claim. 
 3. Timely Filing of Claims.
You must submit your claims within 95 days of the date of service. For a claim for which coordination of benefits applies, the 95-day period does not begin for submission of the claim to the secondary payer until you receive notice of the
payment or denial from the primary payer. If your claim is not submitted within this time frame, you will not be reimbursed for the services—and you may not charge your patient for them. If your failure to timely submit the claim is the result
of an information systems failure or a catastrophic event that substantially interferes with your normal business operations for more than two consecutive business days and about which you notify the Texas Department of Insurance as required by 28
Tex. Admin. Code §21.2819, we will extend the 95 day filing deadline by the number of days in which your business was unable to operate. In the event that you seek and receive a waiver from our electronic filing requirements under 28 Tex.
Admin. Code § 21.3701, you may submit non-electronic claims to the address shown in the Administrative Guide. 
 4. Duplicate
Claims. You may not submit duplicate claims for claims, (defined as a claim for payment made for the same patient on the same date of service for the same services) that are not clean for: 1) 45 days after you files those claims
non-electronically, and 2) 30 days after you files those claims electronically. 
 5. Penalties. If governing law requires us or the
participating entity to pay interest, billed charges, fees, costs or another penalty for a failure to pay your clean claim for covered services within a certain time frame, we will follow those requirements. The interest, billed charges, fees, costs
or other penalty required by law will be our only additional obligation for not satisfying a payment obligation to you in a timely manner. In addition, if we adjudicated a claim of yours that was not clean, there shall be no interest or other late
payment obligation to you even if we subsequently adjust the payment amount based on additional information that you provide or that we obtain. In accordance with Tex. Ins. Code § 843.342, we or the participating entity is not liable for a
penalty for failure to pay a clean claim: (1) if the failure to pay the claim is a result of a catastrophic event that substantially interferes with our normal business operations or those of the participating entity; or (2) if the claim
was paid in accordance with applicable law, but for less than the contracted rate, and: (A) you notify us of the underpayment after the 270th day after the date the underpayment was received; and (B) we or the participating entity pay the
balance of the claim on or before the 30th day after the date we receive the notice. 
 6. Corrective Adjustments for Overpayments.

 (a) In accordance with TAC § 21.2818, we or the participating entity may recover a refund from you due to overpayment
or completion of an audit, by adjusting future claim payments and/or by billing you for the amount of the overpayment, if (i) we notify you of the overpayment not later than the 180th day after the date of receipt of the overpayment; or
(ii) we notify you of the completion of an audit under TAC § 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and amounts for which a refund is due and
for each claim the basis and specific reasons for the request for refund; (B) notice of your right to appeal; and (C) the methods by which we or the participating entity intend to recover the refund. 

(b) If we disagree with a request for recovery of an overpayment, we will provide you with an opportunity to appeal, in accordance with
Tex. Ins. Code § 843.350 and 28 TAC § 21.2818, and we or the participating entity may not recover the overpayment until all appeal rights are exhausted. 
 (c) We or the participating entity may recover overpayments beyond the 180-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material
misrepresentation by you. 
 7. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee Schedule or coding
guideline changes which are intended to substantially alter the overall methodology or reimbursement level of the fee schedule or which result in a material change in payment to you for the same CPT Code, ICD diagnostic code or hospital-based
revenue code will be treated as an amendment to the agreement, and we will give you 90 days written notice of the changes. We will not make retroactive revisions to the coding guidelines and fee schedules. To request a written copy of our
reimbursement policies and methodologies that apply 

 
to specific procedures or services for which you will seek reimbursement under our agreement, or any other information you need to determine that you are being paid according to our agreement,
send your written request to Network Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. We will respond to your request within 30 days of receiving it. We will, at your request, provide the name, edition, and
model version of the software that we use to determine bundling and unbundling of claims. If we disclose fee schedule or reimbursement methodology to you, you may not use or disclose it for any purposes other than management of your practice,
billing activities, for your business operations or in communications with a governmental agency involved in the regulation of health care or insurance. 
 8. Enrollee Hold Harmless. As further described in this section, you shall hold an enrollee harmless for payment of the cost of covered health care services in the event that we or a participating
entity fails to pay you for such services. You hereby agree that in no event, including, but not limited to non-payment by us or a participating entity, or our insolvency or the insolvency of a participating entity, or breach of this agreement
between you and us, shall you bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against an enrollee or persons other than us acting on an enrollee’s behalf for health care
services provided pursuant to this agreement between you and us. This provision shall not prohibit collection of supplemental charges or co-payment amounts from enrollee made in accordance with the terms of the applicable agreement between the
enrollee and us. You further agree that: (a) this provision shall survive the termination of this agreement between you and us regardless of the cause giving rise to termination and shall be construed to be for the benefit of the enrollee; and
that (b) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between you and an enrollee or person acting on an enrollee’s behalf. No amendment or modification of this provision shall be
effective earlier than fifteen (15) days following the Commissioner of the Texas Department of Insurance’s receipt of written notice of such proposed change. 
 9. Provisions Related to Termination. 
 (a) Notice of Termination. We
shall provide written notification of termination of this agreement between you and us to you at least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to enrollee health,
(ii) action against your license to practice or (iii) fraud or malfeasance, in which cases termination may be immediate. 
 (b) Advisory Review Panel Review of Proposed Termination. Prior to termination of this agreement between you and us, we shall give you a written explanation of the reasons for termination. Not
later than 30 days following receipt of the written notice of termination, you may request and shall receive a review of the proposed termination by an advisory review panel selected in accordance with the provisions of Tex. Ins. Code chpt. 843.306.
Such review shall be conducted within sixty (60) days of your request or, at your request, the review process shall be expedited. The decision of the advisory panel must be considered but is not binding on us. We shall provide you, upon
request, a copy of the recommendation of the advisory review panel and our determination. Notwithstanding the above provision, you are not entitled to and no review shall be provided in a case in which there is (a) imminent harm to enrollee
health, (b) an action by a state medical board, licensing board or other government agency that effectively impairs your ability to practice or (c) a case of fraud or malfeasance. 

(c) Notice to Enrollees of Provider Deselection and Termination. We must provide reasonable advance notification of an impending
termination to enrollees receiving care from you. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if your deselection or termination is for reasons related
to imminent harm to enrollees, notification may be given to enrollees immediately. If you are entitled to a review by us of our decision to terminate you pursuant to Texas Insurance Code, chpt. 843.306 and/or 843.307, we will not notify enrollees of
your impending deselection or termination until its effective date or the time the review panel makes its formal recommendation. 

(d) Continuation of Care for Enrollee Special Circumstance. Unless termination of this agreement between you and us is based upon
reasons relating to medical competence or professional behavior, we or the participating entity shall have a continuing obligation to reimburse you if you are treating an enrollee with special circumstance at no less than the rate provided in this
agreement between you and us. For 

 
purposes of this section, “special circumstance” means a condition with regard to which you reasonably believe that discontinuing care by you and transferring the enrollee’s care
to another provider could cause harm to the enrollee, such as a disability, acute condition, life-threatening illness, or pregnancy of more than twenty-four (24) weeks. You must identify the special circumstance and request that the enrollee be
permitted to continue treatment under your care. You must also agree not to seek payment from the enrollee of any amounts for which the enrollee would not be responsible if this agreement between you and we were still in effect. Any dispute
regarding the necessity for continued treatment by you shall be resolved pursuant to our dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or administrative
manual. If you are terminated, the obligation to reimburse you for ongoing treatment of an enrollee with special circumstance continues through: (a) the ninetieth (90th) day after the effective date of your termination; (b) nine
(9) months following the effective date of the termination for an enrollee who at the time of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care, including a follow-up
checkup within the first six (6) weeks of delivery, for an enrollee who is past the twenty-fourth (24th) week of pregnancy at the effective date of the termination. 
 (e) Voluntary Termination by You. You may terminate this Agreement upon 30 days’ written notice if you provide us with such written notice within 30 days of receiving information requested
under Tex. Ins. Code chpt. 843.321, as described in section 7 above. You agree to cooperate with us to give enrollees the notice described in (c) above. 
 10. Posting of Complaint Procedure and Handling of Enrollee Complaints. You shall post in your office a notice to enrollees on the process for resolving complaints with us. Such notice shall
include the Texas Department of Insurance’s toll-free telephone number for filing complaints. We also provide a mechanism for the resolution of any complaints initiated by our Enrollees which provides for reasonable due process, including, in
an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code chpt. 843.255, as applicable. 
 11. No
Retaliatory Action. We shall not engage in any retaliatory action against you, including termination of or refusal to renew this agreement between you and us, because you have, on behalf of an enrollee, reasonably filed a complaint against us or
have appealed a decision made by us. 
 12. Capitation Payments. If reimbursement to you contains capitation payments, we shall comply
with the requirements of the Texas Insurance Code chpts. 843.315 and 843.316. 
 13. No Indemnification for Tort Liability. You and we
agree that nothing in this agreement between you and us shall be construed to require you to indemnify us for any tort liability resulting from our acts or omissions. 
 14. Provider Communication with Enrollees. Nothing in this agreement between you and us shall be construed to prohibit, attempt to prohibit, or discourage you from discussing with or communicating
to an enrollee, with respect to: (a) information or opinions regarding the enrollee’s health care, including medical condition or treatment options; (b) information or opinions regarding our provisions, terms, requirements, or
services as they relate to the enrollee’s medical needs; (c) the fact that this agreement between you and us has terminated or that you shall otherwise no longer be providing medical care or health care services under our products; or
(d) the fact that, if medically necessary covered services are not available through providers contracting with us, then we must, upon your request and within time appropriate to the circumstances relating to the delivery of the services and
the condition of the enrollee, but in no event to exceed five (5) business days after receipt of reasonably requested documentation, allow referral to an appropriate provider. Further, we may not in any way penalize, terminate, or refuse to
compensate (as provided under this agreement between you and us) you for communicating with a current, prospective or former patient, or a party designated by a patient, in any way protected by this section. 

15. Provisions Related to Emergency Services and Post-Stabilization Care. 
 (a) Definition of Emergency Care. You and we agree that for the purpose of providing health care services for enrollees under our benefit contracts, “emergency care” shall mean health
care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent

 
layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could
result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a
pregnant woman, serious jeopardy to the health of her fetus. 
 (b) Post-stabilization Care Approval. If we require prior
approval of post stabilization care requested by a treating provider following emergency services, we shall approve or deny such treatment within one hour of the time of the request. 
 16. Provisions Specific to Podiatrists. The provisions contained in this Section 16 apply only in the event that you are a podiatrist licensed by the Texas State Board of Podiatric Medical
Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within thirty (30) days after the date of your
request, we shall provide a copy of the coding guidelines and payment schedules applicable to the compensation that you shall receive under this agreement between you and us. 
 (b) No Unilateral Material Retroactive Change. We may not unilaterally make material retroactive revisions to the coding guidelines and payment schedules. 

(c) X-Rays and Orthotics. You may, practicing within the scope of the law regulating podiatry, furnish x-rays and nonprefabricated
orthotics covered by an applicable agreement between the enrollee and us. 
 Provisions for fully insured benefit contracts regulated by the
State of Texas but not subject to Texas HMO laws: 
 1. Other Contracts. You are not restricted from contracting with other insurers,
preferred provider plans, preferred provider organizations, or HMOs. 
 2. Quality Care. Any term or condition of this agreement between
you and us that limits your participation on the basis of quality shall be consistent with established standards of care for your profession. 

3. Provider Privileges. If you have hospital or institutional provider privileges and deliver a significant portion of care in a hospital or
institutional provider setting, this agreement between you and us may contain terms and conditions that include the possession of practice privileges at preferred hospitals or institutions. However, if no preferred hospital or institution offers
privileges to enrollees of a class of physicians or practitioners to which you belong, then the lack of such hospital or institutional provider privileges may not be a basis for denial of your participation as a preferred provider. 

4. Provider Billing. This agreement between you and us may prohibit you from billing an enrollee for unnecessary care if a physician or
practitioner panel has determined the care was unnecessary. However, you shall not be required to pay hospital, institutional, laboratory, x-ray or like charges resulting from the provision of services lawfully ordered by you, even though such
service may be determined to be unnecessary. 
 5. Enrollee Referrals. Nothing in this agreement between you and us shall be construed as
a restriction on the classes of physicians and practitioners who may refer an enrollee to another physician or practitioner. In the event that you make a referral for specialty care, nothing in this agreement between you and us shall be construed to
require you to bear the expenses of such referral in or out of the preferred provider panel. 
 6. No Inducement to Limit Medically Necessary
Services. This agreement between you and us does not contain any financial incentives to you, which act directly or indirectly as an inducement to limit medically necessary services. 

 7. Enrollee or Provider Complaints. We provide a mechanism for the resolution of complaints
initiated by an enrollee or you which provides for reasonable due process including, in an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code § 1301.055 and 28 Tex. Admin. Code §3.3706.

 8. Limit on Indemnification. You shall not be required to indemnify or hold us harmless from tort liability resulting from our acts or
omissions. 
 9. Discounted Fee Arrangements. If this agreement between you and us contains a discounted fee arrangement, an enrollee may
be billed only on the discounted fee and not the full charge. 
 10. Prompt Payment. We or a participating entity will make payment to
you pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date we receive an electronic clean claim and not later than 45 days from the date we
receive a non-electronic clean claim, we or a participating entity will either: pay the total amount of the claim in accordance with this agreement; pay the portion of the claim that is not in dispute and notify you in writing why the remaining
portion of the claim is not being paid; pay the total amount of the claim in accordance with this agreement but notify you that the claim is subject to audit; request additional information from you within 30 days of receipt of a clean claim, and
then pay or deny the claim within the time required by law after we receive that information or you fail to timely provide it; or notify you in writing why we or the participating entity will not pay the claim. 

If you submit claims that are not clean, 
  

	 	•	 	 We will notify you within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a clean claim;

  

	 	•	 	 You may be asked for additional information so that your claim may be adjudicated; or 

 

	 	•	 	 Your claim may be denied and you will be notified of the denial and the reason for it; or 

 

	 	•	 	 We may in our discretion pay or have the claim paid by the other applicable participating entity based on the information that you gave in addition to
the information we have. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where you can contact us with questions regarding claims you have submitted, information
regarding any entity to whom we may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of claims or services. 

11. Timely Filing of Claims. You must submit your claims within 95 days of the date of service. For a claim for which coordination of benefits
applies, the 95-day period does not begin for submission of the claim to the secondary payer until you receive notice of the payment or denial from the primary payer. If your claim is not submitted within this time frame, you will not be reimbursed
for the services—and you may not charge your patient for them. If your failure to timely submit the claim is the result of an information systems failure or catastrophic event that substantially interferes with your normal business operations
for more than two consecutive business days and about which you notify the Texas Department of Insurance as required by 28 Tex. Admin. Code §21.2819, we will extend the 95 day filing deadline by the number of days in which your business was
unable to operate. In the event that you seek and receive a waiver from our electronic filing requirements under 28 Tex. Admin. Code § 21.3701, you may submit non-electronic claims to the address shown in the Administrative Guide.

 12. Duplicate Claims. You may not submit duplicate claims for claims, (defined as a claim for payment made for the same patient on the
same date of service for the same services) that are not clean for: 1) 45 days after you files those claims non-electronically, and 2) 30 days after you files those claims electronically. 
 13. Penalties. If governing law requires us or the participating entity to pay interest, billed charges, fees, costs or another penalty for a failure to pay your clean claim for covered services
within a certain time frame, we will follow those requirements. The interest, billed charges, fees, costs or other penalty required by law will be the only 

 
additional obligation for not satisfying in a timely manner a payment obligation to you. In addition, if we adjudicated a claim of yours that was not clean, there shall be no interest or other
late payment obligation to you even if we subsequently adjust the payment amount based on additional information that you provide or that we obtain. In accordance with Tex. Ins. Code § 1301.137, neither we nor or the participating entity will
be liable for a penalty for failure to pay a clean claim: (1) if the failure to pay the claim is a result of a catastrophic event that substantially interferes with our normal business operations or those of the participating entity; or
(2) if the claim was paid in accordance with applicable law, but for less than the contracted rate, and: (A) you notify us of the underpayment after the 270th day after the date the underpayment was received; and (B) we or the
participating entity pay the balance of the claim on or before the 30th day after the date we receive the notice. 
 14. Corrective
Adjustments for Overpayments. 
 (a) In accordance with TAC § 21.2818, we or the participating entity may recover a
refund from you due to overpayment or completion of an audit, by adjusting future claim payments and/or by billing you for the amount of the overpayment, if: (i) we notify you of the overpayment not later than the 180th day after the date of
receipt of the overpayment; or (ii) we notify you of the completion of an audit under TAC § 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and
amounts for which a refund is due and for each claim the basis and specific reasons for the request for refund; (B) notice of your right to appeal; and (C) the methods by which you intend to recover the refund. 

(b) If you disagree with a request for recovery of an overpayment, we will provide you with an opportunity to appeal, in accordance with
Tex. Ins. Code § 1301.132 and 28 TAC § 21.2818, and we or the participating entity may not recover the overpayment until all appeal rights are exhausted. 
 (c) We or the participating entity may recover overpayments beyond the 180-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material
misrepresentation by you. 
 15. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee Schedule or coding
guideline changes which are intended to substantially alter the overall methodology or reimbursement level of the fee schedule or which result in a material change in payment to you for the same CPT Code, ICD diagnostic code or hospital-based
revenue code will be treated as an amendment to the contract, and we will give you 90 days written notice of the changes. We will not make retroactive revisions to the coding guidelines and fee schedules. To request a written copy of our
reimbursement policies and methodologies that apply to specific procedures or services for which you will seek reimbursement under this agreement, or any other information you need to determine that you are being paid according to this agreement,
send your written request to Network Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. We will respond to your request within 30 days of receiving it. We will, at your request, provide the name, edition, and
model version of the software that we use to determine bundling and unbundling of claims. If we disclose fee schedule or reimbursement methodology to you, you may not use or disclose it for any purposes other than management of your practice, to
submit bills, for your business operations or in communications with a governmental agency involved in the regulation of health care or insurance. 
 16. Protected Communications. You shall not be prohibited, penalized, retaliated against, or terminated for communicating information pursuant to Texas Insurance Code art. 3.70-3C §7(c).

 17. Use of Economic Profiling. If we conduct, use, or rely upon economic profiling to terminate you, you shall be informed of our
obligation to make available as requested by you, your economic profile, including written criteria by which your performance was measured in accordance with Texas Insurance Code art. 3.70-3C §3(h). 

18. Quality Assessment. If we engage in quality assessment, we shall do so through a panel of not less than three physicians selected by us from
among a list of physicians contracting with us. 
 19. Immunization or Vaccination Protocol. You are not required to issue an
immunization or vaccination protocol for an immunization or vaccination to be administered to an enrollee by a pharmacist. 

 20. Administration of Immunizations or Vaccinations. This agreement between you and us does not
prohibit a pharmacist from administering immunizations or vaccinations if such immunizations or vaccinations are administered in accordance with the Texas Pharmacy Act art. 4542a-1 and rules promulgated thereunder. 

21. Provisions Related to Emergency Services and Post-Stabilization Care 
 (a) Definition of Emergency Care. You and we agree that for the purpose of providing health care services for enrollees under our benefit contracts, “emergency care” shall mean health
care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an
average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: (1) placing the patient’s health in serious jeopardy;
(2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant woman, serious jeopardy to the health of her fetus. 

(b) Post-stabilization Care Approval. If we require prior approval of post stabilization care requested by a treating provider
following emergency services, we shall approve or deny such treatment within one hour of the time of the request. 
 22. Provisions Related
to Termination. 
 (a) Notice of Termination. We shall provide written notification of termination of this agreement
between you and us to you at least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to enrollee health, (ii) action against your license to practice or
(iii) fraud, in which cases termination may be immediate. 
 (b) Advisory Review Panel Review of Proposed
Termination. Prior to termination of this agreement between you and us, we shall give you a written explanation of the reasons for termination. If you are a physician or practitioner, in accordance with 28 TAC § 3.3706 and Tex. Ins. Code
§ 1301.053(b), you may request and shall receive a review of the proposed termination by a selected advisory review panel. You must make the request in writing to us within 20 business days of receipt of the notification of our intent to
terminate, which shall include any relevant documentation. Such review shall be conducted within sixty (60) days of your request or, if requested by you pursuant to 28 TAC § 3.3706, the review process shall be expedited. The decision of
the advisory panel must be considered but is not binding on us. We shall provide you, upon request, a copy of the recommendation of the advisory review panel and our determination. Notwithstanding the above provision, you are not entitled to and no
review shall be provided in a case in which there is (a) imminent harm to enrollee health, (b) an action by a state medical board, licensing board or other government agency that effectively impairs your ability to practice or (c) a
case of fraud or malfeasance. 
 (c) Notice of Provider Termination to Enrollees. We must provide reasonable advance
notification of your impending termination to enrollees receiving care from you. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if your termination is for
reasons related to imminent harm to enrollees, notification of termination may be given to enrollees immediately. If you are entitled to a review by us of our decision to terminate you pursuant to Tex. Ins. Code Ann. § 1301.057, we will not
notify enrollees of your impending termination its effective date or until the time the review panel makes its formal recommendation, whichever is later. 
 (d) Continuation of Care for Enrollee Special Circumstance. Unless termination of this agreement between you and us is based upon reasons relating to medical competence or professional behavior, we
or the participating entity shall have a continuing obligation to reimburse you if you are treating an enrollee with special circumstance at no less than the rate provided in this agreement between you and us. For purposes of this section,
“special circumstance” means a condition with regard to which you reasonably believe that discontinuing care by you and transferring the enrollee’s care to another provider could cause harm to the enrollee, such as a disability, acute
condition, life-threatening illness, or pregnancy of more 

 
than twenty-four (24) weeks. You must identify the special circumstance and request that the enrollee be permitted to continue treatment under your care. You must also agree not to seek
payment from the enrollee of any amounts for which the enrollee would not be responsible if this agreement between you and we were still in effect. Any dispute regarding the necessity for continued treatment by you shall be resolved pursuant to our
dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or administrative manual. If you are terminated, the obligation to reimburse you for ongoing treatment of an
enrollee with special circumstance continues through: (a) the ninetieth (90th) day after the effective date of your termination; (b) nine (9) months following the effective date of the termination for an enrollee who at the time
of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care, including a follow-up checkup within the first six (6) weeks of delivery, for an enrollee who is past the twenty-fourth
(24th) week of pregnancy at the effective date of the termination. 
 (e) Voluntary Termination by You. You may
terminate this Agreement upon 30 days’ written notice if you provide us with such written notice within 30 days of receiving information requested under 28 Tex. Admin. Code § 3.3703(a)(20), as described in section 15 above. You agree to
cooperate with us to give enrollees the notice described in (c) above. 
 23. No Retaliatory Action. We shall not engage in any
retaliatory action, including termination of or refusal to renew the agreement between you and us, against you because you have, on behalf of an enrollee, reasonably filed a complaint against us or have appealed a decision of ours. 

24. Provisions Specific to Podiatrists. The provisions contained in this section apply only in the event that Provider is a podiatrist licensed by
the Texas State Board of Podiatric Medical Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within
thirty (30) days after the date of your request, we shall provide a copy of the coding guidelines and payment schedules applicable to the compensation that you shall receive under the agreement. 

(b) No Unilateral Material Retroactive Change. We may not unilaterally make material retroactive revisions to the coding guidelines
and payment schedules. 
 (c) X-Rays and Orthotics. You may, practicing within the scope of the law regulating podiatry,
furnish x-rays and nonprefabricated orthotics covered by an enrollee’s benefit contract. 

 AMENDMENT 
 WhiteGlove House Call Health, Inc. (“Medical Group”) is party to an agreement, effective 08/01/2009, (the “Agreement”) with United HealthCare Insurance Company and/or one or more of
its affiliates, (collectively referred to as “United”), under which Medical Group participates in UnitedHealthcare’s network of contracted participating providers. 
 The parties mutually desire to modify certain aspects of their business relationship. Accordingly, the parties hereby amend the Agreement, as follows: 

1. The effective date of this amendment is September 15, 2010. 
 2. To the extent this Amendment conflicts with the Agreement, this Amendment supersedes the conflicting provision of the Agreement. This Amendment further supersedes any provision of the Agreement to the
extent such provision goes beyond the provisions of this Amendment in excluding a Customer, Paver or Benefit Plan from accessing Medical Group’s services under the Agreement. 
 3. The following definitions supersede the same defined terms in the Agreement, and also supersede equivalent defined terms, in the event any exist in the Agreement. For example, the definition of
“Benefit Plan” in this Amendment supersedes the definition of “Benefit Contract”, the definition of “Covered Service” in this Amendment supersedes the definition of “Health Service”, the definition of
“Customer” in this Amendment supersedes the definition of “Member”, and the definition of “Payer” in this Amendment supersedes the definition of “Payor”. 

a. Benefit Plan means a certificate of coverage, summary plan descriptions or other document or agreement, whether delivered in
paper, electronic, or other format under which a Paver is obligated to provide coverage of Covered Services for a Customer. 
 b.
Covered Service is a health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to the terms of the Customer’s Benefit Plan with that Payer. 

c. Customer is a person eligible and enrolled to receive coverage from a Payer for Covered Services. 

d. Payer is a person or entity obligated to a Customer to provide reimbursement for Covered Services under the Customer’s
Benefit Plan, and authorized by United to access Medical Group’s services under this Agreement. 
 e. United’s
Affiliates are those entities controlling, controlled by, or under common control with United HealthCare Insurance Company. 
 4. The
attached “Benefit Plan Descriptions Appendix” is added to the Agreement. Any similar attachment to the Agreement concerning the products, Benefit Plans or networks in which Medical Group will participate is hereby deleted and replaced with
this Appendix. 
 5. The following provision shall be added to the Agreement: 

PacifiCare Protocols. For Customers enrolled in Benefit Plans issued or administered by a subsidiary of either PacifiCare Health
Plan Administrators, Inc. or PacifiCare Health Systems, LLC (“PacifiCare Customers”). Medical Group will be subject to the Protocols described in or made available through the PacifiCare Provider Policy and Procedure Manual
(“PacifiCare Manual”). When this Agreement refers to the Administrative Manual or Guide, it is also referring to the PacifiCare Manual. The PacifiCare Manual will be made available to Medical Group on line or upon request. In the event of
any conflict between this Agreement or the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide or other UnitedHealthcare administrative protocols, and the PacifiCare Manual, in connection with
any matter pertaining to a PacifiCare Customer, the PacifiCare Manual will govern, unless applicable statutes and regulations dictate otherwise. United may make changes to the Administrative 

 
Manual or Guide or PacifiCare Manual or other administrative protocols upon 30 days’ electronic or written notice to Medical Group.” 

6. The following paragraph will be added to the Agreement and will replace any provision in the Agreement to the extent such provision directly conflicts
with it: 
 Payment may be denied in whole or in part if services provided are determined by United to be medically unnecessary,
and Medical Group may not bill the Customer for such services unless the Customer has, with knowledge of United’s determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. 

7. The attached Texas Regulatory Requirements Appendix will be added to the agreement and will supersede and replace any previous regulatory requirements
appendix, addendum or provision in the Agreement. 
 8. Appendix 3 entitled Fee Schedule Sample is deleted in its entirety and replaced with the
following Appendix(cies) 3 Fee Schedule Samples and Fee Schedule Specifications. 
 9. Beginning July 1, 2011, rates for an initial visit
will be determined as follows: 
 If United averages [****] initial visits per month in the Applicable Reporting Period, the rate
shall be [****]. 
 If United averages [****] or more initial visits per month in the Applicable Reporting Period, the rate shall
be [****]. 
 If initial visits per month do not exceed [****] per month during the Applicable Reporting Period, the rate shall
be [****]. 
 10. The Applicable Reporting Period will be January 1 - May 31 for July 1 rate updates and July 1 -
November 30 for January 1 rate updates. 
 11. The PROVIDER DESCRIPTION Section of the Agreement reference page is hereby deleted and
replaced with the following, “Counties serviced by Medical Group in the State of Texas”. 
 12. A United group that has a direct
contract with WhiteGlove House Call Health, Inc., either at the time of execution of this amendment or in the future from the permitted sales efforts of WhiteGlove House Call Health, for Covered Services is not covered by this Agreement during the
term of the agreement between the United group and WhiteGlove House Call Health. Inc. 
 A United group shall be defined as any
group accessing United’s network. 
 13. At the request of UHC, which is only to be when audited, WhiteGlove House Call Health, Inc. will
provide a list of United groups contracted directly with WhiteGlove House Call Health, Inc. UHC agrees to limit the use of that list to purposes related solely to claims audit and administration. 

14. The Agreement term is for a one year from the Effective Date and can be terminated by either party after the one year term with a 120 day written
notice. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 All other provisions of the Agreement shall remain in full force and effect. 

IN WITNESS WHEREOF, the undersigned have executed this Amendment to be effective as of the date set forth above. 

 

	
	WhiteGlove House Call Health, Inc., on behalf of Medical Group
	
	Signature
	
	Print Name
	
	Title
	
	Date

 United HealthCare Insurance Company, on behalf of
itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc., Exorcare of Texas, L.L.C. and no other affiliates, as signed by its authorized representative: 
  

			
	Signature	 	Signature
		
	Print Name	 	Print Name
		
	Title	 	Title
		
	Date	 	Date

 AMENDMENT 
 WhiteGlove House Call Health, Inc. (“Medical Group”) is party to an agreement, effective 08/01/2009, (the “Agreement”) with United HealthCare Insurance Company and/or one or more of
its affiliates, (collectively referred to as “United”), under which Medical Group participates in UnitedHealthcare’s network of contracted participating providers. 
 The parties mutually desire to modify certain aspects of their business relationship. Accordingly, the parties hereby amend the Agreement, as follows: 

1. The effective date of this amendment is September 15, 2010. 
 2. To the extent this Amendment conflicts with the Agreement, this Amendment supersedes the conflicting provision of the Agreement. This Amendment further supersedes any provision of the Agreement to the
extent such provision goes beyond the provisions of this Amendment in excluding a Customer, Paver or Benefit Plan from accessing Medical Group’s services under the Agreement. 
 3. The following definitions supersede the same defined terms in the Agreement, and also supersede equivalent defined terms, in the event any exist in the Agreement. For example, the definition of
“Benefit Plan” in this Amendment supersedes the definition of “Benefit Contract”, the definition of “Covered Service” in this Amendment supersedes the definition of “Health Service”, the definition of
“Customer” in this Amendment supersedes the definition of “Member”, and the definition of “Payer” in this Amendment supersedes the definition of “Payor”. 

a. Benefit Plan means a certificate of coverage, summary plan descriptions or other document or agreement, whether delivered in
paper, electronic, or other format under which a Paver is obligated to provide coverage of Covered Services for a Customer. 
 b.
Covered Service is a health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to the terms of the Customer’s Benefit Plan with that Payer. 

c. Customer is a person eligible and enrolled to receive coverage from a Payer for Covered Services. 

d. Payer is a person or entity obligated to a Customer to provide reimbursement for Covered Services under the Customer’s
Benefit Plan, and authorized by United to access Medical Group’s services under this Agreement. 
 e. United’s
Affiliates are those entities controlling, controlled by, or under common control with United HealthCare Insurance Company. 
 4. The
attached “Benefit Plan Descriptions Appendix” is added to the Agreement. Any similar attachment to the Agreement concerning the products, Benefit Plans or networks in which Medical Group will participate is hereby deleted and replaced with
this Appendix. 
 5. The following provision shall be added to the Agreement: 

PacifiCare Protocols. For Customers enrolled in Benefit Plans issued or administered by a subsidiary of either PacifiCare Health
Plan Administrators, Inc. or PacifiCare Health Systems, LLC (“PacifiCare Customers”). Medical Group will be subject to the Protocols described in or made available through the PacifiCare Provider Policy and Procedure Manual
(“PacifiCare Manual”). When this Agreement refers to the Administrative Manual or Guide, it is also referring to the PacifiCare Manual. The PacifiCare Manual will be made available to Medical Group on line or upon request. In the event of
any conflict between this Agreement or the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide or other UnitedHealthcare administrative protocols, and the PacifiCare Manual, in connection with
any matter pertaining to a PacifiCare Customer, the PacifiCare Manual will govern, unless applicable statutes and regulations dictate otherwise. United may make changes to the Administrative 

 
Manual or Guide or PacifiCare Manual or other administrative protocols upon 30 days’ electronic or written notice to Medical Group.” 

6. The following paragraph will be added to the Agreement and will replace any provision in the Agreement to the extent such provision directly conflicts
with it: 
 Payment may be denied in whole or in part if services provided are determined by United to be medically unnecessary,
and Medical Group may not bill the Customer for such services unless the Customer has, with knowledge of United’s determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. 

7. The attached Texas Regulatory Requirements Appendix will be added to the agreement and will supersede and replace any previous regulatory requirements
appendix, addendum or provision in the Agreement. 
 8. Appendix 3 entitled Fee Schedule Sample is deleted in its entirety and replaced with the
following Appendix(cies) 3 Fee Schedule Samples and Fee Schedule Specifications. 
 9. Beginning July 1, 2011, rates for an initial visit
will be determined as follows: 
 If United averages [****] initial visits per month in the Applicable Reporting Period, the rate
shall be [****]. 
 If United averages [****] or more initial visits per month in the Applicable Reporting Period, the rate shall
be [****]. 
 If initial visits per month do not exceed [****] per month during the Applicable Reporting Period, the rate shall
be [****]. 
 10. The Applicable Reporting Period will be January 1 - May 31 for July 1 rate updates and July 1 -
November 30 for January 1 rate updates. 
 11. The PROVIDER DESCRIPTION Section of the Agreement reference page is hereby deleted and
replaced with the following, “Counties serviced by Medical Group in the State of Texas”. 
 12. A United group that has a direct
contract with WhiteGlove House Call Health, Inc., either at the time of execution of this amendment or in the future from the permitted sales efforts of WhiteGlove House Call Health, for Covered Services is not covered by this Agreement during the
term of the agreement between the United group and WhiteGlove House Call Health. Inc. 
 A United group shall be defined as any
group accessing United’s network. 
 13. At the request of UHC, which is only to be when audited, WhiteGlove House Call Health, Inc. will
provide a list of United groups contracted directly with WhiteGlove House Call Health, Inc. UHC agrees to limit the use of that list to purposes related solely to claims audit and administration. 

14. The Agreement term is for a one year from the Effective Date and can be terminated by either party after the one year term with a 120 day written
notice. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 All other provisions of the Agreement shall remain in full force and effect. 

IN WITNESS WHEREOF, the undersigned have executed this Amendment to be effective as of the date set forth above. 

 

	
	WhiteGlove House Call Health, Inc., on behalf of Medical Group
	
	Signature
	
	Print Name
	
	Title
	
	Date

 United HealthCare Insurance Company, on behalf of
itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc., Exorcare of Texas, L.L.C. and no other affiliates, as signed by its authorized representative: 
  

			
	Signature	 	Signature
		
	Print Name	 	Print Name
		
	Title	 	Title
		
	Date	 	Date

 Benefit Plan Descriptions Appendix 

United may allow Payers to access Medical Group’s services under this Agreement for the Benefit Plan types described below: 

 

	 	•	 	 Benefit Plans where Customers are offered a network of Participating Providers and must select a primary physician. Such Benefit Plans may or may not
include an out-of-network benefit. 

  

	 	•	 	 Benefit Plans where Customers are offered a network of Participating Providers but are not required to select a primary physician. Such Benefit Plans
may or may not include an out-of-network benefit. 

  

	 	•	 	 Benefit Plans where Customers are not offered a network of Participating Providers from which they may receive Covered Services.

 However, this Agreement does not apply to the following: 

 

	 	•	 	 Benefit Plans sponsored, issued or administered by any Payer where the Benefit Plan is intended to replace, either partially or in its entirety, the
traditional Medicare coverage (Medicare Part A and Medicare Part B) issued to beneficiaries by the Centers for Medicare and Medicaid Services. Note: Although Medicare Benefit Plans are excluded from this Agreement, there can be a separate
agreement between the parties or between United Affiliates and the affiliates of Medical Group or other entity authorized to contract on behalf of Medical Group (such as an IPA agreement) providing for Medical Group’s participation in a network
for those Benefit Plans. 

  

	 	•	 	 Benefit Plans for Medicaid Customers. Note: Although Medicaid Benefit Plans are excluded from this Agreement, there can be a separate agreement between
the parties or between United Affiliates and the affiliates of Medical Group or other entity authorized to contract on behalf of Medical Group (such as an IPA agreement) providing for Medical Group’s participation in a network for those Benefit
Plans. 

  

	 	•	 	 Medicare Advantage Private Fee-For-Service Plans 

  

	 	•	 	 Benefit Plans for Medicare Select 

  

	 	•	 	 Benefit Plans for workers’ compensation benefit programs. 

 Appendix 3 - Options PPO 

Representative Options PPO Fee Schedule Sample for: 81349/81350 
 The provisions of this fee schedule apply to Covered Services by Medical Group to Customers covered by Benefit Plans marketed under the name “Options PPO” and Benefit Plans where Customers are
not offered a network of participating physicians and other health care professionals from which they may receive Covered Services. This fee schedule does not apply to Covered Services rendered by Medical Group to Customers covered by Benefit Plans
sponsored, issued or administered by a subsidiary of either PacifiCare Health Plan Administrators, Inc. or PacifiCare Health Systems, LLC. 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the Customer is responsible to pay under the Customer’s Benefit Plan will be subtracted from the listed amount in determining the
amount to be paid by the Payer. The actual payment amount is also subject to matters described in this Agreement, such as the Payment Policies. This information is subject to the confidentiality provisions of this Agreement. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

									
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	  	Site of
Service	  	 Linked

Schedule

ID

					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY- FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 Unless specifically indicated
otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is
responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the
payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note: Maintenance to
this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice: AUSTN 81349 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	  	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17110	  	00	  	 DESTRUCTION BENI
	  	 SURGERY - INTEGUMENTARY
	  	NonFac	  	[****]
	20610	  	00	  	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFac	  	[****]
	36415	  	00	  	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	59400	  	00	  	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	71020	  	00	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	26	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	TC	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	80050	  	TC	  	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80053	  	00	  	 COMPRE METAB PAN
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80061	  	00	  	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	85025	  	00	  	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	87850	  	00	  	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFac	  	[****]
	90471	  	00	  	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	90648	  	00	  	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90558	  	00	  	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90715	  	00	  	 TOAP VACCINE 7 Y
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90716	  	00	  	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90734	  	00	  	 MENINGOCOCCAL CO
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	93000	  	00	  	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	83307	  	00	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	26	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	TC	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	96372	  	00	  	 THERAPEUTIC PROP
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	97110	  	00	  	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	97140	  	00	  	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	99202	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99203	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99204	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99205	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99211	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99212	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99213	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99214	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99215	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99223	  	00	  	 INT HOSP-DAY ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99232	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99233	  	00	  	 SUBSQT HOSP-DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99243	  	00	  	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99244	  	00	  	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99283	  	00	  	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99284	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99285	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99391	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99392	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99393	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99394	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99395	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99396	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

									
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	  	Site of
Service	  	 Linked

Schedule

ID

					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY- FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice: AUSTN 81350 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17110	  	00	 	DESTRUCTION BENI	  	 SURGERY - INTEGUMENTARY
	  	NonFac	  	[****]
	20610	  	00	 	ARTHROCENTESIS A	  	 SURGERY - MUSCULOSKELETAL
	  	NonFac	  	[****]
	36415	  	00	 	COLLECTION OF VE	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	59400	  	00	 	ROUTINE OB CARE	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	71020	  	00	 	RADEX CH 2 VIEWS	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	26	 	RADEX CH 2 VIEWS	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	TC	 	RADEX CH 2 VIEWS	  	 RADIOLOGY
	  	NonFac	  	[****]
	80050	  	TC	 	GENERAL HEALTH P	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80053	  	00	 	COMPRE METAB PAN	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80061	  	00	 	LIPID PANEL	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	85025	  	00	 	BLD COUNT: CMPL	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	87850	  	00	 	IAADADOO STREPT	  	 OFFICE LAB
	  	NonFac	  	[****]
	90471	  	00	 	IMMUNIZATION ADM	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	90648	  	00	 	HUMAN PAPILLOMA	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90558	  	00	 	INFLUENZA VACCIN	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90715	  	00	 	TOAP VACCINE 7 Y	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90716	  	00	 	VARICELLA VIRUS	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90734	  	00	 	MENINGOCOCCAL CO	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	93000	  	00	 	ECG-ROUTINE 12 L	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	83307	  	00	 	TTHRC R-T IMG 2D	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	26	 	TTHRC R-T IMG 2D	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	TC	 	TTHRC R-T IMG 2D	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	96372	  	00	 	THERAPEUTIC PROP	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	97110	  	00	 	THERAP 1/>AREAS	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	97140	  	00	 	MNL TX TECH I/MO	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	99202	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99203	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99204	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99205	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99211	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99212	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99213	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99214	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99215	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99223	  	00	 	INT HOSP-DAY ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99232	  	00	 	SUBSQT HSP-DAY E	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99233	  	00	 	SUBSQT HOSP-DAY	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99243	  	00	 	OFFICE CNSLT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99244	  	00	 	OFC CNSLT NEW/ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99283	  	00	 	EMERG DEPT VISIT	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99284	  	00	 	ER VISIT E&M HIG	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99285	  	00	 	ER VISIT E&M HIG	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99386	  	00	 	1ST PREVENTIVE M	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99386	  	00	 	1ST PREVENTIVE M	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99391	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99392	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99393	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99394	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99395	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99396	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Appendix 3 - Products other than Options PPO 

Representative All-Payer Fee Schedule Sample(s) for: 81349/81350 
 Unless another fee schedule to this agreement applies specifically to a particular benefit contract as it covers a particular customer, the provisions of this appendix apply to covered services rendered
by you to customers covered by benefit contracts sponsored, issued or administered by all participating entities. 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customer’s benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement,
such as the reimbursement policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice : AUSTN 81349 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17110
	  	00	 	 DESTRUCTION BENI
	  	 SURGERY - INTEGUMENTARY
	  	NonFac	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFac	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 80053
	  	00	 	 COMPRE METAB PAN
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 87850
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	 90648
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90558
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90715
	  	00	 	 TOAP VACCINE 7 Y
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90734
	  	00	 	 MENINGOCOCCAL CO
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	 83307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	 96372
	  	00	 	 THERAPEUTIC PROP
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99233
	  	00	 	 SUBSQT HOSP-DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice: AUSTN 81350 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17110
	  	00	 	 DESTRUCTION BENI
	  	 SURGERY - INTEGUMENTARY
	  	Fac	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	Fac	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	Fac	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	Fac	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	Fac	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 80053
	  	00	 	 COMPRE METAB PAN
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 87850
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	Fac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	Fac	  	[****]
	 90648
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90558
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90715
	  	00	 	 TOAP VACCINE 7 Y
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90734
	  	00	 	 MENINGOCOCCAL CO
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	Fac	  	[****]
	 83307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	Fac	  	[****]
	 96372
	  	00	 	 THERAPEUTIC PROP
	  	 MEDICINE - OTHER
	  	Fac	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99233
	  	00	 	 SUBSQT HOSP-DAY
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81349 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 45378
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	 45350
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	 58510
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	 77418
	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	NonFac	  	[****]
	 88308
	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	 88305
	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	 88306
	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	 90649
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90680
	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 00716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 92014
	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	NonFac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	NonFac	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	 97110
	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	 90910
	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	 98941
	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	 93202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99206
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99212
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99213
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99214
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99215
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99223
	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99245
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99398
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 J1745
	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 J2505
	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 J9035
	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	NonFac	  	[****]
	 J0283
	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 J9310
	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 j9355
	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	NonFac	  	AUSTN 81349

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 Schedule Type: FFS 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81350 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 45378
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	 45350
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	 58510
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	 77418
	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	Fac	  	[****]
	 88308
	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	 88305
	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	 88306
	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	Fac	  	[****]
	 90649
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90680
	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 00716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 92014
	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	Fac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	Fac	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	 97110
	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	 90910
	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	 98941
	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	 93202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99206
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99212
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99213
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99214
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99215
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99223
	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99245
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99398
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 J1745
	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 J2505
	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 J9035
	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	Fac	  	[****]
	 J0283
	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 J9310
	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 j9355
	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

													
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	 	  	Site of
Service	 	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	 	0000000	  	  	 	NonFac	  	  	AUSTN 81350

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81349 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	45378	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	45350	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	59400	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	58510	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	77418	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	NonFac	  	[****]
	88308	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	88305	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	88306	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	90471	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	90649	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90669	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90680	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	00716	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	92014	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	NonFac	  	[****]
	93000	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	NonFac	  	[****]
	93307	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	97110	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	90910	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	98941	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	93202	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99203	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99204	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99206	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99212	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99213	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99214	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99215	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99223	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99232	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99233	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99243	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99244	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99245	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99283	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99284	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99285	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99391	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99392	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99393	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99394	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99395	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99398	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	J1745	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	J2505	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	J9035	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	NonFac	  	[****]
	J0283	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	J9310	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	j9355	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

													
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	 	  	Site of
Service	 	  	 Linked

Schedule

ID

					
	 Austin
	  	AUSTN 81350	  	 	0000000	  	  	 	NonFac	  	  	AUSTN 81349

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 Schedule Type: FFS 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81350 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	45378	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	45350	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	59400	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	58510	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	77418	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	Fac	  	[****]
	88308	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	88305	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	88306	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	90471	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	Fac	  	[****]
	90649	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	90669	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	90680	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	00716	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	92014	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	Fac	  	[****]
	93000	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	Fac	  	[****]
	93307	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	93307	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	93307	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	97110	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	90910	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	98941	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	93202	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99203	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99204	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99206	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99212	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99213	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99214	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99215	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99223	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99232	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99233	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99243	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99244	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99245	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99283	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99284	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99285	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99391	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99392	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99393	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99394	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99395	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99398	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	J1745	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	J2505	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	J9035	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	Fac	  	[****]
	J0283	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	J9310	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	j9355	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Texas Regulatory Requirements Appendix 

This Texas Regulatory Requirements Appendix (the “Appendix”) is made part of the Agreement entered into by and among United HealthCare
Insurance Company, contracting on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc., Evercare of Texas, LLC, and the other entities that are United’s Affiliates (collectively referred to as “United”)
and the health care professional or entity named in the Agreement (“Provider”). 
 This Appendix applies to all products or benefit
plans sponsored, issued or administered by or accessed through United, to the extent such products are regulated under Texas laws applicable to HMOs, managed care, insurance and/or preferred provider organizations; provided, however, that the
requirements in this Appendix will not apply to the extent they are preempted by the Medicare Modernization Act or other applicable law. 

United and Provider each agree to be bound by the terms and conditions contained in this Appendix. In the event of a conflict or inconsistency between
this Appendix and any term or condition contained in the Agreement, this Appendix shall control, except with regard to Benefit Plans outside the scope of this Appendix. 
 This Appendix will be deemed to be updated to incorporate any changes to the laws and regulations referenced herein, including any changes to definitions referenced herein, effective as of the date of
such changes. 
 Unless otherwise defined in this Appendix, all capitalized terms contained in the Appendix shall be defined as set forth in the
Agreement. 
 Provisions applicable to fully insured Benefit Plans regulated under Texas HMO law: 

1. Payment. Any financial incentive used or payment made directly or indirectly to Provider under any provision of this Agreement is not made as an
inducement to reduce or limit the medically necessary services to any Customer. 
 2. Prompt Payment of Clean Claims. United or Payer, as
applicable, will make payment to Provider pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date United receive an electronic clean claim and not
later than 45 days from the date United receives a non-electronic clean claim, United or Payer will either: pay the total amount of the claim in accordance with this Agreement; pay the portion of the claim that is not in dispute and notify Provider
in writing why the remaining portion of the claim is not being paid; pay the total amount of the claim in accordance with this Agreement but notify Provider that the claim is subject to audit; request additional information from Provider within 30
days of receipt of a clean claim, and then pay or deny the claim within the time required by law after United receives that information or Provider fails to timely provide it; or notify Provider in writing why United or Payer will not pay the claim.

 If Provider submits claims that are not clean: 
  

	 	•	 	 We will notify Provider within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a clean
claim; 

  

	 	•	 	 You may be asked for additional information so that Provider’s claim may be adjudicated; or 

 

	 	•	 	 Provider’s claim may be denied and Provider will be notified of the denial and the reason for it; or 

 

	 	•	 	 United may in its discretion pay or have the claim paid by the other applicable Payer based on the information that you gave in addition to the
information United has. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where Provider can contact United with questions regarding claims Provider has submitted,

 
information regarding any entity to whom United may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of
claims or services. 
 United or Payer may not refuse to process or pay an electronically submitted clean claim, because the claim is submitted
together with or in a batch submission with a claim that is not a clean claim. 
 3. Timely Filing of Claims. Provider must submit its
claims within 95 days of the date of service. For a claim submitted by an institutional provider; the 95-day period does not begin until the date of discharge. For a claim for which coordination of benefits applies, the 95-day period does not begin
for submission of the claim to the secondary payer until Provider receives notice of the payment or denial from the primary payer. If Provider’s claim is not submitted within this time frame, Provider will not be reimbursed for the services and
Provider may not charge its patient for therm. If Provider’s failure to timely submit the claim is the result of an information systems failure or a catastrophic event that substantially interferes with Provider’s normal business
operations for more than two consecutive business days and about which Provider notifies the Texas Department of Insurance as required by 28 Tex. Admin. Code §21.2819, United will extend the 95 day filing deadline by the number of days in which
Provider’s business was unable to operate. In the event that Provider seeks and receives a waiver from United’s electronic filing requirements under 28 Tex. Admin. Code § 21.3701, Provider may submit non-electronic claims to the
address shown in the Administrative Guide. 
 4. Duplicate Claims. Provider may not submit duplicate claims for claims, (defined as a
claim for payment made for the same patient on the same data of service for the same services) that are not clean for: 1) 45 days after Provider files those claims non-electronically, and 2) 30 days after Provider files those claims electronically.

 5. Penalties. If governing law requires United or Payer to pay interest, billed charges, fees, costs or another penalty for a failure
to pay Provider’s clean claim for covered services within a certain time frame, United will follow those requirements. The interest, billed charges, fees, costs or other penalty required by law will be the only additional obligation for not
satisfying in a timely manner a payment obligation to Provider. In addition, if United adjudicated a claim of Provider’s that was not clean, there ,shall be no interest or other late payment obligation to Provider even if United subsequently
adjusts the payment amount based on additional information that Provider provides or that United obtains. In accordance with Tex. Ins. Code § 843.342, United or Payer is not liable for a penalty for failure to pay a clean claim. (1) if the
failure to pay the claim is a result of a catastrophic event that substantially interferes with the normal business operations of United or Payer; or (2) if the claim was paid in accordance with applicable law, but for less than the contracted
rate, and: (A) Provider notifies the United of the underpayment after the 270th day after the date the underpayment was received; and (B) United or Payer pays the balance of the claim on or before the 30th day after the date United
receives the notice. 
 6. Corrective Adjustments for Overpayments. 

(a) In accordance with TAC § 21.2818, United or Payer may recover a refund from Provider due to overpayment or completion of an
audit, by adjusting future claim payments and/or by billing Provider for the amount of the overpayment, if (i) United notifies Provider of the overpayment not later than the 180th day after the date of receipt of the overpayment; or
(ii) United notifies Provider of the completion of an audit under TAC § 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and amounts for which a refund is
due and for each claim the basis and specific reasons for the request for refund; (B) notice of Provider’s right to appeal; and (C) the methods by which United intends to recover the refund. 

(b) If Provider disagrees with a request for recovery of an overpayment, United shall provide Provider with an opportunity to appeal, in
accordance with Tex. Ins. Code § 843.350 and 28 TAC § 21.28 18, and United or Payer may not recover the overpayment until all appeal rights are exhausted. 
 (c) United or Payer may recover overpayments beyond the 180-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material misrepresentation by
Provider. 

 7. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee schedule or
coding guideline changes which are intended to substantially alter the overall methodology or reimbursement level of the fee schedule or which result in a material change in payment to Provider for the same CPT Code, ICD diagnostic code or
hospital-based revenue code will be treated as an amendment to the Agreement, and United will give Provider 90 days written notice of the changes. United will not make retroactive revisions to the coding guidelines and fee schedules. To request a
written copy of United’s reimbursement policies and methodologies that apply to specific procedures or services for which Provider will seek reimbursement under this Agreement, or any other information Provider needs to determine that Provider
is being paid according to this Agreement, Provider should send a written request to Network Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. United will respond to Provider’s request within 30 days of
receiving it. United will, at request of Provider, provide the name, edition, and model version of the software that the United uses to determine bundling and unbundling of claims. If United discloses fee schedule or reimbursement methodology to
Provider, Provider may not use or disclose it for any purposes other than management of Provider’s practice, billing activities, for Provider’s business operations or in communications with a governmental agency involved in the regulation
of health care or insurance. 
 8. Customer Hold Harmless. As further described in this section, Provider shall hold a Customer harmless
for payment of the cost of covered health services in the event that Payer or United fails to pay the Provider for such services. Provider hereby agrees that in no event, including, but not limited to non¬payment by Payer or United, or United
insolvency, or breach of this Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against Customer or persons other than United acting on Customer’s behalf
for services provided pursuant to this Agreement. This provision shall not prohibit collection of copayments, deductibles or coinsurance for which Customer is responsible in accordance with the terms of the Benefit Plan. Provider further agrees
that: (a) this provision shall survive the termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the Customer, and that (b) this provision supersedes any oral or
written contrary agreement now existing or hereafter entered into between Provider and Customer or person acting on Customer’s behalf- No amendment or modification of this provision shall be effective earlier than fifteen (15) days
following the Commissioner of the Texas Department of Insurance’s receipt of written notice of such proposed change. 
 9. Provisions
Related to Termination. 
 (a) Notice of Termination to Provider. United shall provide written notification of
termination of this Agreement to Provider at least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to Customer health, (ii) action against Provider’s license to
practice or (iii) fraud or malfeasance, in which cases termination may be immediate. 
 (b) Advisory Review Panel Review
of Proposed Termination. Prior to termination of this Agreement. United shall give Provider a written explanation of the reasons for termination. Not later than 30 days following receipt of the written notice of termination Provider may request
and shall receive a review of the proposed termination by an advisory review panel selected in accordance with the provisions of Tex. Ins. Code chpt. 843.306. Such review shall be conducted within sixty (60) days of Provider’s request or,
if requested by Provider, the review process shall be expedited. The decision of the advisory panel must be considered but is not binding on United. United shall provide Provider, upon request, a copy of the recommendation of the advisory review
panel and United’s determination. Notwithstanding the above provision, Provider is not entitled to and no review shall be provided in a case in which there is (a) imminent harm to Customer health, (b) an action by a state medical
board, licensing board or other government agency that effectively impairs the Provider’s ability to practice or (c) a case of fraud or malfeasance. 
 (c) Notice to Customers of Provider Deselection and Termination. United must provide reasonable advance notification of an impending termination of Provider to Customers receiving care from
Provider. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if Provider is deselected or terminated for reasons related to imminent harm to Customers,
notification of the deselection or termination may be given to Customers immediately. If Provider is entitled to a review by United of its decision to deselect or terminate Provider pursuant to

 
Texas Insurance Code chpts. 843.306 and/or 843.307, United will not notify Customers of Provider’s impending deselection or termination until its effective date or until the time the review
panel makes its formal recommendation. 
 (d) Continuation of Care for Customer Special Circumstance. Unless termination
of this Agreement is based upon reasons of medical competence or professional behavior, United or Payer shall have a continuing obligation to reimburse Provider if Provider is treating a Customer with special circumstance at no less than the rate
provided in this Agreement. For purposes of this section, “special circumstance” means a condition with regard to which Provider reasonably believes that discontinuing care by Provider and transferring the Customer’s. care to another
provider could cause harm to the Customer, such as a disability, acute condition, life threatening illness, or pregnancy of more than twenty-four (24) weeks. Provider must identify the special circumstance and request that the Customer be
permitted to continue treatment under the Provider’s care. Provider must also agree not to seek payment from the Customer of any amounts for which the Customer would not be responsible if this Agreement were still in effect. Any dispute
regarding the necessity for continued treatment by Provider shall be resolved pursuant to United’s dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or
administrative manual. The obligation of United or Payer to reimburse a terminated Provider for ongoing treatment of a Customer with special circumstance continues through: (a) the ninetieth (90°) day after the effective date of the
termination; (b) nine (9) months following the effective date of the termination for a Customer who at the time of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care,
including a follow-up checkup within the first six (6) weeks of delivery, for a Customer who is past the twenty-fourth (24th) week of pregnancy at the effective date of the termination. 

(e) Voluntary Termination by Provider. Provider may also terminate this Agreement upon 30 days’ written notice if Provider
provides United with such written notice within 30 days of receiving the information requested under Tex. Ins. Code chpt. 843.321, as described in section 7 above. Provider agrees to cooperate with United to give Customers the notice described in
(c) above. 
 10. Posting of Complaint Procedure and Handling of Customer Complaints. Provider shall post in Provider’s office
a notice to Customers on the process for resolving complaints with United or Payer. Such notice shall include the Texas Department of Insurance’s toll-free telephone number for filing complaints. United also provides a mechanism for the
resolution of any complaints initiated by Customers which provides for reasonable due process, including, in an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code chpt 843.255, as applicable. 

11. No Retaliatory Action. United shall not engage in any retaliatory action, including termination of or refusal to renew this Agreement, against
Provider because Provider has, on behalf of a Customer, reasonably tiled a complaint against United or has appealed a decision of United. 

12. Capitation Payments. If reimbursement to Provider contains capitation payments, United shall comply with the requirements of the Texas Ins.
Code chpts. 843.315 and 843.316. 
 13. No Indemnification for Tort Liability. Provider and United agree that nothing in this Agreement
shall be construed to require Provider to indemnify United for any tort liability resulting from acts or omissions of United. 
 14. Provider
Communication with Customers. Nothing in this Agreement shall be construed to prohibit, attempt to prohibit, or discourage Provider from discussing with or communicating to a Customer, with respect to: (a) information or opinions regarding
Customer’s health care, including medical condition or treatment options; (b) information or opinions regarding the provisions, terms, requirements, or services of United as they relate to the Customer’s medical needs; (c) the
fact that this Agreement has terminated or that Provider shall otherwise no longer be providing medical care or health care services under United’s products; or (d) the fact that, if medically necessary covered services are not available
through providers contracting with United, then United must, upon the request of Provider and within time appropriate to the circumstances relating to the delivery of the services and the condition of the Customer, but in no event to exceed five
(5) business days after receipt of reasonably requested documentation, allow referral to an appropriate provider. Further, United may not in any way penalize, terminate, or 

 
refuse to compensate (as provided under this Agreement) Provider for communicating with a current, prospective or former patient, or a party designated by a patient, in any way protected by this
section. 
 15. Provisions Related to Emergency Services and Post-stabilization Care. 

(a) Definition of Emergency Care. Provider agrees that for the purposes of providing health care services to Customers under
United’s Benefit Plans, “emergency care” shall mean health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not
limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result
in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant
woman, serious jeopardy to the health of her fetus. 
 (b) Post-stabilization Care Approval. If United requires prior
approval of post-stabilization care requested by a treating physician or health care professional following emergency services, and if such health care services are for Customers covered under Benefit Plans regulated by Texas law, United will
approve or deny such treatment within one hour of the time of the request. 
 16. Provisions Specific to Podiatrists. The provisions
contained in this section apply only in the event that Provider is a podiatrist licensed by the Texas State Board of Podiatric Medical Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within thirty (30) days after the date of Provider’s request, United shall provide a copy of the coding guidelines and payment
schedules applicable to the compensation that the Provider shall receive under this Agreement. 
 (b) No Unilateral Material
Retroactive Change. United may not unilaterally make material retroactive revisions to the coding guidelines and payment schedules. 
 (c) X-Rays and Orthotics. Provider may, practicing within the scope of the law regulating podiatry, furnish x-rays and nonprefabricated orthotics covered by a Benefit Plan. 

Provisions applicable to fully insured Benefit Plans regulated by the State of Texas but not subject to Texas HMO laws: 

1. Other Contracts. Provider is not restricted from contracting with other insurers, preferred provider plans, preferred provider organizations, or
HMOs. 
 2. Quality Care. Any term or condition of this Agreement that limits Provider’s participation on the basis of quality shall
be consistent with established standards of care for Provider’s profession. 
 3. Provider Privileges. If Provider has hospital or
institutional provider privileges and delivers a significant portion of care in a hospital or institutional provider setting, this Agreement may contain terms and conditions that include the possession of practice privileges at preferred hospitals
or institutions. However, if no preferred hospital or institution offers privileges to members of a class of physicians or practitioners to which Provider belongs, then the lack of such hospital or institutional provider privileges may not be a
basis for denial of Provider’s participation as a preferred provider. 
 4. Provider Billing. This Agreement prohibits Provider from
billing the Customer for unnecessary care if a physician or practitioner panel has determined the care was unnecessary. However, Provider shall not be required to pay hospital, institutional, laboratory, x-ray or like charges resulting from the
provision of services lawfully ordered by Provider, even though such service may be determined to be unnecessary. 
 5. Customer Referrals.
Nothing in this Agreement shall be construed as a restriction on the classes of physicians and practitioners who may refer a Customer to another physician or practitioner. In the event that

 
Provider makes a referral for specialty care, nothing in this Agreement shall be construed to require Provider to bear the expenses of such referral in or out of the preferred provider panel.

 6. No Inducement to Limit Medically Necessary Services. This Agreement does not contain any financial incentives to Provider that act
directly or indirectly as an inducement to limit medically necessary services. 
 7. Customer or Provider Complaints. United provides a
mechanism for the resolution of complaints initiated by a Customer or Provider which provides for reasonable due process including, in an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code § 1301.055
and 28 Tex. Admin. Code § 3.3705. 
 8. Limit on Indemnification. Provider shall not be required to indemnify or hold United
harmless from tort liability resulting from acts or omissions of United. 
 9. Discounted Fee Arrangements. If this Agreement contains a
discounted fee arrangement, the Customer may be billed only on the discounted fee and not the full charge. 
 10. Prompt Payment. United
or Payer, as applicable, will make payment to Provider pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date United receives an electronic clean
claim and not later than 45 days from the date United receives a non-electronic clean claim, United or Paver will either: pay the total amount of the claim in accordance with. this Agreement; pay the portion of the claim that is not in dispute and
notify Provider in writing why the remaining portion of the claim is not being paid; pay the total amount of the claim in accordance with this Agreement but notify Provider that the claim is subject to audit; request additional information from
Provider within 30 days of receipt of a clean claim, and then pay or deny the claim within the time. required by law after United receives that information or Provider fails to timely provide it: or notify Provider in writing why United or Payer
will not pay the claim. 
 If Provider submits claims that are not clean, 

 

	 	•	 	 United will notify Provider within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a
clean claim; 

  

	 	•	 	 Provider may be asked for additional information so that Provider’s claim may be adjudicated; or 

 

	 	•	 	 Provider’s claim may be denied and Provider will be notified of the denial and the reason for it; or 

 

	 	•	 	 United may in its discretion pay or have the claim paid by an applicable Payer based on the information that Provider gave in addition to the
information United has. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where Provider can contact United with questions regarding claims Provider has submitted,
information regarding any entity to whom United may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of claims or services. 

11. Timely Filing of Claims. Provider must submit Provider’s claims within 95 days of the date of service. For a claim submitted by an
institutional provider, the 95-day period does not begin until the date of discharge. For a claim for which coordination of benefits applies, the 95-day period does not begin for submission of the claim to the secondary payer until Provider receives
notice-of the payment or denial from the primary payer. If Provider’s claim is not submitted within this time frame; Provider will not be reimbursed for the services and Provider may not charge Provider’s patient for them. If
Provider’s failure to timely submit the claim is the result of an information systems failure or catastrophic event that substantially interferes with Provider’s normal business operations for more than two consecutive business days and
about which Provider notifies the Texas Department of Insurance as required by 28 Tex. Admin. Code § 21.2819, United will extend the 95 day filing deadline by the number of days in which Provider’s business was unable to operate- In the
event that Provider seeks and receives a waiver from 

 
United’s electronic filing requirements under 28 Tex. Admin. Code § 21,3701, Provider may submit non-electronic claims to the address shown in the Administrative Guide. 

12. Duplicate Claims. Provider may not submit duplicate claims for claims, (defined as a claim for payment made for the same patient on the same
date of service for the same services) that are not clean for: 1) 45 days after Provider files those claims non-electronically, and 2) 30 days after Provider files those claims electronically. 

13. Penalties. If governing law requires United or Payer to pay interest, billed charges, fees, costs or another penalty for a failure to pay
Provider’s clean claim for covered services within a certain time frame, United will follow those requirements. The interest, billed charges, fees, costs or other penalty required by law will be the only additional obligation for not satisfying
in a timely manner a payment obligation to Provider. In addition, if United adjudicated a claim of Provider’s that was not clean, there shall be no interest or other late payment obligation to Provider even if United subsequently adjusts the
payment amount based on additional information that Provider provides or that United obtains. In accordance with Tex. Ins. Code § 1301.137, United or Payer is not liable for a penalty for failure to pay a clean claim: (1) if the failure to
pay the claim is a result of a catastrophic event that substantially interferes with the normal business operations of United or Payer, or (2) if the claim was paid in accordance with applicable law, but for less than the contracted rate, and:
(A) Provider notifies the United of the underpayment after the 270th day after the date the underpayment was received; and (B) United or Payer pays the balance of the claim on or before the 30th day after the date United receives the
notice. 
 14. Corrective Adjustments for Overpayments. 
 (a) In accordance with TAC § 21.2818, United or Payer may recover a refund from Provider due to overpayment or completion of an audit, by adjusting future claim payments and/or by billing Provider
for the amount of the. overpayment, if: (i) United notifies Provider of the overpayment not later than the 180th day after the date of receipt of the overpayment; or (ii) United notifies Provider of the completion of an audit under TAC
§ 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and amounts for which a refund is due and for each claim the basis and specific reasons for the request for
refund; (B) notice of Provider’s right to appeal; and (C) the methods by which United intends to recover the refund. 
 (b) If Provider disagrees with a request for recovery of an overpayment, United shall provide Provider with an opportunity to appeal, in accordance with Tex. Ins. Code § 1301.132 and 28 TAC §
21.2818, and United or Payer may not recover the overpayment until all appeal rights are exhausted. 
 (c) United or Payer may
recover overpayments beyond the 18O-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material misrepresentation by Provider. 
 15. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee schedule or coding guideline changes which are intended to substantially alter the overall methodology or
reimbursement level of the fee schedule or which result in a material change in payment to Provider for the same CPT Code, ICD diagnostic code or hospital-based revenue code will be treated as an amendment to the contract, and United will give
Provider 90 days written notice of the changes. United will not make retroactive revisions to the coding guidelines and fee schedules. To request a written copy of United’s reimbursement policies and methodologies that apply to specific
procedures or services for which Provider will seek reimbursement under this Agreement, or any other information Provider needs to determine that Provider is being paid according to this Agreement. Provider should send a written request to Network
Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. United will respond to Provider’s request within 30 days of receiving it. United will, on request of Provider, provide the name, edition, and model
version of the software that the United uses to determine bundling and unbundling of claims. If United discloses fee schedule or reimbursement methodology to Provider, Provider may not use or disclose it for any purposes other than management of
Provider’s practice, to submit bills, for Provider’s business operations or in communications with a governmental agency involved in the regulation of health care or insurance. 

 16. Protected Communications. Provider shall not be prohibited, penalized, retaliated against, or
terminated for communicating items pursuant to Tex. Ins. Code Ann. § 1301.067. 
 17. Use of Economic Profiling. If United conducts,
uses, or relies upon economic profiling to terminate Provider, Provider shall be informed of United’s obligation to make available as requested by Provider, Provider’s economic profile, including written criteria by which the
Provider’s performance was measured in accordance with Tex. Ins. Code Ann. § 1301.058. 
 18. Quality Assessment. If United
engages in quality assessment, United shall do, so through a panel of not less than three physicians selected by United from among a list of physicians contracting with United. 
 19. Immunization or Vaccination Protocol. Provider is not required to issue an immunization or vaccination protocol for an immunization or vaccination to be administered to a Customer by a
pharmacist. 
 20. Administration of Immunizations or Vaccinations. This Agreement does not prohibit a pharmacist from administering
immunizations or vaccinations if such immunizations or vaccinations are administered in accordance with the Texas Pharmacy Act art. 4542a-1 and rules promulgated thereunder. 
 21. Provisions Related to Emergency Services and Post-stabilization Care. 

(a) Definition of Emergency Care. Provider agrees that for the purposes of providing health care services to Customers under
Benefit Plans, “emergency care” shall mean health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to
severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in
(1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant woman,
serious jeopardy to the health of her fetus. 
 (b) Post-stabilization Care Approval. If United requires prior approval of
post-stabilization care requested by a treating physician or health care professional following emergency services, and if such health care services are for Customers covered under Benefit Plans regulated by Texas law, United will approve or deny
such treatment within one hour of the time of the request. 
 22. Provisions Related to Termination. 

(a) Notice of Termination to Provider. United shall provide written notification of termination of this Agreement to Provider at
least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to Customer health, (ii) action against Provider’s license to practice or (iii) fraud, in which cases
termination may be immediate. 
 (b) Advisory Review Panel Review of Proposed Termination. Prior to termination of this
Agreement, United shall give Provider a written explanation of the reasons for termination. If Provider is a physician or practitioner, in accordance with 28. TAC § 3.3706 and Tex. Ins. Code § 1301.053(b), Provider may request and shall
receive a review of the proposed termination by a selected advisory review panel. Provider must make the request in writing to United within 20 business days of receipt of the notification of United’s intent to terminate, which shall include
any relevant documentation. Such review shall be conducted within sixty (60) days of Provider’s request or, if requested by Provider pursuant to 28 TAC § 3.3706, the review process shall be expedited. The decision of the advisory
panel must be considered but is not binding on United. United shall provide Provider, upon request, a copy of the recommendation of the advisory review panel and United’s determination. Notwithstanding the above provision, Provider is not
entitled to and no review shall be provided in a case in which there is (a) imminent harm to Customer health, (b) an action by a state medical board, licensing board or other government agency that effectively impairs the Provider’s
ability to practice or (c) a case of fraud or malfeasance. 

 (c) Notice of Provider Termination to Customers. United must provide reasonable
advance notification of an impending termination of Provider to Customers receiving care from Provider. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if
termination of Provider is for reasons related to imminent harm to Customers, notification of termination may be given, to Customers immediately. If Provider is entitled to a review by United of its decision to terminate Provider pursuant to Tex.
Ins. Code Ann. § 1301.057, United will not notify Customers of Provider’s impending termination until its effective date or until the time the review panel makes its formal recommendation, whichever is later. 

(d) Continuation of Care for Customer Special Circumstance. Unless termination of this Agreement is based upon reasons of medical
competence or professional behavior, United or Payer shall have a continuing obligation to reimburse Provider if Provider is treating a Customer with special circumstance at no less than the rate provided in this Agreement. For purposes of this
section, “special circumstance” means a condition with regard to which Provider reasonably believes that discontinuing care by Provider and transferring the Customer’s care to another provider could cause harm to the Customer, such as
a disability, acute condition, life threatening illness, or pregnancy of more than twenty-four (24) weeks. Provider must identify the special circumstance and request that the Customer be permitted to continue treatment under the
Provider’s care. Provider must also agree not to seek payment from the Customer of any amounts for which the Customer would not be responsible if this Agreement were still in effect. Any dispute regarding the necessity for continued treatment
by Provider shall be resolved pursuant to United’s dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or administrative manual. The obligation of United or
Payer to reimburse a terminated Provider for ongoing treatment of a Customer with special circumstance continues through: (a) the ninetieth (90th) day after the effective date of the termination; (b) nine (9) months following the
effective date of the termination for a Customer who at the time of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care, including a follow-up checkup within the first six
(6) weeks of delivery, for a Customer who is past the twenty-fourth (24th) week of pregnancy at the effective date of the termination. 
 (e) Voluntary Termination by Provider. Provider may also terminate this Agreement upon 30 days’ written notice if Provider provides United with such written notice within 30 days of receiving
the information requested under 28 Tex. Admin. Code § 3.3703(a)(20), as described in section 15 above. Provider agrees to cooperate with United to give Customers the notice described in (c) above. 

23. No Retaliatory Action. United shall not engage in any retaliatory action, including termination of or refusal to renew this Agreement, against
Provider because Provider has, on behalf of a Customer, reasonably filed a complaint against United or has appealed a decision of United. 

24. Provisions Specific to Podiatrists. The provisions contained in this section apply only in the event that Provider is a podiatrist licensed by
the Texas State Board of Podiatric Medical Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within
thirty (30) days after the date of Provider’s request, United shall provide a copy of the coding guidelines and payment schedules applicable to the compensation that the Provider shall receive under this Agreement. 

(b) No Unilateral Material Retroactive Change. United may not unilaterally make material retroactive revisions to the coding
guidelines and payment schedules. 
 (c) X-Rays and Orthotics. Provider may, practicing within the scope of the law
regulating podiatry, furnish x-rays and nonprefabricated orthotics covered by a Benefit Plan.

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