HAWAII MEDICAL SERVICE ASSOCIATION QUEST INTEGRATION PARTICIPATING ANCILLARY PROVIDER AGREEMENT FOR AIR AMBULANCE SERVICES

Transcription

1 HAWAII MEDICAL SERVICE ASSOCIATION QUEST INTEGRATION PARTICIPATING ANCILLARY PROVIDER AGREEMENT FOR AIR AMBULANCE SERVICES «ROOT_NUMBER» «ADD_NM_1» «Mail_Date»

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3 TABLE OF CONTENTS I. DEFINITIONS Claim Clean Claim Copayment Covered Services Early and Periodic Screening Diagnosis and Treatment ( EPSDT ) Eligible Charge Emergency Medical Condition Encounter HMSA QUEST Integration Participating Ancillary Provider HMSA QUEST Integration Participating Hospital HMSA QUEST Integration Participating Physician HMSA QUEST Integration Participating Provider HMSA QUEST Integration Participating Provider Handbook Medically Necessary Member Primary Care Provider ( PCP ) Specialist... 3 II. OBLIGATIONS OF PARTICIPATING ANCILLARY PROVIDER Provision of Covered Services Availability Accessibility Licensure Excluded Persons EPSDT Screening Provider Identifier Required Disclosures Credentialing Continuity of Care Quality Improvement Utilization Management Referral Provider-Patient Relationship Nondiscrimination Compliance with QUEST Integration Policies and Procedures Members Eligible for Long-Term Care Marketing Advance Directives Inspection and Access Full Disclosure Disclosure of Information by Providers Auxiliary Aids Staff Interpreter Services i

4 III. OBLIGATIONS OF HMSA Payment Interpreter Services Assistance with Difficult Members Eligibility Determination HMSA QUEST Integration Participating Provider Handbook HMSA QUEST Integration Participating Provider Directory No Discrimination Against Providers IV. COMPENSATION Payment Payment Determination Services That Do Not Meet Payment Determination Requirements Services That Are Not Plan Benefits Prohibition Against Member Billings and Collections Imposition of No-Show Fees Coordination of Benefits and Third Party Collections Claims Refund Claims for Care Rendered to Newborns V. RECORDS Member s Medical Record Retention and Transfer of Medical Records Confidentiality Access to Records VI. INSURANCE Coverage Amounts Proof of Coverage VII. TERM AND TERMINATION Term Termination Immediate Termination Appeal of Termination Transition of Members Information Necessary to Process Outstanding Claims Survival VIII. DISPUTE RESOLUTION Administrative Appeal Expedited Benefits Redetermination Arbitration Upon Exhaustion of Administrative Appeal ii

5 IX. MISCELLANEOUS PROVISIONS Amendments Assignment Captions Cooperation of Parties Entire Agreement Governing Law Legal Compliance Notices Partial Invalidity Relationship of Parties Responsibility for Acts Confidentiality Use of Name Waiver Execution iii

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7 HAWAII MEDICAL SERVICE ASSOCIATION QUEST INTEGRATION PARTICIPATING ANCILLARY PROVIDER AGREEMENT FOR AIR AMBULANCE SERVICES THIS AGREEMENT, effective as of «Effec_Date», is by and between Hawaii Medical Service Association ( HMSA ), a Hawaii nonprofit mutual benefit society, and «Add_Nm_1» ( Participating Ancillary Provider ), and arises out of the following circumstances: 1. HMSA has a contract with the State of Hawaii Department of Human Services ( DHS ), pursuant to which HMSA has agreed to enroll and arrange covered health care services for persons eligible to receive benefits through the State of Hawaii s QUEST Integration ( QUEST Integration ) program; 2. Pursuant to such contract with DHS (the QUEST Integration Contract ), HMSA operates and administers The HMSA Plan for QUEST Integration Members (the HMSA QUEST Integration Plan ); 3. HMSA desires to contract with Participating Ancillary Provider to provide or arrange Covered Services to Members who enroll in the HMSA QUEST Integration Plan; and 4. Participating Ancillary Provider desires to contract with HMSA to provide or arrange services as described in Paragraph 3 above. I. DEFINITIONS Terms used throughout this Agreement are defined as follows: 1.1 Claim. A complete billing, or an adjustment to such billing, for Covered Services submitted by Participating Ancillary Provider on the UB-04 (CMS-1450) or CMS 1500 form, another form approved by HMSA, or by electronic transmission accepted by HMSA. 1.2 Clean Claim. A Claim that can be processed without obtaining additional information of the service from the provider or the provider s designated representative as further defined in the HMSA QUEST Integration Participating Provider Handbook. 1.3 Copayment. A specific dollar amount or percentage of the charge as determined by DHS which is due from the Member at the time of provision of a Covered Service. 1.4 Covered Services. Those services and benefits to which a Member is entitled under Hawaii s Medicaid programs, including QUEST Integration, and which are described in the HMSA QUEST Integration Participating Provider Handbook. 1.5 Early and Periodic Screening, Diagnosis and Treatment ( EPSDT ). Federally mandated program that covers screening and diagnostic services to determine physical and mental conditions in Members less than twenty-one (21) years of age, and health care treatment and other measures to correct or ameliorate any conditions identified during the screening process. 1

8 1.6 Eligible Charge. The Eligible Charge for a Covered Service is the charge listed for the service in Exhibit A hereto, as amended over time. For Covered Services not listed on Exhibit A, the Eligible Charge is the lesser of the actual charge as shown on the claim or (a) (b) for Members who are not Aged, Blind or Disabled under the Hawaii Medicaid Plan (e.g., those who would have been served under the QUEST Expanded Access (QExA) program before QUEST Integration) ( ABD ), the charge listed in the HMSA QUEST Integration Fee Schedule (the Schedule ) in effect at the time of service, or for Members who are ABD, the charge listed for the service in the HMSA Medicaid Fee Schedule ( Medicaid Schedule ) in effect at the time of service. For a Covered Service that does not have a charge listed in the Schedule or Medicaid Schedule, HMSA will establish the Schedule or Medicaid Schedule charge. HMSA reserves the right to adjust the charges listed in the Schedule or Medicaid Schedule upon sixty (60) calendar days' written notice to Participating Ancillary Provider. 1.7 Emergency Medical Condition. An Emergency Medical Condition is a medical condition manifesting itself by a sudden onset of symptoms of sufficient severity (including severe pain) 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 the following: Placing the physical or mental health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part; Serious harm to self or others due to an alcohol or drug abuse emergency; Injury to self or bodily harm to others; or With respect to a pregnant woman having contractions: (i) that there is inadequate time to effect a safe transfer to another hospital before delivery or (ii) that transfer may pose a threat to the health or safety of the woman or her unborn child. An Emergency Medical Condition shall not be defined or limited based on a list of diagnoses or symptoms. 1.8 Encounter. An interaction with the Member during which medical services are provided by Participating Ancillary Provider. 1.9 HMSA QUEST Integration Participating Ancillary Provider. An Ancillary Provider who has entered into a contract with HMSA to provide Covered Services to Members. Ancillary Providers include laboratories, durable medical equipment providers, home health agencies, home infusion therapy providers and hospice providers HMSA QUEST Integration Participating Hospital. A licensed acute care general hospital that has entered into a contract with HMSA to provide Covered Services to Members HMSA QUEST Integration Participating Physician. A doctor of medicine ( M.D. ), a doctor of osteopathy ( D.O. ) or doctor of podiatric medicine ( D.P.M. ) who has entered into a contract with HMSA to provide Covered Services to Members. 2

9 1.12 HMSA QUEST Integration Participating Provider. A licensed health care practitioner or facility that has entered into a contract with HMSA to provide Covered Services to Members HMSA QUEST Integration Participating Provider Handbook. The HMSA QUEST Integration Participating Provider Handbook containing information regarding HMSA s operating policies and procedures with respect to Covered Services rendered to Members Medically Necessary. Medically Necessary services are health interventions as defined in Haw. Rev. Stat. 432E-1.4. This definition is in the HMSA QUEST Integration Participating Provider Handbook, and shall be deemed amended as necessary for consistency with such statute Member. A person who meets applicable eligibility requirements established by DHS and who enrolls in the HMSA QUEST Integration Plan Primary Care Provider ( PCP ). An HMSA QUEST Integration Participating Provider who has self-identified as a PCP on the Provider Fact Sheet and: (i) if a physician, is an M.D. or a D.O. who is either a family practitioner, general practitioner, general internist, pediatrician, or obstetrician/gynecologist, (ii) is an advanced practice registered nurse recognized by the State Board of Nursing as a family nurse practitioner, pediatric nurse practitioner, or certified nurse midwife or (iii) is a physician assistant recognized by the State Board of Medical Examiners as a licensed physician assistant. Notwithstanding the foregoing, HMSA may allow Health Centers, specialists or other health care practitioners to serve as PCPs for Members with chronic conditions subject to compliance with DHS requirements for such arrangements Specialist. An HMSA QUEST Integration Participating Physician who has selfidentified as a Specialist on the Provider Fact Sheet submitted with the Participating Physician s application to join HMSA s QUEST Integration provider network. II. OBLIGATIONS OF PARTICIPATING ANCILLARY PROVIDER 2.1 Provision of Covered Services. Participating Ancillary Provider shall provide Covered Services to Members in accordance with the terms and conditions of this Agreement, the scope of Participating Ancillary Provider s license and professional training in accord with generally accepted medical practices applicable to providers practicing in the similar field under similar circumstances at the time of treatment. Such responsibilities shall include, but not be limited to, maintaining continuity of each Member s care and medical record, including documenting all services provided by Participating Ancillary Provider. 2.2 Availability. Participating Ancillary Provider shall make necessary and appropriate arrangements to ensure that Medically Necessary Covered Services are readily available to Members twenty-four (24) hours a day, seven (7) days a week and, when Participating Ancillary Provider is not available, from another HMSA QUEST Integration Participating Provider who has agreed to provide back-up coverage to Participating Ancillary Provider. Participating Ancillary Provider shall make appropriate and necessary arrangements to ensure that any HMSA QUEST Integration Participating Provider providing such back-up coverage to Participating Ancillary Provider has the same medical specialty as Participating Ancillary Provider and provides such coverage in accordance with all applicable requirements of this Agreement. 3

10 2.3 Accessibility. Participating Ancillary Provider agrees to provide or arrange for Covered Services to Members in accord with the following time frames: (i) emergent care immediately for Emergency Medical Conditions, twenty-four (24) hours a day, seven days a week and without prior authorization, ( (ii) urgent care within twenty-four (24) hours, (iii) pediatric sick care within twenty-four (24) hours, adult sick care within seventy-two (72) hours, and routine and preventive care within twenty-one (21) calendar days for behavioral health visits and non-behavioral health visits, if Participating Ancillary Provider is serving as a PCP and (iv) appointments within four (4) weeks or of sufficient timeliness to meet medical necessity for visits if Participating Ancillary Provider is a specialist and for non-emergency hospital stays. Participating Ancillary Provider shall accept Members for treatment unless Participating Ancillary Provider has requested a waiver from HMSA and HMSA has received a waiver from DHS permitting Participating Ancillary Provider to refuse to accept Members for treatment. 2.4 Licensure. Participating Ancillary Provider warrants and represents that Participating Ancillary Provider shall throughout the term of this Agreement meet all applicable state and federal licensing, certification and recertification requirements required to provide the services contemplated in this Agreement, including all applicable requirements of the Medicaid or QUEST Integration program. Participating Ancillary Provider is and will remain, throughout the term of this Agreement, the holder of a currently valid, unrestricted, and unconditioned: (i) license to practice in the State of Hawaii and if applicable, (ii) Drug Enforcement Agency Controlled Substances Registration Certificate and/or Certificate of Registration for Uniform Controlled Substances. HMSA may waive the drug certification requirement if Participating Ancillary Provider presents evidence that the certification is not required to deliver appropriate medical care. Participating Ancillary Provider shall provide HMSA with written documentation and verification of such current licensing and accreditation upon request, and shall notify HMSA in writing immediately upon becoming aware of any action to suspend, revoke or restrict its license, accreditation, or any other qualification to provide Covered Services. 2.5 Excluded Persons. Participating Ancillary Provider warrants and represents that neither Participating Ancillary Provider, nor any employee, owner, or agent of Participating Ancillary Provider, nor any other person who may provide Covered Services pursuant to this Agreement, has been excluded or suspended from participation in a federal health care program as defined in 42 U.S.C. 1320a-7b(f), including, but not limited to, the State of Hawaii s Medicaid program. Participating Ancillary Provider further warrants and represents that Participating Ancillary Provider does not and shall not at any time during the term of this Agreement employ or contract with any individual or entity who is, or whose owner, those with a controlling interest, or managing employees are, so excluded or suspended. 2.6 EPSDT Screening. Participating Ancillary Provider shall provide EPSDT screening and related services described in the HMSA QUEST Integration Participating Provider Handbook and in accord with all EPSDT requirements established by DHS. 2.7 Provider Identifier. Participating Ancillary Provider shall use the HMSA provider identification number assigned by HMSA as of the Effective Date of this Agreement. In addition, Participating Ancillary Provider shall obtain a national provider identifier ( NPI ) in accordance with 45 C.F.R no later than by May 23, 2007 or as later permitted by DHS. Failure to obtain an NPI as required may result in nonpayment of Claims. 4

11 2.8 Required Disclosures. In addition to such other notice as may be required elsewhere in this Agreement, and except as provided below, Participating Ancillary Provider shall provide written notification to HMSA within five (5) working days (or earlier if the circumstances reasonably warrant earlier disclosure) of the occurrence of any of the events indicated below: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) Participating Ancillary Provider s license to practice in the State of Hawaii is suspended, conditioned, revoked, terminated, or subject to terms of probation or other restriction; or Participating Ancillary Provider s federal and/or state drug license is suspended, conditioned, revoked, or terminated; or Participating Ancillary Provider becomes the subject of any disciplinary proceeding or action before an applicable professional licensing board or a similar agency in any state, or an agency of the federal government, including sanction or disciplinary action by Medicare or Medicaid; or Participating Ancillary Provider is convicted of a fraud or felony; or Any malpractice claim in which Participating Ancillary Provider is a named defendant or any malpractice judgment or settlement; or Participating Ancillary Provider fails to maintain the insurance coverage required under Article VI of this Agreement; or There is a change in Participating Ancillary Provider s business address or federal tax identification number; or In the event that any representation or warranty made by Participating Ancillary Provider in this Agreement, including but not limited to those made in this Article II regarding Excluded Persons and Full Disclosure, is no longer accurate; or Participating Ancillary Provider plans to terminate his/her practice in which event, Participating Ancillary Provider shall give HMSA written notice no less than thirty (30) calendar days prior to the first (1 st ) day of the month in which the termination is effective; or An act of nature or any event beyond Participating Ancillary Provider s reasonable control occurs that substantially interrupts all or a portion of Participating Ancillary Provider s business or practice, or that has a materially adverse effect on Participating Ancillary Provider s ability to perform his/her obligations hereunder; or Any other situation arises that could reasonably be expected to affect Participating Ancillary Provider s ability to carry out his/her obligations under this Agreement. 2.9 Credentialing. Participating Ancillary Provider shall comply with any and all credentialing and recredentialing requirements and procedures as established by HMSA and amended from time to time. Compliance shall be determined by an HMSA credentialing committee. The members of the credentialing committee shall consist of an HMSA Medical Director and other members, selected and appointed by HMSA, a majority of which will be practicing physicians. Failure to meet credentialing or recredentialing requirements may result in termination in accord with Article VII of this 5

12 Agreement. Participating Ancillary Provider s right to appeal the termination decision is set forth in Section 8.1(b) of this Agreement Continuity of Care. Subject to applicable law, Participating Ancillary Provider shall provide appropriate medical information, as described in the HMSA QUEST Integration Participating Provider Handbook, to other providers: (i) when referring a Member to another provider, (ii) at the Member s request, (iii) when the Member transfers to another PCP or (iv) at another provider s request in order to ensure continuity of care and to avoid unnecessary duplication of services, unless the Member specifically objects. Participating Ancillary Provider acknowledges and agrees that HMSA and DHS each reserve the right to immediately transfer a Member to the care of another PCP, or to another health plan, in the event that either HMSA or DHS determines, in its respective sole discretion, that the Member s health or safety is in jeopardy. Participating Ancillary Provider shall fully cooperate in all respects with other providers in the event of such a transfer and at all times in order to assure maximum health outcomes for the Member. In the event that Participating Ancillary Provider s participation terminates during the course of a Member s treatment, Participating Ancillary Provider shall continue to provide services to Members pursuant to Section 7.5 of this Agreement Quality Improvement. As requested by HMSA, Participating Ancillary Provider shall cooperate with and participate in ongoing HMSA quality improvement activities that may include medical care evaluation studies, clinical practice guidelines, peer review, practice pattern analysis based on claims data, audit of medical records, problem identification and resolution, and priority-setting. Participating Ancillary Provider agrees to work in good faith with HMSA to implement corrective actions recommended by an HMSA review committee composed of practicing physicians, and to permit this committee to monitor and evaluate such corrective actions. Participating Ancillary Provider shall not interfere with measures established by HMSA that are designed to maintain quality and control costs Utilization Management. Participating Ancillary Provider shall cooperate and comply with HMSA s utilization management programs, including such utilization management requirements as are described in the HMSA QUEST Integration Participating Provider Handbook. Participating Ancillary Provider acknowledges and agrees that payments to Participating Ancillary Provider for Covered Services rendered pursuant to this Agreement may be reduced or denied if Participating Ancillary Provider fails to satisfy a utilization management requirement and an HMSA Medical Director or his or her designee determines that the service does not meet payment determination requirements set forth in Section 4.2 of this Agreement. Participating Ancillary Provider shall not attempt to collect the reduced or denied payment from the Member. Participating Ancillary Provider s right to appeal a utilization management program decision is set forth in Article VIII of this Agreement. HMSA s utilization management programs may include, but are not limited to: (a) (b) (c) Precertification for payment determination regarding a proposed service; Concurrent review to determine whether a continued inpatient hospital stay or other treatment protocols meet payment determination requirements set forth in Section 4.2 of this Agreement; Retrospective review to evaluate appropriateness of care and care management; and 6

13 (d) Focused review of specific procedures and/or specific providers Referral. Participating Ancillary Provider shall comply with all referral and preauthorization procedures set forth in the HMSA QUEST Integration Participating Provider Handbook. HMSA shall not make benefit payments to Participating Ancillary Provider for any services provided by Participating Ancillary Provider pursuant to a referral that does not comply with the referral and preauthorization requirements in the HMSA QUEST Integration Participating Provider Handbook. Participating Ancillary Provider shall not make referrals for designated health services to health care entities with which Participating Ancillary Provider or a member of Participating Ancillary Provider s family has a financial relationship..a financial arrangement includes a direct or indirect ownership or investment interest (including an option or nonvested interest) in any entity. This direct or indirect interest may be in the form of equity, debt, or other means and includes an indirect ownership or investment interest no matter how many levels removed from a direct interest, or a compensation management with an entity. Notwithstanding the foregoing, no referral shall be required for a Member to receive Covered Services from an HMSA QUEST Integration Participating Provider who is a women s health specialist for women s routine and preventive health care services, including, but not limited to, breast cancer screening (clinical breast exam), Pap smears and pelvic exams Provider-Patient Relationship. Participating Ancillary Provider shall maintain the provider-patient relationship with each Member and be responsible for the medical care and treatment of Members. Nothing contained in this Agreement is intended or shall be interpreted: (i) to interfere with the provider-patient relationship, (ii) to prohibit or otherwise restrict Participating Ancillary Provider from discussing treatment or nontreatment options with Members that may not reflect the position of the HMSA QUEST Integration Plan or may not be covered by the HMSA QUEST Integration Plan, (iii) to prohibit or otherwise restrict Participating Ancillary Provider from acting within the lawful scope of practice, (iv) to prohibit or otherwise restrict Participating Ancillary Provider from advising or advocating on behalf of a Member for the Member s health status, medical care, or treatment or non-treatment options, including any alternative treatments that may be self-administered, (v) to discourage or prohibit providing other medical advice deemed appropriate by Participating Ancillary Provider, even if the information relates to services or benefits not provided under the HMSA QUEST Integration Plan or (vi) to prohibit or otherwise restrict Participating Ancillary Provider from advocating on behalf of any Member to obtain necessary health care services in any grievance system, utilization review process or individual authorization process Nondiscrimination. Participating Ancillary Provider shall accept Members as patients unless Participating Ancillary Provider has a full panel and has notified HMSA that Participating Ancillary Provider is not accepting new patients. Participating Ancillary Provider shall render services to Members in the same manner, in accord with the same standards, during the same hours of operation, and within the same time availability, as for his/her patients who are not Members. Participating Ancillary Provider shall not refuse to render services to a Member or otherwise discriminate against a Member based on the Member s race, color, creed, ancestry, sex, including gender identity or expression, sexual orientation, religion, health status, income status, physical or mental disability, or on any other basis that is prohibited by any applicable federal, state or county law Compliance with QUEST Integration Policies and Procedures. Participating Ancillary Provider shall comply with all applicable provisions of the HMSA QUEST Integration 7

14 Participating Provider Handbook, including but not limited to billing and coding requirements, the HMSA cultural competency plan, and HMSA s compliance plan including all fraud and abuse requirements and activities. Notwithstanding the foregoing, in the event of a conflict between the provisions of the HMSA QUEST Integration Participating Provider Handbook and the terms of this Agreement, the terms of this Agreement shall control Members Eligible for Long-Term Care. If Participating Ancillary Provider identifies a Member that Participating Ancillary Provider believes is eligible for long-term care level of services, Participating Ancillary Provider shall submit a Form DHS 1147 to DHS or its designee and shall submit the Form 1180 to the Aid to Disabled Review Committee ( ADRC ) to determine the Member s disability status Marketing. Participating Ancillary Provider shall submit to HMSA any marketing materials relating to the HMSA QUEST Integration Plan or Medicaid that it develops, and HMSA shall submit such materials to DHS and obtain DHS approval of such materials, prior to Participating Ancillary Provider using or distributing any such materials Advance Directives. Participating Ancillary Provider shall discuss living will and durable powers of attorney in relation to medical treatment with the Member and the Member s immediate family members as required by Haw. Rev. Stat. Ann. 432E and 42 CFR Part 49, subpart I, and 42 CFR Section (d). In addition, Participating Ancillary Provider: (a) (b) (c) (d) Shall not condition the provision of Covered Services or otherwise discriminate against a Member on the basis of whether or not such Member has executed an advance directive; Shall document in a prominent part of each Member s current medical record whether or not the Member has executed an advance directive; Shall comply with HMSA policies and Hawaii law on advance directives, including, but not limited to, Hawaii s Uniform Health-Care Decisions Act, Haw. Rev. Stat. Ann. Chapter 327E; and Shall cooperate with HMSA s educational efforts regarding advance directives Inspection and Access. Participating Ancillary Provider acknowledges and agrees that HMSA, DHS, Department of Health and Human Services of the United States ( HHS ), the General Accounting Office of the Comptroller General of the United States ( GAO ), the HHS Office of the Inspector General ( OIG ), the Medicaid Fraud Control Unit of the Department of the Attorney General, or their respective authorized representatives, shall, during normal business hours, have the right to enter Participating Ancillary Provider s premises or such other places where Participating Ancillary Provider s obligations under this Agreement are being performed to inspect, monitor, or otherwise evaluate the quality, appropriateness and timeliness of services provided pursuant to this Agreement Full Disclosure. Participating Ancillary Provider acknowledges that such disclosure is required by the terms of HMSA s contract with DHS. Participating Ancillary Provider further warrants and represents that Participating Ancillary Provider shall not knowingly have a director, officer, partner or person with more than five percent (5%) of Participating Ancillary Provider s equity, or have an employment, consulting, or other agreement with such a person for the provision of Covered Services pursuant to this 8

15 Agreement, who has been debarred, suspended or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No or under guidelines implementing Executive Order No Participating Ancillary Provider warrants and represents that Participating Ancillary Provider has fully disclosed all significant business relationships, joint ventures, subsidiaries, holding companies, or any other related entity to HMSA and that Participating Ancillary Provider shall bring any new significant relationships arising during the term of this Agreement to HMSA s attention as soon as the relationship is consummated Disclosure of Information by Providers. Participating Ancillary Provider shall comply with all disclosure requirements identified in 42 CFR 455 Subpart B including the following upon execution of this Agreement, upon request from HMSA or DHS, or within thirty-five (35) days after any change in ownership of the disclosing entity: (a) (i) (ii) (iii) The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing entity. The address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address; Date of birth and social security number of each person with an ownership or control interest in the disclosing entity; and Other tax identification number (in the case of a corporation) with an ownership or control interest in the disclosing entity or in any subcontractor in which the disclosing entity has a 5 percent or more interest. (b) (c) (d) (e) Whether the person (individual or corporation) with an ownership or control interest in the disclosing entity is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the person with an ownership or control interest in any subcontractor in which the disclosing entity has a 5 percent or more interest is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child or sibling. The name of any other disclosing entity in which an owner of the disclosing entity has an ownership or control interest. The name, address, date of birth and social security number of any managing employee of the disclosing entity. The identity of any individual who has an ownership or control interest in the disclosing entity, or is an agent or managing employee of the disclosing entity, and has been convicted of a criminal offense related to that person s involvement in any program under Medicare, Medicaid, or the Title XX services program since the inception of those programs. Participating Ancillary Provider shall submit, within thirty-five (35) days of the date on a request by HMSA, the DHS, or the Secretary of the Department of Health and Human Services full and complete information about: 9

16 (f) (g) The ownership of any subcontractor with whom Participating Ancillary Provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and Any significant business transactions between Participating Ancillary Provider and any wholly owned supplier, or between Participating Ancillary Provider and any subcontractor, during the 5-year period ending on the date of the request Auxiliary Aids. Participating Ancillary Provider must offer access to auxiliary aids and services at no cost to Members with disabilities, and document the offer and provision of auxiliary aids to the same extent as the health plan under the QUEST Integration Contract Staff. (a) (b) Medical Staff. Participating Ancillary Provider warrants and represents that all individuals who provide medical Covered Services pursuant to this Agreement shall at all times throughout the term of this Agreement have appropriate training for the provision of Covered Services, including without limitation, flight physiology training and certification of training in advanced cardiac life support, advanced trauma life support, neonatal resuscitation and pediatric advanced life support, and shall have at least two (2) years prior experience in emergency room or intensive care unit settings. In addition, the staff providing Covered Services in a particular instance shall, at a minimum, meet the standards for staff providing the applicable level of care as may be set forth in Exhibit A to this Agreement. Pilots. All captains and co-pilots ( Pilots ) flying aircraft in connection with the provision of Covered Services to Members shall be fully qualified to operate the aircraft provided, including, without limitation: (i) having successfully completed an approved flight safety program at Flight Safety International or equivalent facilities, or being factory trained and having twenty-five (25) hours in the specific type of aircraft provided before flying as a pilot in command on patient missions; (ii) possessing a commercial airplane license with five hundred (500) multi-engine hours, as well as a minimum of two thousand (2000) flight hours as pilot in command; (iii) being in current compliance with all applicable standards set by the FAA for Part 135 air carriers; (iv) being type-rated in any aircraft operated by the Pilot in connection with the provision of Covered Services to Members; and (v) maintaining in good standing throughout the term of the Agreement Airline Transport Pilot certification and First or Second Class Medical certification. If flying instrument flight rules ( IFR ), the Pilot shall have an airplane multi-engine land instrument rating, with a minimum of two hundred fifty (250) hours of instrument flying time to include no more than one hundred twenty-five (125) hours of simulated time and one hundred (100) night hours Interpreter Services. Participating Ancillary Provider shall offer and arrange interpreter services for Members who have limited proficiency with the English language at no cost to the Members, whose primary language is other than English, or who communicate through sign language, and will document the offer and provision of interpreter services to the same extent as the health plan under the QUEST Integration Contract. 10

17 III. OBLIGATIONS OF HMSA 3.1 Payment. HMSA shall pay Participating Ancillary Provider directly for Covered Services in accord with Article IV of this Agreement. 3.2 Interpreter Services. HMSA shall arrange interpreter services for Members who have limited proficiency with the English language, whose primary language is other than English, or who communicate through sign language. 3.3 Assistance with Difficult Members. HMSA shall assist Participating Ancillary Provider with a difficult Member by making arrangements to transfer the Member to another HMSA QUEST Integration Participating Ancillary Provider or HMSA QUEST Integration Participating Physician. Participating Ancillary Provider, however, shall provide written notice to the Member with a copy to HMSA if Participating Ancillary Provider is unable to continue to provide Covered Services due to Member s pattern of: (i) non-compliant or abusive behavior, (ii) failing to pay Copayments or (iii) posing a threat to Participating Ancillary Provider, staff or other patients. 3.4 Eligibility Determination. HMSA shall confirm Member eligibility to Participating Ancillary Provider electronically or telephonically. 3.5 HMSA QUEST Integration Participating Provider Handbook. HMSA shall furnish Participating Ancillary Provider with a copy of the HMSA QUEST Integration Participating Provider Handbook. HMSA reserves the right to amend such policies, procedures, and requirements upon sixty (60) calendar days written notice. 3.6 HMSA QUEST Integration Participating Provider Directory. HMSA shall list Participating Ancillary Provider s name in an HMSA QUEST Integration Participating Provider Directory and distribute the Directory or make it available to HMSA QUEST Integration Participating Physicians and Members. 3.7 No Discrimination Against Providers. HMSA shall not discriminate against Participating Ancillary Provider acting within the scope of Participating Ancillary Provider s license or certification with respect to Participating Ancillary Provider s participation, reimbursement or indemnification solely on the basis of such license or certification. In addition, HMSA shall not discriminate against providers serving high-risk populations or those that specialize in conditions requiring costly treatments. IV. COMPENSATION 4.1 Payment. Except as otherwise provided in this Article IV, Participating Ancillary Provider shall accept the Eligible Charge as payment in full for Covered Services rendered to Members pursuant to this Agreement that are deemed Medically Necessary and appropriate under HMSA s quality improvement and utilization management programs. HMSA shall reimburse Clean Claims submitted by Participating Ancillary Provider for Covered Services rendered to Members pursuant to this Agreement by paying directly to Participating Ancillary Provider the Eligible Charge minus applicable Copayments and payments from third parties described in Section 4.7 of this Agreement. Payment shall be based on the Member s eligibility and HMSA s policies pertaining to the recognition of the service, whether billed alone or in combination with other services. 11

18 Nothing shall preclude HMSA from using different reimbursement amounts for different specialties or for different practitioners in the same specialty. 4.2 Payment Determination. (a) (b) (c) A service or supply qualifies for payment under this Agreement if it qualifies for payment under the QUEST Integration program and is Medically Necessary. Payment determinations are based on policies developed by HMSA Medical Directors in consultation with practicing physicians, as well as HMSA policies, peer-reviewed literature and nationally recognized standards. Any determination that a service or supply does not meet payment determination requirements will be made by an HMSA Medical Director. The fact that a physician may prescribe, order, recommend, or approve a service or supply does not in itself mean that the service or supply meets payment determination requirements. Participating Ancillary Provider s right to appeal a payment determination is set forth in Article VIII of this Agreement. 4.3 Services That Do Not Meet Payment Determination Requirements. Participating Ancillary Provider shall not bill or collect from a Member any charges for services that HMSA determines do not meet HMSA s payment determination requirements, unless a written acknowledgment of financial responsibility signed by the Member or the Member s legal representative is obtained prior to the time services are rendered. Participating Ancillary Provider s right to appeal a decision pertaining to services that do not meet payment determination requirements is set forth in Sections 8.1(a) and 8.2. If a Member self-refers to a specialist or other HMSA QUEST Integration Participating Provider without following procedures (i.e., obtaining prior authorization), HMSA may deny payment to Participating Ancillary Provider. 4.4 Services That Are Not Plan Benefits. Except as set forth in Section 4.3 and Section 4.5, this Agreement does not govern a Participating Ancillary Provider s charges to a Member for services that are not Covered Services. 4.5 Prohibition Against Member Billings and Collections. Except as otherwise provided for herein, Participating Ancillary Provider shall look solely to the health plan for compensation for services rendered. Participating Ancillary Provider agrees that in no event, including but not limited to non-payment by HMSA, insolvency of HMSA or breach of this Agreement, or Participating Ancillary Provider s failure to follow HMSA procedures that results in nonpayment, shall Participating Ancillary Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Member or other persons (other than HMSA) acting on such Member s behalf for Covered Services provided pursuant to this Agreement, nor shall Participating Ancillary Provider look directly to the State of Hawaii for payment of services rendered pursuant to this Agreement. Neither the State of Hawaii nor the Member shall bear any liability for services provided to a Member for which the State does not pay HMSA, or for which HMSA or the State does not pay the Member or Participating Ancillary Provider, or for payment for services rendered by Participating Ancillary Provider that is in excess of the amount that the Member would owe if HMSA provided the payment directly to the Participating Physician or Member. Neither the State of Hawaii nor the Member shall bear any liability for HMSA s failure or refusal to pay valid claims of subcontractor or providers for Covered Services. This provision does 12

19 not prohibit Participating Ancillary Provider from collecting nominal cost sharing amounts as specifically authorized by the Hawaii Medicaid State Plan and the HMSA QUEST Integration Participating Provider Handbook, or fees for services or supplies that are not Covered Services delivered on a fee-for-service basis to Members, or fees for services or supplies that are not Covered Services if a Member self-refers to a specialist or other HMSA QUEST Integration Participating Provider without following procedures (i.e., obtaining prior authorization) and HMSA denies payment to Participating Ancillary Provider, provided that Participating Ancillary Provider shall not bill or collect from a Member any charges for non-covered Services unless a written Agreement of Financial Responsibility or Advance Beneficiary Notice, as applicable, that is: (i) in the form set forth in the HMSA QUEST Integration Participating Provider Handbook, (ii) specific to the service and (iii) signed by the Member or the Member s legal representative, is obtained prior to the time services are rendered. (a) (b) (c) Participating Ancillary Provider agrees that these provisions in this Section 4.5 shall survive the termination of this Agreement regardless of the reason for termination, including insolvency of HMSA, and shall be construed to be for the benefit of the Member. Participating Ancillary Provider agrees that these provisions supersede any oral or written contrary agreement now existing or hereafter entered into between the Participating Ancillary Provider and a Member, or persons acting on such Member s behalf insofar as such contrary agreement relates to liability for payment for, or continuation of Covered Services provided under the terms and conditions of these clauses. Participating Ancillary Provider shall refund any payment received from a resident or family member (in excess of share of cost) on behalf of the Member for the prior coverage period. 4.6 Imposition of No-Show Fees. Participating Ancillary Provider shall not impose a noshow fee for Members who were scheduled to receive a Covered Service. 4.7 Coordination of Benefits and Third Party Collections. Participating Ancillary Provider shall cooperate with HMSA for the proper coordination of benefits with other coverages, both public and private, which are or may be available to pay medical expenses on behalf of the Member. Participating Ancillary Provider shall also assist in the identification and collection of third party payments such as those from workers compensation, other health insurance, auto insurance, and other third party liability sources, in accordance with the procedures in the HMSA QUEST Integration Participating Provider Handbook, including submitting claims for payments to the appropriate third party and including all available information about other coverage or third party liability sources with claims submitted to HMSA s QUEST Integration Plan. 4.8 Claims. Participating Ancillary Provider shall submit Claims under this Agreement only for Medically Necessary Covered Services rendered by Participating Ancillary Provider. Participating Ancillary Provider shall submit Claims that Participating Ancillary Provider certifies to be accurate and complete to HMSA within three hundred sixty-five (365) calendar days after completion of services. No payment will be made for Claims submitted more than 365 days after services were rendered. Participating Ancillary Provider shall not collect payment from Members for any Covered Services for which the Claims submission period has expired. Participating Ancillary Provider has the right to 13

20 request a review by HMSA within sixty (60) calendar days of Participating Ancillary Provider s receipt of HMSA s decision to deny or pay the Claim. 4.9 Refund. Within thirty (30) calendar days of Participating Ancillary Provider s receipt of notice from HMSA, Participating Ancillary Provider shall refund to HMSA any overpayment made by HMSA to Participating Ancillary Provider. HMSA shall have the right to offset the amount of any overpayment not refunded against any future payments due to Participating Ancillary Provider from HMSA under this Agreement or any other agreement with HMSA. HMSA has the right of offset under this Section, regardless of whether Participating Ancillary Provider has assigned the right to receive payments under this Agreement or any other agreement with HMSA, or has otherwise directed HMSA to make payments under this Agreement or any other agreement to a third party Claims for Care Rendered to Newborns. HMSA shall be financially responsible for Claims that meet the payment determination requirements set forth in Section 4.2 above and are for Covered Services rendered to the newborn children of Members during the initial auto-enrollment period following birth. Participating Ancillary Provider shall not look to any individual or entity other than HMSA or the mother s commercial health plan for any payment owed to providers related to care to the newborn. V. RECORDS 5.1 Member s Medical Record. Participating Ancillary Provider shall ensure that a medical record is established and maintained for each Member that fully documents in a detailed and comprehensive manner medical services rendered and billed. Participating Ancillary Provider shall further ensure that such record is legible, signed and dated, and complies with good professional medical practice, Hawaii statutory and regulatory requirements, and the requirements of HMSA s QUEST Integration contract with DHS, including requirements outlined in the HMSA QUEST Integration Participating Provider Handbook, permits effective professional medical review and medical audit processes, and facilitates an adequate system for follow-up treatment. In addition, Participating Ancillary Provider shall make such medical record available to the Member at each Encounter. Participating Ancillary Provider shall guarantee the Member the right to request and receive a copy of his or her medical records, and to request that they be amended, as specified in 45 C.F.R. Part 164. In the event that Participating Ancillary Provider is compensated by capitation payments, Participating Ancillary Provider shall submit on a monthly basis complete and accurate encounter data and medical records to support encounter data upon request from HMSA without the specific consent of the Member, DHS or its designee for the purpose of validating encounters. 5.2 Retention and Transfer of Medical Records. Participating Ancillary Provider shall retain the medical records for services rendered to each Member in accordance with Haw. Rev. Stat and , including retaining the medical records for a Member who is eighteen (18) years of age or older for a minimum of seven (7) years from the date of the last entry in the record and for each Member who is younger than eighteen (18) years of age for the period until the Member attains eighteen (18) years of age, plus seven (7) years. Participating Ancillary Provider shall promptly deliver accurate, appropriate medical information to other QUEST Integration participating providers when a Member transfers to another QUEST Integration health plan or provider within seven (7) business days of receipt of a request when a Member changes PCPs and as outlined in the HMSA QUEST Integration Participating Provider Handbook. 14