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

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

2 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 Vaccines For Children Auxiliary Aids Staff Interpreter Services... 10

3 III. OBLIGATIONS OF HMSA Payment Interpreter Services Assistance with Difficult Members Eligibility Determination HMSA QUEST Integration Participating Provider Handbook HMSA QUEST Integration Partiicpating 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 Diagnosis Related Group (DRG) Patient Transport Claims for Care Rendered to Newborns.14 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 Survival VIII. DISPUTE RESOLUTION Administrative Appeal Expedited Benefits Redetermination Arbitration Upon Exhaustion of Administrative Appeal IX. MISCELLANEOUS PROVISIONS... 20

4 9.1 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... 22

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6 HAWAII MEDICAL SERVICE ASSOCIATION QUEST INTEGRATION PARTICIPATING ANCILLARY PROVIDER AGREEMENT FOR GROUND 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 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 Service. 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

7 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 HMSA QUEST Integration Participating Provider. A licensed health care practitioner or facility 2

8 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 self-identified 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 twentyfour (24) hours a day, seven (7) days a week and, when Participating Ancillary Provider is not available, from another HMSA QUEST Integration Participating Ancillary 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 Ancillary 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. 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 3

9 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 twentyfour (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. 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 4

10 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 in the State of Hawaii is suspended, conditioned, revoked, terminated, expired 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 the 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 Agreement. Participating Ancillary Provider s right to appeal the termination decision is set forth in Section 8.1(b) of this Agreement. 5

11 2.10 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, except in the case of adverse reasons on the part of Participating Ancillary Provider 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 prioritysetting. 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) (d) 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 Focused review of specific procedures and/or specific providers. 6

12 2.13 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 relationship 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 providerpatient 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 non-treatment 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 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 7

13 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) 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; (c) (d) 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 Agreement, who has been debarred, suspended or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or 8

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