HomeMy WebLinkAboutPro Motion Physical Therapy - Healthcare Provider Agreement Healthcare Provider Agreement
This agreement including all Schedules, Amendments and Attachments hereto (Agreement) is
entered into between the City of Yakima (hereinafter "PAYOR") and Pro Motion Physical
Therapy, (hereinafter "PROVIDER"). The effective date of this agreement is the 1st day of
December, 2018.
In consideration of the mutual promises and covenants set forth herein,PAYOR and FACILITY
agree as follows:
1. DEFINITIONS
1.1 Benefit Plan means a program offered by or administered by PAYOR for the payment of
Covered Services provided to an eligible Participant.
1.2 Clean Claim means a claim for Covered Services that(a)is timely received by the
PAYOR and/or its claims administrator,as applicable;(b)(i)when submitted via paper has all the
elements of the UB 04 or CMS 1500(or successor standard)forms; or(ii)when submitted via an
electronic transaction, uses only permitted transaction code sets(e.g. CPT4, ICD9, ICD10,
HCPCS)and has all the elements of the standard electronic formats required by applicable Federal
authority;(c)is a claim for which the Benefit Plan is the primary payor or the Benefit Plan's
responsibility as a secondary payor has been established; and(d)contains no defect,error or other
shortcoming resulting in the need for additional information to adjudicate the claim.
1.3 Coinsurance means a cost-sharing obligation that requires the Participants to pay a
percentage of the cost of specified Covered Services.
1.4 Copayment means the amount that a Participant is responsible to pay under PAYOR's
Benefit Plan at the time of service.
1.5 Covered Services means those specified Medically Necessary health care services for
which a Participant is eligible to receive benefits under the Benefit Plan.
1.6 Deductible means the amount a Participant must pay for Covered Services each calendar or
plan year before a PAYOR commences payment as defined under the Benefit Plan.
1.7 Medical Necessity or Medically Necessary means a medical service or medical supply,
which meets all of the following criteria:
1. It is required for the treatment or diagnosis of a covered medical condition;
2. It is the most appropriate supply or level of service that is essential for the diagnosis
or treatment of the Participant's covered medical condition;
3. It is known to be effective in improving health outcomes for the Participant's
covered medical condition in accordance with sufficient scientific evidence and
professionally recognized standards;
4. It is not furnished primarily for the convenience of the Participant or provider of
services; and
5. If this definition of Medically Necessary is not consistent with the definition of
Medically Necessary in the Benefit Plan,the definition in the Benefit Plan will
control.
Medical necessity alone does not determine coverage.
1.8 Participant means any person who is eligible to receive Covered Services under the
terms and conditions of PAYOR's Benefit Plan.
2. DUTIES OF PROVIDER
2.1 Provide or Arrange for Covered Services
PROVIDER agrees to arrange or provide for the provision of medically necessary Covered
Services on a timely basis,without regard to health status or medical condition,and in accordance
with generally accepted medical practice guidelines and standards pursuant to the terms of this
Agreement. Except in the case of emergency, PROVIDER agrees to verify each Participant's
eligibility prior to providing Covered Services. PROVIDER shall notify PAYOR of all Participant
admissions, whether authorized or not,at the time of admission,or in the event that an admission
occurs on a non-business day, no later than the noon of the next business day after admission.
PROVIDER agrees to furnish Covered Services to Participant on the same basis as such services
are made available to individuals who are not Participants, and without regard to the Participant's
enrollment in PAYOR's Benefit Plan. In providing services under this Agreement, PROVIDER
shall exercise the degree of care,skill and knowledge expected of a prudent health care
PROVIDER. PROVIDER shall remain solely responsible for the quality of services rendered.
2.2 Accessibility and Hours of Service
PROVIDER shall arrange for the provision of Covered Services to Participants during normal
hours for such services.
2.3 Emergency Services
If within PROVIDER's scope of services,PROVIDER shall provide Participant access to
emergency services without a referral or prior approval from PAYOR. PROVIDER shall notify
PAYOR or PAYOR's claims administrator of the provision of emergency services to a Member
within two(2)business days immediately following the provision of such services.
2.4 Provider Updates
PROVIDER shall identify on Schedule B and update periodically,as necessary,the name and
provider identification number of all physicians, mid-level providers and other healthcare
professionals that will be subject to this Agreement. Upon request, PROVIDER shall provide a
current W-9 for a provider tax identification number that is subject to this Agreement.
2.5 Licensing Requirements
PROVIDER and its physicians and other professional healthcare providers shall remain in good
standing with all necessary licenses,certifications and/or registrations required by law, permits or
other approvals required by State and Federal law to provide or arrange for the provision of
Covered Services to Participants. PROVIDER shall submit evidence of such licenses,permits or
other approvals to PAYOR upon request. PROVIDER shall immediately notify PAYOR, in
writing, regarding any revocation or restriction placed upon any such license, permit or other
approval.
For its physicians and other professional healthcare providers, PROVIDER shall promptly notify
PAYOR, in writing, of any action against their license, certification, or registration; any change in
business address; any legal,governmental, or Board action;any change in clinical privileges;any
change in hospital staff privileges; any changes in practice scope; any sanctions or restrictions;any
medical or mental health problems that could affect the care of patients;or any other problem or
situation which may impair the PROVIDER's ability to carry out their responsibilities under this
Agreement.
2.6 Insurance
PROVIDER shall provide and maintain, at its sole cost and expense and for the duration of this
Agreement, policies of general comprehensive liability and professional liability insurance,or self-
insurance, in an amount acceptable to PAYOR. Such policies shall insure against any claim or
claims for damage arising by reason of personal injury or death occasioned directly or indirectly in
connection with the acts or omissions of PROVIDER,agents or employees pursuant to the terms
of this Agreement. PROVIDER shall notify PAYOR immediately but no more than two(2)
business days from notification of any revocation,reduction in coverage,or termination of any
such policy. Upon request, PROVIDER shall provide PAYOR with evidence of compliance with
this insurance requirement in the form of a certificate of insurance or evidence of self-insurance in
an amount and form acceptable to PAYOR.
2.7 Medical Management Programs
PROVIDER agrees to comply with and participate in PAYOR's and/or its claims administrator's
medical management/utilization management programs and requirements, whichever is applicable,
which may include but are not limited to,pre-authorization, notification,concurrent review,
retrospective review,re-admission guidelines,case management,disease management programs,
pharmacy and specialty pharmacy programs, referral management,quality assurance and
improvement programs and medical necessity oversight.
PROVIDER further agrees to share Participant information as specifically related to these
programs. PROVIDER is required to allow access to Participant records, provide for copying and
release of records at PROVIDER's expense,and to speak to the PAYOR or its claims
administrator or designee upon request,as allowed by law, in a timely manner to facilitate the
Medical Management program. Non-compliance with the Medical Management program may
result in non-payment.
2.8 Compliance
PROVIDER agrees to comply with all applicable federal and state laws and regulations.
PROVIDER further agrees to comply with the following:
2.8.1 PROVIDER agrees that in no event,including,but not limited to,non-payment by
PAYOR,insolvency,or breach of this contract shall PROVIDER bill,charge,collect a deposit
from,seek compensation,remuneration,or reimbursement from,or have any recourse against a
Participant or person acting on their behalf,other than PAYOR,for services provided pursuant to
this agreement. This provision shall not prohibit collection of deductibles,co-payments,
coinsurance,and/or non-covered services,which have not otherwise been paid by a primary or
secondary carrier in accordance with terms of the Benefit Plan.
2.8.2 PROVIDER agrees,in the event of PAYOR's insolvency,to continue to provide the
services promised in this contract to Participant until the Participant's discharge from in-patient
facilities.
2.8.3 PROVIDER may not bill the Participant for Covered Services(except for
Deductibles,Co-payments,or Coinsurance)where PAYOR denies payment because the
PROVIDER has failed to comply with the terms or conditions of this Agreement.
2.8.4 Notwithstanding any other provision of this agreement,nothing in this Agreement
shall be construed to modify the rights and benefits contained in the Benefit Plan.
2.9 Non-Covered Services/Exclusions
PROVIDER shall provide notice to Participant of their personal financial obligations for non-
covered services. PROVIDER may bill a Participant for non-covered services if PROVIDER
has,prior to the provision of non-covered services,obtained a written acknowledgment and
acceptance of financial responsibility from the Participant after full disclosure of(i)
PROVIDER's intent to bill Participant for non-covered services,and(ii)the non-liability of
PAYOR for such non-covered services.
2.10 Claims Payment
PROVIDER shall look only to PAYOR for payment of claims. PROVIDER may not collect or
attempt to collect from Participant money owed to PROVIDER by PAYOR.
2.11 Acceptance of Payment
PROVIDER shall accept payment as described in Schedule A as payment in full for Covered
Services rendered, less Coinsurance, Copayments, Deductibles, and non-covered or ineligible
charges as described in the Benefit Plan. Except for Co-payments, PROVIDER agrees to refrain
from billing Participant for any amounts due until such time that the claim is processed by
PAYOR or its claims administrator and any applicable Co-insurance and/or Deductible amounts
have been properly identified on an EOB. PROVIDER further agrees not to balance bill
Participant for the difference between the amounts set forth in Schedule A and PROVIDER's
billed charges. In the event that a claim payment is under dispute or appeal, PROVIDER shall
refrain from seeking payment from the Participant until such dispute is resolved.
2.12 Records
PROVIDER shall establish and maintain medical,financial,and other records for Participants who
receive Covered Services. Such records will be maintained in accordance with generally accepted
medical, accounting, and bookkeeping practices,and will be preserved as may be necessary for
compliance with applicable State and Federal laws, and accrediting bodies of the PROVIDER.
PROVIDER shall make all records relating to this Agreement available to PAYOR and/or its
claims administrator, and governmental authorities having jurisdiction over this Agreement for
inspection and copying at reasonable times upon receipt of at seven (7) days prior written notice.
If PAYOR requests the information pursuant to an inspection or an audit,then PAYOR will
protect the confidentiality of such records in accordance with applicable legal standards. PAYOR
will reimburse PROVIDER for all reasonable copying costs incurred by PROVIDER as a result of
said record inspection or audit.
3. RESPONSIBILITIES OF PAYOR
3.fl Payment for Covered Services
PAYOR shall pay PROVIDER for Covered Services rendered to Participants in accordance with
Section 4 of this Agreement.
3.2 Provider Directories and Promotion
PAYOR agrees to include PROVIDER in appropriate provider directories or website listings.
3.3 Eligibility
PAYOR shall require its claims administrator to confirm a Participant's eligiblity for Covered
Services upon request by PROVIDER. During ordinary business hours,PAYOR shall assure
reasonable access,through standard means of communication,for the confirmation that services
are covered and a Participant is eligible under a Benefit Plan.
3.4 PROVIDER's Right to Inform Patients
PAYOR shall not in any way preclude or discourage PROVIDER from informing Participants of
the care they require, including various treatment options, and whether in their view such care is
consistent with medical necessity, medical appropriateness, or otherwise covered by the
Participant's Benefit Plan,nor prohibit,discourage,or penalize PROVIDER otherwise practicing
in compliance with the law from advocating on behalf of a patient with a health carrier. Nothing
in this Agreement shall be construed to authorize PROVIDER to bind PAYOR or its claims
administrator to pay for any services.
3.5 ID Cards
PAYOR shall provide each Participant with a membership identification card displaying any
applicable network logos,the Participant's name and identifier,group name and/or number,
telephone number to confirm eligibility and benefit verification,utilization management vendor
name and telephone number to confirm necessary pre-authorization for services.
3.6 Explanation off Benefits
PAYOR shall ensure that its claims administrator provides an Explanation of Benefits(EOB)
during the claim adjudication process which,at a minimum, identifies: PAYOR,total billed
charges,allowed amount in accordance with Schedule A,amount PAYOR responsible to pay,
amount Participant responsible to pay,and non-covered codes or services.
4. CLAIMS SUBMISSION AND PAYMENT
4.1 Claims Submission
PROVIDER shall submit a claim for services provided preferably within sixty(60)days but no
event later than one(1)year of the date services were incurred by the Participant,provided the
Participant is identified as an eligible Participant under the Benefit Plan,and shall cooperate with
PAYOR or its claims administrator,as applicable,to provide additional information requested to
process the claim as a Clean Claim.
4.2 Payment of Claims
PAYOR shall pay PROVIDER for Covered Services provided to a Participant,subject to the
following minimum standards:
4.2.1 PAYOR shall pay or cause its claims administrator to pay the rate set forth in
Schedule A for Covered Services provided to Participants within thirty(30)business days of
the date PAYOR and/or its claims administrator receives a Clean Claim, unless PAYOR
and/or its claims administrator makes a reasonable request for additional information or
documents in order to evaluate the claim during this time period. If PAYOR and/or its claims
administrator makes a request for additional information to evaluate the claim, PAYOR and/or
its claims administrator agrees to provide an explanation of the necessary additional
information in a format that meets the requirements of 29 CFR 2560.503-1 and Section 2719
of the Public Health Service Act and its implementing guidance and allow at least 45 days for
the recipient to provide the information;
4.2.2 PAYOR and/or its claims administrator, as applicable,or PROVIDER may
request contractually supported corrective adjustments to a payment made to PROVIDER
hereunder during the twelve(12)months following payment of the claim.Thereafter,the
payment shall be deemed final and PAYOR shall have no obligation to pay and PROVIDER
shall have no obligation to refund.
4.2.3 Claims may be subject to standard claims editing software to detect bundling and
unbundling, as well as incorrect billing. Upon request,PAYOR shall provide PROVIDER
with an explanation of unbundling and incorrect billing edits.
4.2.4 PAYOR or its designated third party auditor("Auditor") may inspect claims data
and billing records relating to the Covered Services provided to PAYOR's Participants at its
expense. Audit materials or documentation provided by PROVIDER will be confined to
PAYOR or Participant-specific information.
These standards do not apply to claims about which there is substantial evidence of fraud or
misrepresentatin by PROVIDER or Participant.
4.3 Coordination of Benefits and Third Party Liability
PROVIDER agrees to cooperate with PAYOR's coordination of benefits(COB)and third party
liability policies and programs.
5. MAINTENANCE OF RECORDS,INSPECTION AND AUDIT
5.1 Maintenance of Records
PROVIDER shall maintain all appropriate medical,administrative and financial records for each
Participant who receives services from PROVIDER. Such records shall be maintained as is
required by law and generally accepted medical practice and professional ethics.
PAYOR shall have the right to request, inspect and audit any and all records of PROVIDER
related to a Participant as permitted by law,and as may be necessary for PAYOR to perform its
obligations under this Agreement. Where documents are requested by PAYOR for audit
purposes, including audits subject to Section 4.2.4,PAYOR shall reimburse PROVIDER for
reasonable costs incurred in providing copies of requested documents, not to exceed a rate of$.10
per page.
PROVIDER shall have the right to request, inspect and audit any and all records of PAYOR
directly related to a Participant as permitted by law,and as may be necessary for PROVIDER to
perform its obligations under this Agreement. Where documents are requested,PROVIDER
shall reimburse PAYOR for reasonable costs incurred in providing copies of requested
documents, not to exceed a rate of$.10 per page.
Neither party shall be reimbursed for copies of documents requested for purposes of
payment of claims, resolution of quality of care or service concerns, complaints and/or
grievances, or medical management review and coverage determinations.
5.2 Record Retention
Both parties shall retain all records relating to this Agreement for a minimum of seven(7)years.
5.3 External Audits
Both parties agree to cooperate with any external audits mandated by state or federal law,and shall
make records available to appropriate state and federal authorities involved in assessing the quality
of care or investigating the grievances or complaints of Participants,subject to applicable state and
federal laws related to the confidentiality of medical records.
6. CONFIDENTIAL,AND PROPRIETARY INFORMATION
6.1 Information Relating to this Agreement
The existence of this Agreement is not considered to be confidential information. However, both
parties agree that all information, including PAYOR information,reimbursement rates and fees in
Schedule A, as well as other information identified by either party as confidential or proprietary,
shall not be disclosed without the prior written consent of the other party. Upon termination of this
Agreement,any documents identified by either party as proprietary shall be returned to the
respective party.
6.2 Participant Health Information
a) The parties agree to comply with the Health Insurance Portability and Accountability Act
of 1996(HIPAA), as amended, and the Health Information Technology for Economic
and Clinical Health Act, as incorporated in the American Recovery and Reinvestment
Act of 2009, as amended(HITECH)all applicable requirements and obligations under
HIPAA and HITECH governing any uses and disclosures of all Protected Health
Information(PHI)or Electronic PHI(E-PHI)that may occur as a result of this Agreement
as applicable to each party. Each party warrants it will maintain and protect the
confidentiality of all PHI and E-PHI in accordance with its obligations under HIPAA,
HITECH,and all applicable federal and state laws and regulations.
b) The parties shall implement a documented privacy program that includes administrative,
technical and physical safe guards designed to prevent the accidental or otherwise
unauthorized use or disclosure of PHI or E-PHI.
c) Upon termination of this Agreement, at the request of the party that owns PHI or E-PHI,
the other party shall promptly return to the requesting party all such PHI or E-PHI which
has been provided to it or dispose of such PHI or E-PHI in a mutually agreed upon
manner.
6.3 Effect of Termination
The parties understand that the requirements of this Section 6, shall survive the termination of this
Agreement.
7. INDEMNIFICATION
PAYOR and PROVIDER shall indemnify and hold the other party harmless from loss,damage,or
defense costs(including,but not limited to reasonable attorney's fees)arising from actual or
alleged wrongful acts or omissions of the other party, its officers,employees,subcontractors,or
other agents in performing services contemplated under this Agreement which are solely the
responsibility of either PAYOR or PROVIDER. Neither party shall be liable for any liability of
the other party, its agents,officers or employees, whether resulting from judgment,settlement,
award fine or otherwise, which arises out of such other party's actions or omissions under this
Agreement.
8. TERM AND TERMINATION
8.1 Term of Agreement
This Agreement will commence effective as of the date specified on page 1 of this Agreement, and
shall continue for a period of one(1)year. Thereafter,this Agreement shall automatically renew
with the same terms and conditions as set forth herein for successive one-year terms unless
terminated in accordance with the terms of this Agreement.
8.2 Termination
8.2.1 Termination Without Cause
Either party may terminate this Agreement without cause, upon ninety(90)days prior written
notice to the other party.
8.2.2 Termination for Cause
Either party may terminate this Agreement for cause by giving the other party thirty(30)days
prior written notice. Such notice shall specify the reasons for the termination and shall provide
the other party thirty(30)days from the date of receipt of the notice of termination to correct
the cause to the satisfaction of the complaining party. Should the cause not be cured within
this thirty(30)day period, termination shall occur thirty(30)days from the end of that period.
8.3 Effect of Termination
This Agreement shall be of no further force or effect as of the effective date of termination except
that:
8.3.1 PAYOR shall be responsible for payment of Covered Services provided by
PROVIDER to a Participant as of the effective date of termination.
8.3.2 PROVIDER shall not seek compensation from the Participant for any Covered
Services provided under the terms of this Agreement prior to the termination date,except for
any applicable Deductible,Copayment or Coinsurance amounts.
8.3.3 PROVIDER shall continue the treatment of Participants who were receiving care
in an inpatient PROVIDER as of the effective date of termination,until the Participant is
discharged from the PROVIDER or transferred in the ordinary course of treatment. PAYOR
shall pay and PROVIDER shall accept the amounts as set forth in Schedule A for treatment
provided to a Participant under this Sub-Section 8.3.3.
9. DISPUTE RESOLUTION
The parties will meet and confer in an attempt to resolve any dispute arising out of or relating to
this Agreement. A dispute not resolved within thirty(30)days of this meeting will be submitted
to mediation, which will be held in a mutually agreed upon location, in accordance with the
American Arbitration Association("AAA") Rules of Procedure for Mediation. A single
mediator,selected by AAA and having at least 10 years' legal experience in health care will
mediate the dispute. If the dispute is not resolved through mediation,the parties will be free to
pursue all legal and equitable remedies otherwise available, provided, however that any action
taken or remedy sought must be initiated within one(1)year of the parties' first meeting to
resolve the dispute.
The provisions of this Section 9 shall not affect either party's right to terminate this Agreement as
provided for under Section 8.2 of this Agreement.
10. GENERAL PROVISIONS
10.1 Independent Contractors
Each party to this Agreement shall be acting as an independent contractor. None of the provisions
of this Agreement are intended to create nor shall be deemed or construed to create any
relationship between the parties hereto other than that of independent entities contracting with
each other solely for the purpose of effecting the provisions of this Agreement.
10.2 Amendment
This Agreement may be amended from time to time by PAYOR, by providing PROVIDER sixty
(60)days advance written notice of the amendment.
10.3 Severability/Conformity with Law
In the event any provision of this Agreement is rendered invalid or unenforceable by any State or
Federal regulation, or declared null and void by any court of competent jurisdiction,the remaining
provisions of this Agreement shall remain in full force and effect to the fullest extent possible
consistent with the intent and purpose of this Agreement, unless the severance of any such
provision substantially impairs the benefits of the remaining provisions of this Agreement. This
Agreement shall be interpreted, and if necessary,amended, to conform to applicable federal and
state law in effect on or after the Agreement's effective date.
10.4 Entire Agreement
This Agreement, its Attachments, and any documents incorporated herein by reference, constitute
the entire Agreement between the parties. No implied covenants shall be read into this
Agreement. This Agreement supersedes all prior agreements between the parties.
10.5 Waiver of Breach
Neither the failure nor delay on the part of either party to exercise any right under this Agreement
shall serve as a waiver of that right. If either party should waive a breach of any provision of this
Agreement, it shall not be deemed or construed as a waiver of any other breach of the same or
different provision.
10.6 Applicable Law
This Agreement shall be governed by and construed in accordance with the laws of the State of
Alaska and applicable Federal laws and regulations.
10.7 Medical Care
It is hereby understood that PROVIDER is solely responsible for all decisions and liability
regarding their medical care and treatment of Participants. It is also agreed that the traditional
relationship between PROVIDER and patient shall in no way be affected by or interfered with by
any of the terms of this Agreement. PROVIDER understands that any determinations made by
PAYOR or its claims administrator and any determinations made in connection with utilization
review are solely for purposes of determining whether services are Covered Services under the
terms of a Benefit Plan and the extent to which payments may be made thereunder. Accordingly,
such determinations shall in no way affect the responsibility of PROVIDER to provide
appropriate services to Participants.
10.8 Assignment
Neither party shall assign this agreement without the express written consent of the other.
10.9 Notices
Any notice required to be given pursuant to the terms and provisions of this Agreement shall be
in writing and shall be sent by U.S. mail, First Class, postage prepaid,to PROVIDER or PAYOR
at their respective addresses set forth on the signature page of this Agreement,except for notice
given under Section VI,which shall be sent by Certified Mail,return receipt requested. Notice
shall be deemed given when received or three(3)business days after notice is deposited in the
mail as set forth above, whichever is earlier.
10.10 Force Majeure
Neither party shall be required to comply with the provisions of this Agreement if the failure to
comply is occasioned by any act of God, bankruptcy, act of a governmental authority responding
to an act of God or other emergency, or the result of a strike, lockout, or other labor dispute.
IN WITNESS WHEREOF,the parties have caused this Agreement to be executed by their
authorized representatives of the d written below.
PRO'S/ PAYOR
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(Print Name) (Print Name)
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Title Title
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Date Date
Contact Info: . Contact Info:
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Business Office Contact Primary Contact Name
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Business Office Address, Suite# Office Address, Suite#
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City, State,Zip Cit , State,Zip
Contact's Phone Numbe'41011/ Contact's'Phone Number/Email
Provider's Tax ID# , CITY CONTRACT
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(606p) RESOLUTION NO:NO: 'Jh�M�r O
Provider's NPI#
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SCHEDULE A
PAYOR shall pay and PROVIDER agrees to accept the rates set forth in this Schedule A as
payment in full for Covered Services provided to Participants in accordance with the terms of the
Benefit Plan:
1. Professional Services (billed on a HCFA or its electronic equivalent)
Provider charges shall be paid at 65%of the provider's billed Charges based on current
fee table. Fee Table is attached at the end of this Contract.
2. Rate Changes
Provider agrees the rates set forth in this Schedule A shall be applied to Provider's
current charges provided to Payor November,2018 for the first year of the Initial Term.
For the second year, and each year renewal term thereafter, Provider agrees to adjust its
billed charges no more than 2%per year.
SCHEDULE B
Please list any additional Tax ID#(s)or NPI#(s)that will be subject to this agreement.
Tax ID#
Provider's Tax ID#, Name
Provider's Tax ID# Name
Provider's Tax ID# Name
NPI#
Provider's NPI# Name
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Provider's NPI# Name
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Provider's NPI# Name
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Provider's NPI# Name
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Provider's NPI# Name
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Provider's NPI# Name
Provider's NPI# Name
Provider's NPI# Name
Provider's NPI# Name
Provider's NPI# Name
** Unless a provider specifically opts out of the contracted agreement, all claims with the TIN(s)
specified in schedule B will process according to the agreement.
Pro Motion for City of Yakima Members
CODE Billed Charge Allowed Charge
97161 $ 130.00 $ 84.50
97162 $ 140.00 $ 91.00
97163 $ 150.00 $ 97.50
97164 $ 110.00 $ 71.50
97530 $ 80.00 $ 52.00
97112 $ 75.00 $ 48.75
97110 $ 60.00 $ 39.00
97140 $ 75.00 $ 48.75
97116 $ 75.00 $ 48.75
97035 $ 35.00 $ 22.75
97033 $ 35.00 $ 22.75
97032 $ 35.00 $ 22.75
97016 $ 35.00 $ 22.75
97014 $ 35.00 $ 22.75
G0283 $ 35.00 $ 22.75
97012 $ 35.00 $ 22.75
95992 $ 85.00 $ 55.25
L3000 $ 247.50 $ 160.88
97763 $ 80.00 $ 52.00
97761 $ 90.00 $ 58.50
97760 $ 90.00 $ 58.50