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HomeMy WebLinkAbout1995-05-16; City Council; Resolution 95-127/I 0 a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RESOLUTION NO. 95-127 A RESOLUTION OF THE CITY COUNCIL OF TH,E CITY OF CARLSBAD, CALIFORNIA, APPROVING THE AGREEMENT WITH NATIONAL UTILIZATION MANAGEMENT CORPORATION, OR NUMC. WHEREAS, the City Council has considered the attached contract document (Exhibit A) and finds it in the best interest of tl City of Carlsbad to become a party to said agreement and to obtain utilization management services for the eligible, employees and dependents of the City in the manner and for the considerations provided by the Agreement; and WHEREAS, a complete and true copy of said Agreement is on file with the clerk of the governing body; NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of Carlsbad, California, as follows: 1. That the above recitations are true and correct. 2. That the Agreement referred to in the recitals above i: incorporated in this resolution by reference. Ill I i I Ill ~ Ill 1 0 c J. 2 3. That the City Council of the City of Carlsbad, California 3 will obtain utilization management services, effective June 1, 199 4 // from National Utilization Management Corporation, or NUMC and has 5 6 7 to exclude such services. revised its contract with The Foundation for Medical Care (Exhibit i 8 9 10 11 1995, by the following vote, to wit: PASSED, APPROVED, AND ADOPTED at a regular meeting of the Carlsbad City Council held on the 16th day of - MAY , 12 13 14 15 16 17 18 AYES: Council Members Lewis , Nygaard, Kullchin, Finnila, Hall ms: None ABSENT: None I’ 21 20 I ATTEST: 22 LdY 23 24 25 ALETm$RANZ, City Clerk 26 KAREN R. KUNDTZ, Assistant City Clerk (SEAL) 27 11 28 , '1 0. EXHIBIT A AGREEMENT This Agreemcnt, entered into this 1st day of June, 1995 by and between NATIONAL UTILIZATION MANAGEMENT CORPORATION, an Arizona corporation, (hereinafter called NUMC) and CITY OF CAIUSBAD, (hereinafter called PARTICIPANT). WHEREAS, PARTICIPANT is an employer, insurance carrier, trust, union, employee organization, gover unit, third party administrator, or any other entity which insures or opera:tes self-insured or self-funded plan(s), health care indemnity coverage, various group health plan(s) or other programs for the provision 01 care services. WHEREAS, PARTICIPANT wishes to engage NUMC to provide one or more of the Utilization Mana Services offered by NUh4C in conjunction with the provision of health care services under said plans policies. NOW THEREFORE, in consideration of the mutual covenants contained herein and for good and v consideration, the legal adequacy of which is hereby acknowledged, the parties hereto agree as follows: I. DEFINITIONS 1 A. Eligible Covered Individual(s) - Any'person(s) entitled to receive services pursuant to PARTICIP Benefit Plan Design. B. Utilization Management Services - System for reviewing the aflpropriate and efficient allocal hospital resources and/or medical services given or proposed to be given to an Eligible Cc Individual. C. Benefit Plan Design - A written program adopted by PARTICIPANT which specifies the healti services which PARTICIPANT shall provide as a benefit to Eligible Covered Individuals and the and conditions applicable to the provision of such services. 11. A. SCOPE OF SERVICES In consideration for the charges set forth therein, NUMC shall provide the services indicated on E: "A", Fee Schedule, which is attached to and made a part of this Agreement. Said services are ou1 in Section I1 B of this Agreement. In the conduct of Utilization. Management Services thereu NUMC shall review health conditions andlor medical procedures in accordance with the specific2 and requirements of Participant's Benefit Plan Design or other programs for the provision of healtk services. CITYCARL mp:G.conuactlrevised/numc .,. 1 41; a 0' B. NUMC DUTIES AND 03LIGATIONS 1. NUMC shall perform medical surgical, and psychiatric: Pre-admission RevieM. Admission Review PRE-CERTIFICATION Concurrent Review Medical Case Management Review Second Surgical Opinion Optional Services Available on Per Case Basis Large Case Management Facility Fee Negotiation for Catastrophic Cases 2. All services performed shall be in accordance with the rules and regulations as proscribed @ Utilization Review Accreditation Commission (URAC) and all Federal, State, and local laws. 3. NUMC, in its conduct of said services shall use recognized, relevant standards and nom medical and vocational rehabilitation, medical need, and fees, and, in the conduct of Utiliz, Review, and Large Case Management, shall consult with tbe Eligible Covered Individ attending physician and other health care providers as appropriate. 4. NUMC shall employ or engage, independent contractors as appropriate; licensed, board eligibl certified physicians, psychologists and counselors with graduate degrees in their specialties, nt and menta1 health workers licensed in their fields to perform reviews. 5. All NUMC services are informational and advisory in nature and will be renderec PARTICIPANT by NUMC acting as an independent contractor. NUMC shall have no authorii responsibility to bind PARTICIPANT to any of NUMC's assessments, recommendati determinations, analyses, findings or certifications and PARTICIPANT reserves the right tc based upon PARTICIPANT'S judgment with respect to any and all claims or issues revie thereunder. 6. Nothing contained herein shall be construed to interfere with the physician-patient relations All parties agree that N"C has not been retained to diagnose [or treat PARTICIPANT'S Elig Covered Individuals. The decision to provide treatment that has not been certified remains with attending physician and the PARTICIPANT'S Eligible Covered Individuals. The decision to for such treatment remains with the PARTICIPANT. C. PARTICIPANT'S DUTIES AND OBLIGATIONS Prior to implementation of this Agreement PARTICIPANT will: 1. Provide NUMC with a copy of their Benefit Plan Design and any changes or modificatj thereto that occur during the term of this Agreement. . 2. Provide NUMC with a completed Utilization Management Questionnaire. 3. Provide NUMC's toll free number to all Eligible Covered Individuals. PARTICIPANT will provide NUMC with the total number of primary insureds prior to the 25th of e, month. CITYCARL mp.G:conuact/revised/d/numc 2 4112.P 0 e. III. COMPENSATION AND BILLING A. NUMC shall be compensated for all services provided under this Agreement in accordance with E: "A", Fee Schedule@) attached hereto and made a part hereof subjtct to the terms and conditio] forth therein. B, PARTICIPANT agrees to remit fees due NUMC within ten (10) dr!ys of receipt of month end t reports. All amounts not paid within the time limit shall bear an interest rate of 1 1/2% per month C. NUMC shall have the right, on or after the first anniversary of this '4greement and on each subse anniversary date thereafter, to modify the service fees listed in Exhibit "A", Fee Schedule. NUMC provide PARTICIPANT thirty (30) days prior written notice of its intent to increase service fees. fee modification notice shall remain in effect until further modification, if any. Upon PARTICIPANT'S receipt of such modification notice, I?ARTICIPANT may reject modification by giving NUMC ten (LO) days written notice. F'ARTICIPANT'S fee modific rejection notice shall operate to immediately terminate this Agreement unless there is mutual w consent to continue. D. NUMC shall rely exclusively on information provided by the PARTICIPANT relative to the number of Eligible Covered Individuals in PARTICIPANT'S group when calculating charge services based on capitated rates. It is mutually understood that accuracy in billing requires that Nl be advised on a monthly basis of any changes in the number of Eligible Covered Individuals and t is PARTICIPANT'S responsibility to promptly notify NUMC of any such changes. NUMC shall not be liable for refunds or adjustments of charges when said notice of change i received on a timely basis. IV. TERM AND TERMINATION OF AGREEMENT A. This Agreement shall commence as of the date of execution and shall continue for a term of 1 ( year, after which this Agreement shall be renewed automatically, on an annual basis. B. Either party may terminate this Agreement, with or without cause, by giving the other party 60 (s days prior written notice of intent to terminate. C. In the event of a material breach, the non-breaching party may terminate this Agreement I providing thirty (30) days prior written notice to the breaching party. The party claiming the rig terminate thereunder shall set forth in the notice the facts underlying the claim that the other party breach of this Agreement. If said breach is remedied within twenty ~(20) days of receipt of said nc this Agreement shall continue in effect for the remainder of the term.. Material breach includes, b not limited to, a failure by either party to perform in whole or in part any provision contained in Agreement. D. Upon termination for any reason, NUMC shall complete services in process only u PARTICIPANT'S specific authorization and agreement to pay ifor such completed services, accordance with the then applicable fee schedule(s). In any event, PARTICIPANT will be liable fo services provided to PARTICIPANT up to the date of termination of this Agreement whether or complete. CKYCARL mp:C:conmctlrevisednmc 3 4/12 ,e 0. V. GENERAL PROV1:;IONS A. LIABILITY INSURANCE The parties, at their sole cost and expense, shall procure and maintain such policies of general lia' professional liability, and other insurance as may be necessary to insure each party and its officer: employees against any liability or claims or damages arising by reason of negligent or willful a omissions by said party, its officers, and employees in the performance of responsibilities unde Agreement or for personal injuries or death, occasioned directly or indirectly by such party officers, or employees in connection with their performance of the: party's responsibilities unde Agreement. Evidence of each party's policy shall be submitted to the other upon written request. B. INDEMNIFICATION 1. PARTICIPANT agrees to indemnify NUMC from any and ,all liability, loss, damage, clai expense of any kind which result from negligent or willful acts or omissions of PARTICIPAP its empioyees regarding the duties and obligations of PARTICIPANTunder this Agreement. 2. NUMC agrees to indemnify PARTICIPANT from any and all liability, loss, damage, clai expense of any kind which result from negligent or willful acts or omissions of NUMC ( employees regarding the duties and obligations of NUMC under this Agreement. 3. Except as provided above, each party hereto shall be responsible at its own expense for defer itself in any litigation brought against it arising out of any activities engaged in connection this Agreement whether or not the other party hereto is a party to a lawsuit. Each party agrc provide to the other party information in its possession which is essential to the othcr p; defense in such litigation. 4. NUMC shall not be liable directly or indirectly for the negligence or willful acts or omissior any independent contractor utilized to provide services covered by this Agreement 01 Addendum. C. ASSIGNMENT PARTICIPANT may not assign any of its rights or delegate any of' its duties thereunder withoul prior written consent of NUMC. D. NOTICES Any notice to be given hereunder shall be in writing and shall be: delivered personally, or sha! deemed delivered if dispatched by certified or registered United States mail, postage prepaid, re receipt requested. Mailed notices shall be mailed to the parties at the addresses set forth below. If to National Utilization Management Corporation: National Utilization Management Corporation, an Arizona corporation 7301 North 16th Street, Suite 203 Phoenix, Arizona 85020 Attention: Constance K. Collins CrrYCARL mp.G:conaacUrevircd/nume 4 4112 0 0' If to PARTICIPANT: City of Carlsbad 1200 Carlsbad Village Drive Carlsbad, California 92008-1989 Attention: Human Resources Assistant Notices delivered personally shall be deemed received at actual receipt. X. RESOLUTION OF DISPUTES All disputes and differences arising between NUMC or an independent contractor engaged by NU and the PARTICIPANT upon which an amicable understanding cannot be reached, are to be decide1 the following method: 1. Mediation The PARTICIPANT shall notify NUMC in writing of the dispute or disagreement. PARTICIPANT shall supply I"C with all pertinent information and state its position on dispute. Upon receipt of this information NUMC will immediately contact the indepenr contractor and require the same information. NUMC will then attempt to mediate the disput the mutual satisfaction of all parties. If mediation is not possible within a reasonable time, nc exceed thirty (30) days from the time of first notice, the following procedure will apply: 2. Arbitration If the dispute cannot be solved by the mediation process described above, the PARTICIPANT 1 elect to submit the dispute to arbitration under the rules of the American Arbitration Associatiol any other method of Arbitration mutually agreed upon by the parties. F. ENFORCEABILITY AND WAIVER The invalidity and nonenforceability of any term or provision of this Agreement shall in no way al the validity or enforceability of any other term or provision. The waiver by either party of a breacl any provision of this Agreement shall not operate as or be construed as a waiver of any subseql breach thereof. G. ACCESS TO INFORMATION; OBTAINING AUTHORIZATIONS 1. PARTICPANT shall grant NUMC access to all pertinent documents and information, incluc medical and personal data within PARTICIPANT'S authority and control pertaining to the sub Eligible Covered Individual, general statistical or summary data, and coverage descriptions benefit plan documents reasonabIy required by NUMC pursuant to its performance of the requer service. PARTICIPANT will reasonably assist NUMC in obtaining from the Eligible COVC Individual his or her consent, in proper form, to review medical and other relevant records where feasible, PARTICIPANT will obtain such consent for NUMC. 2. NLJMC shall have no obligation to provide services thereunder with respect to any Eligible Cow Individual in thc event that such authorizations or releases are not obtained from said Elig Covered Individual. CITYCARL mp.G:contnctireviscd/numc 5 41121 e e .. H. CONFIDENTLALITY; 0WNERS:IIP 1. NUMC shall own all data, documents and software generated by it in the performance of se under this Agreement; shall have the right to retain copies of any documents providl PARTICIPANT; and, subject to the confidentiality constraints hereinafter specified: shall ha1 further right to use any data and documents provided by PARTICIPANT in the general course business. Upon termination Df this Agreement, PARTICIPANT shall be entitled to information in NUMC's possession as may be reasonably necessaxy to assure the continu PARTICIPANT'S administration of specific claims. 2. PARTICIPANT and NUMC acknowledge that the medical, financial and personal inforn collected and reviewed in connection with the subject services and the reports produced pursu those services may be confidential to the covered individual and therefore shall be usec republished only in connection with the administration of benefits and PARTICIPANT'S B Plan Design, policy or program for the provision of health care services, and will not be otht released, disclosed or published by PARTICIPANT or by NUIvlC except as permitted unde Agreement or required by law. I. ENTIRE AGREEMENT This Agreement together with all addenda and attachments contains all the terms and conditions a upon by the parties and supersedes all other Agreements, expressed or implied, regarding the s' matter and supersedes any prior oral understandings PARTICIPANT may have had with respl NUMC services. J. AMENDMENTS Any amendments to this Agreement must be in writing and executed by NUMC and PARTICIPAh K. INDEPENDENT CONTRACTOR NUMC and PARTICIPANT are independent legal entities. Nothing in this Agreement shl construed or be deemed to create a relationship of employer an,d employee, principal and I partnership, joint venture, or any relationship other than that of independent parties contracting each other solely to carry out the provisions of this Agreement for the purposes recited ir Agreement. L. NOTICE Until otherwise specified, all notices and communications required thereunder will be se PARTICIPANT and NUMC at the addresses shown in Section "D". CITYCARL mp.G.contracl/revlse#numc 6 4 0 01 M. INTERPRE t'ATION This Agreement and all questions relating to its validity, interpretation shall be governed by Cali law; performance and enforcement, shall be governed by and construed in accordance with the 1; the state of California IN WITNESS WHEREOF, the parties hereto have executed this Agreement on ithe 1st day of June, 1995. For and on behalf of: For and on behalf of : NATIONAL UTILIZATION MANAGEMENT CITY OF CARLSBAD 7301 North 16th Street, Suite 203 Phoenix, Arizona 85020 .~ Signature /cI& 7L f ,,Y&,J Claude A. Lewis Printe Name 9, /I Printed Name kc, (j43 Mayor Title Title CITYCARL rnp:G:conbacUrensed/numc 7 4/12 e 0 e' EXHIBIT B AMENDMENT TO PPO AGREEMENT This Amendment (ftAmendmentul) amends the San Diego Foundation fo Medical Care Preferred Provider Organization Agreement (ulAgreementtt) by and between City of Carlsbad (hereinafter referred to as fuPAYORff) and San Diego Foundation for Medical Ca (hereinafter referred to as lrPPO1l). RECITALS A. On January 1, 1986, PAYOR and PPO entered into the Agreement. B. PAYOR and PPO wish to execute an Amendment to modify the Agreement. NOW, THEREFORE, .in consideration of the recita:Ls and the mutual obligations of the parties as herein expressed,, PAYOR and PPO agree as follows: 1. The Agreement shall be amended to delete all reference to the PPO's obligations for hospital utilization review. 2. Article 8.2 of the Agreement shall be deleted and replaced with a new Article 8.2 as set forth below: "8.2 PPO ORtion. PAYOR shall pay, or cause to be paid, tc the PPO a sum of $3.25 each month for each Member (excluding covered dependents), enrolled in the PAYOR'S Health Plan. 3. This Amendment shall become effective June 1, 1995. 4. Except as provided for in this Amendment, the Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties have caused this Amendment to be signed on their behalf by their duly authorized representatives at San Diego, California, on the dab of , 1995. PAY OR : PPO : CITY OF CARLSBAD SAN DIEGO FOUNDATION FOR 1200 Carlsbad Village Drive MEDICAL CARE 9555 Chesapeake Drive, #203 rpcc-... ~ - . ".." Katherine P. Osborn - Title: Contract Manacrer