HomeMy WebLinkAboutSan Diego Foundation for Medical Care; 1995-05-23;'Tui SAY -3, -1
May 23 ____ Date
0 Reply Wanted
UNO Reply Necessary
- . - - - - - __ - - - ___ - __ ._ .__ TO File
- From Isabelle Paulsen
- .- - . __ - _. -
- - __ - - - - __ ___.____ - _____ _____.
Julie Clark, Human Resources Department, stated that she would provide a copy of the amendment with Northwestern amending the Sari Diego Foundation €or Medical Care Preferred Provider Organ to the consultant.
Council Meeting May 16, 1995. AB #13,148, Resolution No. 95-1
P
EXHIBIT B e a
AKF,NDMENT TO PPO AGREl3l@NT
This Amendment (rlAmendmentll) amends the San Diego Foundation fo
Medical Care Preferred Provider Organization Agreement (I1Agreement1*) by and between City of Carlsbad (hereinafter referred to as lfPAYORvT) and San Diego Foundation for Medical Ca
(hereinafter ref erred to as rlPPOtl ) .
RECITALS
A. On January 1, 1986, PAYOR and PPO entered into the Agreement.
PAYOR and PPO wish to execute an Amendment to modify the Agreement. B.
NOW, THEREFORE, in consideration of the recitals 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 PPB ODtion. PAYOR shall pay, or cause to be paid, t 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 18th da of MAY , 1995.
PAYOR: PPO :
CITY OF CARLSBAD SAM DIEGO FOUNDATION FOR
1206 Carlsbad Village Drive MEDICAL CARE
9555 Chesapeake Drive, #203
- Katherine P. Osborn
Title: Contract Manaaer
iTE IT- D '9 SAJY a erj
Date May 23 -
UReply Wanted
UNO Reply Necessary
. - - - - __ .. - __ - __ . __ ____ --- __. __ . - _. we _. __ TO
-- From -----___._..__. Isabelle Paulsen - -- _- -. _- __.. ~_____
Today the Human Resources Department provided this office with a copy of
the agreement with San Diego Foundation for Medical Care. Jan Murray,
Human Resources Department, stated that this was a copy from a copy that
is filed in their department.
Riders and amendments attached were processed administratively.
PRI
-- I-- I..,, 4 @ I.
c
SANDIEGQPOmDAmNFOLCmum PREFERRED PROVIDER ORGANIZATION AGUEmENT
This Agreement is made and entered into as of the date sei forth below, by and between CITY OF CARLSBAD (hereinafter refer to as "Payor") and SAN DIEGO FOUNDATION FOR MEDICAL CARE, doing business as SAN DIEGO PPO (hereinafter referred to as the "PPO"
ART1 CLE-1
RECITAL S
1.1 The PPO undertakes to administer, on behalf of third party payors, contracts with hospitals and providers for the economical delivery of health care services to Members covered under self-funded health benefit plans, group and individual he care insurance policies sponsored by third party payors (such a insurance companies, employers, unions, and governmental entiti
1.2 The PPO also conducts an ambulatory utilization revi program, and a hospital review program including preadmission, admission, and concurrent review of health care services, to re delivery of medically unnecessary services to patients covered third party payors' health benefit plans and insurance policies
1.3 The Payor has concluded that it is in the best inter of the Payor and persons enrolled in certain health benefits pl or insurance policies sponsored by the Payor for the Payor to contract with the PPO to administer contracts with hospitals an professional providers to provide services to such Members, and
the PPO to perform utilization review of such services.
ARTICItE 2
DEFINITIONS
2.1 Account. "Account" means an organization or entity which makes a Health Plan available to employees and others.
2.2 HPalth Plan. "Health Plan" means a self-funded heal benefit plan or group or individual health care insurance polic issued by the Payor which complies with the requirements set fc
in this Agreement.
licensed by the state of California which contracts with the PI provide Hospital Services to Members.
contracted for the delivery of Hospital Services to Members, ti types of Hospital Services each Hospital will make available, i the Hospital Rate for such services are listed in Exhibit "A"
2.3 pospitd . "Hospital" means a health care facility
Hospitals which have
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attached hereto, the PPO shall promptly notify the Payor of an addition or deletion of Hospitals and of any change in Hospital Services offered at each Hospital.
charges at which a Hospital contracts to provide Hospital Servi to Members. The Hospital Rate may be changed by separate writt agreements executed at any time during the existence of this Agreement.
2.5 HosDital Services. "Hospital Services" means those inpatient or outpatient Hospital Services, including inpatient acute care and inpatient psychiatric services (including alcoho and drug rehabilitation) as set forth in Exhibit "A", covered under a Health Plan, required by a Member's medical condition, available at a Hospital, which the Hospital contracts to make available to Members at the Hospital Rate.
discretionary act.
dependent) who is entitled to receive Hospital and Provider Services covered under a Health Plan sponsored by the Payor.
2.8 Ron-contractips HosoitaL. "Non-contracting Hospital means a hospital which has not contracted with the PPO to provi Hospital Services to Members, but which does participate in the Foundation Utilization Review Program .
2 -9 Non-contracting Provider . "Non-contract ing Provide I means a provider of medical services who has not contracted wit the PPO to render Provider Services to Members.
2.4 BosDital Rate. "Hospital Rate" means the charge or
2.6 m. "May" is used to indicate a permissive or
2.7 Membeg. "Member" means any person (including a cove
2.10 Provider. 'Provider" means a person who is duly licensed or certified to perform one or more medical services i the state of California and agrees with the PPO to render Provi Services to Members of a Health Plan at the Provider Rate as SE forth in Exhibit "C" and upon the other terms and conditions of this Agreement.
2.11 provider- Rate. "Provider Rate" means the applicable charge for Provider Services rendered to a Member as set forth
Exhibit "C",
2.12 Provider Serv ices. "Provider Services" means those services directly rendered by a Provider to a Member, when suck services are covered under a Health Plan and such services are required by a Member's medical condition.
2.13 Shau. 'Shall" is used to indicate the obligation ( mandatory action.
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2.14 The Fopadation -muon Reaew Proarm. "The Foundation Utilization Review Program" is a comprehensive hospital/patient utilization review system conducted for the Pa? and is administered by the San Diego Foundation for Medical Car
ARTICLE 3
DUTIES OF PPO ABD HOSPITa
3.1 Hospital Services. The PPO shall contract with
3.2 BosDitaf Bi-. The PPO shall contract with Hospi
Hospitals to provide Hospital Services at the Hospital Rate.
by which the Hospitals shall agree not to bill the Payor or a Elember for services determined in advance by the PPO to be medically unnecessary except as otherwise provided in Section 6.1.4.2 .
3.3 Con tract Interpr etation. The PPO shall administer i contracts with each Hospital and shall be responsible for the interpretation of the terms and conditions of the contract with each Hospital.
ARTICliE 4
BOSPI TAT, U TJTi I Z ATIBN REVIEW
4.1 ytiiization Rey.&w. The PPO shall conduct utilizati review of Hospital Services, as set forth in Exhibit RBn, provj to each Member through the Foundation Utilization Review progrE
Such review shall be conducted in PPO Hospitals, and those Noncontracting Hospitals identified in Exhibit "Dm, and shall include the following:
necessity of a scheduled admission. out according to the Foundation Utilization Review Program's policies regarding ambulatory surgery and preoperative hospitalization. These policies shall be available for the Pa3 inspection.
4.1.2 Admission review within one working day aftei
Hospital notifies the PPO of an unscheduled admission to deter1
the medical necessity of the admission.
4.1.3 Periodic concurrent review during the hospit, stay of a Member, based on diagnosis, to determine the medical necessity of continuing stay. Such review is not applicable w
the Hospital Rate is a package rate for each admission.
4.1.4 Periodic concurrent review during the hospit stay of a Member to determine the medical necessity of any lev
4.1.1 Preadmission review to determine the medical
This review shall be carrj
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care higher than acute care. Such review is not applicable whe Hospital Rate is a package rate for each admission,
Hospital of a written Statement of Medical Necessity evaluating medical necessity of a Member's admission, length of stay and services provided and setting forth any date upon which the Hospital or Non-contracting Hospital was notified that further services would no longer be medically necessary.
4.1.6 Submission of quarterly reports to the Payor I employer and/or Account listing each admission that was reviewel including the Hospital or Noncontracting Hospital to which the Member was admitted, the savings realized, the diagnosis, and t length of stay.
Member if such admission was not reported to the PPO in time fo admission or concurrent review. The retrospective review of th itemized bill and medical record shall be completed within nine
(90) days after the PPO receives the itemized bill and a copy o the medical report, The retrospective review shall be advisory only for the purpose of assisting the Payor in evaluating the hospital bill ,
4.2 Sta tisticau. The Payor authorizes incorporatio
the statistical data obtained by the PPO during the performance hospital utilization review described herein in analyses, studi and technical reports furnished to others by the PPO, but neith the Payor nor any Member may be identified by name without thei prior written consent.
4.1.5 Submission to a Hospital or Non-contracting
4.1.7 Retrospective review of each admission of a
ARTICLE
PROVXB&R-
5.1 par ticir>ating Pr ovidem. The PPO has obtained or sh
promptly obtain the agreement of physicians in all major specialties, primary care physicians, and other licensed or certified professional providers, readily accessible to Members render Provider Services to Members upon the terms and conditic of this Agreement .
directory or list of participating Providers and shall provide sufficient copies to the Payor for distribution to all Members (excluding dependents) .
agreement with the PPO, shall accept as payment in full for Provider Services rendered to a Member the lesser of (a) the u! and customary charges, (b) a special contracted rate or (c) thc
5.1.1 The PPO shall make available to the Payor a
. Providers, pursuant to their 5.2 Provi der- BU ..
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Provider Rate determined in accordance with the schedule set fo in Exhibit "C".
5.3 rovid-tion Re-. The PPO shall provide utilizationpreview of services rendered by Providers and Non-contracting Providers as set forth in Section 8.1.2 and Exh
"E". Providers shall be bound by utilization review decisions the PPO,
ARTICLE 6
DUTIES OF PAYOR
6.1 Contents of Health Plan. In order for any self-fund health benefit plan, or group or individual health care insuran policy issued by the Payor to qualify as a Health Plan, the pol must comply with the following requirements.
6.1.1 Such policy shall provide one of the followin incentives for Members to use Hospitals for non-emergency admissions in San Diego County:
6.1.1.1 The co-insurance, if any, for Hospital Services which is the financial responsibility of a Member shal lower when a Member receives such services from a Hospital thar
the case when a Member receives such services from another San Diego County institutional provider; or
6.1.1.2 The deductible, if any, for which a ME is financially responsible shall be at least One Hundred Dolla! ($100) lower for a Member electing to use a Hospital than for z Member who elects to use another San Diego County institutional provider; or
6.1.1.3 One hundred percent (100%) of charges Hospital Services to a Member are paid by the Payor except as otherwise provided in Section 6.1.6.
Hospital Service provided under the policy from any Hospital offering such Hospital Service.
6.1.3 Such policy shall include a provision that tl Payor shall pay a Hospital for Hospital Services at the Hospiti Rate, less any co-insurance or deductible or any other payment which a Member may be personally responsible as specified in tl Payor's Health Plan. The policy shall not deny payment for Hospital Services provided through the later of (1) twelve o'c: (12:00) midnight on a day during which telephone or personal nc of a utilization review decision that such services are medica: unnecessary is given to a Hospital or (2) twelve o'clock (12:0 midnight on the last day for which Hospital Services are deter]
6.1.2 Such policy shall permit a Member to obtain i
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to be medically necessary after review, appeal, or arbitration accordance with the contract between a Hospital and the PPO. Calculation of co-insurance and accumulation of the deductibles any, shall be based upon the Hospital Rates at which a Hospital contracts to provide Hospital Services.
6.1.4 Such policy shall provide that a Hospital may bill a Member for the following:
6.1.4.1 Any part of the Hospital Rate which tl- Payor is not obligated to pay for medically necessary Hospital Services under the applicable Health Plan, including, without limitation, co-payments and deductibles;
6.1.4.2 Any services charged at a Hospital's L and customary rate, which the PPO determines are medically unnecessary, and for which the Payor has no financial responsibility, provided a Member or another responsibile part1 acknowledges receipt of information disclosing, prior to the provision of such services, that they have been determined to t medically unnecessary and, accordingly, will not be covered by applicable Health Plan:
6.1.4.3 Any services other than Hospital Serv: which services may be charged to patients at the Hospital's USI and customary rates:
6.1.4.4 Amounts due and owing under a contract with a Member pursuant to subsection 6.5 hereof .
6.1.5 Nothing contained in Section 6.1.4 shall prec the Payor and/or Account from accepting and paying for medical. unnecessary Hospital Services.
6.1.6 When the Payor is primary under the coordina of benefit rules provided in Title 10 of the California Administrative Code Sections 2232.50 through 2232,56, the Payo shall pay the Hospital Rate, less any co-insurance or deductib any other payment for which a Member may be personally respons as specified in the Health Plan. In a case in which the Payor under the applicable Health Plan, is other than primary, then the coordination of benefit rules referred to above, the Payor shall pay only those amounts which when added to the amounts received by Hospital from other sources, pursuant to the appli coordination of benefit rules, equals 100% of the Hospital Rat
6.2 Benef it Decis-, The Payor shall have sole
responsibility, subject to the provisions of this Agreement, f making final decision as to payment due and owing for Hospital Provider Services provided to a Member.
6.3 Pavm entsto HOSD itas. All bills for Hospital Serv which are correctly submitted by a Hospital to the Payor, or a
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contractor acting for the Payor, shall be due and payable, when such Hospital Services are covered under the Health Plan, not 1; than thirty (30) days after submission except when a utilizatior review decision is pending or under appeal or when the Payor is requesting additional information to determine whether or not tk charges for Hospital Services are payable under the terms of thc Health Plan, In the event the Payor fails to make ninety-five percent (958) of payments to Hospital for Hospital Services whet due and payable or fails to make all such payments within 90 da) of the date payments are due and payable under the Health Plan,
PPO may terminate its contract with the Payor pursuant to Sectic 9.2 hereof.
6.4 Pavments to Providers. The Payor shall pay to each Provider for Provider Services rendered to a Member, when such services are covered by the Payor, and provided such services a, medically necessary in accordance with the utilization review procedures specified in Exhibit "E", the lesser of the followini (a) the usual and customary charge, (b) a special contracted ra or (c) fees calculated in accordance with the Payor's Provider Rates attached hereto as Exhibit "C", less any deductibles, co-payments, or other payments for which the Member may be personally responsible to a Provider under the terms of the Hea Plan. Payment by the Payor shall be due and payable to a provi on or before the thirtieth (30th) day after receipt of correct1 and accurately prepared bill from Provider for Provider Service a Member except when a utilization review decision is pending o under appeal or when the Payor is requesting additional informa to determine whether or not the charges for such services are payable under the Payor's Health Plan.
whenever payment for Hospital Services is not made to a Hospita when due and payable under the Health Plan, such Hospital may refuse to admit Members enrolled in the Health Plan for non-emergencies until such time as those payments due and owing paid in full. If there are reasonable grounds for insecurity b Hospital with respect to timely future payments by the Payor, Hospital may require adequate written assurances of payment bef admitting additional members enrolled in the Health Plan for non-emergencies. In the event Hospital does elect to admit a member enrolled in the Health Plan when payments are in arrears the Payor has failed to provide reasonable assurances, Hospital contract with said Member to pay for Hospital Services at Hospital's usual and customary rate in the event the Payor fail make payment when due and payable for Hospital Services provide the Member .
6.6 PPO Ca a. The Payor shall provide each Member of a
Health Plan (excluding dependent children) a wallet-sized card identifying (1) the Member's participation in the PPO and in tk
hospital utilization review program and (2) the Member's
6.5 Peme dies for La te Pavm ent. The Payor agrees that
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notification responsibilities. The form and content of these c shall be subject to the approval of the PPO and the Payor,
6.7 wna tiQLpf-Bengfits. The Payor shall cause to b returned to a Provider with payment of each bill for Provider Services to a Member a notice identifying any portion of the bi which has been disallowed as a noncovered service or disallowed medically inappropriate pursuant to utilization review procedur incorporated in Section 8.1.2 and set forth in Exhibit "E", and remaining balance due and owing to the Provider for which a Mem is personally responsible under the Health Plan.
6.8 Assignment of Benefirs. The Payor shall, to the ext permitted by law, cause benefits to a Member under a Health Pla be assigned in favor of the treating Provider and Hospital, and shall honor such assignments.
6.9 Provider Directory. The Payor shall provide each Me (excluding dependents) a directory or list of Providers upon receipt of the directory or list from the PPO as provided in Section 5.1.1.
6.10 uajstory. The Payor shall provide the PPO, tc extent permitted by law, the history of each Member's claims fc medical care whenever a bill for Provider Services to a Member first referred to the PPO for utilization review,
ARTICLE 7
EFFECTIVE DA TE-OF A(; REEMENT
7.1 Gf ective Date. This Agreement shall be effective i
. - Jan garv-1- ------- , 1985. Rates for Hospital and Provider Services shall apply only to Members' admissions or treatments Hospital or Provider on or after the effective date of this Agreement,
ARTICJtE 8
FEES AND PA YNENTS TO TW
8.1 Nonth1 y-Feg. The Payor shall pay or cause to be pa
to the PPO a monthly fee for each Member (excluding covered dependents) enrolled in the Payor's Health Plan on the first di the month,
8.2 PPB-ODt ion. Payor shall pay or cause to be paid to
PPO the sum of $4.50 each month for each Member (excluding cov dependents) enrolled in the PayorIs Health Plan. This plan includes:
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8.2.1 Hospital utilization review as described in Section 4.1 and Exhibit 'B" attached hereto,
8.2.2 Utilization review of Provider claims. The P; shall submit or cause to be submitted to the PPO all claims for services provided to a member by Providers and Non-contracting Providers. The PPO shall screen such claims in accordance with guidelines attached hereto as Exhibit "F". Claims that do not 1 the screening will be subjected to utilization review conducted accordance with Exhibit "E". Upon completion of screening or utilization review, as applicable, the PPO shall verify the provision of services, designate whether a claim is appropriate payment, verify the 1974 CRVS coding or CPT coding, and with respect to Provider Services, multiply unit values by conversio factors and calculate the amount of the allowable fees. The PR shall subsequently forward all claims to the Payor, or its administrator, for processing.
8.3 pay ment- to-the PPO. Payment of the monthly fee shal due and payable to the PPO within thirty (30) days after the inclusion of an Account in the Health Plan, Whenever any payme is not made within ten (10) days after the last day of the 30-d period, the unpaid balance shall be subject to a late payment charge at the rate of one and one-half percent (1-1/2%) per mon running from the day after the last day of the 30-day period un paid.
payments shall be accompanied by certification of the number of Members enrolled in the Health Plan on the first day of the rnon (excluding covered dependents and those eligible for extended benefits under the Health Plan) .
8.5 - - ep-. The Payor shall pay, or cause to be paid, to the PPO a one-time charge for each member (excluding covered dependents) of Two Dollars ($2) within thirty (30) days after the inclusion of an Account in the Health Plan. The Two Dollar ($2) fee is not required for Members and covered depende subsequently enrolled after the date the Account is included in Health Plan.
8.4 Certiffcation. of- EnQJlment, The Payor's monthly
ARTICLE- 9
TERM AND- TERHINATION
9.1 Term, This Agreement shall remain in effect for an initial period ending -er - - ~1 _. --, 1981, and shall be renc
annually thereafter for successive periods of one year without further action by either party, unless either party shall, not than ninety (90) days prior to any renewal date, notify the otk party in writing of its intention not to renew this Agreement. Notwithstanding the foregoing, the fees charged by the PPO for
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4
utilization review may be changed by separate written agreement the parties, executed at any time during the existence of this Agreement. Any such change in fees shall be effective in accordance with the terms of such separate agreement, and shall affect the validity of any other provision of this Agreement.
9.2 Terrninaa for Br each. Either party may terminate Agreement upon sixty (60) days' written notice to the other par for breach of the terms and conditions of this Agreement. The following shall, without limitation, be deemed breaches of this Agreement:
9.2.1 Failure to make any payment when due, whether the PPO, a Hospital, or a Provider;
9.2.2 Material breach of any duty to perform any required act;
9.2.3 Failure of any duty to contract upon the term required by this Agreement with a third party, including but no limited to a Member of a Health Plan.
9.2.4 Nothwithstanding the above, in the event of a breach of any of the terms of this Agreement, either party may written notice thereof to the other party who shall have thirty (30) days to cure the breach or this Agreement shall be termina
9.3 Term ination-without- awe. Either party may termina
this Agreement without cause upon ninety (90) days' written not to the other party. terminating this Agreement on the day immediately following nir
(90) days from the date of receipt by the other party.
Agreement is terminated for any reason, the Payor agrees that j
shall continue to make payment to a Hospital for Hospital Servj and a Provider for Provider Services in accordance with the te1 and conditions of this Agreement, so long as the services are covered and benefits are payable under the Health Plan and the Hospital or Provider continues to supply Hospital Services or Provider Services to any member who was hospitalized or treatec prior to the date of termination. The PPO agrees it shall coni to provide utilization review for such Member.
Such written notice shall have the effect
9.4 Ob1 Wtiops- af,ter- Termination. In the event this
ART I Cf , E - Id
CONF- TIAIJTY AND- PROPRIE TARY Rm 3s
10.1 Pestr icfion- on- Rate- Disclosure. Any information
concerning the Hospital and Provider Rate or usual and customa charges of any Hospital or provider received by the Payor from
PPO, a Hospital, or provider in connection with this Agreement
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negotiations concerning this Agreement, or delivery of Hospital Provider Services may be disclosed only to the extent necessary any explanation of benefits to a Member but shall not be disclo: directly or indirectly, by the Payor to any publisher, radio or television station, or other business or person engaged in the public dissemination of information, or any employee thereof. Z information shall not be disclosed in advertising, in any public forum, or in any material disseminated to the general public without first obtaining the prior written consent of the PPO, ar the Hospital or Provider as the case may be.
10.2 yse- of Names. Trademarks; Service Mark&,&mboiLgI Logos. The PPO may identify the Payor in the PPO's advertising publications as a participant in the PPO, and the Payor may identify in advertising and publications the PPO and the Hospitz at which Hospital Services are available under a Health Plan. Neither party shall make any other use of the name, trademarks, service marks, symbols, and logos of the other, presently exist: or later established, without the prior review and written const of the other. Each party shall cease any such usage immediate: upon receipt of a written demand or upon termination of this Agreement, whichever occurs first.
ARTTCLEJL
RELATIONSHIP-RE'IWEEN- TBE. PPO- AND- TH$ PAYOR
11.1 u deDen dent Contractors. The PPO and the Payor are independent entities. Nothing in this Agreement shall be const or deemed to create a relationship of employer and employee, principal and agent, or any other relationship except that of independent parties contracting with each other solely for the purpose of carrying out the provisions of this Agreement.
11.2 TJird Pa+, ties. Nothing in this Agreement is intend to be construed, or deemed to create, any rights or remedies in Member or any other third party.
Auth 0 ri 't y - of. the PPO - t o Pr o vi d e - W t' ii .&ition-Review.
The Payor hereby authorizes the PPO to conduct utilization revi on the Payor's behalf and authorizes the PPO to review medical records of Members and do all things necessary to conduct effec utilization review.
Providers and- Non-contractins Pr oviders.
review determinations with respect to services provided by Contracting and Non-contracting Hospitals and by providers and Non-contracting Providers are merely advisory, and the final determination as to whether such services shall be reimbursed u any Health Plan shall be the responsibility of the Payor acting its discretion.
11.3
11.4 Con tractrng *- and F? ppbcontr acting. EQS~ jtals- and The PPO's utilization
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ARTICJtE U
GENERW- PROVISIQNS
12.1 Wosals for Affilia&m. The PPO represents and warrants that it shall give reasonable consideration to timely written proposals for affiliation by licensed or certified professional and institutional providers as required by law.
12.2 PBO-Insurance. The PPO shall maintain in effect du the term of this Agreement insurance policies, insuring the officers, directors, employees and agents against liability for claims which may be brought by third parties against the PPO as result of services provided pursuant to this Agreement. Said policies shall be in the amount of one million dollars per occurrence and aggregate.
12.3 HOSpita- Insugance. A Hospital contracting with PP shall, subject to the availability of such insurance from insur regularly providing such coverage, have a contractual obligatio maintain a policy of comprehensive general liability and professional liability insurance necessary to insure the Hospit and its emplyoees against liability for damage claims which may arise from performance of Hospital Services.
12.4 JnsDe ction-of-RecQrds. The PPO shall keep true and correct books and records of all services performed under this Agreement for the duration of this Agreement and for five years thereafter. All such records shall be open to inspection and a by the Payor and by the California Insurance Commissioner.
12.5 Liaison. Each party shall appoint a member of its staff to act as liaison for the purpose of coordinating and communicating with the other party during the term of this Agreement, and shall promptly notify the other party of any chz in appointment.
12.6 Not ices. Any notice required by this Agreement ma] given in writing personally to the liaison person designated bj party, or may be given in a writing sent by United States mail, return receipt requested, with postage prepaid and addressed tc each party at the addresses set forth on the signature page, 01 any other address of which a party has given notice in accordar with this Section. Notice shall be deemed given on the date ol delivery or refusal as shown on the return receipt if deliverec mail or the date upon which such notice is personally deliverec writing to a designated liaison person.
12.7 mD Utes. It is understood and agreed that any di
which cannot be amicably resolved by the parties shall be subm to binding arbitration pursuant to Sections 1280-1294.2 of the
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California Code of Civil Procedure. Agreement to arbitrate she survive termination of this Agreement ,
12.8 Wpment, Neither party may assign or transfer E duty of interest in this Agreement, except with the written cor of the other party, and any attempted transfer or assignment without consent shall be void.
12.9 Sever&Le,Tw. The invalidity or unenforceabilit any term or provision in this Agreement shall not affect the validity or enforceability of any other term or provision of tk Agreement .
12-18 Waiver, Waiver of a breach of any provision of thj Agreement shall not be deemed a waiver of any other breach of t same or different provision.
12-11 Amen_ dment. This Agreement may be amended only by t mutual written consent of the parties,
12-12 Headinas . Headings are solely for convenience and shall not be used in interpreting the text of this Agreement.
12.13 w ' re- Aureement. This Agreement, together with Exhibits "A" through "F", constitutes the entire agreement beti t:he parties and as of the effective date hereof supersedes all previous agreements and understandings between the parties wit1 respect to the subject matter hereof.
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IN WITNESS WHEREOF, the parties have executed this Agreeml at San Diego, California, effective as of the date set forth ab1
PAYOR:
City of Carlsbad - Address:- -.__--
- ---- 1200 Elm Avenue
GarLsbad, CA- 92008--. -. . -- ------
BY:.Ft rP;,t- - -_
Ti tl Personnel Director -
SAN DIEGO FOUNDATION FOR
MEDICAL CARE 9555 Chesapeake Drive, Ste 203 P.O. Box 23545 San Diego, California 92123-05
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HENT To PPO AGRE-
This Amendment to the PPO Agreement is made by and between CI'I OF CARLSBAD (hereinafter referred to as lVPayor") and the SAN
DIEGO FOUNDATION FOR MEDICAL CARE, doing business as the SAN
DIEGO PPO (hereinafter referred to as the tlPPOtv).
RECITALS
A. On January 1, 1986, Payor and the PPO entered in to a PP(
B. Payor and the PPO wish to execute an Amendment to modify
Agreement.
this Agreement.
NOW, THEREFORE, in consideration of the recitals and the mutui obligations of the parties as herein expressed, Payor and the agree as follows:
1. Add paragraph 6.11 to Article 6 of the PPO Agreement as follows :
"6.11 Medical Be nefits Prouram Documents. Payor shall
provide the PPO with a copy of the Health Plan's medical benefits program documents applicable to the determinatii of benefits available to Members and updates as they occ The PPO shall have the authority to rely on the accuracy such documents in the performance of its responsibilitie herein. 1v
2. The effective date of this Amendment is November 1, 1991 All other terms and conditions of the PPO Agreement shal remain in full force and effect.
IN WITNESS WHEREOF, the parties have executed this Amendment the date se forth below:
3- , 1991
PPO :
DATED : &!Ah
Payor:
CITY OF CARLSBAD SAN DIEGO FOUNDATION FOR
1200 Elm Avenue MEDICAL CARE
Carlsbad, CA 92008 9555 Chesapeake Drive
San Diego, CA 92123-6394
By:
Tit1e:V.P.. P1 ann ha & Devel 01
0 e
THIRD AMENDMENT TO PPO AGREEMENT
This Third Amendment to the PPO Agreement is made by and between C
CARLSBAD (hereinafter referred to as "Payor") and SAN DIEGO FOUNDA
MEDICAL CARE, doing business as SAN DIEGO PPO (hereinafter referre
"PPC" ) .
RECITALS
A. On January 1, 1986, Payor and PPO entered into a PPO Agreemen.
B. Payor and PPO wish to execute a Third Amendment to modify thi:
agreement.
NOW, THEREFORE, in consideration of the recitals and the mutual ob
of the parties as herein expressed, Payor and PPO agree as follows
1. Revise paragraph 2.11 of the Agreement to read as follows:
"2.11 Provider Rate. "Provider Rate" means the applicable pa'
Prov.ider Services rendered to a. Member as set forth in Exhibit "C"
one hundred twenty (120) days notice by PPO, the Provider Rate may
adjusted by independent actuarial determinations effective upon thl
anni-Jersary date of this Agreement. During the notice period, Pay'
appeal the Provider Rate as allowed by the actuary."
2. In paragraph 6.4, line 7, delete the word "Payor's''.
3. Replace Exhibit "C" with attached Exhibit "C" dated January 1
1991.
4. The effective date of this Amendment is January 1, 1991. All other terms and conditions of the PPO Agreement shall remain :
full force and effect.
IN WITNESS WHEREOF, the parties have executed this Amendment on thc
forth be 1 ow :
DATED: November 6, 1990
Payor: PPO :
CITY OF CARLSBAD SAN DIEGO FOUNDATION FOR MEDIC
1200 Elm Avenue 9555 Chesapeake Drive, Suite :
Carlsbad, California 92008
RECEIVED
&hr 28 1991
s* De F. M. c.
0 e
SECOND AHENDHENT TO PPO AGREEHENT
This second amendment to the PPO Agreement is made by and be
CITY OF CARLSBAD (hereinafter referred to as "Payor") and SA
DIEGO FOUNDATION FOR MEDICAL CARE, doing business as SAN DIE
PPO (hereinafter referred to as "PFO").
RECITALS
A. On January 1, 1986, Payor and PPO entered into a PPO
Agreement.
B. Payor and PPO wish to execute a second amendment to
modify this agreement.
NOW, THEREFORE, in consideration of the recitals and the mut
obligations of the parties as herein expressed, Payor and PE
agree as follows:
1. Exhib.it "C" is amended by substituting the attached revised Exhibit "C" dated February 1, 1990.
2. The effective date of this amendment is February 1,
1990. All other terms and conditions of the PPO
Agreement shall remain in full force and effect.
IN WITNESS WHEREOF, the parties have executed this amendmenl
the date set forth below:
DATED: February 1, 1990
Payor: City of Carlsbad
1200 Elm Avenue
Carlsbad, California
/ L' (- L PPO : San Diego Foundation for Medical Ca
9555 Chesapeake Drive, Suite 203
San Diego, California 92123-0545
By: /- /
Title: L/p , 9k + Ai??
0 0
2
FIRST AMENDMENT TO PPO AGREEMENT
?:.:s fir5.t azendment, ?,I =he ??O ?.q:re;.aenz is made by ar,d be ___ - __ -,-,3L,SBAD ! herernafter referred to 6s "Payor" ) SRC S, .I - n 7, ,, r ," n
S? r 7- - ,, --L=,J ?OI:!I3ATZ=:>.V FCIR !!EDICAL S>.?.E, do:?..; k~~:,~ll?pgs 5s SAX 2I - .-r.:>;.2.::+: ref..rre:d to as "PPO"). ->,- . _. -..._, ,~
?.X c r 7 A> S --
-,, 7, /-. .-. 1 ,:, ~2 ; 2~.!i 3 T*( L , - 1 - 325 3ayor and 2z:l entered :n?() : :--,
L :i-?--ez.en:. . -.
?2y,~r 2nd ?PSI -;:sh t.z -3xecz:e s first amendment to
... 7 v ?@. . - L "y' t.",:s liq~?exect.
- . .a L.
::'-\~;/ - , .nur?~F~3~~, -..u-\-- ln .~.:~~~~eraf~on of :PA? recitals 2nd the .?,x
.-.51:rl.?.c_:,1r13 32 ths Farties 15: herein expressed, Payor ar,d P
3<qr..e 1s :ol:ows:
I i. FI~h~bic "C" 1s a~,er,ded by sunstrtuting the attached
rev~seci SxhrSrt "Z" dated 3uly 17, 1989.
> -I The effect;';^ date of this arnendxent is July 12, 1999.
All sther terns and conditi.3~~ of the PPO Agreement
shall remain 15 full for~ze and effect.
I9 T.7 7- R \VT
-..e ?.it? set forth belotr:
,,--LjdSs WHEREOF, the parties have executed this amenlcer. - -,
3?."?D: July 17, 1999
?.zyqr: City of C'arlsbad
12863 Elm Avenue
Carlsbad , Californ
PPO:
9555 Chesapeake Drive, Suite 203
San Diego, California 92123-0545
C'
0 0 EXHIBIT B
AHEND- To PPO AGREEMENT
This Amendment (llAmendmenttt) amends the San Diego Foundation f
Medical Care Preferred Provider Organization Agreement ("Agreement") by and between City of Carlsbad (hereinafter referred to as "PAYOR") and San Diego Foundation for Medical C (hereinafter referred to as lrPPo~t).
RECITALS
A. On January 1, 1986, PAYOR and PPO entered into the
B. PAYOR and PPO wish to execute an Amendment to modify the
Agreement.
Agreement.
NOW, THEREFORE, in consideration of the recitals and the mutuz obligations of the parties as herein expressed, PAYOR and PPO agree as follows:
1. the PPO's obligations for hospital utilization review.
2. Article 8.2 of the Agreement shall be deleted and replacl with a new Article 8.2 as set forth below:
"8.2 PPO ODtion. PAYOR shall pay, or cause to be paid,
The Agreement shall be amended to delete all reference 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 Amendme to be signed on their behalf by their duly authorized representatives at San Diego, California, on the
of , 1995.
PAYOR: PPO : CITY OF CARLSBAD SAN DIEGO FOUNDATION FOR
1200 Carlsbad Village Drive MEDICAL CARE
9555 Chesapeake Drive, #2C San Die 0, CA 92123
By: - ,mL--. -~-
Katherine P. Osborn
Title: Contra ct Man aaer