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HomeMy WebLinkAbout1995-05-16; City Council; 13148; APPROVAL OF AGREEMENT WITH NATIONAL UTILIZATION MANAGEMENT CORPORATION NUMCs * a 9 a, Dz 2 2 I- o 2 a i z 3 0 o CnTaF CARLSBAD - AGENaBILL ‘%%; a AB# I?; lYg TITLE: DEPT. MTG, 5-16-95 APPROVAL OF AGREEMENT WITH NATIONAL CITY A CITY N DEPT. HR RECOMMENDED ACTION: UTlUZATlON MANAGEMENT CORPORATION Adopt Resolution No. 5 5- \!-?-‘I approving agreement with National Utilization Management Corporation, or NUMC. ITEM EXPLANATION: Northwestern National Life insurance provides health insurance coverage for the majority of City employees. The San Diego Foundation for Medical Care (The Foundation) is the Preferred Provider Organization (PPO) associated with Northwestern National Life Insurance. When medical treatment is provided by a health care provider covered by The Foundation claims are paid at a higher percentage, thus lowering an employee’s out- of-pocket expenses. Alter-Net Medical Services, Inc. (AMS) was a subsidiary of The San Diego Foundation for Medical Care. One function of AMS was to perform utilization management services, which includes hospital pre-admission review, admission review, pre-certification, concurrent review, medical case management review and second surgical opinion. In June 1994, it was announced that Alter-Net Medical Services was beins acquired by USA Health Network. As a result, the Foundation’s utilization management program was incorporated into USA’s national utilization management review entity, National Utilization Management Corporation (NUMC). NUMC currently serves in excess of 200,000 employees and dependents. The Foundation for Medical Care has contracted with NUMC to serve as its utilization management entity. 0 a PAGE 2 OF AB# !gi 11.1% National Utilization Management Corporation (NUMC) will now be responsible for providing the utilization management services enjoyed by City of Carlsbad employees. Because of the new relationship between NUMC and The Foundation, the City of Carlsbad must contract directly wit1 NUMC for utilization management services. The attached Agreement outlines the provisions of the new arrangement between the City of Carlsbad and National Utilization Management Corporation, or NUMC. This agreement will take effect on June 1, 1995. The City’s contract with The Foundation for Medical Care has been amended to exclude fees paid for utilization management services as of June 1, 1995. This revised contract is attached. FISCAL IMPACT: The conversion from Alter-Net Medical Services to National Utilization Management corporation (NUMC) to provide utilization management services will have no fiscal impact during the term of this contract. All payments for utilization management services which were being made to The Foundation will, as of June 1, 1995, be made directly to NUMC. The current health benefit cost projections for employees with Northwestern National Life Insurance medical and dental coverage will not be affected by this change. EXHIBITS: 1. Resolution No. q 5- u? 2. Exhibit A: Contract with National Utilization Management corporation Exhibit B: Amendment to the PPO Agreement With the Foundation for Medical Care 3. 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 e 0 RESOLUTION NO. 95-127 A RESOLUTION OF THE CITY COUNCIL OF THE 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 thc 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 is incorporated in this resolution by reference. /I/ /I/ /I/ 1 2 3 4 5 6 7 0 9 10 11 12 13 14 15 16 17 18 :: 21 22 23 24 25 26 27 28 0 w 3. That the City Council of the City of Carlsbad, California will obtain utilization management services, effective June 1, 1995, from National Utilization Management Corporation, or NUMC and has revised its contract with The Foundation for Medical Care (Exhibit B: to exclude such services. PASSED, APPROVED, AND ADOPTED at a regular meeting of the Carlsbad City Council held on the 16th day of MAY 1995, by the following vote, to wit: 1 AYES: NOES: None Council Members Lewis, Nygaard, Kulchin, Finnila, Hall ABSENT: None 1 ATTEST: / &. x<&i . AUT KRANZ, City Clerk KAREN R. KUNDTZ, Assistant City Clerk (SEAL) LnuIuAI n 0 nnTionni mnnnGEmEnT UTlLIZRTlOll CORPORRTlOn AGREEMENT This Agreement, entered into this 1st day of June, 1995 by and between NATIONAL UTILIZATION MANAGEMENT CORPORATION, an Arizona corporation, (hereinafter called NUMC) and CITY OF CARLSBAD, (hereinafter called PARTICIPANT). WHEREAS, PARTICIPANT is an employer, insurance carrier, trust, union, employee organization, governn unit, third party administrator, or any other entity which insures or operates self-insured or self-funded 1 plan(s), health care indemnity coverage, various group health plan(s) or other programs for the provision of 1 care services. WHEREAS, PARTICIPANT wishes to engage NUMC to provide one or more of the Utilization Manage Services offered by NUMC in conjunction with the provision of health care services under said plans a policies NOW THEREFORE, in consideration of the mutual covenants contained herein and for good and val 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) entitied to receive services pursuant to PARTICIPA Benefit Plan Design. B. Utilization Management Services - System for reviewing the appropriate and efficient allocatic hospital resources and/or medical services given or proposed to be given to an Eligible Co\ Individual. C. Benefit Plan Design - A written program adopted by PARTICIPANT which specifies the health services which PARTICIPANT shall provide as a benefit to Eligible Covered Individuals and the t 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 Ex "A", Fee Schedule, which is attached to and made a part of this Agreement. Said services are out. in Section I1 B of this Agreement. In the conduct of Uhlization Management Services thereur NUMC shall review health conditions andlor medical procedures in accordance with the specifical and requirements of Participant's Benefit Plan Design or other programs for the provision of health services. CITYCARI. 1 4112 mp G contracVreviscdnumc e 0 B. NUMC DUTIES AND 03LIGATIONS 1. NUMC shall perform medical surgical, and psychiatric: Pre-admission Revien Admission Review Concurrent Review Mcdical Case Management Review Second Surgical Opinion Optional Services Available on Per Case Basis PRE-CERTIFICATION Large Case Management Facility Fee Negotiation for Catastrophic Cases 2. All services performed shall be in accordance with the rules and regulations as proscribed by t 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 noms medical and vocational rehabilitation, medical need, and fees; and, in the conduct of Utilizati Review, and Large Case Management, shall consult with the Eligible Covered Individur attending physician and other health care providers as appropriate. NUMC shall employ or engage, independent contractors as appropriate; licensed. board eligible certified physicians, psychologists and counselors with graduate degrees in their specialties, nur! and mental health workers licensed in their fields to perform reviews. 4. 5. All NUMC services are informational and advisory in nature and will be rendered PARTICIPANT by NUMC acting as an independent contractor. NUMC shall have no authority responsibility to bind PARTICIPANT to any of NUMC's assessments, recommcndatioi determinations, analyses, findings or certifications and PARTICIPANT reserves the right to i based upon PARTICIPANT'S judgment with respect to any and all claims or issues review thcrciindcr. Nothing contained herein shall be construed to interfere with the physician-patient relationsh All parties agree that NUMC has not been retained to diagnose or treat PARTICIPANT'S Eligit Covered Individuals. The decision to provide treatment that has not been certified remains with t attending physician and the PARTICIPANT'S Eligible Covered Individuals. The decision to 1 for such treatment remains with the PARTICIPANT. 6. 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 modificatic 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. ClTYCARL 2 41129 mp G contnctirewcdlnumc 0 III. COMPENSATION AND BILLING A. NUMC shall be compensated for all services provided under this Agreement in accordance with Exhi "A", Fee Schedule(s) attached hereto and made a part hereof subjcct to the terms and conditions forth therein. B, PARTICIPANT agrees to remit fees due NUMC within ten (10) d~ys of receipt of month end billi 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 Agreement and on each subsequc anniversary date thereafter, to modlfy the service fees listed in Exhibit "A", Fee Schedule. NUMC sh provide PARTICIPANT thirty (30) days prior written notice of its intent to increase service fees. 7 fee modification notice shall remain in effect until further modification, if any. Upon PARTICIPANT'S receipt of such modification notice, PARTICIPANT may reject SL modification by giving NUMC ten (10) days written notice. PARTICIPANT'S fee modificati rejection notice shall operate to immediately terminate this Agreement unless there is mutual writ1 consent to continue. D. NUMC shall rely exclusively on information provided by the PARTICIPANT relative to the tc number of Eligble Covered Individuals in PARTICIPANT'S group when calculating charges services based on capitated rates. It is mutually understood that accuracy in billing requires that NU be advised on a monthly basis of any changes in the number of Eligible Covered Individuals and tha 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 is 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 (0 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 (sir days prior written notice of intent to terminate. C. In the event of a material breach, the non-breaching party may terminate this Agreement ut providing thirty (30) days prior written notice to the breaching party. The party claiming the righ terminate thereunder shall set forth in the notice the facts underlying the claim that the other party i breach of this Agreement. If said breach is remedied within twenty (20) days of receipt of said not this Agreement shall continue in effect for the remainder of the term. Material breach includes, bL not limited to, a failure by either party to perform in whoie 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 for such completed services, accordance with the then applicable fee schedule(s). In any event, PARTICIPANT will be liable fot services provided to PARTICIPANT up to the date of termination of this Agreement whether or complete. CITYCARL 3 dl21 mp G contractrrcmcdnumc e V. GENERAL PROVI: .IONS A. LIABILITY INSURANCE The parties, at their sole cost and expense, shall procure and maintain such policies of general liabili professional liability, and other insurance as may be necessary to insure each party and its officers, a employees againft any liability or claims or damages arising by reason of negligent or willful acts omissions by said party, its officers, and employees in the performance of responsibilities under t Agreement or for personal injuries or death, occasioned directly or indirectly by such party or oficers, or employees in connection with their performance of the party's responsibilities under t 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, claim expense of any kind which result from negligent or willful acts or omissions of PARTICIPANT its employees regarding the duties and obligations uf PARTICIPANTunder this Agreement. 2. NUMC agrees to indemnify PARTICIPANT from any and all liability, loss, damage, claim expense of any kind which result from negligent or willful acts or omissions of NUMC or employees regarding the duties and obligations of MMC under this Agreement. Except as provided above, each party hereto shall be responsible at its own expense for defend itself in any litigation brought against it arising out of any activities engaged in connection v this Agreement whether or not the other party hereto is a party to a lawsuit. Each party agree: provide to the other party information in its possession which is essential to the other par defense in such litigation. 4. NUMC shall not be liable directly or indirectly for the negligence or willful acts or omissions any independent contractor utilized to provide services covered by this Agreement or Addendum. C. ASSIGNMENT 3. PARTICIPANT may not assign any of its rights or delegate any of its duties thereunder without prior written consent of NLMC. D. NOTICES Any notice to be given hereunder shall be in writing and shall be delivered personally, or shall deemed delivered if dispatched by certified or registered United States mail, postage prepaid, ret 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 CITYCARL 4 'WIU' rnp G contractlrewscdinumc a 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. 2. RESOLUTION OF DISPUTES All disputes and differences arising between NUMC or an independent contractor engaged by NUM and the PARTICIPANT upon which an amicable understanding cannot be reached, are to be decided the following method: 1. Mediation The PARTICPANT T PARTICIPANT shall supply NUMC with all pertinent information and state its position on t dispute. Upon receipt of this information "MC will immediately contact the independc contractor and require the same information. NUMC will then attempt to mediate the dispute the mutual satisfaction of all parties. If mediation is not possible within a reasonable time, not exceed thirty (30) days from the time of first notice, the following procedure will apply: shall notify NUMC in writing of the dispute or disagreement. 2. Arbitration If the dispute cannot be solved by the mediation process described above, the PARTICIPANT rr elect to submit the dispute to arbitration under the rules of the American Arbitration Association any other method of Arbitration mutually agreed upon by the parties. F. ENFORCEABILITY AND WAIVER The invalidity and non-enforceability of any term or provision of this Agreement shall in no way afi the validity or enforceability of any other term or provision. The waiver by either party of a breach any provision of this Agreement shall not operate as or be construed as a waiver of any subsequl breach thereof. G. ACCESS TO INFORMATION; OBTAINING AUTHORIZATIONS 1. PARTICIPANT shall grant NUMC access to all pertinent documents and information, includi medical and personal data within PARTICIPANT'S authority and control pertaining to the subj Eligible Covered Individual, general statistical or summary data, and coverage descriptions a benefit plan documents reasonably required by NUMC pursuant to its performance of the reques service. PARTICIPANT will reasonably assist NUMC in obtaining from the Eligible Cove 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. NUMC shall have no obligation to provide services thereunder with respect to any Eligible Cove Individual in the event that such authorizations or releases are not obtained from said Eligi Covered Individual. 5 4/12/' CITYCARL mp G contracvrcwsedlnumc 0 H. CONFIDENTIALITY; OWNERS :IIP 1. NUMC shall own all data, documents and software generated by it in the performance of sen under this Agreement; shall have the right to retain copies of any documents providcc PARTICIPANT; and, subject to the confidentiality constraints hereinafter specified, shall havc further right to use any data and documents provided by PARTICIPANT in the general course ( business. information in NUMC's possession as may be reasonably necessary to assure the continuif PARTICIPANT'S administration of specific claims. PARTICIPANT and NUh4C acknowledge that the medical, financial and personal inform: collected and reviewed in connection with the subject services and the reports produced pursua those services may be confidential to the covered individual and therefore shall be used republished only in connection with the administration of benefits and PARTICIPANT'S BE Plan Design, policy or program for the provision of health care services, and will not be othei released, disclosed or published by PARTICIPANT or by NUMC except as permitted under Agreement or required by law. Upon termination of this Agreement, PARTICIPANT shall be entitled to 2. I. ENTIRE AGREEMENT This Agreement together with all addenda and attachments contains all the terms and conditions at upon by the parties and supersedes all other Agreements, expressed or implied, regarding the su matter and supersedes any prior oral understandings PARTICIPANT may have had with respe NUMC services. J. AMENDMENTS Any amendments to this Agreement must be in writing and executed by NUMC and PARTICIPAN K. INDEPENDENT CONTRACTOR NUMC and PARTICIPANT are independent legal entities. Nothing in this Agreement sha construed or be deemed to create a relationship of employer and employee, principal and a 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 in Agreement. L. NOTICE Until otherwise specified, all notices and communications required thereunder will be sei PARTICIPANT and NUMC at the addresses shown in Section "D". CITYCARL 6 4, mp.G.cot~tracWrcvlse~ni~c w W M. INTERPRE I'ATION This Agreement and all questions relating to its validity, interpretation shall be governed by Califor law; performdnce and enforcement, shall be governed by and construed in accordance with the law! the state of California IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the 1st day of June, 1995. For and on behalf of: NATIONAL UTILIZATION MANAGEMENT 7301 North 16th Street, Suite 203 Phoenix, Arizona 85020 For and on behalf of: CITY OF CARLSBAD Claude A. Lewis Printed Name ' Printed Name Mayor Title 2. /d Title ClTYCARL 7 4/12, mp G conmcVrcvLscdIniunc e 0 EXHIBIT A CITY OF CARLSEa SET UP FEES: $0 per primary insured. One time fee. No additional fee charged for members added or deleted. BASIS OF PRICING: "Per Capita": $1.25 per primary insured Der month. NUMC SHALL PERFORM THE UTILIZATION MANAGEMENT SERVICES AS LISTED BELOW: Pre-admission Review Admission Review Pre-Certification Concurrent Review Medical Case Management Review Second Surgical Opinion SPECIALTY SERVICES Large Case Management (exclusive of travel & expenses) $100.00 per hour REPORTS PROVIDED BY NUMC: Notification of Pre-certification, Concurrent Review High Dollar Warning - Case by Case and Weekly or Monthly Summaries Re-admission Reports - Monthly Admission Summary - Monthly Utilization Report - Monthly, Quarterly, Annually Executive Summary - Monthly, Quarterly, Annually CARRIER PROVIDES: Insured eligibility list, prior to twentyfifth day of each month Completed Questionnaire Benefit Plan Design CKYCARL 8 UIU9 mp G contract/revuednumc -*---&I-- I W AMI3NDMENT TO PPO AGREEMENT This Amendment (llAmendmenttl) amends the San Diego Foundation for Medical Care Preferred Provider Organization Agreement (ttAgreementtl) by and between City of Carlsbad (hereinafter referred to as IIPAYORgl) and San Diego Foundation for Medical Can (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 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: Agreement. “8.2 PPO Option. PAYOR shall pay, or cause to be paid, to 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 da1 of , 1995. PAYOR: PPO : CITY OF CARLSBAD SAN DIEGO FOUNDATION FOR 1200 Carlsbad Village Drive MEDICAL CARE 9555 Chesapeake Drive, #203 San Diegg, CA 92123 By: \ mk-- - - -_ & Katherine P. Osborn Title: Contract Manaqer