FQHC AGREEMENT FINAL.PDF

FQHC Participation Agreement
This Agreement is entered into by and between UnitedHealthcare Insurance Company, contracting on
behalf of itself Arizona Physicians IPA, Inc., and the other entities that are United's Affiliates
(collectively referred to as "United") and Maricopa County, D.B.A. Maricopa County Department of
Public Health, D.B.A. Public Health Clinical Services ("Facility").
This Agreement is effective on the later of the following dates (the "Effective Date"):
i)
Through contracts with physicians and other providers of health care services, United maintains one or
more networks of providers that are available to Customers. Facility is a provider of health care services.
United wishes to arrange to make Facility's services available to Customers. Facility wishes to provide
those services, under the terms and conditions set forth in this Agreement.
The parties therefore enter into this Agreement.
Article I.
Definitions
The following terms when used in this Agreement have the meanings set forth below:
1.1 Benefit Plan means a certificate of coverage, summary plan description, or other document or
agreement, whether delivered in paper or electronic format, under which a Payer is obligated to
provide coverage of Covered Services for a Customer.
1.2 Covered Service is a health care service or product for which a Customer is entitled to receive
coverage from a Payer, pursuant to the terms of the Customer's Benefit Plan with that Payer.
1.3 Customary Charge is the fee for health care services charged by Facility that does not exceed
the fee Facility would ordinarily charge another person regardless of whether the person is a
Customer.
1.4 Customer is a person eligible and enrolled to receive coverage from a Payer for Covered
Services.
1.5 Facility Physician is a Doctor of Medicine ("M.D."), or a Doctor of Osteopathy ("D.O."), duly
licensed and qualified under the laws of the jurisdiction in which Covered Services are provided,
who practices as a shareholder, partner, or employee of Facility, or who practices as a
subcontractor of Facility. However, a subcontractor of Facility is a Facility Physician only with
regard to services rendered to patients of Facility and billed under Facility's Taxpayer
Identification Number. Additionally, a subcontractor is not a Facility Physician with regard to
any services rendered in a location other than those listed in Appendix I.
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1.6 Facility Non-Physician Provider is a surgical assistant, physician assistant, nurse practitioner,
physical therapist, occupational therapist, speech therapist, mental health provider, or licensed
social worker, who is duly authorized under the laws of the jurisdiction in which Covered
Services are provided, and who renders Covered Services as an employee or subcontractor of
Facility. However, a subcontractor of Facility is a Facility Non-Physician Provider only with
regard to services rendered to patients of Facility and billed under Facility's Taxpayer
Identification Number. Additionally, a subcontractor is not a Facility Non-Physician Provider
with regard to any services rendered in a location other than those listed in Appendix 1.
1.7 Facility Professional is a Facility Physician or a Facility Non-Physician Provider.
1.8 Payment Policies are the guidelines adopted by United for calculating payment of claims to
facilities (including claims of Facility under this Agreement). The Payment Policies operate in
conjunction with the specific reimbursement rates and terms set forth in this Agreement. The
Payment Policies may change from time to time as discussed in section 5.1 of this Agreement.
1.9 Payer is an entity obligated to a Customer to provide reimbursement for Covered Services under
the Customer's Benefit Plan, and authorized by United to access Facility's services under this
Agreement.
1.10 Protocols are the programs and administrative procedures adopted by United or a Payer to be
followed by Facility in providing services and doing business with United and Payers under this
Agreement. These Protocols may include, among other things, credentialing and recredentialing
processes, utilization management and care management processes, quality improvement, peer
review, Customer grievance, or concurrent review. The Protocols may change from time to time
as discussed in section 4.4 of this Agreement.
1.11 United's Affiliates are those entities controlling, controlled by, or under common control with
UnitedHealtheare Insurance Company.
Article IL
Representations and Warranties
2.1 Representations and warranties of Facility. Facility, by virtue of its execution and delivery of
this Agreement, represents and warrants as follows:
i) Facility is a duly organized and validly existing legal entity in good standing under the
laws of its jurisdiction of organization.
ii) Facility has all requisite corporate power and authority to conduct its business as
presently conducted, and to execute, deliver and perform its obligations under this
Agreement. The execution, delivery and performance of this Agreement by Facility have
been duly and validly authorized by all action necessary under its organizational
documents and applicable corporate law. This Agreement has been duly and validly
executed and delivered by Facility and (assuming the due authorization, execution and
delivery of this Agreement by United) constitutes a valid and binding obligation of
Facility, enforceable against Facility in accordance with its terms, except as
enforceability may be limited by the availability of equitable remedies or defenses and by
applicable bankruptcy, insolvency, reorganization, moratorium or similar laws affecting
the enforcement of creditors' rights generally.
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iii) The execution, delivery and performance of this Agreement by Facility do not and will
not violate or conflict with (a) the organizational documents of Facility, (b) any material
agreement or instrument to which Facility is a party or by which Facility or any material
part of its property is bound, or (c) applicable law. Facility has the unqualified authority
to bind, and does bind, itself and Facility Professionals to all of the terms and conditions
of this Agreement, including any Appendices, Attachments and Exhibits, as applicable.
iv) Facility has obtained and holds all registrations, permits, licenses, and other approvals
and consents, and has made all filings, that it is required to obtain from or make with all
governmental entities under applicable law in order to conduct its business as presently
conducted and to enter into and perform its obligations under this Agreement.
v) Facility has been given an opportunity to review the Protocols and Payment Policies. See
the Administrative Manual Appendix for additional information regarding the Protocols
and Payment Policies applicable to Customers.
vi) Each submission of a claim by Facility pursuant to this Agreement constitutes the
representation and warranty by it to United that (a) it has complied with the requirements
of this Agreement with respect to the Covered Services involved and the submission of
the claim, (b) the charge amount set forth on the claim is the Customary Charge and (c)
the claim is a valid claim.
2.2 Representations and warranties of United. United, by virtue of its execution and delivery of
this Agreement, represents and warrants as follows:
i) United is a duly organized and validly existing legal entity in good standing under the
laws of its jurisdiction of organization.
ii) United has all requisite corporate power and authority to conduct its business as presently
conducted, and to execute, deliver and perform its obligations under this Agreement. The
execution, delivery and performance of this Agreement by United have been duly and
validly authorized by all action necessary under its organizational documents and
applicable corporate law. This Agreement has been duly and validly executed and
delivered by United and (assuming the due authorization, execution and delivery of this
Agreement by Facility) constitutes a valid and binding obligation of United, enforceable
against United in accordance with its terms, except as enforceability may be limited by
the availability of equitable remedies or defenses and by applicable bankruptcy,
insolvency, reorganization, moratorium or similar laws affecting the enforcement of
creditors' rights generally.
iii) The execution, delivery and performance of this Agreement by United do not and will not
violate or conflict with (a) the organizational documents of United, (b) any material
agreement or instrument to which United is a party or by which United or any material
part of its property is bound, or (c) applicable law.
iv) United has obtained and holds all registrations, permits, licenses, and other approvals and
consents, and has made all filings, that it is required to obtain from or make with all
governmental entities under applicable law in order to conduct its business as presently
conducted and to enter into and perform its obligations under this Agreement.
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Article III.
Applicability of this Agreement
3.1 Facility's services.
i) This Agreement applies to Covered Services provided at Facility's service locations set
forth in Appendix 1. In the event Facility begins providing services at other service
locations or under other Taxpayer Identification Number(s), those additional Taxpayer
Identification Numbers or locations will become subject to this Agreement only upon the
written agreement of the parties. This subsection 3.1(i) applies to cases when Facility
adds the location itself (such as through new construction or through conversion of a free-
standing location to provider-based), and when Facility acquires, merges or comes under
common ownership with an existing provider that was not already under contract with
United or one of United's Affiliates to participate in a network of health care providers).
ii) In the event Facility acquires or is acquired by, merges with, or otherwise becomes
affiliated with another provider of health care services that is already under contract with
United or one of United's Affiliates to participate in a network of health care providers,
this Agreement and the other agreement will each remain in effect and will continue to
apply as they did prior to the acquisition, merger or affiliation, unless otherwise agreed to
in writing by all parties to the agreements. Similarly, if Facility buys assets of, or leases
space from, a facility that was under contract directly with United or one of United's
Affiliates to participate in a network of health care providers at the time of the asset
purchase or leasing arrangement, and Facility operates a new facility at that location but
does not assume the United contract held by the prior operator, the new facility will
participate in United's network on the same rates and other key terms (including term and
termination) as applied under the prior operator's contract.
iii) Facility may transfer all or some of its assets to another entity, with the result that all or
some of the Covered Services subject to this Agreement will be rendered by the other
entity rather than by Facility, but only if Facility requests that United approve the
assignment of this Agreement as it relates to those Covered Services and only if the other
entity agrees to assume this Agreement. This subsection 3.1(iii) does not limit United's
right under section 9.4 of this Agreement to elect whether to approve the assignment of
this Agreement. This subsection 3.1(iii) applies to arrangements under which another
provider leases space from Facility, or enters into a subcontract with Facility to perform
facility services, after the Effective Date of this Agreement, so that Covered Services that
were subject to this Agreement as of the Effective Date of this Agreement are rendered
and billed instead by the other provider rather than by Facility after the lease or
subcontract takes place.
3.2 Payers and Benefit Plans. United may allow Payers to access Facility's services under this
Agreement for certain Benefit Plans, as described in Appendix 2. Appendix 2 may be modified
by United upon 30 days written or electronic notice.
Section 8.3 of this Agreement will apply with respect to Customers enrolled in Benefit Plan
type(s) that are moved from Appendix 2, section 1 to Appendix 2, section 2.
3.3 Patients who are not Customers. This Agreement does not apply to services rendered to
patients who are not Customers at the time the services were rendered. Section 6.6 of this
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Agreement addresses circumstances in which claims for services rendered to those patients are
inadvertently paid.
3.4 Health care. This Agreement and Customer Benefit Plans do not dictate the health care provided
by Facility or Facility Professionals, or govern Facility's or Facility Professional's determination
of what care to provide its patients, even if those patients are Customers. The decision regarding
what care is to be provided remains with Facility Professionals and with Customers, and not with
United or any Payer.
3.5 Communication with Customers. Nothing in this Agreement is intended to limit Facility's or
Facility Professional's right or ability to communicate fully with a Customer regarding the
Customer's health condition and treatment options. Facility and Facility Professionals are free to
discuss all treatment options without regard to whether or not a given option is a Covered
Service. Facility and Facility Professionals are free to discuss with a Customer any financial
incentives Facility may have under this Agreement, including describing at a general level the
payment methodologies contained in this Agreement.
3.6 Services rendered by Facility Professionals. The following provisions of this Agreement do
not apply to services rendered by Facility Professionals .
i) if United does not credential Facility Professionals: the credentialing requirements in
section 4.1; and the credentialing and recredentialing processes as set forth in the
Protocols; and
ii) if Facility Professionals do not have hospital admitting privileges: sections 4.4(ii)(e) and
4. 8(u).
Article IV.
Duties of Facility
4.1 Provide Covered Services. Facility will provide Covered Services to Customers. Facility must
be in compliance with section 2.1(iv) of this Agreement and, to the extent Facility is subject to
credentialing by United, Facility must be credentialed by United or its delegate prior to furnishing
any Covered Services to Customers under this Agreement.
Facility and Facility Physicians will participate in and cooperate with United's credentialing
program. Facility Non-Physician Providers will participate in and cooperate with United's
credentialing program to the extent those Facility Non-Physician Providers are subject to
credentialing by United.
4.2 Nondiscrimination. Facility will not discriminate against any patient, with regard to quality of
service or accessibility of services, on the basis that the patient is a Customer.
Facility will not require a Customer to pay a "membership fee" or other fee in order to access
Facility for Covered Services (except for co-payments, coinsurance and/or deductibles provided
for under Customer's Benefit Plan) and will not discriminate against any Customer based on the
failure to pay such a fee.
4.3 Accessibility. Facility will provide or arrange for the provision of advice and assistance to
Customers in emergency situations 24 hours a day, seven days a week.
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4.4 Cooperation with Protocols. Facility will cooperate with and be bound by United's and Payers'
Protocols. The Protocols include but are not limited to all of the following:
i) For non-emergency Covered Services, Facility will assist Customers to maximize their
benefits by referring or directing Customers only to other providers that participate in
United's network, except as authorized by United through United's process for approving
out-of-network services for in-network benefits.
ii) If the Customer's Benefit Plan requires the Customer to receive certain Covered Services
from or upon referral by a primary care physician, all referral physicians must adhere to the
following additional protocols when those Covered Services are provided:
a. Notify Customer's primary care physician of referrals to other participating or non-
participating providers.
b. Covered Services must be provided pursuant to the terms and limitations of the
referral notification issued by or on behalf of the Customer's primary care physician.
c. If the Facility Physician providing the Covered Services is a referral physician, the
Facility Physician must also notify the Customer's primary care physician of all
admissions in accordance with the required time frames.
iii) As further described in the Protocols, Facility will provide notification and participate in
utilization management programs regarding certain Covered Services, accept and return
telephone calls from United staff, and respond to United requests for clinical information as
required by United or Payer.
The Protocols will be made available to Facility online or upon request. Some or all
Protocols also may be disseminated in the form of an administrative manual or guide or in
other communications. Currently, the Protocols may be found at
www.uhccommunityplan.com . United will notify Facility of any changes in the location of
the Protocols.
United may change the Protocols from time to time. United will use reasonable commercial
efforts to inform Facility at least 30 days in advance of any material changes to the Protocols.
United may implement changes in the Protocols without Facility's consent if the change is
applicable to all or substantially all of the facilities in United's network located in the same state
as Facility. Otherwise, changes to the Protocols proposed by United to be applicable to Facility
are subject to the terms of section 9.2 of this Agreement applicable to amendments.
4.5 Employees and subcontractors. Facility will assure that its employees, affiliates and any
individuals or entities subcontracted by Facility to render services in connection with this
Agreement adhere to the requirements of this Agreement. The use of employees, affiliates or
subcontractors to render services in connection with this Agreement will not limit Facility's
obligations and accountability under this Agreement with regard to these services. Facility
affiliates are those entities that control, are controlled by or are under common control with
Facility.
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4.6 Licensure. Facility will maintain, without material restriction, such licensure, registration, and
permits as are necessary to enable Facility to lawfully perform this Agreement.
4.7 Liability insurance. Facility will procure and maintain liability insurance. Except to the extent
coverage is a state mandated placement, Facility's coverage must be placed with responsible,
financially sound insurance carriers authorized or approved to write coverage in the state in which
the Covered Services are provided. Facility's liability insurance must be, at a minimum, of the
types and in the amounts set forth below. Facility's medical malpractice insurance must be either
occurrence or claims made with an extended period reporting option. Prior to the Effective Date
of this Agreement and within 10 days of each policy renewal thereafter, Facility will submit to
United in writing evidence of insurance coverage.
TYPE OF INSURANCE MINIMUM LIMITS
Medical malpractice and/or professional Three Million Dollars ($3,000,000.00) per
liability insurance occurrence and Five Million Dollars
($5,000,000.00) in aggregate, if Facility insures
all Facility Professionals in a single policy. This
insurance requirement will also be satisfied if
the Facility insures each Facility Professional
separately, and the coverage for each Facility
Professional is at least One Million Dollars
($1,000,000.00) per occurrence and Three
Million Dollars ($3,000,000.00) in aggregate.
Commercial general and/or umbrella One Million Dollars ($1,000,000.00) per
liability insurance occurrence and aggregate.
In lieu of purchasing the insurance coverage required in this section, Facility may, with the prior
written approval of United, self-insure its medical malpractice and/or professional liability, as
well as its commercial general liability. Facility will maintain a separate reserve for its self-
insurance. Prior to the Effective Date, Facility will provide a statement, verified by an
independent auditor or actuary, that its reserve funding levels and process of funding appears
adequate to meet the requirements of this section and fairly represents the financial condition of
the fund. Facility will provide a similar statement during the term of this Agreement upon
United's request, which will be made no more frequently than annually. Facility will assure that
its self-insurance fund will comply with applicable laws and regulations.
4.8 Notice by Facility. Facility will give notice to United within 10 days after any event that causes
Facility to be out of compliance with section 4.6 or 4.7 of this Agreement, or of any change in
Facility's name, ownership, control, or Taxpayer Identification Number. This section does not
apply to changes of ownership or control that result in Facility being owned or controlled by an
entity with which it was already affiliated prior to the change.
In addition, Facility will give written notice to United within 10 days after it learns of any of the
following:
i) any suspension, revocation, condition, limitation, qualification or other material
restriction on a Facility Professional's licenses, certifications and permits by any
government agency under which a Facility Professional is authorized to provide health
care services;
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II) any suspension, revocation, condition, limitation, qualification or other material
restriction of a Facility Physician's staff privileges at any licensed hospital, nursing home
or other facility at which a Facility Physician has staff privileges during the term of this
Agreement;
iii) indictment, arrest or conviction of a Facility Professional for a felony, or for any criminal
charge related to the practice of the Facility Professional's profession;
iv) the departure of any Facility Professional from Facility; or
v) any changes to the information contained in Appendix 1.
4.9 Customer consent to release of medical record information. Facility will obtain any Customer
consent required in order to authorize Facility to provide access to requested information or
records as contemplated in section 4.10 of this Agreement, including copies of the Facility's
medical records relating to the care provided to Customer.
4.10 Maintenance of and access to records. Facility will maintain reasonable medical, financial and
administrative records related to Covered Services rendered by Facility under this Agreement,
including claims records, for at least 6 years following the end of the calendar year during which
the Covered Services are provided, unless a longer retention period is required by applicable law.
Facility will provide access to these records as follows:
i) to United or its designees, in connection with United's utilization management, quality
assurance and improvement and for claims payment, health care operations and other
administrative obligations, including reviewing Facility's compliance with the terms and
provisions of this Agreement and appropriate billing practice. Facility will provide
access during ordinary business hours within fourteen days after a request is made, except
in cases of a United billing audit involving an allegation of fraud or abuse or the health
and safety of a Customer (in which case, access must be given within 48 hours after the
request) or of an expedited Customer appeal or grievance (in which case, access will he
given so as to enable United to reasonably meet the timelines for determining the appeal
or grievance). If records are requested to adjudicate a claim, Facility will provide copies
of the requested records within fourteen days after the request is made; and
ii) to agencies of the government, in accordance with applicable law, to the extent that
access is necessary to comply with regulatory requirements applicable to Facility, United,
or Payers.
Facility will cooperate with United on a timely basis in connection with any such audit including,
among other things, in the scheduling of and participation in an audit exit interview within 30
days of United's request.
If such information and records are requested by United, Facility will provide copies of the
records free of charge.
4.11 Access to data. Facility represents that in conducting its operations, it collects and reviews
certain quality data relating to care rendered by Facility that is reported in a manner which has
been validated by a third party as having a clear, evidence-based link to quality or safety (e.g.,
AHRQ standards) or which has been created by employer coalitions as proxies for quality (e.g.,
Leapfrog standards).
United recognizes that Facility has the sole discretion to select the metrics which it will track
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from time to time and that Facility's primary goal in so tracking is to advance the quality of
patient care. If the information that Facility chooses to report on is available in the public domain
in a format that includes all data elements required by United, United will obtain quality
information directly from the source to which Facility reported. If the Facility does not report
metrics in the public domain, on a quarterly basis, Facility will share these metrics with United as
tracked against a database of all commercial patients (including patients who are not United
customers). United may publish this data to entities to which United renders services or seeks to
render services, and to Customers.
4.12 Compliance with law. Facility will comply with applicable regulatory requirements, including
but not limited to those relating to confidentiality of Customer medical information.
9.13 Electronic connectivity. When made available by United, Facility will do business with United
electronically. Facility will use www.uhccommunityplan.com to check eligibility status, claims
status, and submit requests for claims adjustment for products supported by UnitedHealthcare
Online® or other online resources as supported for additional products. Facility will use
www.uhcommunityplan.coin for additional functionalities (for instance, notification of
admission) after United informs Facility that these functionalities have become available for the
applicable Customer.
4.14 New Facility Professionals. This section 4.14 applies when United credentials the Facility
Professionals individually.
Facility will notify United at least 30 days before a physician or practitioner becomes a Facility
Professional. In the event that the Facility's agreement with the new Facility Professional
provides for a starting date that would make it impossible for Facility to provide 30 days advance
notice to United, then Facility will give notice to United within five business days after reaching
agreement with the new Facility Professional. In either case, the new Facility Professional will
submit and complete a credentialing application to United within 30 days of the new Facility
Professional's agreement to join Facility, unless the new Facility Physician already has been
credentialed by United and is already a participant in United's network.
4.15 Termination of a Facility Professional from United's network. United may terminate a
Facility Professional's participation in United's network, without terminating this Agreement,
immediately upon becoming aware of any of the following:
i) material breach of this Agreement that is not cured by Facility Professional within 30
days after United provided notice to Facility of the breach;
ii) the suspension, revocation, condition, limitation, qualification or other material
restriction on a Facility Professional's licenses, certifications and permits by any
government agency under which the Facility Professional is authorized to provide health
care services;
iii) the suspension, revocation, condition, limitation, qualification or other material
restriction of a Facility Professional's staff privileges at any licensed hospital, nursing
home or other facility at which the Facility Professional has staff privileges during the
term of this Agreement;
iv) an indictment, arrest or conviction for a felony, or for any criminal charge related to the
practice of Facility Professional's profession;
v) a sanction imposed by any governmental agency or authority, including Medicare or
Medicaid; or
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vi) pursuant to United's Credentialing Plan.
United will notify Facility of the Facility Professional's termination according to the notice
provision set forth in section 9.8 of this Agreement.
4.16 Covered Services by Facility Professionals who are not Participating Providers. Facility will
staff its service locations so that Covered Services can appropriately be rendered to Customers by
Facility Professionals who participate in United's network. A Facility Professional who does not
participate in United's network will not render Covered Services to a Customer.
In the event Covered Services are rendered by a Facility Professional who does not participate in
United's network, Facility and the Facility Professional will not submit a claim or other request
for payment to United or Payer, and will not seek or accept payment from the Customer.
Article V.
Duties of United and Payers
5.1 Payment of claims. As described in further detail in Article VI of this Agreement, Payers will
pay Facility for rendering Covered Services to Customers. United will make its Payment Policies
available to Facility online or upon request. United may change its Payment Policies from time
to time. United's Payment Policies will be broadly applicable rather than targeted specifically to
Facility.
5.2 Liability insurance. United will procure and maintain professional and general liability
insurance, as United reasonably determines may be necessary, to protect United and United's
employees against claims, liabilities, damages or judgments that arise out of services provided by
United or United's employees under this Agreement.
5.3 Licensure. United will maintain, without material restriction, such licensure, registration, and
permits as are necessary to enable United to lawfully perform this Agreement.
5.4 Notice by United. United will give written notice to Facility within 10 days after any event that
causes United to be out of compliance with section 5.2 or 5.3 of this Agreement, or of any change
in United's name, ownership, control, or Taxpayer Identification Number. This section does not
apply to changes of ownership or control that result in United being owned or controlled by an
entity with which it was already affiliated prior to the change.
5.5 Compliance with law. United will comply with applicable regulatory requirements, including
but not limited to those relating to confidentiality of Customer medical information and those
relating to prompt payment of claims, to the extent those requirements are applicable.
5.6 Electronic connectivity. United will do business with Facility electronically by providing
eligibility status, claims status, and accepting requests for claim adjustments, for those Benefit
Plans supported by www.uhecommunityplan.com . United will communicate enhancements in
www.uhccommunityplan.com functionality as they become available, as described in section 4.13
of this Agreement, and will make information available as to which Benefit Plans are supported
by www.uhccommunityplan.com .
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5.7 Employees and subcontractors. United will assure that its employees, affiliates and any
individuals or entities subcontracted by United to render services in connection with this
Agreement adhere to the requirements of this Agreement. The use of employees, affiliates or
subcontractors to render services in connection with this Agreement will not limit United's
obligations and accountability under this Agreement with regard to those services.
Article VI.
Submission, Processing, and Payment of Claims
6.1 Form and content of claims. Facility must submit claims for Covered Services in a manner and
format prescribed by United, as further described in the Protocols. Unless otherwise directed by
United, Facility will submit claims using current UB04 or CMS 1500, as applicable, or successor
forms for paper claims and HIPAA standard professional or institutional claim formats for
electronic claims, as applicable, with current, correct and applicable coding including, but not
limited to, ICD-9-CM, CPT, Revenue and HCPCS coding or any of their successors.
6.2 Electronic filing of claims. Within six months after the Effective Date of this Agreement,
Facility will use electronic submission for all of its claims under this Agreement that United is
able to accept electronically.
6.3 Time to file claims. Unless a longer tirneframe is required under applicable law, all i -nformation
necessary to process a claim must be received by United no more than 90 days from the date
Covered Services are rendered. If Payer is not the primary payer, and Facility is pursuing
payment from the primary payer, the timely filing limit will begin on the date Facility receives
the claim response from the primary payer.
In the event United requests additional information in order to process a claim, Facility will
provide that additional information within 45 days of United's request.
6.4 Payment of Claims. Payer will pay claims for Covered Services according to the lesser of
Facility's Customary Charge or the amount specified in the applicable Payment Appendix to this
Agreement, and in accordance with Payment Policies.
Claims for Covered Services subject to coordination of benefits will be paid in accordance with
the Customer's Benefit Plan and applicable state and federal law.
The obligation for payment under this Agreement is solely that of Payer, and not that of United
unless United is the Payer.
Ordinarily, fee amounts listed in the Payment Appendix(ices) are based upon primary fee sources.
United reserves the right to use gap-fill fee sources where primary fee sources are not available.
United routinely updates its fee schedule in response to additions, deletions, and changes to CPT
codes by the American Medical Association, price changes for immunizations and injectable
medications, and in response to similar changes (additions and revisions) to other service coding
and reporting conventions that are widely used in the health care industry, such as those
maintained by the Centers for Medicare and Medicaid Services (for example HCPCS, etc.).
Ordinarily, United's fee schedule is updated using similar methodologies for similar services.
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United will not generally attempt to communicate routine maintenance of this nature and will
generally implement updates within 90 days from the date of publication.
6.5 Denial of claims for not following Protocols, for not filing timely, for Services not Covered
under the Customer's Benefit Plan, or for lack of medical necessity.
i) Non-compliance with Protocol. Payment may be denied in whole or in part if Facility
does not comply with a Protocol or does not file a timely claim as required under section
6.3 of this Agreement.
In the event payment is denied under this subsection 6.5(i) for Facility's failure to file a
timely claim or to comply with a Protocol regarding notification or regarding lack of
coverage approval on file, Facility may request reconsideration of the denial, and the
denial under this subsection (i) will be reversed if Facility can show that, at the time the
Protocols required notification or prior authorization, or at the time the claim was due:
• Facility did not know and was unable to reasonably determine that the patient was a
Customer, and
• Facility took reasonable steps to learn that the patient was a Customer, and
• Facility promptly submitted a claim after learning the patient was a Customer.
A claim denied under this subsection (i) is also subject to denial for other reasons permitted under
the Agreement; reversal of a denial under this subsection (i) does not preclude United from
upholding a denial for one of these other reasons.
ii) Non-Covered Services. Services not covered under the applicable 13enefit Plan are not
subject to the rates or discounts of this Agreement. Facility may seek and collect
payment from a Customer for such services (provided that Facility obtained the
Customer's written consent).
iii) Denials for lack of medical necessity through the prior authorization process. If a
service would otherwise be a Covered Service, but is not a Covered Service under the
applicable Benefit Plan because it is determined through the prior authorization process
to not meet the Benefit Plan's requirement of medical necessity, as defined in the Benefit
Plan or applicable law (or not meet a similar concept in the Benefit Plan, such as not
being consistent with nationally recognized scientific evidence as available, or not being
consistent with prevailing medical standards and clinical guidelines), Facility may seek or
collect payment from the Customer but only if, prior to receiving the service, the
Customer had knowledge of the determination of non-coverage and specifically agreed in
writing to be responsible for payment of those charges.
6.6 Retroactive correction of information regarding whether patient is a Customer. Prior to
rendering services, Facility will ask the patient to present his or her Customer identification card.
In addition, Facility may contact United to obtain the most current information available to
United on the patient's status as a Customer.
However, such information provided by United is subject to change retroactively, under the
following circumstances, (1) if United has not yet received information that an individual is no
longer a Customer; (2) if the individual's Benefit Plan is terminated retroactively for any reason
including, but not limited to, non-payment of premium; (3) as a result of the Customer's final
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decision regarding continuation of coverage pursuant to state and federal laws; or (4) if eligibility
information United receives is later proven to be false.
If Facility provides health care services to an individual, and it is determined that the individual
was not a Customer at the time the health care services were provided, those services will not be
eligible for payment under this Agreement and any claims payments made with regard to those
services may be recovered as overpayments under the process described in section 6.10 of this
Agreement. Facility may then directly bill the individual, or other responsible party, for those
services.
6.7 Payment under this Agreement is payment in full. Payment as provided under section 6.4 of
this Agreement, together with any co-payment, deductible or coinsurance for which the Customer
is responsible under the Benefit Plan, is payment in full for a Covered Service. Facility will not
seek to recover, and will not accept, any payment from Customer, United, Payer or anyone acting
in their behalf, in excess of payment in full as provided in this section 6.7, regardless of whether
that amount is less than Facility's billed charge or Customary Charge.
6.8 Customer hold harmless. Facility will not bill or collect payment from the Customer, or seek to
impose a lien, for the difference between the amount paid under this Agreement and Facility's
billed charge or Customary Charge, or for any amounts denied or not paid under this Agreement
due to:
i) Facility's failure to comply with the Protocols,
ii) Facility's failure to file a timely claim,
iii) Payer's Payment Policies,
iv) inaccurate or incorrect claim processing,
v) insolvency or other failure by Payer to maintain its obligation to fund claims payments, if
Payer is United, or is an entity required by applicable law to assure that its Customers not
be billed in these circumstances, or
vi) a denial based on lack of medical necessity or based on consistency with nationally
recognized scientific evidence as available, and prevailing medical standards and clinical
guidelines, except as provided in section 6.5 of this Agreement.
This obligation to refrain from billing Customers applies even in those cases in which Facility
believes that United or Payer has made an incorrect determination. In such cases, Facility may
pursue remedies under this Agreement against United or Payer, as applicable, but must still hold
the Customer harmless.
In the event of a default by a Payer other than those Payers covered by clause (v) of this section
6.8, Facility may seek payment directly from the Payer or from Customers covered by that Payer.
However, Facility may do so only if it first inquires in writing to United as to whether the Payer
has defaulted and, in the event that United confirms that Payer has defaulted (which confirmation
will not be unreasonably withheld), Facility then gives United 15 days prior written notice of
Facility's intent to seek payment from Payer or Customers. For purposes of this paragraph, a
default is a systematic failure by a Payer to fund claims payments related to Customers covered
through that Payer; a default does not occur in the case of a dispute as to whether certain claims
should be paid or the amounts that should be paid for certain claims.
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This section 6.8 and section 6.7 will survive the termination of this Agreement, with regard to
Covered Services rendered prior to when the termination takes effect.
6.9 Consequences for failure to adhere to Customer protection requirements. If Facility collects
payment from, brings a collection action against, or asserts a lien against a Customer for Covered
Services rendered (other than for the applicable co-payment, deductible or coinsurance), contrary
to section 6.7 or 6.8 of this Agreement, Facility will be in breach of this Agreement. This section
6.9 will apply regardless of whether Customer or anyone purporting to act on Customer's behalf
has executed a waiver or other document of any kind purporting to allow Facility to collect such
payment from Customer.
In the event of such a breach, Payer may deduct, from any amounts otherwise due Facility, the
amount wrongfully collected from Customers, and may also deduct an amount equal to any costs
or expenses incurred by the Customer, United or Payer in defending the Customer and otherwise
enforcing sections 6.7 through 6.9 of this Agreement. Any amounts deducted by Payer in
accordance with this provision will be used to reimburse the Customer and to satisfy any costs
incurred. The remedy contained in this paragraph does not preclude United from invoking any
other remedy for breach that may be available under this Agreement.
6.10 Correction of claims payments. If Facility does not seek correction of a given claim payment or
denial by giving notice to United within 12 months after the claim was initially processed, it will
have waived any right to subsequently seek such correction under this section 6.10, or through
dispute resolution under Article VII of this Agreement or in any other forum.
Facility will repay overpayments within 30 days of written or electronic notice of the
overpayment. Facility will promptly report any credit balance that it maintains with regard to any
claim overpayment under this Agreement, and will return the overpayment to United within 30
days after posting it as a credit balance.
Recovery of overpayments may be accomplished by offsets against future payments.
6.11 Claims payment issues arising from departure of Facility Professionals from Facility. In the
event a Facility Professional departs from Facility and uncertainty arises as to whether Facility or
some other entity is entitled to receive payment for certain services rendered by such former
Facility Professional, the parties will cooperate with each other in good faith in an attempt to
resolve the situation appropriately.
In the event that Facility's failure to give timely notice under section 4.15 (iv) of this Agreement
resulted in claims payments being made incorrectly to Facility, Facility shall promptly call the
situation to United's attention and return such payments to United. In the event Facility fails to
do so, United may hold Facility liable for any attorneys' fees, costs, or administrative expenses
incurred by United as a result.
In the event that both Facility and some other entity assert a right to payment for the same service
rendered by the former Facility Professional, United may refrain from paying either entity until
the payment obligation is clarified. Provided that United acts in good faith, Facility will waive
any right to receive interest or penalties under any applicable law relating to the prompt payment
of claims.
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Article VII.
Dispute Resolution
The parties will work together in good faith to resolve any and all disputes between them ("Disputes")
including but not limited to all questions of arbitrability, the existence, validity, scope or termination of
this Agreement or any term thereof.
If the parties are unable to resolve any such Dispute within 60 days following the date one party sent
written notice of the Dispute to the other party, and if either party wishes to pursue the Dispute, it may do
so by submitting the Dispute to binding arbitration conducted by the American Arbitration Association
("AAA") in accordance with the Commercial Dispute Procedures of the AAA, as amended by the AAA
Supplementary Healthcare Payer Provider Arbitration Rules, and as they may be further amended from
time to time (see http://www.adr.org ), except that, in any case, a panel of three arbitrators will be used.
Unless otherwise agreed to in writing by the parties, if the party wishing to pursue the Dispute does not
initiate the arbitration within one year after the date on which notice of the Dispute was given, it will have
waived its right to pursue the Dispute in any forum.
Any arbitration proceeding under this Agreement will be conducted in Maricopa County, AZ. The
arbitrator(s) may construe or interpret but must not vary or ignore the tetras of this Agreement and will be
bound by controlling law. The arbitrator(s) have no authority to award punitive, exemplary, indirect or
special damages, except in connection with a statutory claim that explicitly provides for that relief.
The parties expressly intend that any arbitration be conducted on an individual basis, so that no third
parties may be consolidated or joined or allowed to proceed with a class arbitration. The parties agree
that any arbitration ruling allowing class arbitration, or requiring consolidated arbitration involving any
third party(ies), would require immediate judicial review. Notwithstanding anything in this Agreement to
the contrary, this paragraph may not be severed from Article VII of the Agreement under any
circumstances, including but not limited to unlawfulness, invalidity or unenforceability.
If the Dispute pertains to a matter which is generally administered by certain United procedures, such as a
credentialing or quality improvement plan, the policies and procedures set forth in that plan must be fully
exhausted by Facility before Facility may invoke any right to arbitration under this Article VII.
The decision of the arbitrator(s) on the points in dispute will be binding, and judgment on the award may
be entered in any court having jurisdiction thereof. The parties acknowledge that because this Agreement
affects interstate commerce the Federal Arbitration Act applies.
In the event any court determines that this arbitration procedure is not binding or otherwise allows
litigation involving a Dispute to proceed, the parties hereby waive any and all right to trial by jury in, or
with respect to, the litigation. The litigation would instead proceed with the judge as the finder of fact.
In the event a party wishes to terminate this Agreement based on an assertion of uncured material breach,
and the other party disputes whether grounds for the termination exist, the matter will be resolved through
arbitration under this Article VII. While the arbitration remains pending, the termination for breach will
not take effect.
This Article VII will survive any termination of this Agreement.
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Article VIII.
Term and Termination
8.1 Term. This Agreement will take effect on the Effective Date. This Agreement has an initial
term of three years and renew automatically for renewal terms of one year, until terminated
pursuant to section 8.2 of this Agreement.
8.2 Termination. This Agreement may be terminated under any of the following circumstances:
i) by mutual written agreement of the parties;
ii) by either party, upon 120 days written notice, effective at the end of the initial term or at
the end of any renewal term;
iii) by either party upon 60 days prior written notice in the event of a material breach of this
Agreement by the other party; the notice must include a specific description of the
alleged material breach; however, the termination will not take effect if the breach is
cured within 60 days after notice of the termination; moreover, termination may be
deferred as further described in Article VII of this Agreement;
iv) by either party upon 10 days prior written notice in the event the other party loses
licensure or other governmental authorization necessary to perform this Agreement, or
fails to have insurance as required under section 4.7 or section 5.2 of this Agreement;
v) by United upon 10 days prior written notice in the event Facility loses accreditation; or
vi) by United, upon 90 days prior written notice, in the event:
a) Facility loses approval for participation under United's credentialing plan, or
b) Facility does not successfully complete the United's re-credentialing process as
required by the credentialing plan.
8.3 Ongoing Services to certain Customers after termination takes effect. In the event a
Customer is receiving any of the Covered Services listed below, as of the date the termination of
this Agreement takes effect, Facility will continue to render those Covered Services to that
Customer, and this Agreement will continue to apply to those Covered Services, after the
termination takes effect, for the length of time indicated below:
Inpatient Covered Services 30 days or until discharge, whichever comes first
Pregnancy, Third Trimester — Low Risk Through postpartum follow up visit
Pregnancy, First, Second or Third
Trimester — Moderate Risk and High Through postpartum follow up visit
Risk
Non-Surgical Cancer Treatment 30 days or a complete cycle of radiation or
chemotherapy, whichever is greater
End Stage Kidney Disease and Dialysis 30 days
Symptomatic AIDS undergoing active 30 days
treatment
Circumstances where Payer is required As applicable
by applicable law to provide transition
coverage of services rendered by
Facility after Facility leaves the
provider network accessed by Payer.
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Article IX.
Miscellaneous Provisions
9.1 Entire Agreement. In order for this Agreement to be binding, a hard copy must be signed by
both parties. This Agreement is the entire agreement between the parties with regard to its
subject matter, and supersedes any prior written or unwritten agreements between the parties or
their affiliates with regard to the same subject matter.
9.2 Amendment. This Agreement may only be amended in a writing signed by both parties, except
that this Agreement may be unilaterally amended by United upon written notice to Facility in
order to comply with applicable regulatory requirements. United will provide at least 30 days
notice of any such regulatory amendment, unless a shorter notice is necessary in order to
accomplish regulatory compliance.
9.3 Nonwaiver. The waiver by either party of any breach of any provision of this Agreement is not a
waiver of any subsequent breach of the same or any other provision.
9.4 Assignment. This Agreement may not be assigned by either party without the written consent of
the other party, except that this Agreement may be assigned by United to any of United's
Affiliates.
Additionally, if United transfers to a third party all of its business described in a given line item in
Appendix 2, section 1, United may assign this Agreement, only as it relates to that transferred
business, to that third party. Such an assignment will not impact the relationship of the parties
under this Agreement with regard to the remainder of United's business.
9.5 Relationship of the parties. The sole relationship between the parties to this Agreement is that
of independent contractors. This Agreement does not create a joint venture, partnership, agency,
employment or other relationship between the parties.
9.6 No third-party beneficiaries. United and Facility are the only entities with rights and remedies
under this Agreement.
9.7 Calendar days. Unless this Agreement specifically provides otherwise, all references in this
Agreement to a period of days refers to calendar days.
9.8 Notice procedures. Any notice required to be given under this Agreement must be in writing,
except in cases in which this Agreement specifically permits electronic notice, or as otherwise
permitted or required in the Protocols. Acceptable forms of written notice include facsimile, first
class mail, certified mail, or overnight delivery by a national, recognized delivery service. All
notices of termination of this Agreement by either party must be sent by certified mail, return
receipt requested, addressed to the appropriate party at the address set forth on the signature
portion of this Agreement. Each party will provide the other with proper addresses, facsimile
numbers and electronic mail addresses.
9.9 Confidentiality. Neither party may disclose to a Customer, other health care providers, or other
third parties any of the following information (except as required by an agency of the
government):
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i) any proprietary business information, not available to the general public, obtained by the
party from the other party;
ii) the specific reimbursement amounts provided for under this Agreement, except by either
party for purposes of administration of benefits or to inform Customers and/or referring
providers about the cost of a particular Covered Service or set of Covered Services; or
iii) any customer list of the other party regardless of how such customer list was generated.
This section 9.9 does not preclude the disclosure of information by United to a third party as part
of the process by which a Payer is considering whether to purchase services from United.
At least 48 hours before either party issues a press release, advertisement, or other media
statement about the business relationship between the parties, that party will give the other party a
copy of the material the party intends to issue.
9.10 Governing law. This Agreement will be governed by and construed in accordance with the laws
of the state in which Facility renders Covered Services, and any other applicable law.
9.11 Regulatory appendices. One or more regulatory appendix may be attached to this Agreement,
setting forth additional provisions included in this Agreement in order to satisfy regulatory
requirements under applicable law. These regulatory appendices, and any attachments to them,
are expressly incorporated into this Agreement and are binding on the parties to this Agreement.
In the event of any inconsistent or contrary language between a regulatory appendix and any
other part of this Agreement, including but not limited to appendices, amendments and exhibits,
the regulatory appendix will control, to the extent it is applicable.
9.12 Severability. Except as otherwise set forth in this Agreement, any provision of this Agreement
that is unlawful, invalid or unenforceable in any situation in any jurisdiction will not affect the
validity or enforceability of the remaining provisions of this Agreement or the lawfulness,
validity or enforceability of the offending provision in any other situation or jurisdiction.
9.13 Survival. Notwithstanding the termination of this Agreement, this Agreement will continue to
apply to Covered Services rendered while this Agreement was in effect. Additionally, section 9.9
of this Agreement, (except for the last paragraph) will survive the termination of this Agreement.
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THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE
ENFORCED BY THE PARTIES.
Maricopa County, D.B.A. Maricopa County Address to be used for giving notice to
Department of Public Health, D.B.A. Public Facility under this Agreement:
Health Clinical Services as signed by its
authorized representative
Signature Street 1645 E. Roosevelt Street
Print Name City Phoenix
Title State AZ Zip Code 85006
Date Email
UnitedHealthcare Insurance Company, on behalf of itself Arizona Physicians IPA, Inc., and its
other affiliates, as signed by its authorized representative:
Signature
Print Name
Title
Date
Address to be used for giving notice to United under this Agreement
Street 1 E Washington #1700
City Phoenix_
State AZ Zip Code 85004
Contract Number: 984765
For Plan Use Only:
Month and year in which agreement is first effective:
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FQHC Participation Agreement with United Healthcare
C-86-15-079-3-00
FOR AND ON BEHALF OF
MAR1COPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date

that are rendered by Facility to Customers covered by all Medicare Advantage Benefit Plans, as described
in this Agreement. Payer will pay claims for Covered Services according to the lesser of Facility's
Customary Charge or the applicable fee schedule, and in accordance with Payment Policies.
"FQHC Covered Services" are services which CMS defines as Covered Services when provided by an
PQHC.
Facility will submit claims using current CMS 1500 or successor forms for paper claims and HIPAA
standard professional format for electronic claims, as applicable, with applicable coding including, but not
limited to, 1CD, CPT, and HCPCS coding.
Payment Appendix - Arizona Medicaid and CHIP, and Children's Rehabilitative Services and
Medicaid Long Term Care
Federally Qualified Health Centers ("FQHC")
This Payment Appendix applies to Covered Services rendered by Facility to Customers covered under the
following type(s) of Benefit Plans as described in this Agreement:
Arizona Medicaid Benefit Plans and Arizona CHIP Benefit Plans.
Children's Rehabilitative Services Benefit Plans.
Arizona Medicaid Long Term Care Benefit Plans.
Section 1
Definitions
Any capitalized terms used herein, but not otherwise defined, will have the meanings ascribed to them in
the Agreement.
Fee Schedule: The Arizona Medicaid fee schedule published by the applicable Arizona Medicaid
Agency (the "Arizona Medicaid Program").
FQIIC Covered Services: Services which the Arizona Medicaid Program defines as Covered Services
when provided by an FQHC.
Medicaid Rate Letter: Written notice from the Arizona Medicaid Program to Facility regarding the
Medicaid rate payable to Facility for FQHC Covered Services.
Per Visit: The fiat rate payment made to Facility for all Covered Services rendered to a Customer,
during a one calendar day period, for all service categories listed in the FQHC Covered Services Table.
Unless otherwise specified in this Appendix, the Per Visit, together with any co-payment, deductible or
coinsurance for which the Customer is responsible under the Benefit Plan, will be considered payment in
full for all Covered Services rendered to the Customer including, but not limited to, physician and other
professional fees billed by the Facility on a claim, (including services rendered by non-physician
personnel, regardless of whether those personnel are employed by Facility and regardless of whether
those services are characterized as professional services), nursing care, diagnostic and therapeutic
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services, durable medical equipment, supplies (including, but not limited to anesthesia supplies),
medications, Facility and ancillary services.
Section 2
Contracted Rate for Covered Services
2.1 Contract Rate. For Covered Services rendered by Facility to a Customer, United will pay
Facility the lesser of (i) Facility's Customary Charges for Covered Services or (ii) the applicable
contract rate determined in accordance with Section 2.2 of this Appendix. Payment under this
Appendix will be less any applicable co-payments, deductibles and coinsurance and is subject to
the requirements set forth in the Agreement, such as the Payment Policies.
2.2 Covered Services. For FQHC Covered Services rendered by Facility to a Customer, the contract
rates will be the rates set forth in the FQHC Covered Services Table.
FQHC Covered Services
Service Category Payment Method Contract Rate
FQHC Covered Services Per Visit Rate 100% of the Facility
specific Arizona
Medicaid Program Per
Visit rate for FQHC
Covered Services
For FQHC Covered Services rendered by Facility to a Customer that are not payable under the
FQHC Covered Services Table, the contract rates will be 100% of the Arizona Medicaid Fee
Schedule rate.
If an applicable state or federal program is available to provide items or payment directly to
Facility for specific Covered Services for Customers subject to this Appendix that would
otherwise be payable under this Appendix, the applicable program will apply and not this
Appendix. (For example, the Vaccines For Children program currently provides vaccines free of
charge, and therefore no amount will be payable under this Appendix for vaccines within the
Vaccines For Children program. However, the administration of such vaccine may be payable
under this Appendix if payment is not provided under the Vaccines For Children program for
vaccine administration.)
2.3 Billing and Filing of Claims. Facility will submit a single claim for all Covered Services
performed during one calendar day for a Customer. Facility will immediately notify United if
Facility files more than one claim for services provided to a Customer on one calendar day.
Facility will bill using a CMS 1500 or successor form or its electronic equivalent. All claims
submitted under this Appendix must use CPT Codes, HCPCS Codes, ICD-9 Codes or its
successor and other codes in compliance with HIPPA standard data set requirements. Claims
submitted without HIPPA standard data set requirements may be denied.
Section 3
Miscellaneous Provisions
3.1 Inclusive Rates. The contract rates established by this Appendix for the service categories listed
in this Appendix are all-inclusive and represent the entire payment, including but not limited to
any applicable tax, for the provision to the Customer of all Covered Services that are in the given
service category, including but not limited to those Covered Services that are generally provided
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as a part of the service in the given service category. No additional payments will be made for
any Covered Services billed for separately by Facility.
Covered Services billed for separately by Facility that are not generally provided as a part of the
service categories listed in this Appendix are not subject to reimbursement under this Appendix,
but may be payable under another appendix to this Agreement or under another agreement.
3.2 Payment Code Updates. United will have the right to Update any codes, such as Revenue
Codes, ICD-9-CM Codes or successor version, HCPCS Codes and/or CPT Codes, from time to
time according to changes in the industry, including among other things (a) the latest edition of
the Current Procedural Terminology (CPT) manual which is revised by the American Medical
Association, (b) the latest edition of the HCPCS manual which is revised by the Centers for
Medicare and Medicaid Services (CMS), (c) the latest edition of the ICD-9-CM or successor
version which is issued by the U.S. Department of Health and Human Services, and (d) the latest
guidelines from the National Uniform Billing Committee. United will not generally notify
Facility of these code updates.
3.3 Changes to Medicaid State Agency FQHC/RHC Services Rate and Reimbursement
Methodology. With regard to all Covered Services that are reimbursed under this Appendix and
based on the Arizona Medicaid Program (Medicaid State agency) rate (including a contract rate
that is a fixed percentage of the Arizona Medicaid Program rate) and reimbursement
methodology, the contract rate and reimbursement methodology under this Appendix will be
adjusted consistent with changes made by the Arizona Medicaid Program, as finalized and
published, and as further described in this Sections 3.3, 3.3(i) and 3.3(11). In the case of a contract
rate that is a fixed percentage of the Arizona Medicaid Program Rate, the new contract rate, after
a change to the Arizona Medicaid Program Rate, will be the same fixed percentage of the new
Arizona Medicaid Program Rate; the timetable for implementing the change is described in
Section 3.3(i).
i) Rate Changes. With regard to Covered Services reimbursed under this Appendix using
a Per Visit Payment, the contract rate will be adjusted in accordance with this Section
3.3(i). Facility agrees to provide United with a copy of the annual or any interim
Medicaid Rate Letter applicable to Facility within 30 days of Facility's receipt of such
Medicaid Rate Letter. The contract rate under this Appendix using a Per Visit Payment
Method will be updated within 90 days after Facility provides United with the Medicaid
Rate Letter then in effect. Changes include without limitation the addition or deletion of
CPT/HCPCS codes that the Arizona Medicaid Program covers at Facility. The effective
date of the contract rate change will be the effective date of United's implementation of
the Arizona Medicaid Program Rate change. Claims for dates of service on or after the
effective date of the Arizona Medicaid Program Rate change that were adjudicated before
United implemented the change will not be adjusted to the new contract rate unless
required by law.
ii) Arizona Medicaid Program Payment Changes. If the Medicaid agency changes the
manner in which it reimburses or changes the Medicaid primary fee source such that
United is required to make significant programming or platform changes in order to
implement the Medicaid agency changes, United will make commercially reasonable
efforts to implement the Medicaid agency changes, within a reasonable time frame, from
the date the change is published in the Medicaid agency's official correspondence to
United or is otherwise formally communicated by the Medicaid agency to United.
Facility agrees that, in such case, it will accept the current payment as set forth in this
Appendix until such a time as United can implement the Medicaid agency change. At
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such time as United is able to implement the change, United will communicate the
change and the effective date of the change via a copy of a new payment appendix. From
that effective date forward, the contract rate will be calculated based on the new
Medicaid agency payment.
If United is unable, through commercially reasonable efforts, to incorporate the Medicaid agency
payment changes in their entirety, United will so notify Facility within 90 days from the date the
change is published in the Medicaid agency's official correspondence to United, or otherwise
formally communicated by the Medicaid agency. The parties will then negotiate in good faith for
a period of up to 60 days to amend the Agreement to replace this Appendix with a new appendix
and stated effective date for the new contract rates. If the parties have not reached an agreement
upon such an amendment within the aforementioned 60 day period, either party may initiate
Dispute Resolution according to this Agreement.
3.4 Services Not Payable Under This Appendix But May Be Payable Under Another Appendix
To The Agreement Or Under Another Agreement. The following FQHC Covered Services
are not subject to payment under this Appendix: Chiropractic Services, Mental Health Services,
and Vision Services. Facility should refer to the Arizona Medicaid Program provider manual as
coding for the aforementioned services may change from time to time. In the event Facility is a
party to another agreement with United or an affiliate of United that is applicable to those
services rendered to a Customer, or another appendix to the Agreement applies to these services
rendered to a Customer the services below may be payable under that agreement or appendix
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Attachments in effect as of the Effective Date:
X Appendix I: Facility Practice Locations and Facility Professionals Roster
Appendix 2: Benefit Han Descriptions
X Administrative Manual Appendix
Payment Appendices:
X Medicare Advantage Payment Appendix
X Medicaid and/or CHIP Payment Appendix(ices)
Remla tory Appendices:
State Regulatory Requirements Appendix (list all states as applicable)
X Medicare Advantage Regulatory Requirements Appendix
X Medicaid and/or CHIP Regulatory Requirements Appendix(ices)
Arizona Medicaid Benefit Plans and Arizona CHIP Benefit Plans
Children's Rehabilitative Services Benefit Plans
Arizona Medicaid Long Term Care Benefit Plans
Other:
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Appendix 1
Facility Practice Locations and Facility Professional Roster
Facility attests that this Appendix identifies all services and locations covered under this Agreement
IMPORTANT NOTE: Facility acknowledges its obligation under Section 4.8 to promptly report any
change in Facility's name or Taxpayer Identification Number. Failure to do so may result in denial of
claims or incorrect payment.
BILLING ADDRESS=
Identify only if a common name and address appears on all Facility practice location bills that
utilize the Facility's Tax ID under the Agreement.
Practice Name: Maricopa County, D.B.A. Maricopa County Department of Public
Health, D.B.A. Public Health Clinical Services
Street Address: 1645 E. Roosevelt Street
City: Phoenix State: AZ Zip: 85006
Tax ID Number (TIN): 866000472
National Provider ID (NPI):
PRACTICE LOCATIONS-(complete one for each service location
Clinic Name Clinic Name Clinic Name
Attached Attached Attached
Street Address Street Address Street Address
City City City
State and Zip Code State and Zip Code State and Zip Code
Phone Number Phone Number Phone Number
TIN (If different from above) TIN (If different frotn above) TIN (If different from above)
National Provider ID (NPI) National Provider ID (NP!) National Provider ID (NP!)
1. CTICKLOCATIONS (compkte one forikack service _lout' ii _
Clinic Name Clinic Name Clinic Name
Street Address Street Address Street Address
City City City
State and Zip Code State and Zip Code State and Zip Code
Phone Number Phone Number Phone Number
TIN (If different from above) TIN (If different from above) TIN (If different from above)
National Provider ID (NP!) National Provider ID (NP!) National Provider ID (NPI)
UnitedHealtheare
UHC-CP/FQ1-1C.RHC.4.12.AZ Page 23 Confidential and Proprietary

UnitedHealthcare
UHC-CP/FQ1-1C.RLIC 4.12.AZ Page 22 Confidential and Proprietary

Facility Professional Roster
IMPORTANT NOTE: Facility acknowledges its obligation to notify United of any change in Facility
Professionals in accordance with Article IV and Section 4.8. Failure to do so may result in denial of
claims or incorrect payment.
Facility represents that it has provided United with a Facility Professional Roster that includes all of the
following data elements for each Facility Professional:
Name of Professional (first name, middle initial, last name)
Degree (MD, DO, NP, PA, other)
Gender (MJF)
Provider Specialty(ies) (primary, secondary, additional specialties)
Willing to be listed/assigned as a Primary Care Professional "PCP" (Y/N)
State License Number
Medicaid ID Number
NPI Number
Foreign Language(s)
Admitting Hospital(s)
If any data element is not applicable to a specific Facility Professional, Facility will indicate "not
applicable" in the appropriate field. Acceptable formats include in writing, electronically in Excel, ANSI,
or text (comma delineated) formats.
UnitedHealthcare
U1-1C-CP/FQHCSLI-1C4.12.AZ Page 23 Confidential and Proprietary

Appendix 2
Benefit Plan Descriptions
Section 1. United may allow Payers to access Facility's services under this Agreement for the
Benefit Plan types described in each line item below, unless otherwise specified in section 2 of this
Appendix 2:
UnitedHealthcare Community Plan Medicare Advantage Benefit Plans.
Arizona Medicaid Benefit Plans and Arizona CHIP Benefit Plans.
Children's Rehabilitative Services Benefit Plans.
Arizona Medicaid Long Term Care Benefit Plans.
Section 2. Notwithstanding the above section 1 of this Appendix, this Agreement will not apply to
the Benefits Plan types described in the following line items:
Note: Excluding certain Benefit Plans or programs from this Agreement does not preclude the parties
or their affiliates from having or entering into a separate agreement providing for Facility's
participation in a network for such Benefit Plans or Programs.
Section 3. Definitions:
Note: United may adopt a different name for a particular Benefit Plan, and/or may modify information
referenced in the definitions below regarding Customer identification cards. If that happens, section 1 or
section 2 of this Appendix will continue to apply to those Benefit Plans as it did previously, and United
will provide Facility with the updated information. Additionally, United may revise the definitions in this
section 3 to reflect changes in the names or roles of United's business units, provided that doing so does
not change Facility's participation status in Benefit Plans impacted by that change, and further provided
that United provides Facility with the updated information.
MEDICARE:
1.• Medicare Advantage Benefit Plans means Benefit Plans sponsored, issued or administered by a
Medicare Advantage organization as part of:
(i) the Medicare Advantage program under Title XVIII, Part C of the Social Security Act, or
(ii) the Medicare Advantage program together with the Prescription Drug program under Title
XVIII, Part C and Part D, respectively, of the Social Security Act,
as those program names may change from time to time.
UnitedHealtheare
UHC-CP/FQHC.RHC.4.12.AZ Page 24 Confidential and Proprietary

UnitedHealthcare Community Plan Medicare Advantage Benefit Plans means Medicare
Advantage Benefit Plans subject to the UnitedHealthcare Community Plan Protocols. Those
Benefit Plans will include a reference to "CP" on the back of the valid identification card of any
Customer eligible for and enrolled in those Benefit Plans.
MEDICAID, CHIP AND OTHER STATE PROGRAMS:
Medicaid Benefit Plans means Benefit Plans that offer coverage to beneficiaries of a program
authorized by Title XIX of the federal Social Security Act, and jointly financed by the federal and
state governments and administered by the state.
Arizona Medicaid Benefit Plans means Medicaid Benefit Plans issued in Arizona that include a
reference to "UnitedHealthcare Community Plan" on the valid identification card of any
Customer eligible for and enrolled in that Benefit Plan.
Arizona Medicaid Long Term Care Benefit Plans (also known as "Arizona Long Term Care
System" program or "ALTCS") means long term care Medicaid Benefit Plans issued in Arizona
that include a reference to "Evereare Select" on the valid identification card of any Customer
eligible for and enrolled in that Benefit Plan.
Children's Health Insurance Program ("CHIP") Benefit Plans are Benefit Plans under the
program authorized by Title XXI of the federal Social Security Act that is jointly financed by the
federal and state governments and administered by the state.
Arizona CHIP Benefit Plans (also known as "KidsCare") are CHIP Benefit Plans issued in
Arizona that include a reference to "UnitedHealthcare Community Plan" on the valid
identification card of any Customer eligible for and enrolled in that Benefit Plan.
Children's Rehabilitative Services Benefit Plans means Benefit Plans issued in Arizona that
include references to both "Children's Rehabilitative Services" and "UnitedHealtheare
Community Plan" on the valid identification card of any Customer eligible for and enrolled in
that Benefit Plan.
Unitedflealthcare
ILTHC-CP/FQ1-1C.RTICA.12,AZ Page 25 Confidential and Proprietary

Administrative Manual Appendix
For the Benefit Hans for which Facility may provide Covered Services under this Agreement, Facility is
subject to additional requirements of one or more provider manuals ("Administrative Manuals"). When
this Agreement refers to Protocols or Payment Policies, it is also referring to the Administrative Manuals.
For Benefit Plans subject to a particular Administrative Manual, the Administrative Manual controls if it
conflicts with a provision of this Agreement. However, the Additional Manual does not control where it
conflicts with applicable statutes and regulations. The Administrative Manuals will be made available to
Facility on a designated website and upon request. The names of the Administrative Manuals, the
websites to view and download them, and the Benefit Plans to which they apply, are listed in Table 1
below. United may change the location of a website or the Customer identification card identifier used to
identify Customers subject to a given Administrative Manual; if United does so, United will infoiiim
Facility.
United will notify Facility of any changes in the location of the Administrative Manuals. Facility may
request a copy of the Administrative Manual(s). United may make changes to the Administrative
Manuals in accordance with the provisions of this Agreement relating to Protocol and Payment Policy
changes.
Table 1:
Type of Benefit Plan Description of Applicable Website
Administrative Guide
UnitedHealthcare UnitedHealthcare Community Plan uhccommunityplan.com
Community Plan Physician, Health Care Professional,
Medicare Advantage Facility and Ancillary Provider
Benefit Plans Administrative Guide for Medicare
Arizona Medicaid and UnitedHealthcare Community Plan uhccommunityplan.com
CHIP Benefit Plans Physician, Health Care Professional,
Facility and Ancillary Provider
Administrative Guide for Medicaid
Arizona Medicaid Long UnitedHealthcare Community Plan uhccommunityplan.com
Term Care Benefit Plans Physician, Health Care Professional,
Facility and Ancillary Provider
Administrative Guide for Long Term
Care
Children's UnitedHealthcare Community Plan uhccommunityplan.com
Rehabilitative Services Physician, Health Care Professional,
Benefit Plans Facility and Ancillary Provider
Administrative Guide for Children's
Rehabilitative Services
Payment Appendix - Medicare Advantage
Services other than FQHC Covered Services
Medicare Advantage Fee Information Document: AZ 95274
Unless another Payment Appendix to this Agreement applies to a particular Medicare Advantage Benefit
Plan as it covers a particular Customer for Covered Services that are not FQHC Covered Services, the
provisions of this Payment Appendix apply to Covered Services that are not FQHC Covered Services and
Unitedliealtheare
UlIC-CP/FQHC.REIC.4.12.AZ Page 26 Confidential and Proprietary

Urdtecillealtheare
Payment Appendix
Medicare and Medicaid Enrollees (MME) Fee Information Document
Fee Schedule Specifications: as of 11/12/2014
Report Date: 11112/2014
Fee Schedule ID: AZ 95274 - NonFacility
Linked Fee Schedule ID: AZ 95275- Facility
Type Of Service Primary Fee Source Pricing Level
EVALUATION & MANAGEMENT Currant Year CMS RBRVS Carrier Locality (0310200) 100.000%
EVALUATION & MANAGEMENT - NEONATAL Current Year CMS RBRVS Garner Locality (0310200) 100.000%
EVALUATION & MANAGEMENT - PREVENTIVE Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
EVALUATION a, MANAGEMENT- NURSING FACILITY SVCS Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY - INTEGUMENTARY Currant Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY - MUSCULOSKELETAL Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY-RESPIRATORY Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY - CARDIOVASCULAR Current Year CMS RBRVS Carrier Locality (0310200) 130.000%
SURGERY - HEMIC & LYMPHATIC Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY - MEDIASTINUM & DIAPHRAGM Current Year CMS RBRVS Carrier Locality (0310200) 130.000%
SURGERY - DIGESTIVE Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY - URINARY Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY-MALE GENITAL Current Year CMS RBRVS Carrier Locality (0310203) 100.000%
SURGERY-FEMALE GENITAL Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY - MATERNITY & DELIVERY Current Year CMS RBRVS carrier Locality (0310200) 100.000%
SURGERY-ENDOCRINE Current Year CMS RBRVS Carrier Locality (3310200) 100.000%
SURGERY-NERVOUS Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
SURGERY EYE & OCULAR ADNEXA Current Year CMS RBRVS Carrier Locality (0310200) 100,000%
SURGERY-AUDITORY Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
RADIOLOGY Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
RADIOLOGY - BONE DENSITY Current Year CMS SERVE Carrier Locality (0310200) 100.000%
RADIOLOGY-CT Current Year CMS RBRVS Carrier Locality (0310200 100.000%
RADIOLOGY - MAMMOGRAPHY Current Year CMS RBRVS Carrier Locality (0310200) locum%
RADIOLOGY - MRI Current Year CMS RBRVS Carder Locality (0310200) 100.000%
RADIOLOGY - MRA Current Year CMS RBRVS Carrier Locality (0310200) 100,000%
RADIOLOGY - NUCLEAR MEDICINE Current Year CMS RBRVS Carder Locality 0315200) 100.000%
RADIOLOGY - PET SCANS Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
RADIOLOGY - RADIATION THERAPY Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
RADIOLOGY - ULTRASOUND Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
LAB - PATHOLOGY Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
OFFICE LAB Current Year CMS Clinical Lab Schedule National Limit 100.000%
CLINICAL LABORATORY Current Year CMS Clinical Lab Schedule National UAL 100.000%
MEDICINE - OPHTHALMOLOGY Current Year CMS RBRVS Carrier Locailly (0310200) 100.000%
MEDICINE - CARDIOVASCULAR Current Year CMS SERVO Carrier Locality (0310200) 103.000%
MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
MEDICINE- CHIROPRACTIC MANIPULATIVE TREATMENT Current Year CMS RBRVS Carrier Locality (0310200) 103.000%
MEDICINE - PHYSICAL MED AND REHAB - MODALITIES Current Year CMS RBRVS Carder Locality (0310200) 100.000%
MEDICINE- PHYSICAL MED AND REHAB -THERAPIES&OTHER Current Year CMS RBRVS Carrier Locality (0310200) 103.000%
MEDiCINE - ENTERAL FORMULA Current Year CMS RBRVS Carrier Locality (0310200) 100.090%
MEDICINE-OTHER Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
MEDICINE - IMMUNIZATION ADMINISTRATION Current Year CMS RBRVS Carder Locality (0310200) 100.000%
MEDICINE CHEM ADMIN Current Year CMS RBRVS Carrier Locality (0310200) 100.000%
OBSTETRICS - GLOBAL Current Year CMS RBRVS Carder Locality (0310200) 100.000%
IMMUNIZATIONS CMS Drug Pricing 100.000%
INJECTABLES/OTHER DRUGS CMS Drug Pricing 100.000%
INJECTABLES ONCOLOGY/THERAPEUTIC CHEMC DRUGS CMS Drug Pricing 100.000%
INJECTADLES - IVIG CMS Drug Pricing 100,000%
INJECTABLES-SALINE & DEXTROSE SOLUTIONS CMS Drug Pricing 100.000%
DME & SUPPLIES Current Year CMS DME Floor 50.000%
DME & SUPPLIES - RESPIRATORY Current Year CMS DME Floor 50.000%
DME & SUPPLIES - ORTHOTICS Current Year CMS DME Floor 00,000%
DME & SUPPLIES - PROSTHETICS Current Year CMS DME Floor 00.000%
DME & SUPPLIES - OSTOMY Current Year CMS DME Floor 60.000%
AMBULANCE Current Year CMS Ambulance Schedule - Urban (9310200) 100.000%
Default Percent of Eligible Charges: 40,00%
ProtessionalfTechnical Modifier Pricing: Fee Source-Based
Site of Service: Site of Service applies. CMS Assignment (ASC POS 24 = F)
Anesthesia Conversion Factor (Based on a 15 minute Anesthesia Time Unit Value): $ 17.63
Calculation of Anesthesia Partial Units: Proration
Schedule Type: FPS
Last Routine Maintenance Update: 10-01-2014
Fixed Fees: 36415- $3.00 36410- $3.00 07004- 514.00 V5242 - $2500.00 V5243 - $2500.00 V5244 - $2500.00 V5245 - $2500110 V5246 - $2500.00 V5247- $2500.00 V5248 -
$5000.00 V5249 - $5000110 V5250 - $5000.00 V5251 - $5000.00 V5252 - $5000110 V5253 - $5000.00 V5254 - $2500.00 V5255 - $2500.00 V5256 - $2500.00 V5257 - $2500.00
V5258 - $5000.00 V5259 - $5000.00 V5260 - 05000.00 V5261 - $5000.00 V5262 - $2500.00 V5263 - 05000.00
Fee Amounts listed In the fee schedule are eli-inclusive, Including without limitation any applicable taxes. Unless specifically indicated otherwise, Fee Arrounls represent global fees and may be subject to
reductions based on appropriate Modifier (for example, professional and technical modifiers). As used in the previous sentence, "global fees" refers to services billed without a Modifier, for which the Fee
Amount includes both the professional component and the technical component Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customer's benefit contract
will be subtracted from the listed Fee Amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the Payment
Policies. No payments will be made for any CMS additional compensation programs, including without limitation incentive or bonus payment programs. Please remember that this information is subject to
the confidentiality provisions of this agreement.
Confidential and Proprietary Not for Distribution to Third Paz -lies
Version 4.0 Page 1 of 7

Unitecillealthcare
Payment Appendix
Medicare and Medicaid Enrollees (MME) Fee Information Document
Representative Fee Schedule Sample: as of t1/12/2014
Report Date: 1.1/12/2014
Fee Schedule ID: AZ 95274- NonFacility
Linked Fee Schedule ID: AZ 95275 - Facility
CPT/HCPCS Modifier CPT/I-ICPCS Description Type of Service Place of Service Fee Amount
59400 00 GB CARE ANTEPART OBSTETRICS - GLOBAL Non.. FacifitY $ 2159.21 ...--
59-5710 6E37.hi -EAkTiim CA 6B-StEriiibS" 6:0671/47 — -Nonr.,acility $ 2387.34
66984 oa CATARACT REMOVAL SURGERY EYE & OCULAR AR-EXA NonFacility . $ 667.09,
77418 00 INTENS Mal Tx DE —RADIOLOGY - RADIATION THERAPY NonFacility ._...._.1.;;.69..,:d.76.8,.
88305 LEVEL IV SURG LAB PATHOLOGY -- NonFacility
8856-6- - 26 LEVEL IV SURG LAB - PATHOLOGY NonFacillty $ 38.19
88305 TC LEVEL IV SORG PA LAB - PATHOLOGY NonFacility„.. $ 31.87 Fr
90480 00 - IM ADM THRU 1-8-W - MEDICINE-':)m-MNIZATIOW-ATYMINISTRATION Frc.,F.cility ?.„44 8
90649 00 HUMAN PAPILLOMA IMMUNIZATIONS NonFacility $ 14 '6.86
99570 PNEUMOCOCCAL CON IMMUNIZATIONS WOnFiciiiry
92014 .7, -„, ORI-Ifi4TgoitAL MEDICINE - OPHTHALMOLOGY. NonFaciiity
93306 00 EEO ffi-i-k6"-i-TT MEDICINE-. CARDIOVASCULAR NonEacility
93306 ECHO .[THRC R-T 2 MEDIUNY:-CARDIOVASCULAR NonFacility $ 64.22
"9-i-66 3 TC - ECHO-T-1'Hk. R-T 2 MEDICINE - CARDIOVASCULAR' ---Froil,..*aii- -$ 162.96-
99203- 00 OFFICE OUTPATIEN EVALUATION Sk MANAGEMENT NonFacility 4 4.)7.-3-6-
99204 00 OFFICE OUTPATIEN. EVALUATION,& MANAGEMENT — NonFacillty --- 176-6:61-
90205 _ OFFICE OUTPATIEN mkrafTeN-RUZZOIV- NonFaeilk
99212 OFFICE OUTPATIEN EVALUATION & MANAGEMENT NonFacility $$24035:3653
99213 OFFICE OUTPATIEN EVALUATION & MANAGEMENT NonEadlity 7 '$ 72-.56-
9921.4- 36- OFFICE OUTPATIEN EVALUATION & MANAGEMENT N'e-n-FacilifY , -$-iang-
99216 OFFICE OUTPATIEN EVALUATION 8,..ivIARAWVENt---- -- -CWW6.11iiif" - — "rTiY.41 . "
99222 _ 00 'INITIAL HOSPITAL EVALUATION &MANAEOENT ' NonFacility , „..„, $.r 03..D,
99223 00 INITIAL HOSPITAL EVALUATION 'EVALUATION &MANAGEMENT NonEa.cility
99232 HOSPITAL CA EVALUATION 'isionFacility
99233 ses .c.r:=7 . +\.;.,..._....,.......:-:... IL ..........ccLIL....... tr.,0I.--;
97207 00 &PRE "6154§Iffid-- 'ANTI ATia"-Z"aKRAawE-N-r— -- -- - ., .Non. F.. .a. r... lily 7$"'Pl1-6'8 41.: ri
99283 00 EMERGENCY DEPART ,-.,Ii&kfloil & MANAGEMENT — — NoilFacility -$61-,67
99284 00 ---EMERGENCY DEPART EVALUATION & MANAGEMENT NonFacIlity 1%1„2.1,377.060;
99285 ' --- EMERGENCY DEPT . --- V EVALUATION & MANAGEMENT .....uu..e.aa--..d—a,...--.....-...,,,,,,,, , -NonFaciiiiii 7e I.,... %., . •....a,-. $ 172,88
k-e) ' ' au CRITICAL CARE IL - •,,.YALLJ'AiTdr4 i MXINAGEMENT - Nonl,acility
99308 03 SHSQ NURSING FAC EVALUATION & MANAGEMENT-NURSING FACILITY SVCS
99309 00 SBSO NURSING EAC EVALUATION & MANAGEMENT- NURSING FACILITY-WES' NonFacility $ 90.48
...—
'gib) oci PERIODIC PREVENT EVALUATION-WVANAGEMENT- PREVENTIVE NonFacility
6-6,i92-----15- 'PERIODIC PREVENT EVAagffi-DN g,MANAGEVENT -FREVENTIVE NonFacifity 175-07
66T§F-- oil -15`b.lobieThTtEVENT garaTUN-CUNAGE-Mair PREVENTIVE -- NenFecility $ 118.16
99396 00 prklaifi:-,sEil'air EVALUATION & MANAGEMENT- PREVENTIVE - NonFaciiity .,„ _.,1$1..57 125.07,, 0
99397 00 PERIODIC PREVENT ------- EVALUATION &MANAGEMENT - PREVENTIVE NonFacility - $ 135.59
00202 --156 - SCR MAMMO PRobtib"— , RADIOLOGY -MAMMOGRAPHY MAMMOGRAPHY -- .- - NonFacility
`GLiZoi 26 - -SCR-MAMMO PRODUC - - -FablaOGY -MAMMOGRAPHY — TiOnFacility
00202 TO SCR MAM!,710 PRODUC RADIOLOGY - MAMMOGRAPHY - — NonFacility $ 98.48 .
J0178 00 INJECTION AFORE-- INJECTABLES/OTHER DRUGS NonFacility $ 980.56-
J1745 CO INJECTION 1NFLIX — INJECTABL ES-ONC.OLOGYILHERAPEUTIC CHEMO DRUGS nr.IFF,'1"1
J2323 00 INJECTION NATAL INJECTABLES/OTHER CRJGS NonFacitty $ 14.95
J2505 00 INJECTION PEGFIL RECTABLES-ONCCLOGY/THERAPEUTie CHEMO DRUGS NonFacillty $.3368.78
J2770 00 INJE-CTENTiATiir- INJECT"ABLEVOTHER DRUGS -1,16We-a i'I;Y $ 396756-
19035 00 INJECTION BEVACI INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS NonEaclIlty $ 66.55
19263 00 INJECTION OXALIP _ INJECTABLES-ONCOILDGY/THERAPEUTIC CHEMO DRUGS NusFacilsy _ _ 6.6„:33
39305 00 - - INJECTION PEMETR INJECTABLE-8-:ONCOLOGY/THERAPEUTIG CHE60 DRUGS- NonFecility
J9310 00 INJECTION, RITUX INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS NonFacility $ 707.47 ,
39365 00 -.1i43E-EtTON, TRAST INJECTABLES-ONCOLOGY/THERAP-E-H-CEHEMO DRUGS NonFacility fiiTH
Default Percent of Eligible Charges: 40.00%
ProfessionalfTechnical Modifier Pricing: Foe Source -Based
Site of Service Price Differential: Site of Service applies. CMS Assignment (ASC POS 24= F)
Anesthesia Conversion Factor (Based on a 15 minute Anesthesia Time Unit Value): $ 17.63
Calculation of Anesthesia Partial Units: Proration
Schedule Type: FFS
Last Routine Maintenance Update: 10-01-2014
Fee Amounts fisted in the fee schedule are all-inclusive, including without [Imitation any applicable taxes. Unless spedfically indicated otherwise, Fee Amounts represent global fees and may be subject to
reductions based on appropriate Modifier (tor example, professional and technical modifiers). As used in the previous sentence. "global fees refers to services billed without a Modifier, for which the Fee
Amount includes both the professional component and the technical component. Arty co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract
will be subtracted from the listed Fee Amount In determining the amount lobe paid by the payer. The actual payment amount Is also subject in matters described in this agreement, such as the Payment
Policies. No payments will be made for any CMS additional compensation programs, including without finitaf on Incentive or bonus payment programs. Please rernembet that this intonation is subject to
the confidentiality provisions of this agreement.
Confidential and Proprietary Not for Distribution to Third Parties Version 4.0 Page 2 of 7

frdted ealtheare
Payment Appendix
Medicare and Medicaid Enrollees (MME) Fee Information Document
Representative Fee Schedule Sample: as of 11/12/2014
Report Date: 11/12/2014
Fee Schedule ID; AZ 95274 - NonFacility
Linked Fee Schedule ID: AZ 95275 - Facility
CPT/HCPCS Modifier CPTIFICPCS Description Type of Service Place of Service Fee Amount
59400 00 OB CARE ANTEPART OBSTETRICS - GLOBAL Facility ---- $ 2159.21
59510 00 -1511-AMP'atiim CA OBSTETRICS - GLOBAL Facility $ 2387.34
66984 oo CATARACT REMOVAL SIJiiiaiii- -- EYE & OCULAR _ ADNEXA -- _„,......_ Facility $ 667.09
ri4 18 INTENS MOD TX DE _____.---„,- „----- -- -----_ Facility-*-------mva- -
00 LEVEL IV SURG PA LAB - PATHOLOGY Facility $ 70.0E'
88305 26 LEVEL IV SURG PA •LAB - PATHOLOGY Facily $ 38,19
88305 TC LEVEL IV SUNGPA. LAB - PATHOLOGY- ---- Facility .
00 IM ADM'TBBLI 18YR - titbiariff- IMMUNIZATION ADMINISTRATION .$-234.1.887
-66E41- ao - WOMAN pApILLOmA IMMUNIZATIONS Facility $ 149.86
90670 - 00 PNE‘UMOCOCCAL da:1- IMMUNIZATC6NS $ 153.96
92014 MEDICAL XM MEDICINE - OP-H-TT-171- ,MOC6ge---- Facility FacilitY $ 87.28-
90306 Ea6f1HRC R-T MEDICINE - CARDIOVASCULAR Facility $ 227.18
55.506 -126 ECHO TTHRCR-T2 MEDICINE - CARDIOVASCULAR Facility • $ 64.22-
`g'3`cie-- MEDICINE "--CARDIOVASCULAR - ---- Facility $76516-
99203 OFFICE OUTPATIEN EVALUATION &MANAGEMENT - Facility
wria-617-4-crigfi EVALUATION &MANAGEMENT Faciiry ------ $ 131.00
7916-6- orFICE OLITPATIEN --- "EVALUATION kriANAbEmbe - Facility „ $ i 69.14
99217 pc OFFICE OUTPATIEN EVALUATION & MANAGEMENT ,.,..._ -------__ Facility „.-... $$ 5251.289
99200 30 -"OFFICE OLIVA-TIEN o-----Frr-krTrEtAEN-r . Facility
V5Tr- moic --OFFICE-CU-TPA-TIEN EVALUATION & MANAGEMENT FanilitY $ 79.73
9921.5 00 OFFICE 'OLTPATighl- EVALUATION .••••••,,,,,,,,,,,,Y, & MANAGEMENT ,;:cciiii tyty .••••-•••••••••.,,,,,, ,....,,•• • • • $ n• • 110.81 ,-,,,,,IY, 'L.,. ••
99222 — 00 INITIAL HOSPITAL EVALUATION &MANAGEMENT
99223 INITIAL HOSPITAL EVAL- LIATION & MANAGEMENT • ..I•••••••_,, • Ea` , Facility : 12:1:3
SBSQ ROSPITA CA ..:K.... . . EVA EVALUATION • & MANAGEMENT MANAGEMENT Facility ' " - ' - ' ' ' r " ' ' r ' ' r ' = ' - -Sc. : ::
99232 00
99233 51350 HOSPITAL CA EVALUATION & MANAGEMENT
99244- 7 00 OFFICEdTISULTAT " EVALUATION & MWAGEMENT- -- ------ - 4 '.------ _-. - - .,-•••••,••••••• FF"cc:IP HLY ••,.2, - $4 .15'5 6::611-
59283 - WO. EMERGENCY DEPART " Facility --_-----------7-1-
99284 - 00 - DEPART - EVALUATION & MANAGEMENT Facility ......., ,,,,,,,..,...• $$1 6171 . •••••• 607
ME- oo- EMERGENCY „ DEPT V • EVALUATION Facility
99291 E V7LL-LrA-Tiati & MA birGEMETI ---. f - - ' "-- - - - Facility $ 223.4 12
99358 - 00 - SBSO NURSING FAC -- EVALUATION & MANAGEMENT - NURSING FACILITY SVCS „- _Facility $ 68.73
99305 00 SBSQ NURSING PAC - EVALUATION &MANAGEMENT - NURSING FACILITY SVCS Facility $ 90.48
00391 - ao . PEPAcoic PREVENT - EVALUATION 8. MANAGEMENT - PREVENTIVE - - Facility $ 73.90_
"$$$-0"2 00 ----PERIODIC PREVENT ---- EVALUATION & MANAGEMENT - PREVENTIVE , _ - Facility - $ 77.87
99395 --, PERIODIC PREVENT - EVALUATION & MANAGEMENT - PREVENTIVE- Facility $ 89.82
90306 00 PERIODIC PREVENT '- - EVALUATION & M-AFIA-afFigT : PTIE-ITE-NtrVE---- "-- -- Facility - ---------gar
99397- 00 PERIODIC PREVENT - EVALUATION & MANAGEMENT-PREVENTIVE - - Facility --.-_-_- $$$19302867, _- 89
SUR MANIMO PRODUC . - RADIOLOGY-MAMMOGRAPHY „-- - Facility $ 1 33:/7
665E- A SCR MAMMO PF-LODUC -..„. RADIOLOGY MAMMOGRAPHY - -- .-,
G-0202 SCR MAMMO rhEibuc -- RADIOLOGY - MAMMOGRARAY . -7 Facility -
J0178 30 " -- NJECIABLESiCITHER DRUGS - --- Facility - -- $-9161-0 --.-
J1745 00 INJECTION INFLIX .-`-- ' INIOTABLESIONCOLOGY/THEBAFEUTIC CH-EMO DRUGS -
J2323 INJECTION NATAL INJECTABLESIOTHER DRUGS . Fa-c „ i illitYy - - : 7142;
JAcis -63 INJECTION PEGHL INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS - Facility ,,n.. m $ 336.6JE.
J2778- 00 WI crliA RAN'ibl-- MEcfABLEsiblITEITD "RU6T- - - ' Facility _ .. -$ 36s.L.... 9
J9035 Da INJECTION BEVACI INJECTABLES-ONCOLOGYfillERAPEUTIC CHEMO OIL. „-- Faciliy _ A 88 .8,/,
J9263 INJECTION OXALIP " -INdECTABLE-11a)LOGWAE-- RAP-EUT/C CHEMO DRUGS Facility $ 3.57
J9305 00 INJECION FTotTR-- ICE-6-CABC.Es-oNcoL6.3777-iMisPiTif-dritiZiMUCT-- .„..... Facility $ 69.33
JOOlO ----65 INJECTION, RITUX INIECT- ABLES-ONGoi_OGY/THERAPEUTIC CHEMO DRUGS Facility ---- $$7V2Z
J9355 00 INJECTION, TRAST INJECTABLES-ONCOLOGYKkRAPEUTIC CHEMO DRUGS Facility
Default Percent of Eligible Charges: 4020%
Professlonal/Technical Modifier Pricing: Fee Source-Based
Site of Service Price Differential: Site of Service applies. CMS Assignment 1ASC POS 24 "
Anesthesia Conversion Factor (Based on a 15 minute Anesthesia Time Unit Value): $ 17.63
Calculation of Anesthesia Partial Units: Proration
Schedule Type: FES
Last Routine Maintenance Update: 10-01-2014
Fee Amounts listed in the fee schedule are all-Inclusive, includiog without limitation any applicable taxes. Unless specifically indicated otherwise, Fee Amounts represent global fees and may be subject to
reductions based on appropriate Modifier (for example, professional and technical modifiers). As used in the previous sentence, "global fees " refers to services billed without a Modifier, for which the Fee
Amount includes both the professional component and the technical component. Any co -payment, deductible or coinsurance that the customer is responsible to pay under the customer 's benefit contract
will be subtracted from the listed Fee Amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described In this agreement, such as the Payment
Policies. Na payments will be made for any CMS additional compensation programs, including without limitation incest Ye or bonus payment programs. Please remember that this Information is subject to
the confidentiality provisions of this agreement.
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Section 1. Definition of Terms
Unless otherwise defined in this document, capitalized terms will have the meanings ascribed to them in the Agreement.
AMA: American Medical Association located at: www.ama-assn,orn.
Anesthesia Conversion Factor: The dollar amount that will be used in the calculation of time-based and non-time based Anesthesia Management fees in
accordance with the Anesthesia Payment Policy. Unless specifically stated otherwise, the Anesthesia Conversion Factor indicated is fixed and will not change. The
Anesthesia Conversion Factor is based on an anesthesia time unit value of 15 minutes. In the event that any of United's claims systems cannot administer a 15 minute
anesthesia time unit value, then the Anesthesia Conversion Factor will be calculated as follows:
[ (Value of 15 minute Anesthesia Conversion Factor 115) * anesthesia time unit value ]
For example, an Anesthesia Conversion Factor of $60.00 (based on a 15-minute anesthesia time unit value) would be calculated to an Anesthesia Conversion Factor of
$40.00 (based on a 10-minute anesthesia time unit value).
Example: [ ($60.00 / 15)* 10 $40.00]
Anesthesia Management: The management of anesthesia services related to medical, surgical or scopic procedures, as described in the current Anesthesia
Management Codes list attached to the Anesthesia Payment Policy located at www,unitedhealthcareonline corn.
Calculation of Anesthesia Partial Units:
Proration: Partial time units will be prorated and calculated to one decimal place rounded to the nearest tenth. For example, if the anesthesia time unit value is based
on 15 minutes and if 17 minutes of actual time is submitted on a claim, then the 17 minutes will be divided by 15. The resulting figure of 1.1333 will be rounded to the
nearest tenth and the total time units for the claim will be 1.1 time units.
In the event that any of United's claims systems cannot administer the calculation of partial units as indicated above, a different calculation method will be useduntil
such time as the appropriate system enhancements can be programmed and implemented. That different calculation methodwill result in a Fee Amount that is no less
than the Fee Amount that would apply under the Proration method described above.
CMS: Centers for Medicare and Medicaid Services located at: www.cms.hhs.gov .
Conversion Factor: A multiplier, expressed in dollars per relative value unit, which converts relative values into Fee Basis amounts.
CPT/HCPCS: A set of codes that describe procedures and services, including supplies and materials, performed or provided by physicians and other health care
professionals. Each procedure or service is identified with a 5 digit code. The use of CPITICPCS simplifies the reporting of services.
CPT/HCPCS Description: The descriptor associated with each CPTIHCPCS code.
Default Percent of Eligible Charges: In the event that a Fee Basis amount is not sourced by either a primary or alternate Fee Source, such as services submitted
using unlisted, unclassified or miscellaneous codes, the codes are subject to correct coding review and will be priced at the contracted percentage indicated within this
document.
Expired Code: An existing CPT or IICPCS code that will be expired by the entity that published the code (for example, CMS or the AMA).
Fee Amount: The contract rate for each CPT/HCPCS. The calculation of the Fee Amount is impacted by a variety of factors explained within this document including,
but not limited to, Professional/Technical Modifier Pricing, Carrier Locality, CMS year, Place of Service and Pricing Level.
Fee Basis: The amount published by the Fee Source upon which the Pricing Level will be applied to derive the Fee Amount.
Fee Schedule ID: United's proprietary naming/numbering convention that is used to identify the specific fee schedule which supports the terms of the contractual
agreement. This is the fee schedule for services performed in nonfacility Places of Service.
Fee Schedule Specifications: Documentation of the underlying calculation methodology and criteria used to derive the Fee Amounts contained within the fee
schedule.
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Fee Source: The primary or alternate entity or publication that is supplying the Fee Basis.
Fixed Fees: Fee Amounts that are set at amounts which do not change. The Fee Amounts listed are intended for pricing purposes only and are subject to other matters
described in this Agreement, such as the Payment Policies.
Future Payment Terms: The general description of any pricing terms which will be implemented on a scheduled future effective date.
Last Routine Maintenance Update: The effective date on which this fee schedule was most recently updated. Please refer to the Routine Maintenance section of
this document for more information about Routine Maintenance updates.
Linked Fee Schedule ID: United's proprietary naming/numbering convention that is used to identify the specific fee schedule for each specific contractual
agreement. This is the fee schedule for services performed in facility Places of Service.
Modifier: A Modifier provides the means to report or indicate that a service or procedure has been altered by some specific circumstance but not changed in its
definition or code.
Place of Service: The facility or nonfacility setting in which the service is performed. This may also be referred to by CMS as Payment Type.
Pricing Level: The contracted percentage or amount that will be multiplied times the primary or alternate Fee Basis amount in order to derive the Fee Amount.
Primary Fee Source (Carrier Locality): The main Fee Source used to supply the Fee Basis amount for deriving the Fee Amount within each Type of Service
category. For instance, if the Fee Amounts for a given category of codes are derived by applying a particular Pricing Level to the CMS Resource-Based Relative Value
Scale (RBRVS), then CMS RBRVS is the Primary Fee Source. The Carrier Locality is designated to indicate the exact CMS geographic region upon which the Fee
Amounts are based.
Professional/Technical Modifier Pricing: Fee Source-Based: Fee Amounts for Modifiers (for example, -TC or -26 Modifiers) are derived using the Fee Basis
amount as published by the primary or alternate Fee Source.
RVU: Relative Value Unit as publishedby CMS. United uses the RVU that is used by CMS. For example, if CMS uses a transitional RVU, then United will as well.
Replacement Code: One or more new CPT or HCPCS codes that are the exact same services or descriptions and will replace one or more Expired Codes within the
same Type of Service category.
Report Date: The actual date that this document was produced.
Representative Fee Schedule Sample: A representative listing of the most commonly used CPT/HCPCS codes and fees, along with other relevant pricing
information, for each specific Fee Schedule ID. The Fee Amounts listed are intended for pricing purposes only and are subject to other matters described in this
Agreement, such as the Payment Policies.
Schedule Type: FES: This is a fee-for-scrvice fee schedule, Unless stated otherwise, the Fee Amount indicated will be used to calculate payment to you as farther
described within this document.
Site of Service Price Differential: Site of Service applies. CMS Assignment (ASC POS 24 =F): This fee schedule follows CMS guidelines for determining
when services are priced at the facility or nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be
priced at the facility fee schedule). CMS guidelines can be located at: www.ems.hhs..gov.
In the event that any of Uniteets claims systems cannot administer the calculation of Site of Service Differential pricing as indicated above, a different calculation
method will be used -mita such time as the appropriate system enhancements can be programmed and implemented. That different calculation method will result in a Fee
Amount that is no less than the Fee Amount that would apply under the method described above,
Type of Service: A general categorization of related CPT/HCPCS codes. Type of Service categories are intended to closely align with the CPT groupings in 'the
Current Procedural Terminology code book (as published by the AMA) and the HCPCS groupings (as published by CMS),
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The Office Lab Type of Service category represents those lab tests, as detemainedby United, in which the lab test result is necessary to make an informed treatment
decision while the patient is in the office,
A partial or complete crosswalk mapping of CPT/HCPCS to Type of Service categories is available to you upon request.
Section 2. Alternate Fee Sources
In the event the Primary fee Source contains no published Fee Basis amount, alternate (or "gap fill") Fee Sources may be used to supply the Fee Basis amount for
deriving the Fee Amount. For example, if a new CPDHCPCS code has been created within the Type of Service category of codes described above, and CMS has not yet
established an RBRVS value for that code, we use one of the Fee Sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential
RBRVS. For that CPT/I-WPCS code, we adopt the RBRVS value established by the gap-fill Fee Source, and determine the Fee Amount for that CPTHCPCS code by
applying to the RBRVS the same Conversion Factor and Pricing Level that we apply to the CMS RBRVS for those CPT/HCPCS codes that have CMS RBRVS
values. At such time in the future as CMS publishes its own RBRVS value for that CPT/HCFCS code, we would begin using the Primary Fee Source, CMS, to derive
the Fee Amount for that code and no longer use the alternate Fee Source.
More infonirtatn about all of our Fee Sources can be located at:
• Centers for Medicare and Medicaid Services (CMS) RBRVS and Fee Schedules: www.cms.hhs.gov
• Centers for Disease Control and Prevention (CDC) Private Sector Selling Price: www.cdc.gov/vaecines/nrograms/vfc/cdc-vac-price-list.litin
• Thomson Reuters Red Book: . yvwyv micromedex.com
• RI Health Systems: www.reimburseincritcodes,corn
• Ingenix Essential RBRVS: www.ingenixonline.com
• American Society of Anesthesiologists: www.asahq.orR
Section 3. Routine Updates
Routine updates occur when United mechanically incorporates revised information created by the Fee Source, and as described below, to update the Fee Amounts
calculated in accordance with this Fee Information Document. United routinely updates its fee schedule: (1) to stay current with applicable coding practices; (2) in
response to price changes for immunizations and injectable medications; and (3) to remain in compliance with IIIPAA requirements. United will not generally attempt
to communicate routine updates of this nature.
The types of routine updates, and their respective effective dates, are described below.
a. Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees
This fee schedule follows a "current year" construction methodology and will remain current with RVU, Conversion Factor, and flat rate fee (non-RVU based fees such
as OW fees) changes as the basis for deriving Fee Amounts. Therefore, the annual publication of RVUs and Conversion Factors by CMS will affect this fee schedule.
United will use reasonable commercial efforts to implement the updates in its systems on or before the later of (i) 90 days after the effective date of any modification
made by the Fee Source or (ii) 90 days after the date on which the Fee Source initially places inforination regarding such modification in the public domain (for
example, when CMS distributes program memoranda to providers). United will make the updates effective in its system on the effective date of the change by the Fee
Source. However, claims already processed prior to the change being implemented by United will not be reprocessed unless otherwise required by law. Unless
specifically stated otherwise, for those anesthesia services that are contracted on a time-based methodology, the Anesthesia Conversion Factor indicated within this
document is fixed and will not change. Please refer to the Anesthesia Conversion Factor section above. In the event that CMS does not publish a complete set of Fee
Basis amounts for a specific. code (for example: Global, -IC, and -26 fees) and the code contains a status code of "C" (indicating the code is cattier priced), United will
use reasonable commercial efforts to establish Fee Amounts for all modifiers associated with the code based on fee information available and published by the local
fiscal intermediary and by fiscal intermediaries from other locations.
b. Quarterly Updates in Response to Changes Published by Primary Fee Sources
United updates its fee schedule in response to changes published by Primary Fee Sources as a result of additions, deletions, and changes to CPT codes by the AMA or
HCPCS codes by CMS and any subsequent changes to CMS' annual update. United updates its fee schedules for new CPDHCPCS codes using the applicable
Conversion Factor and Pricing Level of the original construction methodology along with the then-current RVU of the published CPT/HCFCS code. The effective date
of the updates described in this subsection b. will be no later than the first day of the next calendar quarter after final publication by the Fee Source, except that if that
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quarter begins less than 60 days after _final publication, the effective date will be no later than the first day of the calendar quarter following the next calendar quarter.
For example, if final publication by the Fee Source is on April 10, the fee update under this subsection b. will be effective no later than July 1, and if final publication by
the Fee Source is on June 10, the fee update under this subsection b. will be effective no later than October 1. In the event that CMS does not publish a complete set of
Fee Basis amounts for a specific code (for example: Global, -TC, and -26 fees) and the code contains a status code of "C" (indicating the code is carrier priced), United
will use reasonable commercial efforts to establish Fee Amounts for all modifiers associated with the code based on fee information available and published by the local
fiscal intermediary and by fiscal intermediaries from other locations.
United G. Price routinely Changes updates for Immunizations the Fee Amounts in and response Injectables to price changes for immunizations and injectables published by the Fee Sources. In addition, United's Executive
Drug Pricing Forum (EDPF) meets on a quarterly basis to review and evaluate the drug prices that will be used in each quarterly update. The EDPF may address topics
including pricing for emerging drugs, anticipated manufacturer price changes, and special circumstances (for example, HIN I vaccine). Based on supporting information
provided by the drug manufacturer or the Fee Source, United's EDPF may elect to establish a Fee Amount or override a Fee Amount, as published by the Fee Source, in
favor of a Fee Amount that is more appropriate and reasonable for a particular vaccine or drug. These Fee Amount updates will be effective as describedbelow.
The effective date of updates wider this subsection c. will be no later than the first day of the next calendar quarter after final publication by the Fee Source, except that
if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the calendar quarter following the next calendar
quarter. For example, if final publication by the Fee Source is on April 10, the fee update under this subsection c. will be effective no later than July 1, and if final
publication by the Fee Source is on Rine 10, the fee update under this subsection c. will be effective no later than October 1.
United d. Other reserves Updates the right, but not thc obligation, to perform other updates as may be necessary to remain consistent with a Primary Fee Source. United also will perform
other updates as may be requiredby applicable law from time to time, United will use reasonable commercial efforts to implement the updates in its systems on or
before the later of (i) 90 days after the effective date of any modification made by the Fee Source or (ii) 90 days after the date on which the Fee Source initially places
information regarding such modification in the public domain (for example, when CMS distributes program memoranda to providers). United will make the updates
effective in its system on the effective date of the change by the Fee Source. However, claims already processed prier to the change being implemented by United will
not be reprocessed unless otherwise required by law,
For United More is committed Information to providing transparency related to our fee schedules. If you have questions about this fee schedule, please contact Network Management at the
address and phone number on your contract or participation agreement or you may use our fee schedule look-up function on the web at:
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210.
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MEDICARE ADVANTAGE REGULATORY REQ1UIREMENTS APPENDIX
THIS MEDICARE ADVANTAGE REGULATORY REQUIREMENTS APPENDIX (this
"Appendix") supplements and is made part of the network participation agreement (the
"Agreement") between United and the physician or provider named in the Agreement ("Provider").
SECTION 1
APPLICABILITY
This Appendix applies to the Covered Services Provider provides to Medicare Advantage
Customers. In the event of a conflict between this Appendix and other appendices or any provision
of the Agreement, the provisions of this Appendix shall control except: (1) with regard to Benefit
Plans outside the scope of this Appendix; (2) as noted in Section 2 of this Appendix; or (3) as
required by applicable law.
SECTION 2
DEFINITIONS
For purposes of this Appendix, the following terms shall have the meanings set forth below;
provided, however, in the event any definition set forth in this Appendix is in conflict with any
definition in the Agreement for the same or substantially similar term, the definition for such term
in the Agreement shall control. All other capitalized terms not otherwise defined in this Appendix
shall be as defined in the Agreement.
2.1 Benefit Plan: A certificate of coverage, summary plan description, or other document or
agreement, whether delivered in paper, electronic, or other format, under which a Payer is
obligated to provide coverage of Covered Services for a Customer. Benefit Plan may also be
referred to as benefit contract, benefit document, plan, or other similar term under the
Agreement.
2.2 CMS Contract: A contract between the Centers for Medicare & Medicaid Services
("CMS") and a Medicare Advantage Organization for the provision of Medicare benefits
pursuant to the Medicare Advantage Program under Title XVIII, Part C of the Social Security
Act.
2.3 Cost Sharing: Those costs, if any, under a Benefit Plan that are the responsibility of the
Customer, including deductibles, coinsurance, and copayments. Cost Sharing may also be
referred to as patient expenses or other similar term under the Agreement.
2.4 Covered Service: A health care service or product for which a Customer is entitled to
receive coverage from a Payer, pursuant to the terms of the Customer's Benefit Plan with that
Payer. A Covered Service may also be referred to as a health service or other similar term under
the Agreement.
PSMG/UHN PROVIDER.MEDICAREREGAPX.08.13 1 Confidential and Proprietary

2.5 Customer: A person eligible and enrolled to receive coverage from a Payer for Covered
Services. A Customer may also be referred to as an enrollee, member, patient, covered person,
or other similar term under the Agreement.
2.6 Dual Eligible Customer: A Medicare Advantage Customer who is: (a) eligible for
Medicaid; and (b) for whom the state is responsible for paying Medicare Part A and B Cost
Sharing.
2.7 Medicare Advantage Benefit Plans: Benefit Plans sponsored, issued or administered by
a Medicare Advantage Organization as part of the Medicare Advantage program or as part of the
Medicare Advantage program together with the Prescription Drug program under Title XVIII,
Part C and Part D, respectively, of the Social Security Act (as those program names may change
from time to time).
2.8 Medicare Advantage Customer or MA Customer: A Customer eligible for and
enrolled in a Medicare Advantage Benefit Plan in which Provider participates pursuant to the
Agreement.
2.9 Medicare Advantage Organization or MA Organization: For purposes of this
Appendix, MA Organization is either United or Payer.
2.10 Payer: An entity obligated to a Customer to provide reimbursement for Covered
Services under the Customer's Benefit Plan and authorized by United to access Provider's
services under the Agreement. A Payer may also be referred to as a payor, participating entity or
other similar term under the Agreement.
2.11 United: UnitedHealthcare Insurance Company and/or one or more of its affiliates.
SECTION 3
PROVIDER REQUIREMENTS
3.1 Data. Provider shall submit to MA Organization all risk adjustment data as defined in 42
CFR 422.310(a), and other Medicare Advantage program-related information as may be
requested by MA Organization, within the timeframes specified and in a form that meets
Medicare Advantage program requirements. By submitting data to MA Organization, Provider
represents to MA Organization, and upon MA Organization's request Provider shall certify in
writing, that the data is accurate, complete, and truthful, based on Provider's best knowledge,
information and belief.
3.2 Policies. Provider shall cooperate and comply with MA Organization's policies and
procedures.
3.3 Customer Protection. Provider agrees that in no event, including but not limited to, non-
payment by MA Organization or an intermediary, insolvency of MA Organization or an
intermediary, or breach by United of the Agreement, shall Provider bill, charge, collect a deposit
PSMG/UHN PROVIDER.MEDICIREREGAPX.08.13 2 Confidential and Proprietary

from, seek compensation, remuneration or reimbursement from, or have any recourse against any
MA Customer or person (other than MA Organization or an intermediary) acting on behalf of the
MA Customer for Covered Services provided pursuant to the Agreement or for any other fees that
are the legal obligation of MA Organization under the CMS Contract. This provision does not
prohibit Provider from collecting from MA Customers allowable Cost Sharing. This provision
also does not prohibit Provider and an MA Customer from agreeing to the provision of services
solely at the expense of the MA Customer, as long as Provider has clearly informed the MA
Customer, in accordance with applicable law, that the MA Customer's Benefit Plan may not cover
or continue to cover a specific service or services.
In the event of MA Organization's or an intermediary's insolvency or other cessation of operations
or termination of MA Organization's contract with CMS, Provider shall continue to provide
Covered Services to an MA Customer through the later of the period for which premium has been
paid to MA Organization on behalf of the MA Customer, or, in the case of MA Customers who are
hospitalized as of such period or date, the MA Customer's discharge.
This provision shall be construed in favor of the MA Customer, shall survive the termination of the
Agreement regardless of the reason for termination, including MA Organization's insolvency, and
shall supersede any contrary agreement, oral or written, between Provider and an MA Customer or
the representative of an MA Customer if the contrary agreement is inconsistent with this provision.
For the purpose of this provision, an "intermediary" is a person or entity authorized to negotiate
and execute the Agreement on behalf of Provider or on behalf of a network through which
Provider elects to participate.
3.4 Dual Eligible Customers. Provider agrees that in no event, including but not limited to,
non-payment by a state Medicaid agency or other applicable regulatory authority, other state source,
or breach by United of the Agreement, shall Provider bill, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any recourse against any Dual Eligible
Customer, person acting on behalf of the Dual Eligible Customer, or MA Organization (unless
notified otherwise) for Medicare Part A and B Cost Sharing, Instead, Provider will either: (a)
accept payment made by or on behalf of MA Organization as payment in full; or (b) bill the
appropriate state source for such Cost Sharing amount. If Provider imposes an excess charge on a
Dual Eligible Customer, Provider is subject to any lawful sanction that may be imposed under
Medicare or Medicaid. This provision does not prohibit Provider and a Dual Eligible Customer
from agreeing to the provision of services solely at the expense of the Dual Eligible Customer, as
long as Provider has clearly informed the Dual Eligible Customer, in accordance with applicable
law, that the Dual Eligible Customer's Benefit Plan may not cover or continue to cover a specific
service or services.
3.5 Eligibility. Provider agrees to immediately notify MA Organization in the event Provider
is or becomes excluded from participation in any federal or state health care program under Section
1128 or 1128A of the Social Security Act. Provider also shall not employ or contract for the
provision of health care services, utilization review, medical social work or administrative services,
with or without compensation, with any individual or entity that is or becomes excluded from
PSMG/WINPROVIDERMEDICAREREGAPX08.13 3 Confidential and Propriekny

participation in any federal or state health care program under Section 1128 or 1128A of the Social
Security Act.
3.6 Laws. Provider shall comply with all applicable federal and Medicare laws, regulations,
and CMS instructions, including but not limited to: (a) federal laws and regulations designed to
prevent or ameliorate fraud, waste, and abuse, including but not limited to, applicable provisions
of federal criminal law, the False Claims Act (31 U.S.C. §3729 et seq.), and the anti-kickback
statute (§1 128B of the Social Security Act); and (b) 1-11PAA administrative simplification rules at
45 CFR Parts 160, 162, and 164.
3.7 Federal Funds. Provider acknowledges and agrees that MA Organization receives
federal payments under the CMS Contract and that payments Provider receives from or on behalf
of MA Organization are, in whole or in part, from federal funds. Provider is therefore subject to
certain laws that are applicable to individuals and entities receiving federal funds.
3.8 CMS Contract. Provider shall perform the services set forth in the Agreement in a
manner consistent with and in compliance with MA Organization's contractual obligations under
the CMS Contract.
3.9 Records.
(a) Maintenance; Privacy and Confidentiality; Customer Access. Provider shall
maintain records and information related to the services provided under the Agreement,
including but not limited to MA Customer medical records and other health and
enrollment information, in an accurate and timely manner. Provider shall maintain such
records for the longer of the following periods:
in the case of records containing information related to the medical loss
ratio information reported to CMS by the MA Organization, including, for
example, infounation related to incurred claims and quality improvement
activities, at least ten (10) years from the date such medical loss ratio information
is reported to CMS by the MA Organization, or
(ii) in the case of all records, at least ten (10) years from the final date of the
CMS Contract period in effect at the time the records were created, or such longer
period as required by law.
Provider shall safeguard MA Customer privacy and confidentiality, including but not
limited to the privacy and confidentiality of any information that identifies a particular
MA Customer, and shall comply with all federal and state laws regarding confidentiality
and disclosure of medical records or other health and enrollment information. Provider
shall ensure that MA Customers have timely access to medical records and information
that pertain to them, in accordance with applicable law.
PSMG/UHN PROVIDERMEDICAREREGAPX08.13 4 Confidential and Proprietaly

(b) Government Access to Records. Provider acknowledges and agrees that the
Secretary of Health and Human Services, the Comptroller General, or their designees
shall have the right to audit, evaluate and inspect any pertinent books, contracts, computer
or other electronic systems (including medical records), patient care documentation and
other records and information belonging to Provider that involve transactions related to
the CMS Contract. This right shall extend through the longer of the following periods:
(i) in the case of records containing information related to the medical loss
ratio information reported to CMS by the MA Organization, including, for
example, information related to incurred claims and quality improvement
activities, at least ten (10) years from the date such medical loss ratio information
is reported to CMS by the MA Organization, or
(ii) in the case of all records, at least ten (10) years from the later of the final
date of the CMS Contract period in effect at the time the records were created or
the date of completion of any audit, or longer in certain instances described in the
applicable Medicare Advantage regulations.
For the purpose of conducting the above activities, Provider shall make available its
premises, physical facilities and equipment, records relating to MA Customers, and any
additional relevant information CMS may require.
MA Organization Access to Records. Provider shall grant MA Organization or its
designees such audit, evaluation, and inspection rights identified in subsection 3.9(b) as
are necessary for MA Organization to comply with its obligations under the CMS
Contract. Whenever possible, MA Organization will give Provider reasonable notice of
the need for such audit, evaluation or inspection, and will conduct such audit, evaluation
or inspection at a reasonable time and place. Provider shall submit medical records of
MA Customers to the MA Organization as may be requested, within the timeframes
specified, for the purpose of (i) CMS audits of risk adjustment data and (ii) for other
purposes medical records from providers are used by MA Organization, as specified by
CMS. Provision of medical records must be in the manner consistent with 1-11PAA
privacy statute and regulations.
3.10 MA Organization Accountability; Delegated Activities. Provider acknowledges and
agrees that MA Organization oversees and is accountable to CMS for any functions and
responsibilities described in the CMS Contract and applicable Medicare Advantage regulations,
including those that MA Organization may delegate to Provider or others. If MA Organization
has delegated any of its functions and responsibilities under the CMS Contract to Provider
pursuant to the Agreement, the following shall apply in addition to the other provisions of this
Appendix:
(a) Provider shall perform those delegated activities specified in the Agreement, if
any, and shall comply with any reporting responsibilities as set forth in the Agreement.
PSMG/UHN Pl?OVIDER.MEDICAREREGAPX08.13 5 Confidential and Proprietary

(b) If MA Organization has delegated to Provider any activities related to the
credentialing of health care providers, Provider must comply with all applicable CMS
requirements for credentialing, including but not limited to the requirement that the
credentials of medical professionals must either be reviewed by MA Organization, or the
credentialing process must be reviewed, pre-approved and audited on an ongoing basis by
MA Organization.
(c) If MA Organization has delegated to Provider the selection of health care
providers to be participating providers in MA Organization's Medicare Advantage
network, MA Organization retains the right to approve, suspend or teuninate the
participation status of such health care providers.
(d) Provider acknowledges that MA Organization shall monitor Provider's
performance of any delegated activities on an ongoing basis. If MA Organization or
CMS determines that Provider has not performed satisfactorily, MA Organization may
revoke any or all delegated activities and reporting requirements. Provider shall
cooperate with MA Organization regarding the transition of any delegated activities or
reporting requirements that have been revoked by MA Organization.
3.11 Subcontracts. If Provider has any arrangements, in accordance with the terms of the
Agreement, with affiliates, subsidiaries, or any other subcontractors, directly or through another
person or entity, to perform any of the services Provider is obligated to perform under the
Agreement that are the subject of this Appendix, Provider shall ensure that all such arrangements
are in writing, duly executed, and include all the terms contained in this Appendix. Provider
shall provide proof of such to MA Organization upon request. Provider further agrees to
promptly amend its agreements with such subcontractors, in a manner consistent with the
changes made to this Appendix by MA Organization, to meet any additional CMS requirements
that may apply to the services.
3.12 Offshoring. Unless previously authorized by MA Organization in writing, all services
provided pursuant to the Agreement that are subject to this Appendix must be perfointed within the
United States, the District of Columbia, or the United States territories.
SECTION 4
OTHER
4.1 Payment. MA Organization or its designee shall promptly process and pay or deny
Provider's claim no later than sixty (60) days after MA Organization or its designee receives all
appropriate information as described in MA Organization's administrative procedures. If Provider
is responsible for making payment to subcontracted providers for services provided to MA
Customers, Provider shall pay them no later than sixty (60) days after Provider receives request for
payment for those services from subcontracted providers.
4.2 Regulatory Amendment. MA Organization may unilaterally amend this Appendix to
comply with applicable laws and regulations and the requirements of applicable regulatory
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authorities, including but not limited to CMS. MA Organization shall provide written or
electronic notice to Provider of such amendment and its effective date. Unless such laws,
regulations or regulatory authority(ies) direct otherwise, the signature of Provider will not be
required in order for the amendment to take effect.
PSMG/UHN PROVIDERMEDICAREREGAPX.08.13 7 Confidential and Proprietaty