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HomeMy WebLinkAboutC12-416 Rocky Mountain Health Maintenance Organization Immunization Services AgreementIMMUNIZATION SERVICES AGREEMENT (County Health Department) ROCKY MOUNTAIN HEALTH Eagle County Government,d/b/a Eagle County HHS, MAINTENANCE ORGANIZATION,INC.,(herein “Contractor”) a Colorado nonprofit corporation U/b/a Rocky Mountain Health Plans,(herein “RMHMO”) Address of RMHMO and RME:Address of Contractor: 2775 Crossroads Boulevard 551 Broadway Post Office Box 10600 Eagle,CO 8163 1-0660 Grand Junction,CO 81502-5600 Tax I.D.No.:846000762 Rocky Mountain Entities (RME5)offer and administer Health Care Plans in Colorado. Health Care Plans offered by RMEs are marketed under the trade name of “Rocky Mountain Health Plans.” Contractor desires to participate in the delivery of Immunization Services to Covered Persons under the attached Terms and Conditions.Contractor will be reimbursed for such Immunization Services as set forth in the attached Terms and Conditions. This Agreement describes Contractor’s duties and obligations with regard to all lines of business for which RME offers a Health Care Plan.The particular lines of business and categories of Covered Persons for which Contractor shall provide Health Care Services under this Agreement are set forth on Exhibit A.To the extent this Agreement describes duties and obligations for a particular line of business or category of Covered Person for which Contractor does not provide services,those duties and obligations are not applicable to Contractor or RME. Contractor and RIVIHMO agree to all Terms and Conditions,attached,along with the Exhibits described below,all of which are incorporated herein by this reference. This Agreement is dated and shall be effective on the date set forth below by RMIIMO as the effective date. ROCKY MOUNTAIN HEALTH Eagle County Government,U/b/a Eagle County HHS MAINTENANCE ORGANIZATION INC. a Colorado nonprofit corporation U/b/a Rocky Mountain Health Plans Stephen K.Erken3rack,President and CEO (Signature) (Print/type name) Effective Date: _____________________ Title:(Ait RvY1kN (To be completed by RMHMO) ATTACHMENTS: Exhibit A:Compensation and Covered Lines of Business Exhibit B:Immunization Record Form Exhibit C:Law Exhibit Page 1 of 16 TERMS AND CONDITIONS Definitions.The words and terms below each have the following definitions: A.“Charges”shall mean the usual and customary charges hilled by Contractor for Immunization Services. B.“CHP+Contract”shall mean the agreement between RMHMO and the Colorado Department of Health Care Policy and financing (CDHCPf)pursuant to which RMHMO provides Health Care Services to members of the Child Health Plan Plus (CHP+)Program. C.“CHP+Covered Person”shall mean a person enrolled in the CHP+Program under a contract between RMHMO and CDHCPf,and for whom RMHMO provides Health Care Services under a Health Care Plan. D.“Claims Payment Criteria”shall mean those criteria that have been adopted by RME for the payment of Health Care Services,as subsequently amended from time to time. Claims Payment Criteria may include,but not be limited to,all claims payment programs, including but not limited to industry standard methodologies,such as Medicare Program Guidelines,Medicare’s Standard Correct coding Initiatives,Ingenix and DMERC,used by RIvIE in the adjudication of claims. E.“Coinsurance”shall mean the amount a Covered Person must pay for expenses incurred for Health Care Services after Covered Person has paid the applicable Deductible. F.“Consumer Protection Standards Act” shall mean the Consumer Protection Standards Act for the operation of Managed Care Plans found at section 10-16-701,et seq.,C.R.S. G.“Co-Payment”shall mean the predetermined amount,whether stated as a percentage or a fixed dollar,that a Covered Person must pay to receive specific Health Care Services. H.“Covered Person”shall mean a person who is eligible and enrolled in a Health Care Plan providing for Health Care Services.Only those categories of Covered Persons which are selected on attached Exhibit A will be included as Covered Persons under this Agreement. I.“Deductible”shall mean the amounts to be paid by the Covered Person for Health Care Services,before the Covered Person is entitled to benefits from the Health Care Plan. J.“Federal Health Care Program”shall mean any health care program offered or administered by the United States Government or for which the United States Government provides financial participation,including,but not limited to, Medicare. K.“HCO Covered Person”shall mean a Private Plan Covered Person who is eligible and enrolled in a Health Care Plan offered or administered by Rocky Mountain HealthCare Options,Inc.(“HCO”). L.“Health Care Plan”shall mean any health care plan offered or administered by RIvIE which:(1)RME is authorized by law to sell or administer and as to which no order or other governmental regulation has been issued which prevents the sale,operation,or administration thereof,(2)is provided pursuant to a contract between CDHCPF and RME for Medicaid Recipients,(3)is provided pursuant to a contract between CDHCPF and RME for CHP+Covered Persons,or (4)is provided pursuant to a contract between the Centers for Medicare &Medicaid Services (CMS)and RME for Medicare Beneficiaries.Health Care Plans shall not include plans offered by an RME that are state regulated Medicare supplemental policies offered pursuant to Article 1$of Title 10 of the Colorado Revised Statutes.Health Care Plans describe all services Covered Persons are entitled to receive and all service maximums, limitations and exclusions.Copies of Health Care Plans and/or summaries regarding such plans,along with any changes to such plans,will be provided to Contractor by RME,upon request. M.“Health Care Services”shall mean those services provided to Covered Persons,limited to Page 2 of 16 the benefits and subject to the exclusions described in the Covered Person’s Health Care Plan. N.“Immunization Services”shall mean those immunizations which are either administered orally or injected and the related services for those immunizations.Such immunizations are described in attached Exhibit A,are provided by a Nurse and performed pursuant to appropriate procedures and protocol as required by law or RME’s Medical Director.The Immunization Services a Covered Person is entitled to receive are limited to the benefits and subject to the exclusions described in the Covered Person’s Health Care Plan. 0.“Material Change”shall mean a change to this Agreement that decreases Contractor’s payment or compensation for services provided pursuant to this Agreement,changes RME’s administrative procedures in a way that may reasonably be expected to significantly increase Contractor’s administrative expense,replaces the maximum allowable cost list used by RME for reimbursement of generic prescription drug claims with a new and different maximum allowable cost list for reimbursement of generic prescription drug claims,or adds a new category of coverage to this Agreement.A Material Change does not include:(a)a decrease in payment or compensation resulting solely from a change in a published fee schedule upon which the payment or compensation is based and the date of applicability is clearly identified in this Agreement;(b)a decrease in payment or compensation resulting from a change in the fee schedule specified in a contract for pharmacy services such as a change in a fee schedule based on average wholesale price or maximum allowable cost;(c)a decrease in payment or compensation that was anticipated under the terms of this Agreement,if the amount and date of applicability of the decrease is clearly identified in this Agreement;(d)an administrative change that may significantly increase Contractor’s administrative expense, the specific applicability of which is clearly identified in this Agreement;(e)changes to an existing prior authorization,precertification, notification,or referral program that do not substantially increase Contractor’s administrative expense;or (f)changes to an edit program or to specific edits;however, Contractor shall be provided notice of the changes and the notice shall include information sufficient for Contractor to determine the effect of the change. P.“Medicaid Contract”shall mean the agreement between RME and CDHCPF pursuant to which RME provides Health Care Services under a Health Care Plan to Medicaid Recipients. Q.“Medicaid Recipient”shall mean a person CDHCPF certifies as eligible for Medicaid benefits under a Medicaid Contract. R.“Medical Director”shall mean the person designated by RMHMO as Medical Director or Chief Medical Officer or such person’s designee. S.“Medical Emergency”shall mean Health Care Services provided in connection with an event which a prudent lay person reasonably believes threatens his or her life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health. T.“Medical Practice Review Committee” (MPRC)shall mean the committee appointed by RIvIE to provide for ongoing quality improvement and utilization review of Medical Services provided to Covered Persons. U.“Medical Services”shall mean all medical, surgical,radiological,anesthesia and pathological outpatient and inpatient services which a Covered Person is entitled to receive pursuant to the Covered Person’s Health Care Plan,but shall exclude services rendered by optometrists,chiropractors and therapists. V.“Medically Necessary”Health Care Services are those services provided to a Covered Person that are required to preserve such Covered Person’s health according to the standards of medical practice in the Service Area.The fact that a Participating Physician or other health care professional may prescribe, order,recommend or approve a service or supply does not,in itself,make such service or supply Medically Necessary.The fact that a claim for a Health Care Service was paid by a Federal Health Care Program or State Health Page 3 of 16 Care Program does not,in itself make such Health Care Service Medically Necessary.If a dispute arises regarding the standards used to determine whether a specific Health Care Service is Medically Necessary,the decision rests solely with the Medical Director. W.“Medicare Beneficiary”shall mean a person entitled to the benefits provided under the federal health insurance program for people 65 or over and certain disabled people pursuant to an agreement between RME and CMS. X.“Nurse”shall mean,for purposes of this Agreement,a person who is licensed by the State of Colorado as a Licensed Practical Nurse (LPN)or a Registered Nurse (RN),and is either employed by or under contract with Contractor. Y.“Participating Physician”shall mean a person who holds a degree of Doctor of Medicine or Doctor of Osteopathy,is licensed by the State of Colorado to practice medicine, has a written agreement directly with RME,a Self Insured Employer or with an organization contracting with RIvIE,to provide Medical Services to Covered Persons under Health Care Plans,is certified to participate in the Medicare program under Title XVIII of the Social Security Act,and is not currently prohibited,excluded, suspended,debarred or otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program. Z.“Primary Care Physician”shall mean any Participating Physician who has a substantial practice in the fields of internal medicine,family practice,or pediatrics,and who has been designated by a Covered Person as the Participating Physician who is to attend to the Covered Person’s routine care and coordinate Medical Services in accordance with the Primary Care Procedures established by RME. AA.“Primary Care Procedures”shall mean those procedures established by RME for obtaining and receiving Health Care Services under a Health Care Plan. BB.“Private Plan Covered Persons”shall mean all Covered Persons except Medicaid Recipients, Medicare Beneficiaries,CHP+Covered Persons and Self Insured Plan Covered Persons. CC.“Rocky Mountain Entity”or “RME”shall mean RMHMO,HCO,CNIC Health Solutions, Inc.(CNIC)or any health maintenance organization,insurance company,health service corporation,or third party administrator: (1)that is a subsidiary of RMHMO,HCO or CNIC; (2)whose Health Care Plans are administered or sold by or through RMHMO,HCO,CNIC or Rocky Mountain Health Management Corporation;or (3)that has contracted with RMHMO, HCO,CNIC or any subsidiary of RMHMO, HCO or CNIC for the provision of medical or other health care related services to Covered Persons. References to “RME”shall mean the RME on whose behalf Immunization Services are being provided or the RME who is acting as a third party administrator for a Self Insured Employer’s Health Care Plan under which Health Care Services are being provided. DD.“Self Insured Employer”shall mean a self insured employer or plan sponsor offering self funded health care coverage to employees and their dependants,which employer or plan sponsor contracts with RME for RIvIE to provide third party administration services,including allowing such employer or plan sponsor to have access to RME’s networks or sub-networks of participating providers to provide services under the Self Insured Employer’s Health Care Plan. For purposes of this Agreement,Self Insured Employer shall mean the Self Insured Employer that offers the Health Care Plan for which Contractor is providing Health Care Services. EE.“Self Insured Plan Covered Persons”shall mean all Covered Persons who are eligible and enrolled in a self insured Health Care Plan which is administered by an RME. FF.“Service Area”shall mean the State of Colorado. GG.“State Health Care Program”shall mean any health care program offered or administered by or through a state or for which a state provides financial participation,including,but Page4ofl6 not limited to Medicaid,CHP+Program or a state employee health care plan. 2.Duties and Obligations of Contractor. A.Immunization Services to Covered Persons.Contractor shall provide,through the services of a Nurse,Immunization Services to Covered Persons pursuant to appropriate procedures and protocol as required by law or RME’s Medical Director.Every Nurse shall verify that the Covered Person:(1)has an RME identification card;and (2)signs an immunization record form,attached as Exhibit B of this Agreement.Contractor shall update the Covered Person’s immunization record and shall send the completed Exhibit B to the Covered Person’s Primary Care Physician and RME. B.Immunization Equipment Biohazardous Waste.Contractor shall dispose of all biohazardous waste,according to applicable local,state and federal law,including, but not limited to,needles,vials and syringes generated by Contractor in the performance of the duties required by this Agreement. C.Prior Authorization and Verification, Standing Referrals,and No Financial Disincentives. (1)Prior Authorization and Verification. Contractor is solely responsible for obtaining any required prior authorization from RME for services,treatments or procedures ordered or recommended by Contractor.The Covered Person shall not have this responsibility.If prior authorization from RME is required for a particular service provided to a Covered Person,such prior authorization will only be issued by RME in writing.If Contractor desires to verify the eligibility of a Covered Person or obtain information regarding the benefits under a Covered Person’s Health Care Plan,Contractor can telephone RME or use on-line eligibility as available to receive such information.Such verification, however,does not constitute prior authorization. (2)Standing Referral,A Covered Person is entitled to receive a Standing Referral,for medically necessary treatment,to a specialist or specialized treatment center participating in RIVIE’s network or participating in a subdivision or subgrouping of RME’s network if the subdivision or subgrouping demonstrates network adequacy pursuant to section 10-16-704, C.R.S.The Primary Care Physician for the Covered Person,in consultation with the specialist and Covered Person,shall determine that the Covered Person needs ongoing care from the specialist in order to make the Standing Referral.A time period for the Standing Referral of up to one (1) year,or a longer period of time if authorized by RME or an entity that contracts with RME,shall be determined by the Primary Care Physician in consultation with the specialist or specialized treatment center. The specialist or specialized treatment center shall refer the Covered Person back to the Primary Care Physician for primary care. To be reimbursed by RME or an entity contracting with RME,treatment provided by the specialist shall be for a Covered Person and must comply with the provisions contained in the Covered Person’s Health Care Plan.The Primary Care Physician shall record the reason,diagnosis,or treatment plan necessitating the Standing Referral.For the purpose of this paragraph, a Standing Referral shall mean a referral by the Covered Person’s Primary Care Physician to a specialist or specialized treatment center participating in RME’s network for ongoing treatment of a Covered Person.This paragraph shall only apply to Health Care Services provided to Private Plan Covered Persons and CHP+Covered Persons. (3)No Financial Disincentives.Contractor shall not be subject to financial disincentives based on the number of referrals made to participating providers for Health Care Services as long as Contractor adheres to RME’s or an RME intermediary’s utilization review policies and procedures,if any. D.Licensure.Contractor operates and is governed by section 25-1-501 et.seq.,C.R.S. Evidence of obtaining andlor maintaining compliance with such legal requirements shall be submitted to RME upon written request. Contractor shall provide copies of all and Page 5 of 16 (c)in connection with action by theaccreditation,certification and related documents to RIVIE upon request.Contractor shall notify RME immediately of the occurrence of any of the following: (1)revocation or suspension of Contractor’s ability to participate in the Medicare program;or (2)any action or situation that might or will materially affect Contractor’s ability to carry out its responsibilities under this Agreement. Contractor shall provide the Medical Director with any records pertaining to such matter as may be requested by the Medical Director. F.Records. (1)Contractor shall keep complete and accurate financial books and records pertaining to all billings and payments for Immunization Services to Covered Persons. Such books and records pertaining to Covered Persons shall be available to RME for inspection,copying and audit at the request of RME. (2)Contractor shall keep and maintain adequate medical records for Covered Persons meeting the minimum medical record documentation requirements of the Medical Director and as required by RME’s Medicaid Contract and/or CHP+Contract, as applicable.A copy of the minimum medical record documentation may be reviewed at the offices of RMHMO. Contractor shall permit the Medical Director to review the medical records of Contractor pertaining to any Covered Person: (a)to determine compliance with the medical record documentation requirement of the Medical Director and as required by RME’s Medicaid Contract and/or CHP+Contract,as applicable; (b)to assess quality of care,whether Immunization Services are or were Medically Necessary,and appropriateness of care;and/or MPRC. (3)All records referred to in this paragraph shall be available for inspection, examination and copying: (a)by RME,the State of Colorado and the United States Departments of Health and Human Services and Labor and their agents involved in assessing the quality of care or investigating Covered Persons’grievances or complaints or for other purposes allowed by applicable law; (b)at all reasonable times at Contractor’s place of business or at such other mutually agreeable location in Colorado;and (c)in a form maintained in accordance with the general record keeping standards applicable to such books and records. (4)In providing any records under this Agreement,RIvIE and Contractor shall comply with applicable state and federal laws relating to privacy and confidentiality of medical records,including,but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (5)Contractor shall provide copies or permit RME to make copies of records referred to in this paragraph at a fee of fifteen cents ($0.15)per page. (6)Contractor and RME shall cooperate and comply with audits and inspections of records or facilities,including site visits,as required by the Medical Director,RME or under state or federal law. (7)Contractor shall share with providers, who are treating or have treated a Covered Person,medical record information which facilitates the continuity of Health Care Services consistent with state and federal statutes and regulations. F.Contractor Liability Insurance.Contractor shall obtain and/or maintain liability insurance Page 6 of 16 which provides coverage to Contractor of not less than $1,000,000 per incident and $3,000,000 aggregate per year for any claims arising from or in connection with the provision of Immunization Services pursuant to this Agreement and for any claims arising as a result of the selection by Contractor of persons to provide Immunization Services to Covered Persons.Contractor shall furnish to RMHMO a certificate of such insurance,which provides for thirty (30)days’advance written notice to Contractor and RIVIHMO of any cancellation, reduction,modification or change in coverage. If Contractor is a public entity,the insurance required in this paragraph may be provided as authorized for such entity under the Colorado Governmental Immunity Act.Contractor does not waive protection of the Colorado Governmental Immunity Act. G.No Recourse Against Covered Persons or Colorado.Contractor hereby agrees that in no event,including,but not limited to,nonpayment by RME,RME’s insolvency,or breach of this Agreement,shall Contractor bill,charge,collect a deposit from,seek compensation, remuneration or reimbursement from,or have any recourse against a Covered Person,the State of Colorado,any Federal Health Care Program or State Health Care Program or persons (other than the RME)acting on the Covered Person’s behalf,for services provided pursuant to this Agreement.This provision does not prohibit Contractor from collecting Deductibles, Coinsurance or Co-Payments as specifically provided in the Covered Person’s Health Care Plan or fees or supplemental charges for uncovered services delivered on a fee-for- service basis to Covered Persons.Contractor further agrees that:(1)this provision shall survive the termination of this Agreement, regardless of the reason for termination, including insolvency of RME,and shall be construed to be for the benefit of Covered Persons,the State of Colorado and any Federal Health Care Program or State Health Care Program,and (2)this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Contractor and a Covered Person or persons acting on a Covered Person’s behalf insofar as such contrary agreement relates to liability for payment for or continuation of services provided pursuant to this Agreement.No changes,modifications, additions or deletions shall be made to the provisions of this paragraph without the prior written consent of the Secretary of the United States Department of Health and Human Services and such changes,modifications, additions or deletions shall become effective on a date no earlier than thirty (30)days afler the Colorado Commissioner of Insurance has received written notice of such proposed changes,modifications,additions or deletions with regard to Health Care Plans which are not self insured Health Care Plans.This paragraph shall not apply in the event of the insolvency of a Self Insured Employer who offers a self insured Health Care Plan administered by RME. H.No Recourse Against Medicaid Recipients. Contractor hereby agrees that Medicaid Recipients shall not be held liable for any of the following: (1)RME’s debts,in the event of RME’s insolvency; (2)Health Care Services provided to the Medicaid Recipient for which: (a)the State of Colorado does not pay RME;or (b)the State of Colorado or RME does not pay the individual or health care provider that furnishes the services under a contractual,referral,or other arrangement;and (3)Payments for Health Care Services furnished under a contract,referral,or other arrangement,to the extent that those payments are in excess of the amount that the enrollee would owe if RME provided the services directly. I.Compliance.Cooperation and Participation in RIvIE’s Policies and Procedures.Contractor and Physicians shall comply with policies and procedures and cooperate and participate in all aspects in the programs and systems implementing such policies and procedures pertaining to the provision of Medical Services to Covered Persons pursuant to Health Care Plans,including compliance with Primary Care Procedures,policies and procedures pertaining to the MPRC and RME’s quality improvement Page 7 of 16 program,Health Care Plan grievance procedures for Covered Persons,credentialing process,and billing process.Contractor and Physicians shall participate in and cooperate with the rules, regulations,procedures and decisions established by the utilization management program for the Health Care Plans,including, but not limited to,precertification requirements and procedures,referral processes and reporting of clinical encounter data.Within fourteen (14) days of a request by Contractor,RME shall provide Contractor with a copy of RIVIE’s Provider Manual and/or associated materials which describe the programs,policies and procedures referenced in this paragraph. J.Expressing Disagreement.No entity, individual or group of providers covered by this Agreement shall be prohibited or discouraged from protesting or expressing disagreement with a medical decision,medical policy,or medical practice of RME or an entity representing or working for RME (e.g.,a utilization review company),RME or any entity representing or working for RME shall not be prohibited or discouraged from protesting or expressing disagreement with a medical decision,medical policy,or medical practice of an entity, individual or group of providers covered by this Agreement.RME allows open communication regarding providers discussing appropriate treatment alternatives for Medically Necessary Health Care Services with Covered Persons and RME will not penalize providers for such discussions with Covered Persons. K.Medicaid Recipients Right to Participation.Contractor recognizes the Medicaid Recipient’s right to participate in decisions regarding the Medicaid Recipient’s health care,including the right to refuse treatment and to express preferences about future treatment decisions. L.Underutilization.RME does not compensate for denials nor does it offer incentives that encourage denials.Incentives, including compensation for Health Care Services provided to any Covered Person,are not based on the quantity or type of denial decisions rendered.RIvIE advises Contractor of the need for special concern about the risks of underutilization.Under no circumstances shall Contractor withhold the provision of Medically Necessary Health Care Services. M.Third Party Recovery and Coordination of Benefits.Contractor shall assist and cooperate in the recovery from third parties of any costs or expenses paid or incurred by RME or a Self Insured Employer on behalf of Covered Persons for which such third party is or may be liable. Such cooperation shall include furnishing records and testimony as needed.RME shall pay Contractor reasonable expenses incurred by Contractor in providing testimony for such matters.Upon payment to Contractor for services provided to a Covered Person pursuant to this Agreement,Contractor hereby assigns to RME or a Self Insured Employer,as applicable, all rights of Contractor to obtain payment from a third party for such services,including,but not limited to,rights of subrogation and reimbursement and lien rights.Contractor shall execute or provide any additional documents relating to such assignment upon RME’s reasonable request.In obtaining payment for services provided under this Agreement, Contractor shall comply with the Health Care Plan’s rules on coordination of benefits for Covered Persons.Contractor shall comply with all conditions and requirements for coverage under any primary policy,including,but not limited to,filing claims,providing notice and information,and obtaining prior authorization as may be required by the primary policy. Contractor’s failure to comply with this provision shall result in non-coverage under the Health Care Plan of any services or benefits subject to coverage by the primary policy. N.Claims to RME.In addition to the requirements for claims submission set forth below,Contractor shall use best efforts to submit claims in electronic format and shall include the National Provider Identifier (NPI)of the ordering or referring provider of Health Care Services on all claims submitted to RIVIE. (1)Claims for Private Plan Covered Persons,CHP+Covered Persons,Self Insured Plan Covered Persons and Medicare Beneficiaries.Contractor shall submit HIPAA éompliant claims to RME,on Uniform Health Care Claim Forms as defined in Section 10-16-106.3,C.R.S., within one hundred twenty (120)days of the Page 8 of 16 date services were rendered.If claims are not submitted within this period,then RME or a Self Insured Employer,as applicable, and Covered Persons shall not be liable for payment thereof.In instances where RME or a Self Insured Employer,as applicable,is secondarily liable,such time period shall be deemed to run from the date of the primary insurer’s final determination,but in no event shall the time to submit a claim to RME exceed three hundred sixty-five (365)days fiorn the date services were rendered.RME may waive this limitation with respect to any particular billing provided that such waiver shall not be construed to be or constitute a waiver of the time limits herein as to any other billing or billings.If RME determines that RME’s payment of a claim was either made in error or was an overpayment,RME shall make adjustment to the claim within one hundred eighty (180) days from the date of the original explanation of benefits,unless the adjustment concerns claims related to coordination of benefits with federally funded health benefit plans,including Medicare and Medicaid,in which event an adjustment of such claim shall be made within thirty-six (36)months from the date of service.If RME does not make the adjustment within such one hundred eighty (180)day period,or thirty-six (36)month period,as applicable,the payment shall be considered final and RME shall be deemed to have waived any objection to the payment.If Contractor disagrees with an RME denial of a claim or with the amount paid to Contractor by RME for a claim, Contractor must notify RME of its disagreement within one hundred eighty (180)days from the date of the original explanation of benefits or denial is issued, unless the disagreement concerns claims related to coordination of benefits with federally funded health benefit plans, including Medicare and Medicaid,in which event the notice of disagreement of such claim shall be made within thirty-six (36) months from the date of service.If Contractor does not notify RIVIE of its disagreement within such one hundred eighty (180)day period,or thirty-six (36) month period,as applicable,the payment or denial shall be considered final and Page 9 of 16 Contractor shall be deemed to have waived any objection to the payment or denial.Any limitations on adjustments to claims shall not apply to instances of reported fraud or abuse pursuant to Section 10-1-128,C.R.S. (2)Claims for Medicaid Recipients. Contractor shall submit HIPAA compliant claims to RME for Health Care Services provided to Medicaid Recipients in accordance with federal and state statutes, regulations and guidelines,the Medicaid Contract and the Colorado Medicaid guidelines. 0.Publicity.Contractor shall not use the trade name or trademark of RME,or advertise or broadcast in any way Contractor’s association with or relationship to RME,including without limitation by enumeration,newspapers,radio, television,signs,handout items and mailed items without the prior written approval of RIVIE’s marketing director or other person designated by RME. P.Hold Harmless by Contractor.To the Extent allowed by law,Contractor agrees to indemnify and hold RMHMO and RME harmless from any and all claims,demands, actions,causes of action,and expenses of any kind which may result or arise out of any alleged act or neglect caused or alleged to have been caused by Contractor or any of its agents, employees,or representatives in the performance or omission of any act relating to this Agreement. Q.Collection of Entitlement Payments. Whenever a Medicaid Recipient,Medicare Beneficiary or other Covered Person is eligible to receive any payment for covered Immunization Services from any legal entitlement program,Contractor shall,by following its customary collection procedures, attempt to collect such payments. R.Extension of Benefits.Provided that RME continues to comply with all tenns of this Agreement,Contractor shall be responsible to continue to provide benefits to a Covered Person in the event of termination of the Covered Person’s Health Care Plan to the extent RIVIE is required by state or federal law to continue benefits for the Covered Person or if such continuation of benefits is voluntary by RME. S.Non-Discrimination in Providing Services. Contractor shall not discriminate against any Covered Person on the basis of such Covered Person’s coverage being provided by an RME, the type of Health Care Plan under which the Covered Person is enrolled,source of payment for services provided under this Agreement,sex, age,race,color,religion,origin,health status,or handicap in providing Immunization Services under this Agreement. T.Non-Discrimination-Publicly Financed Programs.Contractor shall not discriminate, with respect to the provision of Medically Necessary Health Care Services,against any Covered Person who is a participant in a publicly financed program. U.Co-Payments,Coinsurance,Deductibles and Non-Covered Services.Contractor shall collect Co-Payments,Coinsurance and Deductibles from Covered Persons as may be required by Health Care Plans.To assure accurate payment of amounts owed, Coinsurance and Deductibles shall not be collected from Covered Persons until the claim for the Health Care Services has been processed and the explanation of benefits has been issued. Currently,Contractor is required to collect Co Payments,Coinsurance and Deductibles from Covered Persons except when Contractor provides Health Care Services to a Medicaid Recipient who is Co-Payment exempt or to a Private Plan Covered Person,not including an HCO Covered Person,in any of the following counties:Archuleta,Delta,Dolores,Eagle, Garfield,Grand,Gunnison,Jackson,Lake,La Plata,Mesa,Montezuma,Montrose,Ouray, Pitkin,Rio Blanco,San Juan,San Miguel and Summit.Contractor shall provide notice to Covered Persons of their personal financial obligations for non-covered services.RME will notify Contractor if Contractor’s obligation to collect Co-Payments,Coinsurance and Deductibles,as described in this paragraph, changes. V.Compliance with Exhibit C.Contractor shall comply with the terms of Exhibit C. W.Duties and Obligations Required by Law. To the extent any state or federal law requires that an RME have Contractor perform certain duties or obligations,Contractor shall perform such duties and obligations. X.Ownership Statement.To the extent Contractor provides Health Care Services to Medicaid Recipients,Contractor shall,upon request,provide an Ownership Statement to RIvIE as may be required by the State of Colorado for Medicaid subcontractors. Y.Discontinuance of Services to Covered Persons.Upon sixty (60)days’notice to RIVIE, Contractor may decline to provide services pursuant to this Agreement to new Covered Persons.The notice to RME shall state the reason or reasons for this action,for the purposes of this paragraph,“new Covered Persons”means those Covered Persons who have not received services from Contractor in the immediately preceding three (3)years.A Covered Person shall not become a “new Covered Person”solely by changing their coverage from one entity providing health care coverage to another entity providing health care coverage. Z.Proprietary Infonnati on,Contractor agrees that all information provided to Contractor by RME with respect to this Agreement,including,without limitation, compensation and all other terms of this Agreement,are proprietary and shall not be disclosed or communicated by Contractor in any manner to any third parties,except for disclosures on a need to know basis as may be necessary to administer the terms of this Agreement and disclosures required by applicable law.This section shall survive termination of this Agreement regardless of the cause for termination. 3.Duties and Obligations of RME. A.Financial Books and Records.RME shall keep and maintain in accordance with generally accepted accounting practices such financial and accounting records as are reasonable or necessary to administer Health Care Plans and to perform RME’s obligations under this Agreement. Page 10 of 16 B.Collection of Premiums and Income. RME shall exercise in good faith its best efforts to collect and receive all premiums and other items of income to which it is legally entitled. Any act,or refusal to act,on the part of an RME with respect to the collection or receipt of premiums or other items of income upon the advice of its legal counsel shall be deemed to be in good faith. C.Eligibility of Covered Persons.RME shall maintain a current eligibility data system and the mechanism for Contractor’s access to that system and for reconciliation of errors for Private Plan Covered Persons,Medicare Beneficiaries and CHP+Covered Persons. Contractor will be notified by RME of the mechanisms available to verify eligibility and any changes to such mechanisms.F or Medicaid Recipients,eligibility should be verified by using the system available through the State of Colorado.For Self Insured Plan Covered Persons,Contractor may verify eligibility by contacting the third party administrator of the self insured plan at the telephone number indicated on the Covered Person’s ID card.All documentation relating to eligibility verification for Covered Persons should be retained by Contractor. D.Administrative and Management Services. RME shall perform,or will arrange for the performance of all administrative,marketing, enrollment,financial,accounting,claims processing,payment,and other support services as are necessary or appropriate for the administration of its Health Care Plans and the performance of its obligations pursuant to this Agreement. F.Identification Cards.RME will provide Private Plan Covered Persons,Medicare Beneficiaries,CHP+Covered Persons and Self Insured Plan Covered Persons with an identification card which contains an address where claims can be sent and a phone number where inquiries may be directed. 4.Compensation. A.Payment.RME will pay Contractor the amount specified on Exhibit A,made a part hereof by this reference,for Medically Necessary Immunization Services provided to Covered Persons.RME will not pay Contractor for any Immunization Services if Contractor has previously been notified by RME that the RME will not pay Contractor for such particular Immunization Services.To the extent a Health Care Plan requires Contractor to collect Co Payments,Coinsurance or Deductibles, compensation paid to Contractor shall be reduced by the amounts of the applicable Co Payments,Coinsurance or Deductibles to be collected by Contractor. B,Third Party Administration of Self Insured Plans.If an RME is a third party administrator of a Health Care Plan offered by a Self Insured Employer,Contractor will provide Health Care Services to Self Insured Plan Covered Persons who are provided coverage under such Health Care Plan.Liability for payment under this Agreement for Health Care Services provided to Self Insured Plan Covered Persons shall be with the Self Insured Employer who is sponsoring the self insured Health Care Plan and not the RIVIE who is acting as the third party administrator. Payment however,on behalf of the Self Insured Employer,will be made through the RME that is providing third party administration but such RME shall have no liability for the payment. C.Time of Payment. (1)Private Plan Covered Persons,CHP+ Covered Persons and Medicaid Recipients. Clean Claims for Health Care Services provided to Private Plan Covered Persons, CHP+Covered Persons and Medicaid Recipients shall be paid,denied,or settled within thirty (30)calendar days after receipt by RME if submitted electronically and within forty-five (45)calendar days after receipt by RME if submitted by any other means.If RME requests information from Contractor regarding a claim,Contractor must supply RME with the requested information within thirty (30)days,or the claim will be denied. (2)Medicare Beneficiaries and Self Insured Plan Covered Persons.Except as otherwise provided by law or as may be required by RME under any contractual obligations, RME shall use its best effort to pay Contractor the applicable compensation amount for Health Care Services provided to Page 11 of 16 Medicare Beneficiaries and Self Insured Plan Covered Persons within sixty (60)days following receipt of a “Clean Claim.” For purposes of this Agreement,a Clean Claim shall mean a claim for payment of Health Care Services provided to Covered Persons that is submitted to RME by Contractor which meets all requirements for the definition of a “Clean Claim”as set forth in section 10-16-106.5(2), C.R.S.A Clean Claim does not include a claim for payment of expenses incurred during a period of time for which premiums are delinquent,except as otherwise required by law. D.Reduction in Compensation Amount.To the extent RME is paid on a cost basis for Health Care Services provided under a Federal Health Care Program or a State Health Care Program, and payment to RME is reduced,RME shall have the right to adjust payment to Contractor for applicable Health Care Services accordingly. E.Compensation Denied/Adjusted.RME may deny or adjust any compensation due Contractor in the event the Immunization Services provided by Contractor to Covered Persons do not comply with the standards of quality of care or utilization of care as established by RME or the MPRC,or the fees or charges for such Immunization Services do not comply with Claims Payment Criteria as established by RME. 5.Ouality Improvement and Utilization Review. A.Effective Quality Improvement and Utilization Review Programs.The parties recognize the necessity for quality improvement and utilization review programs and shall cooperate to achieve effective programs. B.Records and Studies.Contractor shall provide the Medical Director access to medical and other records of Covered Persons for the purpose of conducting quality improvement and utilization review programs.Contractor agrees to assist and cooperate with RIvIE in conducting quality improvement and utilization review for Covered Persons,in person or by telephone.If RME requests Contractor to conduct a quality improvement study or utilization review program for Covered Persons,then the RME will pay Contractor for such activity based upon a mutually agreed upon fee. C.Contractor Review.Contractor may conduct its customary and usual programs for quality improvement and utilization review upon Covered Persons.The findings of such reviews of Covered Persons shall be provided to RME to the extent allowed by Colorado law. 6.Effective Date and Termination. A.Effective Date/Duration.This Agreement is effective beginning as of the date of this Agreement,and shall continue in effect from year to year after such date unless otherwise terminated in accordance with the provisions of this Agreement. B.Termination for Breach.This Agreement may be terminated by RMHMO or Contractor upon a material breach of this Agreement, provided that the breaching party does not cure the breach within sixty (60)days following receipt of a written notice from the non- breaching party specifying the breach and requesting that it be cured. C.Unilateral Termination.Notwithstanding the foregoing,this Agreement may be terminated by RMHMO or Contractor without cause on at least ninety (90)days’prior written notice to the other party.Such termination,however,cannot occur earlier than one (1)year from the date of this Agreement if this Agreement includes services provided under a Federal Health Care Program or State Health Care Program. D, RMHMO may terminate this Agreement immediately with notice to Contractor for any of the following causes: (1)Contractor’s license provided to it by the Colorado Department of Public Health and Environment is revoked or suspended; (2)Contractor’s federal certification to participate in the Medicare program under Title XVIII of the Social Security Act is revoked or suspended;or Page 12 of 16 (3)RMHMO reasonably determines that continuation of this Agreement may negatively affect Covered Persons’care. E.Continuation of Benefits for Covered Persons.Contractor hereby agrees that in the event of RIvIE’s insolvency or other cessation of operations of RME,Contractor will continue to provide benefits to Covered Persons through the period for which premium has been paid,and continue benefits to Covered Persons confined in an inpatient facility on the date of insolvency or other cessation of operations until their discharge.Contractor hereby agrees that under no circumstances,including,but not limited to, nonpayment by RME,insolvency of RiME,or breach of this Agreement,will Contractor bill, charge,seek compensation,remuneration or reimbursement from,or have recourse against Covered Persons,the State of Colorado,any Federal Health Care Program or State Health Care Program or persons acting on Covered Person’s behalf for services provided pursuant to this Agreement.This provision shall not prohibit collection of Co-Payments,Coinsurance or Deductibles,where applicable,or charges for uncovered services delivered on a fee-for- service basis,to Covered Persons.Contractor further agrees that (I)this provision shall survive the termination of this Agreement, regardless of the reason for termination, including insolvency of RME,and shall be construed to be for the benefit of Covered Persons,the State of Colorado and any Federal Health Care Program or State Health Care Program,and (2)this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Contractor and a Covered Person or persons acting on a Covered Person’s behalf insofar as such contrary agreement relates to liability for payment for or continuation of services provided pursuant to this Agreement.No changes,modifications, additions or deletions shall be made to the provisions of this paragraph without the prior written consent of the Secretary of the United States Department of Health and Human Services and such changes,modifications, additions or deletions shall become effective on a date no earlier than thirty (30)days after the Colorado Commissioner of Insurance has received written notice of such proposed changes,modifications,additions or deletions. This paragraph does not apply to Health Care Services provided to Self Insured Plan Covered Persons. F.Medical Director Right of Suspension. The Medical Director shall,during the term of this Agreement,have the right to suspend Contractor as an RME provider if the Medical Director determines that the failure to take such action may result in imminent danger to the health of a Covered Person or Covered Persons. G.Discontinuance of Medicare,Medicaid or CHP+Lines of Business.RIvIHMO may discontinue the Medicare,Medicaid and/or CHP+lines of business and/or Contractor’s right and obligation under this Agreement to provide services to Covered Persons who are Medicare Beneficiaries,Medicaid Recipients and/or CHP+ Covered Persons upon sixty (60)days’prior written notice to Contractor. H.Limitations on Termination.RMHMO shall not terminate this Agreement because a provider covered by this Agreement:(1) expresses disagreement with a decision by RME, or an entity representing or working for RME,to deny or limit benefits to a Covered Person;(2) assists a Covered Person in seeking reconsideration of such decision;(3)discusses with a current,former or prospective patient any aspect of the patient’s medical condition,any proposed treatments or treatment alternatives, whether covered by a Health Care Plan or not,or policy provisions of a Health Care Plan;or (4) makes a personal recommendation regarding selection of a health plan based on personal knowledge of the health needs of such patients. This paragraph shall not be construed as a limitation on either party’s right to terminate this Agreement without cause,as set forth herein. I.Continuity of Care.If this Agreement is terminated by RMHMO without cause and RME fails to provide written notice of the termination to Covered Persons who are patients of Contractor as required by the Consumer Protection Standards Act,Contractor will continue to provide covered services to RME Covered Persons for sixty (60)days following the date of termination.If coverage for a Covered Person under a Health Care Plan is terminated for any reason other than nonpayment of premium,fraud,or abuse, Contractor shall continue to provide covered Page 13 of 16 services to such a Covered Person who is being treated at an inpatient facility until such Covered Person is discharged.For any covered services provided under this subparagraph,RME will pay Contractor the compensation rate set forth in this Agreement.This paragraph shall only apply to the extent applicable law requires the continuity of care as described in this paragraph.This paragraph shall only apply to Health Care Services provided to Private Plan Covered Persons and CHP+Covered Persons. J.List of Contractor Patients.Within five (5) working days following the date Contractor gives or receives a written notice of tennination of this Agreement pursuant to the termination provisions of this Agreement,Contractor will provide RIvIE with a list of Contractor’s patients who are covered by an RME Health Care Plan. K.Termination During the First Year.In the event this Agreement is terminated within one (1)year from the date of this Agreement,then RMHMO and Contractor shall not enter into any new financial arrangements with each other regarding the subject matter of this Agreement until the one (1)year period expires. 7.General Provisions. A.Construction of Agreement.To the extent any of the definitions or other provisions of this Agreement with regard to Private Plan Covered Persons conflict with the definitions or provisions in a Health Care Plan or the Consumer Protection Standards Act,the definitions and provisions of the Health Care Plan or the Consumer Protection Standards Act shall prevail. B.No Rights to Covered Persons.This Agreement shall not be construed to provide any right to a Covered Person or to increase the duties or responsibilities of the parties hereto beyond the requirements established by this Agreement.The sole purpose of this Agreement is to establish the respective rights and duties of the parties hereto,each to the other.Any rights of a Covered Person are derived solely from the Covered Person’s Health Care Plan. C.Governing Law and Venue.This Agreement shall be governed by the laws of the State of Colorado.This Agreement shall be governed by and construed in accordance with all laws, regulations and contracts of CDHCPF relating to CHP+Covered Persons and Medicaid Recipients who are Covered Persons,and all laws,regulations and contracts of CMS relating to Medicare Beneficiaries who are Covered Persons.Venue of all matters shall be in Denver County,Colorado. D.Severability.If any provision of this Agreement is held to be invalid or unenforceable,the remaining provisions shall continue in full force and effect,unless the invalid or unenforceable provision is material to this Agreement and its invalidity or unenforceability results in substantial economic detriment to either party to this Agreement. E.Assignment,Contractor’s rights,duties and responsibilities pursuant to this Agreement may not be assigned or delegated by Contractor without the prior written consent of RMHMO. RIVIHMO may assign its rights,duties and responsibilities pursuant to this Agreement,but only if such assignee assumes all such rights, duties and responsibilities. F.Right of Setoff.If any amounts are owed to any RME by Contractor,any RME shall have the right to setoff such amounts from any amounts owed to Contractor by any RME. G.ationyjti Provjd.ers.This is not an exclusive Agreement.Contractor acknowledges that RME may offer Covered Persons financial incentives to use certain providers.Contractor agrees to cooperate with RIvIE and its contractees and providers in the provision of health care to Covered Persons. H.Authority to Contract.The undersigned individuals represent that they are fully authorized to execute this Agreement on behalf of the respective parties,perform the obligations under this Agreement,and make all representations,warranties,and grants as set forth herein, I.Relationship of Parties.This Agreement is intended to create the relationship of independent contractor on the part of Contractor as to the performance of its duties and obligations under this Agreement.Nothing contained herein shall be interpreted to create Page 14 of 16 any relationship of agency,partnership or joint venture between RME and Contractor,including any officer,director,employee or shareholder of RME or Contractor.Neither party shall represent or hold themselves out to any person or entity other than is consistent with the relationship of independent contractor. J.Entire Agreement.This Agreement,and the Exhibits attached to this Agreement,constitute the entire understanding and agreement of the parties,and shall supersede all prior understandings and agreements of the parties on the subject matter of this Agreement. K.Amendments. (1)Material Amendments.Upon at least ninety (90)days prior written notice, RMHMO may unilaterally amend this Agreement to make Material Changes to this Agreement.If Contractor objects in writing to an amendment containing a Material Change within fifteen (15)days and there is no resolution of the objection,either party may terminate this Agreement upon written notice of termination provided to the other party not later than sixty (60)days before the effective date of the amendment.If Contractor does not object to the amendment,the amendment shall be effective as specified in the amendment. Notwithstanding the above,if the subject of an amendment containing a Material Change is the addition of a new category of coverage and Contractor objects as specified in this paragraph,the amendment shall not be effective as to Contractor,and the objection shall not be a basis upon which RMHMO may terminate this Agreement. (2)Non-Material Amendments.Upon at least fifteen (15)days prior written notice, RMHMO may unilaterally amend this Agreement to make administrative,non- Material Changes to this Agreement. (3)State and federal Law Amendments.In addition to RMHMO’s right to amend the Agreement as set forth above,RIVIHMO may unilaterally amend this Agreement in order to comply with any applicable federal or state laws or regulations.Any such unilateral amendment shall become effective on the date stated in the notice of amendment provided that such date is fifteen (15)days following RMHMO’s notice to Contractor of the amendment,except that the amendment may become effective on an earlier date if any applicable state or federal law,statute or regulation that was the basis of the amendment requires a specific date of compliance,which date is less than fifteen (15)days following RIvIHMO’s notice. L.Notices.Whenever required hereunder, notices,except notices of termination and breach,shall be deemed sufficiently given if made in writing,upon mailing,via United States Mail,or a recognized overnight delivery service, to the address of the parties set forth on the signature page of this Agreement.Notices of termination and breach shall be deemed sufficiently given if made in writing,upon mailing,via United States Mail,postage prepaid, certified mail,return receipt requested,or via a recognized overnight delivery service,to the addresses of the parties set forth on the signature page of this Agreement.The address to which notices are given may be changed by notice of change of address given in the method and manner provided herein. M.Waiver.No party will be deemed to have waived any rights hereunder unless the waiver is made in writing and signed by the waiving party or that party’s duly authorized representative. The failure to exercise any right or remedy under this Agreement shall not operate as a waiver of such right or remedy.All rights and remedies provided for under this Agreement are cumulative.A waiver by any party of a breach of a provision of this Agreement or warranty or representation set forth herein will not constitute a waiver of that provision,warranty or representation or any other provision,warranty or representation. N.Benefit.The terms and provisions of this Agreement shall bind and benefit Contractor and permitted assigns,and shall bind and benefit RIvIHMO and its agents,employees, representatives,successors and assigns.An RME other than RMHMO shall be a third party beneficiary of this Agreement to the extent that Contractor provides services to Covered Persons enrolled under such RME’s Health Care Plan,or under a Health Care Plan for which such RME is Page 15 of 16 a third party administrator.To the extent an Relationship: RME other than RMHMO is a third party beneficiary of this Agreement,such RME shall also have the obligations of RIvIE under this Agreement as set forth herein.Each RME shall only have obligations under this Agreement for those services provided under the terms of this Name of Other Provider: Agreement to Covered Persons enrolled under such RME’s Health Care Plan or for which ______________________ Health Care Plan such RME is a third party administrator.Except as provided in this ______________________ paragraph,no other person or entity shall be a third party beneficiary of this Agreement. Name: 0.Disclosure of Interests,Contractor must complete the following only if Contractor will provide Health Care Services to Medicaid Recipients under this Agreement.The following Address: list contains a full disclosure of (a)the names and addresses of all individuals with any financial interest in the party who is entering into this Agreement with RMHMO,(b)a description of whether any of the individuals listed are related to each other as spouse,parent, child or sibling,and (c)the name of all other Relationship: Medicaid providers in which any of the listed ______________________ individuals has a financial interest: Name: Name of Other Provider: Address: Page 16 of 16 EXHIBIT A TO IMMUNIZATION SERVICES AGREEMENT (County Health Department) COMPENSATION Notwithstanding any other provisions of this Agreement,Covered Persons under this Agreement shall include only the lines of business /categories of Covered Persons which are checked below: Private Plan Covered Persons Self Insured Plan Covered Persons Medicare Beneficiaries Medicaid Recipients CHP+Covered Persons 1.Private Plan Covered Persons and Self Insured Plan Covered Persons.RIvIE will pay Contractor the Average Wholesale Price (AWP)*for the serum and one hundred percent (100%)of the Medicare rate as determined by use of the current edition of the Resource Based Relative Value Schedule (RBRVS)as an administration fee per injection for each immunization listed in the chart below which is provided to a Private Plan Covered Person or a Self Insured Plan Covered Person.RIVIE will pay Contractor as set forth in the chart below for in-office laboratory procedures provided to a Private Plan Covered Person or a Self Insured Plan Covered Person. 2.Medicare Beneficiaries and Medicare Beneficiaries/Medicaid Recipients.RIVIE will pay Contractor AWP*for the serum and one hundred percent (100%)of the Medicare rate as determined by use of the current edition of RBRVS as an administration fee per injection for each immunization listed in the chart below which is provided to a Covered Person who is a Medicare Beneficiary or both a Medicare Beneficiary and Medicaid Recipient,except that if such Covered Person is under the age of 19,the administration fee shall be payment in full for the Immunization Services.RME will pay Contractor as set forth in the chart below for in-office laboratory procedures provided to a Medicare Beneficiary or a Covered Person who is both a Medicare Beneficiary and a Medicaid Recipient. 3.Medicaid Recipients.for in-office laboratory procedures and immunizations provided to a Medicaid Recipient, RME will pay Contractor,as payment in full,the amount Contractor would receive from the Colorado Department of Health Care Policy and Financing (CDHCPF)under the Medicaid program,as administered by CDHCPF for such immunizations. 4.CHP+Covered Persons.For in-office laboratory procedures and immunizations provided to a CHP+Covered Person,RME will pay Contractor,as payment in full,the amount Contractor would receive from CDHCPF under the CHP+ Program,as administered by CDHCPF for such immunizations. Contractor shall use the CPT codes listed below,or the most culTent codes describing such procedures,when completing each “CMS 1500”form to be submitted to RME.Except as set forth below,Contractor’s administration fee shall include all vaccine and supplies required for the Immunization Services provided by Contractor pursuant to this Agreement.While the CPT codes listed below are a general range of codes,Contractor shall provide the necessary Immunization Services for which Contractor or Contractor’s staff are licensed and qualified to provide through or on behalf of Contractor and for which appropriate CPT codes for such services are defined. *(l)For Medicare Beneficiaries,RME will not pay Contractor for these items which are only reimbursable under Medicare Part D. (2)During the term of this Agreement,in the event the pricing source used to determine AWP changes the methodology by which AWP is calculated or reported,or AWP is no longer used as an industry pricing methodology,RIvIHMO will notif’ Contractor of the new pricing methodology that will be used in lieu of AWP,provided that the pricing methodology is a standard used in the industry.If such notice is given by RMHMO to Contractor,the new pricing methodology as described by RIvIHMO in such notice shall be used instead of AWP and shall be updated as described in such notice. EXHIBIT A Page 1 of2 f[DESCRIPTION Of IMMUNIZATION CODES 90281 —Immune Globttlins (must be reported in addition to the administration codes 90399 90780 —90784 as appropriate) 90471 Immunization administration (includes percutaneous,intradermal,subcutaneous, intramuscular and jet injections;one vaccine (single or combination vaccine/toxoid).Must be reported in addition to the vaccine and toxoid codes 90476 —90749. 90472 Immimization administration (includes percutaneous,intradermal,subcutaneous, intramuscular and jet injections);each additional vaccine (single or combination vaccine/toxoid)(List separately in addition to code for primary procedure).Must be reported in addition to the vaccine and toxoid codes 90476 —90749. 90476 —Vaccines,Toxoids (90476 90748 identify the vaccine product only.To report 90749 the administration of a vaccine/toxoid,the vaccine/toxoid product codes 90476 90749 must be used in addition to an immunization administration code 90471, 90472. fI COMPENSATION FOR IN-OFFICE LABORATORY TESTS CODES 86580 Skin Test,tuberculosis,intradermal 100%of the Medicare rate as detennined by use of the current edition of RBRVS If Medicaid Recipients are not Covered Persons under this Agreement,and Contractor or Health Care Professional, as applicable,provides services otherwise covered under this Agreement to a Medicaid Recipient,RME will pay Contractor the amount Contractor or Health Care Professional,as applicable,would receive from CDHCPF under the Medicaid program,as administered by CDHCPF for such services. EXHIBIT A Page 2 of 2 EXHIBIT B TO IMMUNIZATION SERVICES AGREEMENT (County Health Department) IMMUNIZATION RECORD FORM Please complete the following information for our records: Date: ___________________ Birthday: Covered Person’s Name: ___________________________________ Phone: Address: __________________________________________________________________ Street City State Zip Code Parent(s)/Guardian(s): ____________________________________________ Doctor’s Name: ________________ If you or your child are provided healthcare coverage by Rocky Mountain Health Maintenance Organization,Inc., Rocky Mountain HealthCare Options,Inc.or a self insured employer who uses an RME as a third party administrator for your health care plan,we will bill Rocky Mountain Health Maintenance Organization or Rocky Mountain HealthCare Options,Inc.for the immunizations received today.We will also be sending a record of the immunizations received today to your or your child’s physician. Covered Person /Parent/Guardian Signature: Dear Doctor: The following immunizations were given to the above named Covered Person at ______________ on the date shown.This form has been provided to you for the purposes of updating your patient records.Please retain for your files. DPT 1st 2nd 3rd 4th 5th 1St 3rd 4th OPV 1st 2’3td 4111 IPV 1st 3rd 4th HIB 151 2nd 3rd 4th Varicella yst 2’’ MMR lIt 2nd l 2d 3rd TB 1st 2nd 3rd 4th Hemophilus B 151 2nd •3rd 4th Adult Td lIt 2 3rd 4111 Influenza 1st 2nd 3rd 4th Pneumonia 1St 2i,d 3rd 4th Other: EXHIBIT B Page 1 of 1 EXHIBIT C TO AGREEMENT The terms of this Exhibit are made a part of and are included within the Agreement to which this Exhibit is attached.Any party (Contractor)entering into the Agreement with RMHMO shall comply with all applicable terms and conditions of this Exhibit.The applicability of each paragraph depends on the type of Health Care Plan for which Contractor provides Health Care Services and is noted below. SECTION 1.The paragraphs in Section I apply to all Health Care Plans. 1.Non-Discrimination.Contractor agrees to comply with all applicable state and federal laws respecting discrimination and unfair employment practices. 2.Equal Opportunity.It is the policy of RMHMO to provide equal opportunity and to prevent discrimination based on race,color,national origin,age or disability in admission or access to,or treatment or employment in,RMHMO programs,health care plans,and activities to the extent required by applicable law. Contractor shall comply with this policy as may be required by law.All federally funded benefits and services are provided in accordance with Title VI of the Civil Rights Act,as amended,Section 504 of the Rehabilitation Act,as amended,the Age Discrimination Act of 1975,as amended,the Americans with Disabilities Act of 1990, as amended,as well as other related laws.All Contractors and subcontractors are notified of their responsibility to comply with these laws.The EEO Officer is responsible for compliance with state and federal equal opportunity laws.The EEO Officer is also responsible for implementing the Equal Opportunity Plan.If Contractor or a Covered Person has any questions concerning this policy,Contractor or Covered Person should contact the RMHMO Member Concerns Coordinator at (800)346-4643or (970)243-7050,or TTY (970)248- 5019 or ($00)704-6370;para asistencia en Español Ilame al (800)346-4643. 3.cpijgpccflan.RMHMO has a compliance plan (Compliance Plan)in place.Contractor shall not take any action to cause a violation of the terms of this Compliance Plan.A copy of the Compliance Plan will be provided to Contractor upon written request.Contractor shall contact the Compliance Officer at RMHMO if Contractor becomes aware of or suspects any fraud,waste,abtise or non-compliance with the Compliance Plan. 4.tilegal Aliens.Contractor certifies that Contractor does not knowingly employ or contract with any illegal aliens to perform services under the Agreement.If RME obtains actual knowledge that Contractor knowingly employs or contracts with an illegal alien to perform services under the Agreement,RME shall 1) notify Contractor within three (3)days that RME has actual knowledge that Contractor is employing or contracting with an illegal alien to perform services under the Agreement;and 2)terminate the Agreement,unless, within three (3)days of receiving notice from RME,(a)Contractor stops employing or contracting with the illegal alien to perform services under the Agreement,or (b)Contractor provides information to RME to establish that Contractor has not knowingly employed or contracted with the illegal alien to perform services under the Agreement.If Contractor becomes aware that Contractor has employed an illegal alien to perform services under the Agreement,whether knowingly or unknowingly,Contractor must end such employment immediately. SECTION II.The paragraphs in Section II apply to Federal Health Care Programs. 1.Incorporation of Federal Acquisition Regulations by Reference.Because RMHMO is a contractor with the federal government,the following provisions are incorporated by reference into the Agreement with the same force and effect as if the provisions were given in full text.These provisions are incorporated into the Agreement only to the extent required by applicable law.Upon request,RMHMO will make the full text of the provisions available: A.Equal Opportunity (48 C.F.R.§52.222-26); B.Utilization of Small Business Concerns and Small Disadvantaged Business Concerns (48 C.F.R. EXHIBIT C Page 1 of7 §52.219-8); C.Small Btisiness and Small Disadvantaged Business Subcontracting Plan (48 C.F.R.§52.219-9); D.Certification of Nonsegregated Facilities (48 C.F.R.§52.222-21); E.Affirmative Action for Special Disabled Veterans,Veterans of the Vietnam Era,and Other Eligible Veterans (48 C.f.R.§52.222-35); F.Affirmative Action for Workers with Disabilities (48 C.F.R.§52.222-36); G.Employment Reports on Special Disabled Veterans,Veterans of the Vietnam Era,and Other Eligible Veterans (48 C.f.R.§52.222-3 7); H.Fees or Kickbacks By Subcontractors (Anti Kickback Procedures)(48 C.F.R.§52.203-7);and 2.Program Eligibility.RMHMO and Contractor represent to the other that they have not been debarred, sttspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program.Contractor will take no action during the term of this Agreement which would result in its being debarred,suspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program,In addition,during the term of this Agreement,Contractor has not and will not arrange or contract with any employee,contractor,or agent for the provision of items or services under this Agreement who Contractor knows or should know is debarred,suspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program.If either party determines that the other party is,or becomes during the term of this Agreement,debarred,suspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program,the party that is not debarred,suspended,or made otherwise ineligible may terminate this Agreement immediately. 3.Notice of Non-segregated Facilities.To the extent required by applicable law,Contractor certifies that Contractor does not and will not maintain or provide for Contractor’s employees any segregated facilities as defined in 48 C.f.R.§52.222-21(a)at any of Contractor’s establishments,and that Contractor does not and will not permit Contractor’s employees to perform their services at any location under Contractor’s control where segregated facilities are maintained.Contractor agrees that a breach of this certification shall be a violation of the Equal Opportunity provision in paragraph I. 4.Prohibition Against Use of CMS Funds to Influence Legislation on Appropriations.No part of any funds paid to Contractor under this Agreement for Health Care Services provided to Medicare Beneficiaries shall be used to pay the salaries or expenses of Contractor or any agent acting for Contractor to influence legislation or appropriations pending before Congress. 5.Disclosttre of Information.Contractor shall establish and maintain procedures and controls so that no information contained in its records or obtained from CMS or others in carrying out the terms of the Agreement shall be used by or disclosed by it,its agents,officers or employees,except as provided in Section 1106 of the Social Security Act (42 U.S.C.§1306)and regulations prescribed thereunder. 6.Termination of CMS Contract.In the event RMHMO’s Medicare contract is terminated or non renewed,the Agreement,to the extent it concerns RMHMO’s Medicare contract with CMS,will be terminated unless CMS and RMHMO agree to the contrary.Such termination shall be accomplished by delivery of a written notice to Contractor of the date upon which said termination will be effective.Notwithstanding the foregoing,if RMHMO desires to continue the Agreement relative to RMHMO’s business after the Medicare contract between CMS and RMHMO has been terminated or non-renewed,RMHMO may do so provided that RMHMO assures to CMS in writing that CMS’obligations will terminate at the time the Medicare contract terminates or is non renewed,subject to termination cost provisions provided for in the Medicare contract. 7.Liquidated Damages.The following provision is applicable only if the Agreement contains a liquidated damage provision which is related solely to Medicare.CMS,after consultation with RMHMO,shall have the right to determine that the specified levels of performance have not been attained by Contractor.In such event,CMS may direct RMHMO to notify Contractor of CMS’determination that liquidated damages apply and EXHIBIT C Page 2 of 7 to set-off the liquidated damages against Contractor.CMS shall reimburse RMHMO for all reasonable costs relating to this activity and shall honor any judgment or award rendered against RMHMO directly resulting from the enforcement of such provision as directed by CMS.failure of RMHMO to timely comply with such direction,shall constitute cause for the application of any and all administrative,statutory,and judicial remedies which may be available to CMS pursuant to CMS’agreement with RMHMO,including,but not limited to, offsetting an amount equivalent to the amount of such unenforced liquidated damages.In the event that such offset is made,RMHMO shall be obligated to continue to perform all terms and conditions of such agreement without additional payment from CMS attributable to such offset amounts. 8.CMS Reguirements for Medicare Contracts.Contractor shall comply with all applicable requirements of law,with regard to providing Health Care Services to Medicare Beneficiaries.Contractor agrees to the following regarding providing Health Care Services to Medicare Beneficiaries: A.The Department of Health and Human Services (HHS),the Comptroller General,or their designees may audit,evaluate,or inspect any books,contracts,medical records,patient care documentation, and other records of Contractor that pertain to any aspect of services performed,reconciliation of benefit liabilities,and determination of amounts payable under the Agreement,or as HHS,the Comptroller General, or their designees may deem necessary to enforce RMHMO’s contract with CMS to provide services to Medicare Beneficiaries.Contractor shall comply with the provisions of 45 C.f.R.§74,et seq.,concerning granting HHS and the Comptroller General of the United States,and any other authorized representatives, access to books,documents,papers and other records. B.Contractor shall make available,for the purposes specified in paragraph (A)above,its premises,physical facilities and equipment,records relating to its Medicare Beneficiaries,and any additional relevant information that CMS may require. C.HHS,the Comptroller General,or their designees right to inspect,evaluate,and audit extends through 10 years from the end of the final contract period or completion of audit,whichever is later unless- (1)CMS determines there is a special need to retain a particular record or group of records for a longer period and notifies Contractor at least 30 days before the normal disposition date; (2)There has been a termination,dispute,or allegation of fraud or similar fault by Contractor,in which case the retention may be extended to 6 years from the date of any resulting final resolution of the termination,dispute,fraud,or similar fault;or (3)CMS determines that there is a reasonable possibility of fraud or similar fault,in which case CMS may inspect,evaluate,and audit Contractor at any time. D.Contractor agrees that it will require all related entities,contractors and subcontractors to agree that: (I)HHS,the Comptroller General,or their designee has the right to inspect,evaluate and audit any pertinent exhibits,books,documents,papers,and records of the related entity, contractor or subcontractor; (2)HHS’and the Comptroller General’s right to inspect,evaluate and audit any pertinent information for any particular contract period,will exist through ten (10)years from the final date of the contract period or the date of completion of any audit,whichever is later. E.Contractor agrees to provide Health Care Services to Medicare Beneficiaries in a manner consistent with professionally recognized standards of health care. F.Contractor shall comply with the confidentiality and enrollee acctiracy requirements of CMS regulations with regard to Medicare Beneficiaries. EXHIBIT C Page 3 of 7 G.All contracts or written arrangements between Contractor and sttbcontractors or first tier or downstream entities for the provision of Health Care Services to Medicare Beneficiaries must contain a provision requiring that any services or other activity performed by such subcontractor,or first tier or downstream entity are consistent and comply with RMHMO’s contractual obligations under its contract with CMS. H.RMHMO may only delegate functions regarding services for Medicare Beneficiaries to Contractor,a subcontractor or downstream entity in a manner consistent with the requirements,laws,rules. and regulations governing Medicare.All contracts or written arrangements,including the delegation of any of RMHMO’s activities or responsibilities under RMHMO’s contract with CMS,must specify that the related entity,contractor or subcontractor must comply with all applicable Medicare laws,regulations,and CMS instructions. SECTION III.The paragraphs in Section III apply to State Health Care Programs. 1.Confidentiality.RMHMO is subject to the requirements of 45 C.F.R.§205.50,as amended,section 10-16-423,C.R.S.,as amended,and 42 C.F.R.§431.304—43 1.307,as amended,regarding confidentiality of health information about Medicaid Recipients.Contractor shall hold and receive any health information about Medicaid Recipients subject to the above confidentiality requirements.Contractor shall comply with 42 C.f.R. part 43 1,subpart F,including 42 C.F.R.§431.301,and section 26-1-114,C.R.S.,regarding the confidentiality of information concerning applicants for and recipients of public assistance.Contractor shall protect the confidentiality of all Medicaid Recipient records and other materials that are maintained in accordance with the terms of RMHMO’s Medicaid Contract.Except for purposes directly connected with administration of RMHMO’s Medicaid Contract,no information about or obtained from any Medicaid Recipient in the possession of Contractor shall be disclosed in a form identifiable with the Medicaid Recipient without prior written consent of the Medicaid Recipient or,if such Medicaid Recipient is a minor,withotit the written consent of such minor’s parent or guardian. 2.Program Eligibility.RMHMO and Contractor represent to the other that they have not been debarred, suspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program.Contractor will take no action during the term of this Agreement which would result in its being debarred,suspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program.In addition,during the term of this Agreement,Contractor has not and will not arrange or contract with any employee,contractor,or agent for the provision of items or services tinder this Agreement who Contractor knows or should know is debarred,suspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program.If either party determines that the other party is,or becomes during the term of this Agreement,debarred,suspended or made otherwise ineligible to participate in any State Health Care Program or Federal Health Care Program,the party that is not debarred,suspended,or made otherwise ineligible may terminate this Agreement immediately. 3.Certifications.Pursuant to requirements of RMHMO’s Medicaid Contract,RMHMO is required to include in the Agreement and obtain from Contractor the following certifications without modification: Contractor certifies to the best of Contractor’s knowledge and belief as follows: A.Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion --Lower Tier Member. (I)The prospective Lower Tier Member certifies,by submission of this contract,that neither it nor its principals is presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily excluded from participation in this transaction by any federal department or agency. (2)Where the prospective Lower Tier Member is unable to certify to any of the statements in this certification,such prospective participant shall attach an explanation to this contract. EXHIBIT C Page 4 of 7 “Lower Tier Member”is defined to include Contractor and its principals,agents and subcontractors who are obligated to perform services pursuant to the terms of this contract. Contractor shall include,without modification,the above certification in any subcontract to the Agreement it may enter into. B.Certification Regarding Limitation on Use of Appropriated Ftands to Influence Certain Federal Contracting and Financial Transactions. (I)No federal appropriated funds have been paid or will be paid or will be paid by or on behalf of Contractor to any person for influencing or attempting to influence an office or employee of any agency,a member of Congress,an officer or employee of Congress,or an employee of a member of Congress in connection with the awarding of any federal contract,the making of any federal grant,the making of any federal loan,the entering into of any cooperative agreement and the extension,continuation,renewal,amendment,or modification of any federal contract,grant,loan,or cooperative agreement that utilizes federal funds. (2)If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency,a member of Congress,an officer or employee of Congress,or an employee of a member of Congress in connection with this federal contract,grant,loan,or cooperative agreement,Contractor shall complete and submit Standard Form —LLL,“Disclosure Form to Report Lobbying,”in accordance with its instructions. Contractor shall require that the language of the above certification be included in any subcontract to the Agreement that it may enter into. 4.Records and Audits.Contractor shall maintain a complete file of all records,documents, communications,and other materials which pertain to the operation of the program/project or the delivery of services to Medicaid Recipients under this Agreement sufficient to disclose fully the nature and extent of services/goods provided to each Covered Person.These records shall be maintained according to statutory or general accotinting principles and shall be easily separable from other Contractor records.Such files shall be sufficient to properly reflect all direct and indirect costs of labor,materials,equipment,supplies and services,and other costs of whatever nature for which a payment was made and shall include,but are not limited to: A.All medical records,service reports,and orders prescribing treatment plans; B.Records of goods,including such things as drugs and medical equipment and supplies,and copies of original invoices for such goods;and C.Records of all payments received for the provision of such services or goods. All such records,documents,communications,and other materials shall be maintained by Contractor for a period of six (6)years from the date services are provided under this Agreement,or for such further period as may be necessary to resolve any matters which may be pending with regard to such services,or until an audit by or on behalf of the federal or state government has been completed with the following qualification:If an audit by or on behalf of the federal and/or state government has begun but is not completed at the end of the six (6)year period, or if audit findings have not been resolved after a six (6)year period,the materials shall be retained until the resolution of the audit finding. 5.Untrtie or Misleading Information.Contractor shall not knowingly provide untrue or misleading information,as defined at sections IO-l6-4l3(l)(a)-(c),C.R.S.,regarding RMHMO’s Medicaid Plan other Medicaid managed care organizations,or Medicaid eligibility,to RMHMO Medicaid Recipients. 6.Medicaid Recipient Rights. A.Contractor shall provide interpreter services for Medicaid Recipients with communication disabilities or non-English speaking Medicaid Recipients when such an interpreter is necessary in order to render effective communication in connection with the provision of Health Care Services.RMHMO will EXHIBIT C Pages of7 assist Contractor in providing information in alternative formats and in an appropriate manner that takes into consideration the special needs of those who,for example are visually limited or have limited reading proficiency. B.Contractor shall provide Medicaid Recipients,in terms the Medicaid Recipients can understand, an explanation of the Medicaid Recipients complete medical condition,recommended treatment,risk(s)of the treatment,expected results and reasonable medical alternatives,If the Medicaid Recipient is not capable of understanding the information,the explanation shall be provided to the Medicaid Recipient’s biological, adoptive or foster parent,guardian or designated client representative,and documented in the Medicaid Recipient’s medical record. C.Contractor shall ensure that Medicaid Recipients have the rights set forth in 42 C.f.R.section 438.100(b)(2),including but not limited to the right to be free from any form of restraint or seclusion used as a means of coercion,discipline,convenience or retaliation,consistent with 42 C.F.R.,section 438.1 00.(b)(2)(v). 7.Physical Barriers.Physical barriers and barriers to communication shall not inhibit Medicaid Recipients with disabilities from obtaining covered health care services. 8.Medicaid and CHP+Contracts Statutes and Regulations.Pursuant to requirements of RMHMO’s Medicaid Contract and CHP+Contract,Contractor and any subcontractor of Contractor shall comply with the following statutes and regulations: A.Sections 1894 and 1934 of the Social Security Act,as implemented by regulations at 42 C.f.R., Part46O B.Age Discrimination Act of 1975 (42 U.S.C.Sections 6101,et seq.) C.Age Discrimination in Employment Act of 1967 (29 U.S.C.621-634) D.Americans with Disabilities Act of 1990 (ADA)(42 U.S.C.12101,et seq.) E.Environmental Protection Agency Regulations (40 C.F.R.Part 15) F.94-165 Energy Policy and Conservation Act G.Equal Pay Act of 1963 (29 U.S.C.206(d)) H.Immigration Reform and Control Act of 1986,P.L.99-603 (8 U.S.C.1324b) I.Section 306 of the Clean Air Act (42 U.S.C.1857 Ii) J.Section 508 of the Clean Water Act (33 U.S.C.1368) K.Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.794) L.Title VI of the Civil Rights Act of 1964 (42 U.S.C.2000d) M.Title VII of the Civil Rights Act of 1964 (42 U.S.C.2000e) N.Title IX ofthe Education Amendment of 1972 (20 U.S.C.1681,et seq.) 0.Section 24-34-302,et seq.,Colorado Revised Statutes 1997,as amended Contractor shall also comply with any and all laws and regulations applicable to these laws prohibiting discrimination on the basis of race,color,national origin,age,sex,religion and handicap,including Acquired Immune Deficiency Syndrome (AIDS)or AIDS-related conditions,covered under Section 504 of the Rehabilitation Act of 1973,as amended,cited above.Included is 45 C.F.R.9236(e),which reqcures affirmative steps be taken to assure that small and minority businesses are utilized,when possible,as sources of supplies, equipment,construction and services.This assurance is given in consideration of and for the purpose of obtaining any and all federal and/or state financial assistance.Any provider who feels that he/she has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the U.S. Department of Health and Human Services Office for Civil Rights. EXHIBIT C Page 6 of 7 9.Certifications.Pursuant to requirements of RMHP’s CHP+Contract,RMHP is required to include in the Agreement and obtain from Contractor the following: A.Lobbying. (I)No Federal or appropriated funds have been paid or will be paid by or on behalf of Contractor.to any person for influencing or attempting to influence an officer or employee of an agency,a member of Congress,an officer or employee of Congress or an employee of a member of Congress in connection with the awarding of any contract,the making of any grant,the making of any loan,the entering into of any cooperative agreement,and the extension,continuation,renewal, amendment or modification of any contract,grant,loan or cooperative agreement that utilizes Federal funds, (2)Ii any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of an agency,a member of Congress,an officer or employee of Congress in connection with this Federal Contract,grant,loan, or cooperative agreement,the Contractor shall complete and submit Standard Form LLL, “Disclosure form to Report Lobbying”,in accordance with its instrtrctions. (3)Contractor shall require that the language of this certification be included in the award documents for subawards at all tiers (including subgrants and Contracts under grants,loans, and cooperative agreements)and that all subclients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into.Submission of the certification is a prerequisite for making or entering into this transaction imposed by section 1352,title 31,U.S.Code.Any person who fails to file the required certification shall be stibject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Contractor shall include,without modification,the above certification in any subcontract to the Agreement it may enter into. B.Suspension and Debarment.Contractor certifies that,to the best of its knowledge and belief,that the Contractor and its principals: (1)Are not presently debarred,suspended,proposed for debarment,declared ineligible or voluntarily excluded from covered transactions by any federal department or agency. (2)l-Iave not within a three (3)year period preceding this Contract been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,or attempting to obtain,or performing a public (Federal,State or local) transaction or contract under a public transaction;violation of Federal or State antitrust statutes or commission of embezzlement,theft,forgery.bribery,falsification or destruction of records,making false statements,or receiving stolen property. (3)Are not presently indicted for’,or otherwise criminally or civilly charged by a governmental entity (Federal,State or local)with commission of any of the offenses enumerated in subparagraph 2 of this certification;and (4)Have riot within a three (3)year period preceding this Contract had one or more public transactions (Federal,State or local)terminated for convenience or default Contractor shall require that the language of the above certification be included in any subcontract to the Agreement that it may enter into. EXHIBIT C Page 7 of 7 ADDENDUM TO IMMUNIZATION SERVICES AGREEMENT FOR FAMILY PLANNING SERVICES ROCKY MOUNTAIN HEALTH Eagle County Government,cl/b/a Eagle County MAINTENANCEORGANIZATION,INC.,HHS,(herein “Contractor”) a Colorado nonprofit corporation d/b/a Rocky Mountain Health Plans,(herein “RIvEHMO”) Address of RMHMO and RME:Address of Contractor: 2775 Crossroads Boulevard Post Office Box 626 Post Office Box 10600 551 Broadway Grand Junction,CO 81502-5600 Eagle,CO 81631-0660 Tax LI).No.:846000762 RMHMO and Contractor are parties to an Immunization Services Agreement dated _______ 2012 for the provision of Immunization Services to Covered Persons.The Immunization Services Agreement and any amendments thereto shall be referred to collectively as the “Agreement.”All definitions and terms of the Agreement are incorporated herein by this reference. RIvIHMO and Contractor desire to enter into this Addendum for the purpose of Contractor arranging for the provision of Family Planning Services to Covered Persons.Contractor will be reimbursed for such Family Planning Services as set forth in the attached Terms and Conditions. This Addendum describes Contractor’s duties and obligations with regard to all lines of business for which RME offers a Health Care Plan.The particular lines of business and categories of Covered Persons for which Contractor shall provide Health Care Services under this Addendum are set forth on Exhibit 1.To the extent this Addendum describes duties and obligations for a particular line of business or category of Covered Person for which Contractor does not provide services,those duties and obligations are not applicable to Contractor or RME. Contractor and RMHMO agree to all Terms and Conditions,attached,along with the Exhibits described below,all of which are incorporated herein by this reference. This Addendum is dated and shall be effective on the date set forth below by RMHMO as the effective date. ROCKY MOUNTAIN HEALTH Eagle County Government,cl/b/a Eagle County MAINTENANCE ORGANIZATION,INC.,IffiS a Colorado nonprofit corporation cl/b/a Rocky Mountain __ Stephen K.ErkenBrack,President and CEO Rv’yoN (Print/type name) Effective Date:ttThLLttW £Title:CHPrl1V1A (To be eomp1eed by R1MO)J Page 1 of4 ATTACHMENTS: Exhibit 1:Compensation for family Planning Services TERMS AND CONDITIONS Additional Definitions.The words and terms below shall have the following definitions: A.“Family Planning Services”shall mean an office visit comprised of basic health screening,including screening and any needed treatment for sexually transmitted diseases according to state protocols, personal history review,birth control education and prescription of basic birth control methods,including oral birth control pills,condoms,gels,depo provera, diaphragm and rhythm counseling provided by a Nurse Practitioner to Covered Persons. family Planning Services will also include outside contraceptive methods such as IUD and cervical cap,which are provided by a Participating Physician. B.“Nurse Practitioner”shall mean an advanced practice nurse who:(1)is licensed to practice in Colorado pursuant to Section 12-38-111.5,C.R.S.,(2)obtains specialized education or training through a nationally accredited education program designed for nurse practitioners,(3)applies to and is accepted by the Colorado Board of Nursing for inclusion in the advanced practice registry,and (4)is employed by or under contract with Contractor. 2.F ainily Planning Services. A.Family Planning Serviceyeied Persons.Contractor shalt arrange for the provision of family Planning Services to Covered Persons through contracts with or employment of Nurse Practitioners and Participating Physicians.In alTanging for such services,Contractor shall comply with the terms of the Agreement and this Addendum. B.Compensation for family Planning Services.RME will pay Contractor the amounts specified on attached Exhibit 1 for Medically Necessary family Planning Services provided by Nurse Practitioners and Participating Physicians to Covered Persons.Contractor agrees to accept payment in accordance with Exhibit 1 as flail payment and complete satisfaction of any claim for compensation due for family Planning Services provided to Covered Persons by Nurse Practitioners and Participating Physicians.To the extent a Health Care Plan requires Contractor to collect Co-Payments,Coinsurance or Deductibles,compensation paid to Contractor shall be reduced by the amounts of the applicable Co-Payments,Coinsurance or Deductibles to be collected by Contractor. To the extent that this Addendum and the Agreement both set forth compensation rates for Family Planning Services,the terms of this Addendum shall supersede the terms of the Agreement. A.Service Area for family Planning Services.family Planning Services described in this Addendum shall only be provided at the address(es)set forth on the signature page of this Addendum. B.Licensure.Contractor operates and is governed by Section 25-1-501 et.seq., C.RS.Evidence of obtaining and/or maintaining compliance with such legal requirements shall be submitted to Rl\4E upon written request.Contractor’s facility shall be duly licensed by all federal,state and local licensing agencies which require licensure for providing any of the family Planning Services herein and shall obtain and maintain certification to participate in 3.General Provisions. Page 2 of4 the Medicare program under Title XVIII of the Social Security Act.All Nurse Practitioners shall be duly licensed by the State of Colorado as advanced practice nurses.Evidence of obtaining and/or maintaining such licenses shall be submitted to RIVIE upon request.Contractor shall notify RME immediately of the occurrence of any of the following: (1)Revocation or suspension of Contractor’s state license or federal certification to participate in the Medicare program; (2)Loss of any license which Contractor is required to obtain for the provision of Family Planning Services; (3)Any action,decision or recommendation by CMS in any way limiting or restricting Contractor’s participation in the Medicare program, or by the State of Colorado in any way limiting Contractor’s participation in the Medicaid program; (4)Any suit or claim regarding the provision of Family Planning Services; (5)The revocation,suspension or refusal to renew any license held by a Nurse Practitioner employed by or under contract with Contractor;or (6)Any action or situation that might or will materially affect Contractor’s ability to carry out its responsibilities under this Addendum. Contractor shall provide the Medical Director with any records pertaining to such matter as may be requested by the Medical Director. C.Credentials of Participating Physicians. Each Participating Physician shall:(1)hold the degree of Doctor of Medicine or Osteopathy as defined by Colorado statutes, (2)at all times during the term of this Addendum be culTently licensed by the Colorado Board of Medical Examiners without restriction,(3)completely and accurately make application to and be accepted by RIvIE as a Participating Physician of RME,(4)at all times during the term of this Addendum be certified to participate in the Medicare program under Title XVIII of the Social Security Act,(5)at all times during the term of this Addendum not be prohibited from participation in any federal health care program or state health care program,and (6)at all times during the term of this Addendum continue to have admitting privileges in at least one hospital, if applicable,based on the Participating Physician’s clinical specialty.Contractor shall provide copies of all licensure and related documents to RME upon request. D.Professional Standing.Contractor agrees to inform the Medical Director immediately of any fact,event or circumstance affecting the credentials, licensing or liability of a Participating Physician,including,but not limited to,the following: (1)suits or claims for professional liability; (2)any action,decision or recommendation by the clinical department,administrative staff or peer review organization of any hospital or clinic limiting,restricting or changing Participating Physician’s relationship to such hospital or clinic; (3)any action,decision or recommendation by any department or agency of the United States govermnent or the State of Colorado in any way limiting or restricting Participating Physician’s participation in any federal health care program or state health care program; (4)the referral by the State Board of Medical Examiners of any matter to the Page 3 of4 State of Colorado Attorney General’s Office for action;and (5)any disciplinary action taken against Participating Physician by the Colorado Board of Medical Examiners or a professional review committee. Contractor shall provide the Medical Director with any records pertaining to such matter as may be requested by the Medical Director. such date unless otherwise terminated in accordance with the provisions of this Addendum. 4.Effect.Except as set forth in this Addendum,all terms,covenants and conditions of the Agreement shall remain in full force and effect. E.Duties and Obligations Under Agreement.Except as otherwise set forth in this Addendum,Contractor shall arrange for the provision of Family Planning Services to Covered Persons under the same terms and conditions as set forth in the Agreement for the provision of Immunization Services to Covered Persons.Contractor and RME shall have the same duties and obligations with regard to the provision of Family Planning Services as such parties have in the Agreement with regard to the delivery of Immunization Services. F.Entire Agreement.This Addendum, and the Exhibits attached to this Addendum, constitute the entire understanding and agreement of the parties with regard to family Planning Services covered under this Addendum,and shall supersede all prior understandings and agreements of the parties on the subject matter of Family Planning Services covered under this Addendum. G.Termination.This Addendum shall be subject to termination on the same terms and conditions as set forth in the Agreement. Upon termination of the Agreement,this Addendum shall terminate.The termination of this Addendum,however,shall not terminate the Agreement. H.Effective Date/Duration.This Addendum shall be effective beginning as of the date of this Addendum,and shall continue in effect from year to year after Page 4 of 4 EXHIBIT 1 TO ADDENDUM TO IMMUNIZATION SERVICES AGREEMENT FOR FAMILY PLANNING SERVICES COMPENSATION FOR FAMILY PLANNING SERVICES Notwithstanding any other provisions of this Addendum,Covered Persons under this Addendum shall include only the lines of business /categories of Covered Persons which are checked below: Private Plan Covered Persons Self Insured Plan Covered Persons Medicare Beneficiaries LI Medicaid Recipients CHP+Covered Persons Compensation for Family Planning Services shall be the Allowed Charges as set forth below.If Contractor’s billed charges for any family Planning Services provided to Covered Persons are less than the Allowed Charges for Family Planning Services set forth in this Addendum,Contractor shall be reimbursed billed charges for the service instead of the Allowed Charges set forth in this Addendum.All Allowed Charges shall be subject to the Claims Payment Criteria. 1.Private Plan Covered Persons.Self Insured Plan Covered Persons and Medicare Beneficiaries.RME will pay Contractor for Family Planning Services provided to Private Plan Covered Persons,Self Insured Plan Covered Persons and Medicare Beneficiaries as set forth in the table below.Contractor shall use the CPT Codes or J Codes listed below,(or the most current codes describing such procedures),when completing each claim form to be submitted to RME. CPT CODES! UCPCS CODES DESCRIPTION OF FAMILY PLANNING SERVICES COMPENSATION RATE CPT Codes:99201 Office or other outpatient visits for the evaluation and 100%of the Medicare rate as 99204 management of a new patient;presenting problems are determined by use of the straightforward,or of low or moderate severity current edition of the Resource ..Based Relative Value Schedule 99211 -99214 Office or other outpatient visit for the evaluation and RBRVSmanagementofanestablishedpatient,that may or may not require the presence of a physician,presenting problems are straightforward,or of low or moderate complexity CPT Codes:Periodic comprehensive preventive medicine evaluation or 100%of the Medicare rate as 99381 —99397 re-evaluation of an individual including age and gender determined by use of the appropriate history,examination,counseling/anticipatory current edition of the RBRVS guidance/risk factor reduction interventions and the ordering of laboratory/diagnostic procedures for new or established patients. CPT Codes:99401 Preventive medicine counseling and/or risk factor reduction 100%of the Medicare rate as and 99402 intervention(s)provided to an individual;15 minutes or 30 determined by use of the minutes current edition of the RBRVS CPT Codes:Insertion,removal and/or possible reinsertion of 100%of the Medicare rate as I 1 975 -1 1977 implantable contraceptive devices determined by use of the Diaphragm or cervical cap fitting with instructions current edition of the RBRVS 57170 Insertion or removal of intrauterine device (IUD) 58300 -58301 Exhibit 1 Page 1 of2 CPT CODES! HCPCS CODES DESCRIPTION OF FAMILY PLANNING SERVICES COMPENSATION RATE In Office Laboratory In Office Laboratory Only CPT codes for the level of Current RME In-Office CLIA certification held by Contractor.All other Clinical Laboratory fee Schedule Laboratory Services will be provided by RME contracted Laboratory Providers Vaccines,Toxoids As appropriate for the Contractor to provide in the scope of 100%of AWP* and Other their services Injectables CPT Codes:Administration of Immunizations and Injections.To report 100%of the Medicare rate as 90471-90474,the administration of an injectable,the appropriate determined by use of the 96360-96379 administration CPT or HCPCS codes must be used in current edition of the RBRVS HCPCS Codes addition to the J Codes set forth above. G0008__G00l0 HCPCS Codes HCPCS Codes (except those listed above under 100%of the Medicare rate as administration of immunizations and injections)determined by use of the current edition of the Durable Medical Equipment Regional Carrier (DMERC)fee schedule *(a)Allowed Charges for these items will not apply to pharmaceuticals reimbursed under Medicare Part D for a Medicare Beneficiary if RMHMO notifies Contractor of a different methodology,process and/or right for reimbursement for such pharmaceuticals.In the event such notification is given,Allowed Charges shall be determined in accordance with the methodology,process and/or right specified in the notice. (b)During the term of this Addendum,in the event the pricing source used to determine AWP changes the methodology by which AWP is calculated or reported,or AWP is no longer used as an industry pricing methodology,RMHMO will notify Contractor of the new pricing methodology that will be used in lieu of AWP, provided that the pricing methodology is a standard used in the industry.If such notice is given by RIVIHMO to Contractor,the new pricing methodology as described by RMHMO in such notice shall be used instead of AWP and shall be updated as described in such notice. 2.CHP+Covered Persons.RME will pay Contractor for family Planning Services provided to a CHP+ Covered Person,by either a Nurse Practitioner or a Participating Physician,the amount Contractor would receive from the Colorado Department of Health Care Policy and Financing (CDHCPF)under the CHP+Program,as administered by CDHCPF for such services. 3.Medicaid Recipients.RIvIE will pay Contractor for family Planning Services provided to a Medicaid Recipient,by either a Nurse Practitioner or a Participating Physician,the amount Contractor would receive from CDHCPf under the Medicaid program,as administered by CDHCPf for such services. If Medicaid Recipients are not Covered Persons under this Addendum,and Contractor or Health Care Professional,as applicable,provides services otherwise covered under this Addendum to a Medicaid Recipient, RME will pay Contractor the amount Contractor or Health Care Professional,as applicable,would receive from CDHCPF under the Medicaid program,as administered by CDHCPf for such services. Exhibit 1 Page 2 of 2