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HomeMy WebLinkAboutC97-103 Sloans Lake Managed Care IncC:C)SLOANSLAKEMANAGEDCARE,INC.UTILIZATIONREVIEWANDCATASTROPifiCCASEMANAGEMENTAGREEMENTThisAgreementiseffectivethe1stdayofSeptember,1996,byandbetweenEagleCountyGovernment(herein“ParticipatingPlan”)andSloansLakeManagedCare,Inc.,aColoradocorporation,(herein“SLMC”).PREMISESWhereas,SLMCcanprovideutilizationreviewandcatastrophiccasemanagementservicesforCoveredIndividualsenrolledinahealthbenefitplanofferedbyParticipatingPlan,andWhereas,SLMCshallestablish,operateandcontinuouslymaintainutilizationreviewandcatastrophiccasemanagementprogramsacceptabletotheParticipatingPlanandinaccordwithprotocolsagreeduponby$LMCandtheParticipatingPlan,NowTherefore,inconsiderationofthemutualpromisesandcovenants,thepartiesagreeasfollows:ARTICLEIDEFINITIONS1.1“Agreement”meansthisUtilizationReviewandCatastrophicCaseManagementAgreementbetweentheparties.1.2“CoveredIndividuals”meansthoseeligibleemployees,membersorotherconstituentsoftheParticipatingPlanaswellastheireligibledependents.ARTICLEIISLMCRESPONSIBILI’UES2.1SLMCshallinstituteandmaintainduringthetermofthisAgreementthefollowingprogramsofutilizationreviewandcatastrophiccasemanagement:A.PrecertificationInpatient1.Pre-AdmissionReview:prospectivereviewforelectivehospitaladmissionsinvolvingadeterminationofwhetheradmissionsaremedicallyPP0777/UR-ICIEAGLE.COUNTY/9.18.%bh1 aCnecessarythroughareviewoftheadmittingdiagnosis,applicablesecondarydiagnoses,medicalhistoryandfactualcircumstances.2.ReviewofEmergencyAdmissions:medicalreviewofindicationsforemergencyadmittance.3.ConcurrentReview:determinationofthecontinuedneedforhospitalstaybasedonreviewofpatientstatus,includingcomplications,bylicensedprofessionalsatdesignatedintervalsagreeduponbySLMCandtheParticipatingPlan;proposalsforlessintensivealternatemeansofcare.B.CatastrophicCaseManagement1.CaseManagement:systematicapproachtoidentifyinghighcostclaimsituations,assessingpotentialopportunitiestocoordinatecare,andformulatingcosteffectivequalitycareprograms.2.Evaluation:anindepthassessmentofthepatient’sconditionanddialoguewiththephysician,familyandotherhealthcareproviders.3.Review:casemanagementprogramisreviewedbytheMedicalDirectorforqualityassurance.Theprogramisreassessedweeldyorhi-weeklywhicheverisappropriate.Significantdevelopmentsarediscussedwiththeclaimadministrator.4.SLMCshalldeterminewhichcaseswillbemanagedunderthecatastrophiccasemanagementprogram.Typicalmedicalconditionsthatfrequentlyresultincatastrophiccasemanagementare:AIDSIHW+MalignantNeoplasmBurns(FullThickness)OrganTransplantationCVA,Severe,ComplicatedPretermLaborCysticfibrosisProgressiveNeurologicalDiseasesHigh-RiskInfantSpinalCordInjuiyMajorHeadTraumaTraumaticAmputation2.2SLMCshallperformsuchservicesforCoveredIndividualswhoreceivecareoutsideandwithinitsservicearea.2.3SLMCshallmonitorthepracticeandutilizationpatterns,includingspecialtyreferrals,oftheproviders.2.4SLMCshallprovidetheParticipatingPlanwithutilizationreportsforutilizationreviewservicesperformed.Suchreportsshallbeprovidedquarterly.$LMCfurtheragreestocomply,withinareasonabletime,withtheParticipatingPlanreasonablerequestsforchangesinthefrequencyofsuchreports.PPO777IUR-ICIEAGLE.COUNTY)9.18.96bh2 0CARTICLEffiPARTICIPATINGPLAN’SOBLIGATIONS3.1TheParticipatingPlanagreestoprovideSLMCwiththeenrollmentdatalistedonExhibitAonanannualbasis,whichshallbeusedtoprovidetheParticipatingPlanwithannualqualityassurancereports.3.2TheParticipatingPlanagreestoprovide$LMCwithacopyoftheirplandocument.3.3TheParticipatingPlanshallberesponsiblefortheprintinganddistributionofmaterialsregardingutilizationreviewservicestoCoveredIndividuals.ARTICLE1VAUTHORIZATIONANDCONFIDENTIALITY4.1TheParticipatingPlangrantsto$LMCtherighttoreviewCoveredIndividuals’medicalrecords.4.2SLMCrepresentsandwarrantsthatitwillmaintaintheprivacyandconfidentialityofallmedicalrecordsorothermedicalinformationthat$LMCobtainsfromahospitalorphysicianconcerningCoveredIndividualsoftheParticipatingPlan.SLMCfurtheragreesitwillutilizethemedicalinformationitobtainsonlyforutilizationreviewdeterminationsandcatastrophiccasemanagementandwillnotreleasesuchmedicalinformationtoanythirdpartywithoutpriorwrittenconsentofthepatientandtheParticipatingPlanunlessrequiredtoreleasesuchmedicalinformationbycourtorder.SLMCmaydevelopandreleasestatisticalcompilationsandcomparisonsforpurposesofstatisticalreportingaslongasCoveredIndividualsoftheParticipatingPlanarenotidentifiedbyname.ARTICLEVCOMPENSATION5.1TheParticipatingPlanwillpaySLMCmonthlyfeesasfollows:$1.50peremployeepermonthforutilizationreviewservicesasdescribedunderArticleII.SuchfeesshallbebasedonthenumberofemployeescoveredunderthisAgreementonthefirstdayofeachmonthandduenolaterthanthelastdayofthemonth.TheParticipatingPlanshallprovide$LMCwithastatementlistingthenumberofemployeescoveredunderthisAgreementwitheachpaymentofthemonthlyfees.Latepaymentchargeswillbecomputedattherateofoneandonehalfpercent(1.5%)oftheoverdueamountpermonthorthemaximumlawfulamount,whicheverisless.ParticipatingPlanwillalsobeliableforallcoststocollectanypastdueamounts,includinganycollectionagencyorattorneys’fees.Eachpaymentshallincludeastatementexplainingthebasisofcalculationsofthisfeeinaformatmutuallyagreeduponbytheparties.SLMCretainstherighttorequestindependentverificationofemployeelivesforanygivenmonth.PPO777IUR-ICIEAGLECOUNTY/9.18.96bh3 005.1.aSLMCshallprovidecatastrophiccasemanagementservicesasdescribedunderArticleII.Feesfortheseservicesshallbe$90.00perhourandshallbebilledonamonthlybasis.TheParticipatingPlanshallremitsuchfeesnolaterthan30daysfollowingthereceiptofthebillingstatement.Latepaymentchargeswillbecomputedattherateofoneandonehalfpercent(1.5%)oftheoverdueamountpermonthorthemaximumlawfulamount,whicheverisless.ParticipatingPlanwillalsobeliableforallcoststocollectanypastdueamounts,includinganycollectionagencyorattorneys’fees.Eachbillingstatementshallexplainthebasisofcalculationofthisfee.ARTICLEVITERMOFAGREEMENT6.1ThisAgreementshallcontinueforaperiodoftwelve(12)monthsanditshallberenewedforsuccessiveone-yearperiodseffectiveeachSeptember1StunlessterminatedassetforthinParagraph6.2.6.2ThisAgreementmaybeterminatedatanytimebymutualconsentofbothparties.ThisAgreementmaybeterminatedwithoutcausebyanyofthepartiesheretouponnotlessthansixty(60)dayspriorwrittennoticetotheotherparty.Anysuchwrittennoticeshalldesignatetheintendeddateoftermination.ThefeesoutlinedunderArticleVshallremainineffectuntilthedesignateddateoftermination.6.3Terminationshallhavenoeffectupontherightsandobligationsofthepartiesarisingoutofanytransactionsoccurringpriortotheeffectivedateofsuchtermination.ARTICLEVIIINSIJRANCE7.1$LMCagreestomaintainatitsexpenseduringthetermofthisAgreementprofessionalliabilityinsuranceintheamountofonemillion($1,000,000)peroccurrencetoonemillion($1,000,000)aggregatetocoveranyclaimsthatcouldarisefromtheprovisionofservicesunderthisAgreement.ARTICLEVifiARBITRATION8.1Thepartiesheretoagreethat,anydispute,orclaimarisingoutoforrelatingtothemaking,performanceorinterpretationofthisAgreementshallberesolvedbyarbitrationconductedbytheJudicialArbiterGroup,Inc.,inDenver,ColoradooranyothermutuallyagreeabledisputeresolutionorganizationorentityinaccordancewiththeColoradoRulesofCivilProcedure.DisputesarisinginconnectionwiththisAgreementPP0777/UR-ICIEAGLE.COUNTY/9.18.96bh4 CCbetweenoramongothersnotpartiestothisAgreement,andanydisputesorclaimsconcerningmedicalmalpracticenegligenceorothertorts,shallnotbesubjecttoarbitration.ARTICLEIXMISCELLANEOUSPROVISIONS9.1Anynoticerequiredtobegivenpursuanttothetermsandprovisionshereofshallbeinwritingandshallbesentbycertifiedmail,returnreceiptrequested,postageprepaid,tothefollowingaddresses:ParticipatingPlan:EagleCountyGovernment500BroadWay,P.O.Box479Eagle,CO81631$LMC:SloansLakeManagedCare,Inc.13555.ColoradoBlvd.,Ste.902Denver,CO$0222NoticetoCoveredIndividualsshallbeinwritingandsentbyRegularU.S.MailtotheiraddresseslastshowninSLMCsrecords.9.2ThisAgreementshallnotbeassignedortransferredbyeitherpartywithoutthewrittenconsentoftheotherparty.Notwithstandingtheforegoing,eachpartyshallhavetherighttoassigntheAgreementandtodelegateallrights,dutiesandobligationshereunder,whetherinwholeorinparttoanyparent,affiliate,successor,subsidiaryorganizationorcompanyoftheparties.9.3Theinvalidityorunenforceabiityofanytermorprovisionhereofshallinnowayaffectthevalidityorenforceabilityofanyothertermorprovision.9.4ThewaiverofanybreachofthisAgreementbyeitherpartyshallnotconstituteacontinuingwaiverorawaiverofanysubsequentbreachofeitherthesameorofanyotherprovisionofthisAgreement.9.5ThisAgreementmaybeexecutedincounterpartsandthecounterpartsreadtogetherasoneAgreement.9.6ThisAgreementshallbegovernedbythelawsoftheStateofColoradoastoconstruction,interpretation,andperformance.9.7ThisAgreementshallbebindinguponandinuretothebenefitsofthepartiesheretoandtheirrespectivesuccessorsandassigns,subjecttotherestrictionssetforthherein.PP0777/UR-ICIEAGLE.COUNTY/9.1896bh5 009.8ThisAgreementisintendedasthecompleteintegrationofallunderstandingsbetweenthepartieshereto.Nopriororcontemporaneousaddition,deletionorotheramendmentheretoshallhaveanyforceoreffectwhatsoever,andnosubsequentnovation,renewal,addition,deletionorotheramendmentheretoshallhaveanyforceoreffectwhatsoever,unlessreducedtowritingandsignedbytheparties.NoticetoorconsentofCoveredIndividualsshallnotberequiredforanymodificationstothisAgreement.ThepartiesheretohaveexecutedthisAgreementonthedatefirstwrittenabove.SloansLakeManagedCare,Inc.1mrVicePresidentofCommercialandGovernmentBusinessDevelopmentTitleEagleCountyGovernmentBY:TitleDateDatePPO777IUR-ICIEAGLE.COUNTY/9.18.96bh6 CCEXHIBITAENROLLMENTDATADataElementDescriptionSubscriberNumberfamilyID/AlphanumericMemberNumberMembersuffix:01=PrimaryV02=SpouseV03-89=Dependents90-99=OtherNumericSubscriberSS#Contractholdersocialsecuritynumberusedtoidentifyfamilies/NumericGroupNumberEmployergroupnumber/AlphanumericLastNameMemberslastname/AlphanumericFirstNameMembersfirstname/AlphanumericInitialMembersmiddleinitial/AlphaAddressMembershomeaddressrequiredforsubscribers!AlphanumericCityMemberscityrequiredforsubscribers/AlphanumericStateMembersstateabbreviationrequiredforsubscribers/AlphanumericZipcodeMemberszipcoderequiredforsubscribers/AlphanumericPhoneSubscribershomephonenumberandMembersifdifferentthanthesubscribers/NumericSexMMaleF=Female/AlphaMemberSS#Memberssocialsecuritynumber/NumericPPO777IUR-IC/EAGLE.COUNTY/9.18.96bh EXHIBITAPage200DataElementRelationshipBirthDateStatusEnrollDateDisenrollDateChangePolicyNumberDescriptionRelationshiptosubscriber:P=PrimaryS=SpouseD=DependentO=OtherAlphaMembersdateofbirthFormat=MM-DD-YYYY/AlphanumericRecordstatus:C=ChangeF=EnrollmentD=DisenroilmentAlphaEffectivedateofcoverage/AlphanumericEndingdateofcoverage/AlphanumericChangeflagtoindicatewhatdemographicalinformationhaschanged.Requiredfor“C”status.Subscriberspolicynumber/AlphanumericPP0777!UR-IC/EAGLE.COUNTY/9.18.96bh