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HomeMy WebLinkAboutC97-003 Rocky Mountain Health Maintenance OrganizationC’970320MOUNTAINHMOJanuary6,1997RECRIVP,)JAN07799EAGt6DearRMHMOParticipatingProvider:Thepurposeofthisletteristoinformyouofanamendmenttoyourprovideragreement(Agreement)withRockyMountainHealthMaintenanceOrganization,Inc.(RMHMO).TheColoradoGeneralAssemblyenactedHouseBill96-1216,whichrequiresanyentityprovidinghealthcoverageintheStateofColoradotoincludecertainprovisionsinitscontractswithhealthcareproviders.YourAgreementisthereforeamendedasprovidedintheattachedExhibitY,effectivethirty(30)daysfollowingthedatethisnoticeismailedtoyou,oratsuchothertimeasmaybespecifiedinyourAgreementastheeffectivedateofsuchanamendment.Thisnoticehasbeensenttoyoubycertifiedmail,asrequiredbyyourAgreement.Itisnotnecessaryforyoutotakeanyotheraction,unlessyouareaprovidernetwork,excepttofilethisExhibitYwithyourAgreement.Ifyouareaprovidernetwork,youwillneedtoamendyourcontractswithyourindividualproviders,assetforthintheattachedExhibitY.Thankyouforyourcontinuedcooperation.Ifyouhaveanyquestions,pleasecontactoneofRMHMO’sProfessionalRelationsRepresentativesatanyofouroffices,asfollows:GrandJunctionat1-800-843-0719or244-7760;GlenwoodSpringsat(970)945-1211;Durangoat(970)385-5135;Denverat(303)643-9692;andPuebloat(719)543-3598.Sincerely,ROCKYMOUNTAINHEALTHMAINTENANCEORGANIZATION,INC.By___Michael.Weber,ExecutiveDirectorAttachment:ExhibitY2775CrossroadsBlvd.,P0.Box10600,GrandJunction,Colorado81502-5600(970)244-7760•TollFree:7-800-843-0779•Fax:(970)244-7880 CClEXHIBITYAMENDMENTTOPROVIDERAGREEMENTThetermsofthisExhibitYshallconstituteanamendmenttotheprovideragreement(Agreement)betweenRockyMountainHealthMaintenanceOrganization,Inc.(RMHMO)andtheRMHMOparticipatingprovidertowhomtheenvelopethatcontainsthisExhibitYisaddressed(Contractor).ExceptforthechangessetforthinthisExhibitY,allotherterms,covenantsandconditionsoftheAgreement,includinganyprioramendmentstotheAgreement,shallremaininfullforceandeffect.1.TheprovisionintheAgreemententitled“Compliance,CooperationandParticipationinRME’sRules,Regulations,ProceduresandDecisions”shallbeamendedasfollows:a.IfthefollowingsentenceisincludedintheAgreement,itshallbedeleted:ContractoragreestoprovidedeliveryofMedicalServicesinthespiritofcooperationandgoodfaithwithoutnegativecommentsorstatementsregardingRME,itsemployees,RockyMountainHealthManagementCorporation,itsemployeesoranyHealthCarePlan.b.IfthefollowingsentenceisincludedintheAgreement,itshallbedeleted:NeitherContractor,oranyotherproviderwhoprovidesservicespursuanttothisAgreement,norRMEshallbeprohibitedfromprotestingorexpressingdisagreementwithamedicaldecision,medicalpolicy,ormedicalpracticeoftheotherparty.c.Thefollowingsentencesshallbeadded:NoindividualorgroupofproviderscoveredbythisAgreementshallbeprohibitedfromprotestingorexpressingdisagreementwithamedicaldecision,medicalpolicy,ormedicalpracticeofRMEoranentityrepresentingorworkingforRME(e.g.,autilizationreviewcompany).RMEoranyentityrepresentingorworkingforRMEshallnotbeprohibitedfromprotestingorexpressingdisagreementwithamedicaldecision,medicalpolicy,ormedicalpracticeofanindividualorgroupofproviderscoveredbythisAgreement.2.IfparagraphswiththeheadingssetforthbelowarenotalreadyincludedintheAgreement,thefollowingparagraphsshallbeaddedtotheAgreement.IfparagraphswiththeheadingssetforthbelowarealreadyincludedintheAgreement,thoseparagraphsshallbereplacedintheirentiretybythefollowingparagraphs:EXHIBITYPage1of2 Ca.ProviderContracts.Contractorshallinclude,ineachandeveryoneofitsunderlyingcontractsauthorizingContractortonegotiateandexecutecontractswithcarriersonbehalfofproviders,aprovisionsubstantiallysimilartothefollowing:EachandeverycontractwhichContractornegotiatesandexecuteswithcarriers,onbehalfoftheproviderscoveredbythisintermediary-providercontract,shallcontainaprovisionstatingthat:I)Noindividualorgroupofproviderscoveredbythecontractshallbeprohibitedfromprotestingorexpressingdisagreementwithamedicaldecision,medicalpolicy,ormedicalpracticeofthecarrieroranentityrepresentingorworkingforsuchcarrier(e.g.,autilizationreviewcompany);2)Thecarrieroranentityrepresentingorworkingforsuchcarriershallnotbeprohibitedfromprotestingorexpressingdisagreementwithamedicaldecision,medicalpolicy,ormedicalpracticeofanindividualorgroupofproviderscoveredbythecontract;and3)ThecarriershallnotterminateanycontractexecutedbyContractorbecauseanyindividualorgroupofproviderscoveredbythecontract(a)expressesdisagreementwithadecisionbythecarrieroranentityrepresentingorworkingforsuchcarriertodenyorlimitbenefitstoaCoveredPerson,or(b)assiststheCoveredPersoninseekingreconsiderationofthecarrier’sdecision,or(c)discusseswithacurrent,former,orprospectivepatientanyaspectofthepatient’smedicalcondition,anyproposedtreatmentsortreatmentalternatives,whethercoveredbyaHealthCarePlanornot,policyprovisionsofaplan,oraprovider’spersonalrecommendationregardingselectionofahealthplanbasedontheprovider’spersonalknowledgeofthehealthneedsofsuchpatients.b.LimitationsonTermination.RMHMOshallnotterminatethisAgreementbecauseaprovidercoveredbythisAgreement:(1)expressesdisagreementwithadecisionbyRME,oranentityrepresentingorworkingforRME,todenyorlimitbenefitstoaCoveredPerson;(2)assistsaCoveredPersoninseekingreconsiderationofsuchdecision;or(3)discusseswithacurrent,formerorprospectivepatientanyaspectofthepatient’smedicalcondition,anyproposedtreatmentsortreatmentalternatives,whethercoveredbyaHealthCarePlanornot,orpolicyprovisionsofaHealthCarePlan;or,(4)makesapersonalrecommendationregardingselectionofahealthplanbasedonpersonalknowledgeofthehealthneedsofsuchpatients.Thisparagraphshallnotbeconstruedasalimitationoneitherparty’srighttoterminatethisAgreementwithoutcause,assetforthherein.EXHIBITYPage2of2