HomeMy Public PortalAbout082-2016 - BOW-Reid Hospital for health care services for covered individualsREID HOSPITAL & HEALTH CARE SERVICES
HEALTH CARE SERVICES AGREEMENT WITH
CITY OF RICHMOND, INDIANA
This Health Care Services Agreement ("Agreement")
is entered into by and among Reid Hospital & Health Care
Services, Inc. ("Reid"); Reid Physician Associates, Inc.
("RHPA"); and City of Richmond, Indiana ("City ") as of
June 1, 2016 (the "Effective Date").
WITNESSETH:
WHEREAS, City desires to contract with Reid and
RHPA for the provision of Health Care Services to
Covered Individuals as set forth in this Agreement and as
consistent with City's Health Benefit Plan; and,
WHEREAS, Reid and RHPA are willing to provide
Health Care Services to Covered Individuals pursuant to
the terms of this Agreement;
NOW, THEREFORE, in consideration of the mutual
promises set forth below, the parties agreed as follows:
ARTICLE I
Unless otherwise required by applicable law, the
following definitions shall apply to this Agreement:
1.1 "Covered Individual" means an individual who
is eligible to receive Health Care Services under a Health
Benefit Plan sponsored by City.
1.3 "Emergency" means a medical condition that
manifests itself by such acute symptoms of sufficient
severity, including severe pain, that a prudent layperson
with an average knowledge of health and medicine could
reasonably expect the absence of immediate medical
attention to result in any of the following: (i) placing the
health of the Covered Individual, or with respect to a
pregnant woman, the health of the woman or her unborn
child, in serious jeopardy; (ii) serious impairment to bodily
functions; or (iii) serious dysfunction of any bodily organ
or part. With respect to a pregnant woman who is having
contractions, "Emergency" means (i) a situation in which
there is inadequate time to effect a safe transfer to another
provider before delivery; or (ii) a situation in which
transfer may pose a threat to the health or safety of the
woman or the unborn child.
1.4 "Emergency Services" means those services
and supplies, including an appropriate medical screening,
rendered to evaluate, diagnose or stabilize a Covered
Individual in an Emergency.
1.5 "Health Benefit Plan" means a plan or program
of health care benefits offered by City for the benefit of City
employees and their dependents as set forth in a certificate of
insurance, plan document or written agreement. The Health
Benefit Plan describes the health care benefits for which
Covered Individuals are eligible and identifies a Covered
Individual's responsibility, if any, for payment of Health Care
Services. A copy of the Health Benefit Plan to which this
Agreement applies is attached as Exhibit B.
1.6 "Health Care Services" means those Medically
Necessary hospital, physician and ancillary medical services,
accommodations and supplies to which a Covered Individual
is entitled under a Health Benefit Plan, and which Reid
and/or RHPA offer to the public generally.
1.7 "Medical Necessity" or "Medically Necessary"
means a health care service or supply that is appropriate for
the diagnosis or treatment of an injury, sickness or other
health condition and is (i) consistent with the symptoms
presented by or diagnosis of a Covered Individual; (ii)
consistent with accepted medical standards; (iii) not chiefly
custodial in nature; (iv) not investigational, experimental or
unproven; (v) not excessive in scope, duration or intensity to
provide safe, adequate and appropriate treatment; and (vi) not
provided only as a convenience to the Covered Individual or
the Affiliate Provider.
1.8 "Professional Providers" means those physicians,
ancillary practitioners and professional staff employed by or
under contract to RHPA to provide professional services to
Covered Individuals or to the public generally.
ARTICLE II
PROVIDER OBLIGATIONS
2.1 Hospital Services. Reid shall use commercially
reasonable efforts to make its hospital services available to
Covered Individuals 24 hours per day, seven days per week
in the same manner offered to the public generally. Reid
shall render Health Care Services in a manner that does not
discriminate based upon race, color, national origin, ancestry,
religion, sex, age, marital status, sexual orientation, veteran
status, source of payment, or on any illegal basis. Reid shall
accept as payment in full the negotiated rates in Exhibit A.
2.2 Professional Services. RHPA shall require
Professional Providers to abide by, the terms of this
Agreement, and the provisions of the Health Benefit Plan not
inconsistent with this Agreement and to:
Contract No. 82-2016
2.2.1 Render Health Care Services in a
competent, professional and ethical manner, consistent
with community standards of care.
2.2.2 Maintain appropriate medical records of
Health Care Services rendered to Covered Individuals and
grant access to such records by City, Reid and their
respective authorized agents, to the fullest extent permitted
by applicable law.
2.2.3 Cooperate with and participate in the
review and audit procedures required by City, and in any
grievance procedure or appeals process set forth in the
Health Benefit Plan, provided, however, claims of alleged
medical malpractice or professional liability are not subject
to the grievance procedure or appeals process, it being the
understanding an agreement of the parties that all such
claims shall be resolved solely in accordance with the
Indiana Medical Malpractice Act.
2.2.4 If permitted by statute, be a qualified
provider under the Indiana Medical Malpractice Act.
2.2.5 Provide Health Care Services to Covered
Individuals on a basis and in a manner no less favorable
than similar services are made available to patients who are
not Covered Individuals.
2.3 Professional Provider Qualifications. RHPA
shall assure that each Professional Provider:
2.3.1 Holds all licenses, permits and approvals
necessary to provide Health Care Services as contemplated
in this Agreement;
2.3.2 Has never been excluded from
participation in Medicare or any other federal program; and
2.3.3 Satisfies all other credentialing criteria
necessary for participation.
2.4 Medical Management Programs. Reid and
RHPA shall participate in such reasonable utilization
review, quality assurance and other medical management
programs required by City relating to Health Care Services
rendered to Covered Individuals.
2.5 Claims Submission, Billing and Collection.
Unless otherwise required or permitted by the applicable
Health Benefit Plan, Reid and RHPA shall submit claims
on forms or through an electronic medium approved by
City or its third party administrator within 90 days of the
later of: (a) the date of service, (b) the date Reid or RHPA
receives notice of the primary payor's liability if the City
is not the primary payor, (c) the date Reid or RHPA
receives notice of City 's liability if the Covered Individual
fails to provide accurate coverage information prior to the
provision of Health Care Services, or (d) such other date
acceptable to City in the event of extenuating circumstances.
2.6 Wellness and Care Manager. RHPA shall employ
an individual on an up to full-time basis to act as a wellness
and care manager for Covered Individuals ("Wellness and
Care Manager"). The Wellness and Care Manager shall
facilitate high quality, cost effective health care and health
service utilization for Covered Individuals and shall perform
all reasonable tasks necessary to accomplish such goal,
including, but not limited to the following: (a) monitor and
manage utilization of Health Care Services; (b) administer a
wellness program; (c) provide or arrange for the provision of
health and wellness education to Covered Individuals; (d)
provide or arrange for the provision of health and wellness
coaching to Covered Individuals; (e) manage Covered
Individuals with chronic disease to improve compliance; and
(f) identify and manage at -risk Covered Individuals. The
parties shall meet monthly to review utilization and the health
and wellness of Covered Individuals. This monthly meeting
will also be used to discuss and address other health care
costs and payment related issues. Once established, the
parties shall agree to meet quarterly to review utilization,
health care costs, and payment related issues.
ARTICLE III
CITY'S OBLIGATIONS
3.1 Reid Health Network. The City and/or Plan may
share with Covered Individuals, the pricing schedules
attached to this Agreement but the City and/or Plan will not
steer, direct or otherwise alter a Covered Individual's choice
of provider from which to receive health care services.
Nothing in this Agreement, precludes Covered Individuals
from obtaining Health Care Services from providers other
than Reid Health Network.
3.2 Identification Cards. City shall cause to be issued
to all Covered Individuals an identification card that provides
sufficient information to enable Reid and RHPA to verify the
individual's enrollment in a Health Benefit Plan listed on
Exhibit B. The identification card shall include the name or
logo of City and sufficient contact information to allow the
Reid, RHPA and Professional Providers to verify that the
holder is a Covered Individual.
3.3 Claims Processing. City shall ensure that claims
for Health Care Services are processed accurately and timely,
and that Reid and RHPA timely receive such claims data,
enrollment information and mutually agreeable reports as
may be necessary for them to perform their obligations under
this Agreement.
3.4 Provider Relations. City shall forward to Reid all
complaints regarding Reid, RHPA or any Professional
Provider and shall cooperate with Reid as may be reasonably
necessary to address any such complaints.
ARTICLE IV
COMPENSATION
4.1 Payment for Health Care Services. City shall
ensure that timely filed Clean Claims for Health Care
Services rendered to Covered Individuals by Affiliate
Providers are paid timely and in accordance to the
Affiliate Provider Fee Schedule set forth on Exhibit A.
Clean Claims shall be paid within thirty (30) days of
receipt. For purposes of this Agreement, a "Clean Claim"
shall be one that has no defect or impropriety and includes
relevant details and substantiating documentation adequate
to determine whether the claim is actually payable by the
City's Plan, or excluded. City shall notify Reid or RHPA
of any deficiencies in a submitted claim not more than
thirty (30) days for a claim that is filed electronically, or
forty-five (45) days for a claim that is filed on paper, and
describe any remedy necessary to establish a Clean Claim.
Failure of City to notify Reid or RHPA as required under
this Agreement established the submitted claim as a Clean
Claim.
4.2 No Balance Billing. Reid and RHPA each
represents and warrants that neither it nor any Professional
Provider will, directly or indirectly, bill, charge, collect a
deposit from, seek compensation, remuneration or
reimbursement from, or have any recourse against Covered
Individuals for Health Care Services rendered pursuant to
this Agreement other than the collection of authorized
copayments, deductibles, coinsurance amounts and
amounts for non -covered services that are collected in
accordance with the requirements of the applicable Health
Benefit Plan. This hold harmless provision shall survive
termination of this Agreement with respect to Health Care
Services rendered to Covered Individuals during the term
of this Agreement, regardless of the reason for termination.
ARTICLE V
TERM AND TERMINATION
5.1 Term. This Agreement shall commence on the
Effective Date set forth in the Preamble and shall continue
in effect until December 31, 2016 or as otherwise
terminated pursuant to this Article V.
5.2 Termination by Mutual Agreement.
Agreement may be terminated by written joint mutual
consent of both parties at any time.
5.3 Termination for Cause. Any party may, at any
time, terminate this Agreement for cause in the event the
defaulting party fails to cure a breach to the reasonable
satisfaction of the complaining party within sixty (60) days
after receiving written notice of the alleged breach;
provided, however, that if the Agreement is terminated
Reid pursuant to this Section 5.4, the Agreement will
automatically terminate as to RHPA unless otherwise agreed
in writing by the parties.
5.4 Termination of Individual Professional Providers.
This Agreement shall automatically terminate, immediately
upon RHPA's written notice, as to any Professional Provider
whose affiliation with RHPA is severed or terminated. City
or RHPA may also terminate this Agreement as to any
Professional Provider, without adversely affecting the
participation of Reid, RHPA or any other Professional
Provider, immediately upon written notice in the event of any
of the following:
5.4.1 Revocation, suspension or restriction of
any license, permit, registration or certificate required to
perform that provider's obligations under this Agreement;
5.4.2 Exclusion from participation in any
federally funded healthcare program, including Medicare and
Medicaid;
5.4.3 Lapse of required medical malpractice or
professional liability insurance coverage that is not
immediately replaced;
5.4.4 Any involuntary resignation of clinical
privileges or medical staff membership, or any voluntary
resignation while under disciplinary investigation at any
healthcare facility;
5.4.5 Conviction of a felony or any criminal
charge involving moral turpitude;
5.4.6 Any impairment or incapacity making it
impossible for the practitioner to render medical services to
patients safely and effectively; or
5.4.7 Upon an adverse final action in a grievance
proceeding pursued by Reid, RHPA or City .
5.5 Rights and Obligations upon Termination. If this
Agreement is terminated for any reason, it shall be of no
further force and effect from and after the date of termination
except for Section 5.2; provided, that all rights or obligations
accrued through the date of termination shall remain.
5.6 Continuation of Benefits After Termination. If a
Covered Individual is a hospital inpatient or is undergoing an
active course of treatment on the effective date of the
termination of this Agreement, Reid, RHPA and Professional
Providers shall continue to provide Health Care Services
until discharge, completion of the course of treatment or, if
sooner, appropriate alternative arrangements for care have
been made. With respect to a pregnant woman who is in her
fourth or later month of pregnancy, Professional Providers
shall continue to provide Health Care Services pursuant to
this Agreement through the end of the post-partum period if
requested by the patient. City shall compensate Reid and
RHPA for the provision of Health Care Services pursuant
to this Agreement during a continuation of benefits period.
This continuation of benefits provision shall survive
termination of this Agreement.
ARTICLE VI
GENERAL PROVISIONS
6.1 Amendment. This Agreement may only be
amended in writing upon the mutual consent of the parties.
6.2 Assi ng ment. This Agreement may not be
assigned by any party without the prior written consent of
the other parties; provided, however, that a party may
assign its rights and responsibilities under this Agreement
to any successor or related entity upon giving notice to the
other parties. This Agreement shall be binding and shall
inure to the benefit of the parties hereto and their
respective permitted successors and assigns.
6.3 Dispute Resolution. If a dispute arises between
City and Reid or RHPA, or between City and any
Professional Provider, regarding a party's obligations
under this Agreement, the complaining party shall provide
written notice of the issue(s) in dispute to the other parties.
The parties shall meet, in person or telephonically, with or
without legal counsel, and make good faith efforts to
resolve the dispute. If the dispute is not resolved to the
satisfaction of the complaining party within sixty (60)
days, or such longer period as the parties may agree in
writing, the dispute may then be submitted to non -binding
mediation conducted in Indiana in accordance with the
American Health Lawyers Association Alternative
Dispute Resolution Service Rules of Procedure for
Mediation. If the Parties cannot agree upon a mediator,
each shall select one name from a list of mediators
maintained by any bona fide dispute resolution provider or
other private mediator; the two selected shall then choose
a third person who will serve as mediator. The Parties
agree to have the principals participate in the mediation
process, including being present throughout the mediation
session(s). The Parties shall have 45 days within which to
commence the first mediation session following the
conclusion of their good faith negotiations or expiration of
the time within which to negotiate.
The Parties agree that any mediated settlement agreement
may be converted to an arbitration award or judgment (or
both) and enforced according to the governing rules of
civil procedure. The Parties further confirm their
motivating purpose in selecting mediation is to find a
solution that serves their respective and mutual interests,
including
their continuing business/professional relationship.
Notwithstanding the foregoing, neither Party shall be
precluded from seeking injunctive or other equitable relief
in court in connection with the enforcement of those
sections of this Agreement that permit actions for
injunctive relief.
6.4 Compliance with Laws. The Parties agree that this
Agreement is intended to comply with all applicable state
and federal laws, rules, and regulations including, but not
limited to, the Medicare and Medicaid Fraud and Abuse
Statute and Regulations, any applicable nondiscrimination
laws, and the employment eligibility verification laws
("Laws"). If, at any time, this Agreement is found to violate
any applicable provision of these Laws, or if either Party has
a reasonable belief that this Agreement creates a material
risk of violating the Laws, and after consultation with the
other Party, and thirty (30) days after written notice to the
other Party, the Parties shall renegotiate the portion of this
Agreement that creates the violation of the Laws. If the
Parties fail to reach agreement within sixty (60) days
following said written notice, this Agreement shall
terminate..
6.5 Entire Agreement. This Agreement constitutes the
entire understanding and agreement of the parties concerning
the provision of Health Care Services to Covered Individuals,
during the term of this Agreement.
6.6 Governing Law. This Agreement shall be
governed by and construed in accordance with the laws of the
state of Indiana, except to the extent state law is pre-empted
by applicable federal law. All legal disputes shall be filed in
a court of competent jurisdiction in Wayne County, Indiana.
6.7 Indemnification. Reid and RHPA each agrees to
indemnify and hold City , and its owners, directors, officers,
employees, agents and assigns, harmless from and against
any claim, liability, obligation, costs or expenses, including
reasonable attorney's fees, incurred by City arising out of
any act or omission of Reid, RHPA or any Professional
Provider in connection with that provider's responsibilities
under this Agreement. City shall immediately notify Reid
upon learning of any claim for which City might seek
indemnification from Reid, and shall cooperate fully with
Reid in the defense of such claim.
City agrees to indemnify and hold Reid, RHPA and
Professional Providers, and their respective owners, directors,
officers, employees, agents and assigns, harmless from and
against any claim, liability, obligation, costs or expenses,
including reasonable attorney's fees, incurred by them arising
out of any act or omission of City in connection with its
responsibilities under this Agreement. Reid or RHPA shall
immediately notify City upon learning of any claim for which
Reid or RHPA might seek indemnification from City , and
shall cooperate fully with City in the defense of such claim.
6.8 Independent Contractor Relationship. Reid, RHPA
and City agree that each is acting as an independent
contractor of the others and not as an agent or employee of
either other party. This Agreement is not intended to create
nor shall it be construed to create a joint venture, partnership
or any other relationship among the parties. The Health Care
Services performed by a Professional Provider shall be the
sole responsibility and duty of that Professional Provider.
6.9 Non-exclusive Agreement. This Agreement is
non-exclusive as to all parties and any party may contract
with any other person or entity for the provision of medical
services as each shall determine in its sole discretion.
6.10 Notice. Any written notice required to be given
pursuant to this Agreement may either be personally
delivered or sent by registered or certified mail, return
receipt requested, postage prepaid, to the individual
identified on the signature page of this Agreement at the
address there indicated (or such new address as either party
shall give notice to the other).
6.11 Communications Between Covered Individuals
and Providers. Notwithstanding any other provision of this
Agreement to the contrary and regardless of any benefit or
coverage exclusions or limitations associated with any
Health Benefit Plan, none of Reid, RHPA or any
Professional Provider shall be prohibited from discussing
fully with a Covered Individual any issues related to the
Covered Individual's health, including recommended
treatments, treatment alternatives, treatment risks and the
consequences of any benefit coverage or payment decision
made by City or its Plan Sponsor, if any.
6.12 Severability. If any one or more of the terms or
conditions of this Agreement shall be for any reason held
invalid, illegal or unenforceable by a court of competent
jurisdiction, such invalidity, illegality or unenforceability
shall not affect any other provision of this Agreement and
this Agreement shall remain in full force and effect.
6.13 Third Party Rights. Except as otherwise expressly
stated herein, the parties agree that they do not intend to
create any enforceable rights in any third parties under this
Agreement and that there are no third party beneficiaries to
this Agreement.
6.14 Waiver of Breach. The failure of any party hereto
to insist upon the strict performance of any provision of this
Agreement shall not be deemed a waiver of any breach of the
Agreement or of the right to insist upon strict performance of
such provision at any future time.
IN WITNESS WHEREOF, each party has caused its duly authorized officer to execute this Agreement on the date(s) set
forth below, intending to be legally bound to the terms and conditions of this Agreement.
REID HOSPITAL HEALTH ARE SERVICE , INC.
By: % 2"14
Authorized Signa re Ilate
Printed: Galz') C,�-
Title:
Address: 1100 Reid Parkway
Richmond, IN 47374
REID PHYSICIA ASSOCIATE , INC.
By:
Authoriz?1W
ignatu to
o�
Printed:
Title: � , Cfo
Address: 1100 Reid Parkway_
Richmond, IN 47374
1259317
CITY OF RI-HMOHMO NDIANA.
By:
7_'�/ 4
Auth
orized Date
rizeed SSignature Printed: Apbilv-6m
Vicki Robinson
Title: President
Address:
50 North 5th Street
Richmond, In 47374
APPROVED: \
— avid 3 . S , Mayor
Date: �--�- 2I' NO
Exhibit A
PROVIDER FEE SCHEDULE
Reid and RHPA, as applicable, shall be entitled to the lesser of their billed charges or the negotiated fees set forth in this Exhibit A
as payment in full for Health Care Services rendered to Covered Individuals.
Hospital Services. Inpatient and outpatient services rendered to an eligible Covered Individual by an Affiliate Provider
shall be reimbursed in accordance with the City 's health plan benefit schedule as shown in this Agreement based on,
Reid's then -current billed charges as published on its charge description master ("Hospital Base Rate") less the Covered
Individual's copays, co-insurance and/or deductibles, provided, however, the following case rates shall apply for the
specified inpatient services, and specified case rates will not increase during the term of this Agreement without written
mutual consent of both parties. The following case rates shall be inclusive of cardiothoracic surgery professional fees,
anesthesiology professional fees, pathology professional fees, and cardiology professional fees, where applicable.
MS-DRG
DESCRIPTION
CASE RATE
Normal Delivery
774
VAGINAL DELIVERY W COMPLICATING DIAGNOSES
$ 5,700.00
775
VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES
$ 5,700.00
776
POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R.
PROCEDURE
$ 5,700.00
767
VAGINAL DELIVERY W STERILIZATION &/OR D&C
$ 5,700.00
768
VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C
$ 5,700.00
Cesarean Section
765
CESAREAN SECTION W CC/MCC
$ 10,580.00
766
CESAREAN SECTION W/O CC/MCC
$ 10,580.00
Nursery
792
PREMATURITY W/O MAJOR PROBLEMS
$ 2,000.00
793
FULL TERM NEONATE W MAJOR PROBLEMS
$ 2,000.00
794
NEONATE W OTHER SIGNIFICANT PROBLEMS
$ 2,000.00
795
NORMAL NEWBORN
$ 2,000.00
The DRGs abiove do.nof i►tclude physician fees
MS-DRG
DESCRIPTION
CASE RATE
Coronary Bypass
$ 80,000.00
232
CORONARY BYPASS W PTCA W/O MCC
$ 80,000.00
233
CORONARY BYPASS W CARDIAC CATH W MCC
$ 80,000.00
234
CORONARY BYPASS W CARDIAC CATH W/O MCC
$ 80,000.00
235
CORONARY BYPASS W/O CARDIAC CATH W MCC
$ 60,000.00
236
CORONARY BYPASS W/O CARDIAC CATH W/O MCC
$ 60,000.00
Above IiRGs includes physicri'fees CT.urgeon, card dlogisi, path i�gist, aneslaesiologist
1. Radiology Services. Notwithstanding Paragraph 1, the following radiology services rendered by Reid shall be
reimbursed at 85 % of Reid's then -current billed charges as published on its charge description master (a copy of which is
attached hereto): Furthermore, during the term of this Agreement, the then billed charges will remain the same with no
increase without mutual consent of the parties.
CPT Code Description
70450 CT HEAD I
70470 CAT SCAN HEAD III
70486 CT SINUSES / FACIAL BONES 1
70551 MRI BRAIN W/O CONTRAST
70553 MRI BRAIN W/WO
71010 CHEST SINGLE VIEW
71020 CHEST TWO VIEWS (PA&LAT)
71250 CT THORAX I
72141 CERVICAL SURVEY W/O CONTRAST
72148 LUMBAR SURVEY WO CONTRAST
72192 CT SCAN PELVIS I
72193 CT SCAN PELVIS II
73110 WRIST THREE VIEWS
73221 UPPER EXTREMITY WITH JOINT
73630 FOOT THREE VIEWS
73718 MRI, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S)
73721 LOWER EXTREMITY WITH JOINT
74000 ABDOMEN SINGLE KUB
74150 CT ABDOMEN I
74160 CT SCAN ABDOMEN 11
74176 CT ABDOMEN/PELVIS I
76801 ULTRASOUND OB < 14 WKS
77051 COMPUTER -AID DETECT MAMMO
77052 COMPUTER -AID DETECT SM
77080 DEXA AXIAL (SPINE/HIPS)
77418 IMRT TREATMENT
78223 GALL BLADDER SCAN
78452 MYOCARDIAL PERFUSION
78815 PET/CT SKULL B-M THIGH
2. Laboratory Services. Notwithstanding Paragraph 1, laboratory services rendered by Reid or RHPA shall be reimbursed at
the lesser of provider's billed charge or the attached fee schedule (Exhibit A-1). The fee schedule will remain the same
with no increase without mutual consent of the parties.
Exhibit A-1
Laboratory Fee Schedule
CPT
Code
$$
CPT
Code
$$''
CPT
Code
$$
36415
$ 12.00
80198
$ 27.92
82131
$ 149.68
36416
$ 9.00
80200
$ 2792
82135
$ 152.14
80047
$ 29.37
80201
$ 83.41
82136
$ 79.77
80048
$ 4.56
80202
$ 53.04
82139
$ 160.50
80050
$ 14.53
80299
$ 37.75`'
82140
$ 79.36
80051
$ 5.58
80400
$ 53.51
82145
$ 30.71
80053
$ 5.70
; 80428
$ 125.66
82150
$ 16.80
80055
$ 45.58
80438
$ 62.82 ''
82154
$ 77.44
80061
$ 5.14
80439
$ 83.76 `
82157
$ 62.59
80069
$ 7.59
80500
$ 67.50
82160
$ 34.65
80074
$ 96.32
81000
$ 6.28
82163
$ 124.22
80076
$ 5.02
81001
$ 5.02
82164
$ 38.73
80100
$ 86.95
81002
$ 5.02
82172
$ 13.95
80101
$ 16.74
81003
$ 4.39;-
82175
$ 34.33
80102
$ 30.71
81005
$ 3.89 ''
82180
$ 33.49
80103
$ 47.29
81015
$ ` 1.74
82190
$ 28.11
80150
$ 45.37
81025
$ 12.67
82205
$ 30.71
80152
$ 28.74
81050
$ 6.82
82232
$ 27.92
80154
$ 54.28
81099
$ 6.27
82239
$ 26.96
80156
$ 27.92
82000
$ 20.57
82240
$ 78.53
80157
$ 72.93
82003
$ 69.08
82247
$ 3.77
80158
$ 62.12
82009
$ 10.89'''
82248
$ 6.99
80160
$ 62.82
82010
$ 53.61
82261
$ 150.04
80162
$ 27.92
82013
$ 165.68
82270
$ 5.58
80164
$ 33.49
82016
$ 213.54
82271
$ 8.55
80166
$ 32.10
82017
$ 311.24
82272
$ 5.58
80168
$ 31.42
82024
$ 79.56
82274
$ 3.77
80170
$ 27.92
82030
$ 205.53
82300
$ 25.12
80172
$ 32.90
82040
$ 3.76
82306
$ 78.69
80173
$ 42.83
82042
$ 5.21 ''
82308
$ 37.49
80174
$ 41.87
82043
$ 15.35 `'
82310
$ 3.77
80176
$ 31.42
82044
$ 15.35 ''
82330
$ 20.94
80178
$ 13.96
82055
$ 20.94 ''
82340
$ 8.38
80182
$ 46.06
82085
$ 23.73 -
82355
$ 47.11
80184
$ 27.92
82088
$ 54.66
82360
$ 34.89
80185
$ 27.92
82103
$ 29.31
82365
$ 57.02
80186
$ 46.75
82104
$ 148.29
82370
$ 48.85
80188
$ 31.42
82105'
$ 28.48
82373
$ 27.92
80192
$ 27.92
82106
$ 37.42
82374
$ 8.38
80194
$ 32.80
82107
$ 30.71
82375
$ 64.89
80195
$ 83.74
82108
$ 62.82
82378
$ 34.89
80196
$ 25.12
82127
$ 78.16
82379
$ 33.49
80197
$ 71.11
82128
$ 33.37
82380
$ 55.82
CPT
Code
$$
CPT
Code
$$
CPT
Code
$$
82382
$ 33.99
82652
$ 41.88
82977
$ 6.99
82384
$ 48.16
82656
$ 276.36
82978
$ 185.63
82390
$ 25.82
82657
$ 75.13
82985
$ 16.75
82397
$ 29.31
82658
$ 311.53
83001
$ 34.89
82435
$ 3.77
82664
$ 37.25
83002
$ 34.89
82436
$ 25.54
82668
$ 54.43
83003
$ 31.42
82438
$ 24.40
82670
$ 50.25
83010
$ 26.81
82441
$ 133.65
82671
$ 58.44
83013
$ 104.73
82465
$ 6.99
82672
$ 60.00
83014
$ 23.66
82480
$ 27.55
82677
$ 33.49
83015
$ 36.28
82482
$ 34.89
82679
$ 121.13
83018
$ 55.83
82486
$ 52.82
82690
$ 196.32 `
83020
$ 21.78
82489
$ 157.71
82693
$ 88.99
83021
$ 78.98
82491
$ 15.85
82696
$ 32.68
83033
$ 35.21
82492
$ 38.74
82705
$ 8.38
83036
$ 6.28
82495
$ 32.10
82710
$ 163.30
83037
$ 21.26
82507
$ 131.20
82715
$ 14.92 `
83050
$ 41.32
82520
$ 30.71
82725
$ 21.93
83051
$ 67.83
82523
$ 85.01
82726
$ 259.18
83060
$ 46.61
82525
$ 52.42
82728
$ 22.32''
83068
$ 19.64
82528
$ 95.18
82731
$ 214.87
83069
$ 46.00
82530
$ 39.48
82735
$ 122.47
83070
$ 51.08
82533
$ 27.92
82742
$ 53.04
83080
$ 241.18
82540
$ 14.36
82746
$ 27.92 ''
83088
$ 52.42
82541
$ 42.89
82747
$ 30.71
83090
$ 25.82
82542
$ 118.62
82757
$ 97.71 ''
83150
$ 42.36
82544
$ 389.40
82759
$ 249.59
83491
$ 66.15
82550
$ 3.77
82760
$ 18.93:
83497
$ 45.02
82552
$ 13.95
82775
$ 99.95
83498
$ 44.70
82553
$ 39.37
82776
$ 14.18
83500
$ 210.45
82565
$ 3.77
82784
$ 18.00 `
83505
$ 185.36
82570
$ 8.78
82785
$ 30.71
83516
$ 17.50
82575
$ 16.75
82787
$ 92.67
83518
$ 48.86
82585
$ 8.93
82803
$ 58.55
83519
$ 77.44
82595
$ 9.30
82805
$ 58.55
83520
$ 23.42
82600
$ 135.94
82926
$ 122.17
83525
$ 39.08
82607
$ 9.12
82941
$ 42.48
83527
$ 9.16
82608
$ 34.73
82943
$ 37.68 "
83540
$ 9.12
82610
$ 88.72
82945
$ 6.98
83550
$ 16.75
82615
$ 68.05
82947'
$ 3.77
83586
$ 62.17
82626
$ 73.95
82948
$ 6.98
83593
$ 56.44
82627
$ 39.08
82950
$ 6.99
83605
$ 28.62
82633
$ 149.03
82951
$ 12.56
83615
$ 6.98
82634
$ 52.33
82952
$ 1.39
83625
$ 15.35
82638
$ 37.89
82955
$ 72.45"
83630
$ 54.16
82646
$ 85.36
82960
$ 34.89 ;'1
83631
$ 54.15
82649
$ 80.59
82962
$ 3.77 ''
83632
$ 136.79
82651
$ 109.30
82963
$ 326.59
83655
$ 27.92
H
CPT
Code
$$
CPT
Code
$$
CPT
Code
$$
83661
$ 137.75
83912
$ 7.61
84165
$ 22.32
83662
$ 31.66
83914
$ 26.13
84166
$ 22.32
83663
$ 162.46
83915
$ 57.59
84181
$ 19.27
83670
$ 65.53
83916
$ 45.37
84182
$ 56.93
83690
$ 10.92
83918
$ 161.01
84202
$ 37.68
83695
$ 13.95
83919
$ 25.78 `'
84206
$ 37.68
83698
$ 242.30
83921
$ 37.68
84207
$ 84.44
83700
$ 237.72
83925
$ 30.71
84210
$ 31.06
83701
$ 44.67
83930
$ 52.96 ''
84220
$ 55.27
83704
$ 140.96
83935
$ 62.591'
84228
$ 52.83
83718
$ 5.58
83937
$ 50.72 ''
84233
$ 50.66
83719
$ 166.09
83945
$ 68.05
84234
$ 51.22
83721
$ 40.48
83950
$ 116.52
84235
$ 54.53
83727
$ 224.01
83970
$ 57.79
84238
$ 43.96
83735
$ 3.42
83986
$ 37.68
84244
$ 48.17
83785
$ 19.38
83992
$ 30.71
84252
$ 146.19
83788
$ 68.40
83993
$ 177.31
84255
$ 57.23
83789
$ 237.98
84022
$ 63.85
84260
$ 71.87
83805
$ 66.03
84030
$ 75.83 '
84270
$ 34.97
83825
$ 34.17
84060
$ 51.08
84275
$ 35.08
83835
$ 38.79
84066
$ 27.92 '''
84285
$ 127.01
83840
$ 30.71
84075
$ 6.98
84295
$ 3.77
83857
$ 40.58
84078
$ 31.54
84300
$ 8.38
83858
$ 122.82
84080
$ 73.95 `
84302
$ 24.40
83864
$ 142.33
84081
$ 78.58
84305
$ 87.07
83866
$ 17.82
84087
$ 139.30
84307
$ 70.70
83872
$ 12.03
84100
$ 3.77
84311
$ 136.50
83873
$ 47.53
84105
$ 8.38
84315
$ 7.39
83874
$ 21.84
84106
$ 71.19.
84375
$ 61.48
83880
$ 58.61
84110
$ 59.26
84376
$ 124.92
83883
$ 26.56
84120
$' ` 127.01
84377
$ 18.62
83885
$ 58.93
84126
$ 176.93 ''
84378
$ 426.66
83887
$ 78.16
84132
$ 3.77
84392
$ 8.38
83890
$ 7.61
84133
$ 8.38 ,
84402
$ 27.92
83891
$ 7.61
84134
$ 34.47 '
84403
$ 32.15
83892
$ 7.61
84138
$ 98.05 `
84425
$ 34.34
83893
$ 7.61
84140
$ 63.15
84430
$ 88.76
83894
$ 7.61
84143
$ 128.40
84432
$ 51.65
83896
$ 7.61
84144
$ 27.92
84436
$ 4.39
83897
$ 17.48
84146
$ 34.89
84439
$ 17.22
83898
$ 45.34
84150
$ 215.35
84442
$ 65.10
83900
$ 52.26
84153
$ 9.12
84443
$ 4.26
83901
$ 45.34
84154
$ 27.92 '
84445
$ 101.33
83902
$ 47.40
84155
$ 3.77
84446
$ 93.52
83903
$ 45.34
84156
$ 10.92
84449
$ 105.14
83904
$ 45.34
84157
$ 6.98 `
84450
$ 3.77
83908
$ 14.40
84160
$ 6.98
84460
$ 3.77
83909
$ 17.46
84163
$ 66.31
84466
$ 27.92
11
CPT
Code
$$
CPT
Code
$$
CPT
Code
$$
84478
$ 6.99
85210
$ 82.01-
85557
$ 114.21
84479
$ 8.38
85220
$ 82.01
85576
$ 48.86
84480
$ 25.14
85230
$ 82.01
85597
$ 137.29
84481
$ 41.87
85240
$ 60.99 ''
85610
$ 6.90
84482
$ 53.80
85244
$ 93.87
85611
$ 30.01
84484
$ 37.75
85245
$ 7466
85612
$ 46.06
84488
$ 28.68
85246
$ 74.66
85613
$ 46.06
84490
$ 13.77
85247
$ 61.23
85635
$ 151.15
84510
$ 143.31
85250
$ 78.53
85651
$ 6.27
84520
$ 3.77
85260
$ 82.01
85652
$ 6.90
84540
$ 8.38
85270
$ 78.53
85660
$ 6.99
84545
$ 27.89
85280
" $ 78.53 `
85670
$ 36.98
84550
$ 6.99
85290
$ 65.61
85705
$ 56.68
84560
$ 8.38
85291
$ 60.99
85730
$ 11.66
84580
$ 24.47
85292
$ 68.01
85732
$ 36.98
84585
$ 34.10
85293
$ 145.92
85810
$ 28.62
84586
$ 70.37
85300
$ 59.88 `_
85999
$ 25.14
84588
$ 80.26
85301
$ 29.91 ''
86000
$ 20.08
84590
$ 26.04
85302
$' 23.86
86001
$ 28.17
84591
$ 80.96
85303
$ 98.39:
86003
$ 16.43
84597
$ 83.74
85305`
$ 67.08
86005
$ 23.04
84600
$ 66.03
85306
$ 98.39
86021
$ 11.23
84620
$ 59.88
85307
$ 33.92 `
86022
$ 108.86
84630
$ 33.49
85335
$ 223.66
86023
$ 32.41
84681
$ 36.28
85347
$ 121.42
86038
$ 18.15
84702
$ 13.96
85360
$ 39.68
86039
$ 17.85
84703
$ 13.95
85362
$ 23.72
86060
$ 13.96
84999
$ 21.65
85366
$ 66.30
86063
$ 13.95
85002
$ 27.92
85378
$ 32.10
86140
$ 6.28
85004
$ 5.58
85379
$ 48.86
86141
$ 9.07
85007
$ 5.58
85380
$ 32.10 `
86146
$ 39.08
85008
$ 5.58
85384
$ 13.95
86147
$ 39.08
85009
$ 7.36
85385
$ 85.16
86148
$ 59.55
85013
$ 4.20
85397
$ 74.66
86156
$ 31.42
85014
$ 4.20
85400
$ 26.28
86157
$ 33.28
85018
$ 4.14
85410
$ 67.08
86160
$ 25.14
85025
$ 4.56
85415
$ 108.80
86161
$ 42.85
85027
$ 3.77
85420
$ ' 92.13
86162
$ 53.04
85032
$ 3.43
85421
$` 98.58
86171
$ 32.10
85041
$ 5.58
85441
$' 17.85°
86200
$ 36.78
85044
$ 6.99
85445
$ 21.03
86215
$ 28.62
85045
$ 6.99
85460
$ 92.55
86225
$ 20.68
85046
$ 15.39
85461
$ 15.77
86226
$ 48.80
85048
$ 5.58
85475
$ 46.01
86235
$ 18.83
85049
$ 6.98
85520
$ 119.61
86255
$ 41.00
85060
$ 38.02
85540
$ 25.13
86256
$ 27.09
85097
$ 106.08
85549
$ 82.69
86277
$ 66.32
85130
$ 188.42
85555
$ 43.09
86294
$ 77.46
12
CPT
Code
$$
CPT
Code
$$,
CPT
Code
$$
86300
$ 32.94
86617
$ 40.01
86720
$ 19.54
86301
$ 37.49
86618
$ 28.90
86723
$ 42.94
86304
$ 35.59
86619
$ 71.46 `
86727
$ 91.77
86305
$ 52.88
86622
$ 33.28
86729
$ 45.37
86308
$ 11.19
86625
$ 54.62
86735
$ 19.75
86309
$ 15.30
86628
$ 16.12
86738
$ 28.62
86316
$ 52.88
86631
$ 36.43
86741
$ 160.50
86317
$ 27.12
86632
$ 30,37';
86744
$ 13.48
86318
$ 13.95
86635
$ 20.60
86747
$ 23.76
86320
$ 41.23
86638
$ 24.84 _
86750
$ 102.68
86325
$ 11.54
86641
$ 43.26
86753
$ 30.62
86327
$ 41.23
86644
$ 28.63 -
86756
$ 27.92
86329
$ 34.47
86645
$ 28.63
86757
$ 28.62
86331
$ 6.10
86648
$ 112.01
86762
$ 19.54
86332
$ 33.72
86651
$ 20.03
86765
$ 32.10
86334
$ 31.51
86652
$ 20.03
86768
$ 8.06
86335
$ 47.54
86653
$ 20.03
86774
$ 41.17
86336
$ 17.88
86654
$ 20.03
86777
$ 28.63
86337
$ 18.13
86658
$ 9.43
86778
$ 28.63
86340
$ 53.18
86663
$ 28.62
86780
$ 25.12
86341
$ 44.67
86664
$ 28.62
86781
$ 25.12
86343
$ 93.05
86665
$ 28.62
86784
$ 86.54
86353
$ 74.71
86666
$ 44.21 ,
86787
$ 30.71
86355
$ 15.64
86668
$ 39.08''
86788
$ 38.83
86356
$ 115.41
86671
$ 105.73
86789
$ 34.33
86357
$ 15.64
86674
$ 19.54''
86790
$ 72.78
86359
$ 27.92
86677
$ 49.74
86793
$ 114.46
86360
$ 27.92
86682
$ 122.47
86800
$ 25.12
86361
$ 27.92
86684
$ 90.04
86803
$ 33.49
86367
$ 69.79
86687
$ 51.30
86804
$ 150.75
86376
$ 35.58
86689
$ 102.23
86805
$ 56.57
86382
$ 25.13
86692
$ 42.58 "
86807
$ 284.72
86384
$ 34.89
86694
$ 27.92'[
86808
$ 270.35
86403
$ 25.82
86695
$ 27.92
86812
$ 35.58
86406
$ 49.11
86696
$ 27.92 ''
86813
$ 197.27
86430
$ 11.19
86698
$ 19.88 `
86816
$ 46.28
86431
$ 10.36
86701
$ 13.96
86817
$ 219.08
86480
$ 197.15
86702
$ " 32.10
86821
$ 61.09
86580
$ 23.20
86703
$ 22,41
86849
$ 27.84
86592
$ 5.58
86704
$ 20.94
86850
$ 12.69
86593
$ 5.58
86705
$ 20.94
86860
$ 67.62
86602
$ 15.18
86706
$ 20.94 ;
86870
$ 50.61
86603
$ 26.52
86707
$ 20.94 ;'
86880
$ 13.10
86606
$ 25.12
86708
$ 20.94
86885
$ 13.10
86609
$ 53.03
86709
$ 20.94 ;'
86886
$ 20.94
86611
$ 22.31
86710
$ 36.43
86900
$ 4.88
86612
$ 17.78
86713
$ 5.95
86901
$ 4.88
86615
$ 25.13
86717
$ 12.07 ;
86905
$ 11.07
13
CPT
Code
$$
CPT
Code
$$
CPT
Code
;$$
86906
$ 16.12
_87206
$ 28.38
87450
$ 35.58
86923
$ 105.00
87207
$ 25.14
87471
$ 95.26
86941
$ 70.57
87209
$ 15.49
87476
$ 220.80
86971
$ 22.54
87210
$ 8.38
87480
$ 34.25
86976
$ 153.98
87220
$ 13.84
87486
$ 213.54
86977
$ 153.98
87230
$ 39.99
87490
$ 22.34
86978
$ 131.90
87252
$ 32.02 ;
87491
$ 32.10
86999
$ 68.63
87253
$ 10.49 °
87496
$ 352.24
87015
$ 8.47
87254
$ 18.97
87497
$ 353.12
87040
$ 20.94
87255
$ 42.36
87498
$ 90.90
87045
$ 12.56
87260
$ 32.95
87510
$ 34.25
87046
$ 28.23
87265
$ 16.04
87516
$ 71.18
87070
$ 15.43
87269
$ 80.33
87517
$ 120.42
87071
$ 11.66
87270
$ 32.10
87521
$ 115.84
87075
$ 16.74
87271
$ 74.86
87522
$ 150.74
87076
$ 10.21
87272
$ 42.36
87526
$ 227.50
87077
$ 17.94
87273
$ 65.35
87528
$ 205.17
87081
$ 11.66
87274
$ 12.92
87529
$ 75.65
87086
$ 3.77
87275
$ 2156
87530
$ 67.69
87088
$ 12.77
87276
$ 21.57
87532
$ 407.55
87101
$ 37.04
87278
$ 39.08
87533
$ 621.09
87102
$ 14.33
87279
" $ 21.56
87535
$ 391.67
87103
$ 26.83
87280
$ 41.87 `
87536
$ 136.77
87106
$ 49.95
87281
$ 80.94
87538
$ 169.38
87107
$ 13.14
87290
$ 29.31
87555
$ 16.64
87109
$ 79.03
87299
$ 21.56 ''
87556
$ 354.51
87110
$ 21.69
87300
$ 30.63 ``f'
87560
$ 16.64
87116
$ 13.68
87301
$ 28.33
87561
$ 154.42
87118
$ 33.49
87305
$ 286.12 ''
87581
$ 122.23
87140
$ 6.90
87320
$ 29.41
87590
$ 22.34
87143
$ 52.56
87324
$ 40.00
87591
$ 32.10
87147
$ 9.75
87327
$ 34.11-
87620
$ 125.20
87149
$ 80.96
87328
$ 35.60
87621
$ 62.80
87158
$ 30.65
87329
$ 35.60
87641
$ 57.00
87166
$ 8.38
87337
$ 31.09
87650
$ 22.34
87168
$ 59.32
87338
$ 78.87
87653
$ 170.04
87169
$ 46.55
87340
$ 20.94
87660
$ 34.25
87172
$ 9.77
87341
$ 20.94 `
87797
$ 22.32
87176
$ 7.60
87350
$ 20.94
87798
$ 237.49
87177
$ 12.56
87380
$ 50.25
87799
$ 277.74
87181
$ 8.38
87385
$ 157.71
87800
$ 102.31
87184
$ 8.38
87390
$ 41.44
87801
$ 163.01
87185
$ 8.38
87400
$ 84.83
87804
$ 34.00
87186
$ 8.78
87420
$ 46.06
87807
$ 60.54
87188
$ 36.95
87425
$ 60.00
87880
$ 11.04
87190
$ 16.80
87427
$ 46.06
87899
$ 44.65
87197
$ 69.80
87430
$ 33.04
87900
$ 408.12
87205
$ 5.82
87449
$ 25.12
87901
$ 527.58
14
CPT
Code
$$
CPT
Code_
$$,
CPT
Code
$$
87902
$ 465.76
88280
$ 47.73
87903
$1,249.85
88283
$ 154.92
87904
$ 69.44
88285
$ 22.55
87999
$ 16.75
88289
$ 110.34
88104
$ 19.00
88291
$ 55.39
88106
$ 41.88
88300
$ 16.27
88107
$ 44.39
88302
$ 34.89
88108
$ 53.03
88304
$ 49.41
88112
$ 102.44
88305
$ 81.97
88130
$ 34.89
88307
$ 170.78
88141
$ 13.96
88309
$ 237.54
88142
$ 20.45
88311
$ 16.13'
88143
$ 49.94
88312
$ 85.98
88150
$ 15.35
88313
$ 15.49
88155
$ 21.57
88314
$ _ 85.44
88160
$ 29.31
88321
$ 89.79
88161
$ 29.31
88323
$ 160.99
88162
$ 101.69
88325
$ 270.49
88164
$ 15.35
88331
$ 103.86
88165
$ 30.71
88332
$ 48.09
88166
$ 102.44
88342
$ 111.36
88172
$ 82.49
88346
$ 73.95
88173
$ 100.49
88347
$ `' 69.63
88174
$ 59.16
88348
$ 213.54
88175
$ 28.04
88358
$ 202.37
88182
$ 54.43
88360
$ 158.64
88184
$ 24.85
88361
$ 26.30
88185
$ 13.06
88365
$ 90.86
88187
$ 164.66
88368
$496.00
88188
$ 46.02
88372
$ 136.30
88189
$ 69.53
88385
$ 218.63
88199
$ 53.83
88386
$ 218.63
88230
$ 72.03
88399
$ 84.89
88233
$ 50.25
89050
$ 32.10
88235
$ 50.25
89051
$ 37.68
88237
$ 37.27
89055
$ 54.16
88245
$ 203.53
89060
$ 43.76
88248
$ 255.77
89160
$ 22.02
88262
$ 354.63
89190
$ 12.56
88263
$ 187.26
89300
$ 26.29
88264
$ 286.56
89310
$ 56.58
88267
$ 213.21
89320
$ 66.09
88269
$ 170.29
89321
$ 26.30
88271
$ 117.86
89325
$ 63.49
88272
$ 144.61
99199
$ 30.40
88273
$ 96.47
88274
$ 139.06
88275
$ 117.86
15
Exhibit B
(Original)
Health Benefit Plan
16