Exhibit 10.4
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
WITH
Online Care Group, P.C.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
1
ANTHEM BLUE CROSS AND BLUE SHIELD
PROVIDER AGREEMENT
This Provider Agreement (hereinafter "Agreement") is made and entered into by and between Rocky Mountain Hospital and Medical Service, Inc., doing business as Anthem Blue Cross and Blue Shield and HMO Colorado, Inc. doing business as HMO Colorado, Anthem Health Plans, Inc. doing business as Anthem Blue Cross and Blue Shield, Anthem Insurance Companies, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield, Anthem Insurance Companies, Inc. doing business as Anthem Blue Cross and Blue Shield, Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield, Anthem Health Plans of Maine, Inc. doing business as Anthem Blue Cross and Blue Shield, RightCHOICE Managed Care, Inc., Anthem Health Plans of New Hampshire, Inc. doing business as Anthem Blue Cross and Blue Shield and Matthew Thornton Health Plan, Inc., Rocky Mountain Hospital and Medical Service, Inc. doing business as Anthem Blue Cross and Blue Shield and HMO Colorado, Inc. doing business as HMO Nevada, Empire HealthChoice HMO, Inc. (d/b/a Empire BlueCross BlueShield HMO or Empire Blue Cross HMO) and Empire HealthChoice Assurance, Inc. (d/b/a Empire BlueCross BlueShield or Empire Blue Cross), Community Insurance Company doing business as Anthem Blue Cross and Blue Shield, Anthem Health Plans of Virginia, Inc. doing business as Anthem Blue Cross and Blue Shield, Blue Cross Blue Shield of Wisconsin doing business as Anthem Blue Cross and Blue Shield, each of which is deemed to be a party to this Agreement as to the Networks and programs set forth on the Provider Networks Attachment in each State Specific Provisions Attachment, and each of which has an independent relationship with Provider (as defined below) (hereinafter each referred to as "Anthem" or the "Anthem Entities") and Online Care Group, P.C. (hereinafter "Provider"). Each Anthem Entity shall be solely responsible and liable for its respective obligations created under this Agreement, and in no case shall any of them be responsible for any obligations of each other. In consideration of the mutual promises and covenants herein contained, the sufficiency of which is acknowledged by the parties, the parties agree as follows:
ARTICLE I
DEFINITIONS
"Affiliate" means any entity that is: (i) owned or controlled, either directly or through a parent or subsidiary entity, by Anthem, or is under common control with Anthem, and (ii) that is identified as an Affiliate on Anthem's designated web site as referenced in the provider manual(s). Unless otherwise set forth in this Agreement, an Affiliate may access the rates, terms and conditions of this Agreement.
"Agency" means a federal, state or local agency, administration, board or other governing body with jurisdiction over the governance or administration of a Health Benefit Plan.
"Anthem Rate" means the lesser of one hundred percent (100%) of Eligible Charges for Covered Services, or the total reimbursement amount that Provider and Anthem have agreed upon as set forth in the Plan Compensation Schedule ("PCS"). The Anthem Rate includes applicable Cost Shares, and shall represent payment in full to Provider for Covered Services.
"Audit" means a post-payment review of the Claim(s) and supporting clinical information reviewed by Anthem to ensure payment accuracy. The review ensures Claim(s) comply with all pertinent aspects of submission and payment including, but not limited to, contractual terms, Regulatory Requirements, Coded Service Identifiers (as defined in the PCS) guidelines and instructions, Anthem medical policies and clinical utilization management guidelines, reimbursement policies, and generally accepted medical practices. Audit does not include medical record review for quality and risk adjustment initiatives, or activities conducted by Anthem's Special Investigation Unit ("SIU").
"Claim" means either the uniform bill claim form or electronic claim form in the format prescribed by Plan submitted by a provider for payment by a Plan for Health Services rendered to a Member.
"CMS" means the Centers for Medicare & Medicaid Services, an administrative agency within the United States Department of Health & Human Services ("HHS").
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 2 | 1841672798 #1350526454 |
"Cost Share" means, with respect to Covered Services, an amount which a Member is required to pay under the terms of the applicable Health Benefit Plan. Such payment may be referred to as an allowance, coinsurance, copayment, deductible, penalty or other Member payment responsibility, and may be a fixed amount or a percentage of applicable payment for Covered Services rendered to the Member.
"Covered Services" means Medically Necessary Health Services, as determined by Plan and described in the applicable Health Benefit Plan, for which a Member is eligible for coverage.
"Government Contract" means the contract between Anthem and an applicable party, such as an Agency, which governs the delivery of Health Services by Anthem to Member(s) pursuant to a Government Program.
"Government Program" means any federal or state funded program under the Social Security Act, and any other federal, state, county or other municipally funded program or product in which Anthem maintains a contract to furnish services. For purposes of this Agreement, Government Program does not include the Federal Employees Health Benefits Program ("FEHBP"), or any state or local government employer program.
"Health Benefit Plan" means the document(s) that set forth Covered Services, rules, exclusions, terms and conditions of coverage. Such document(s) may include but are not limited to a Member handbook, a health certificate of coverage, or evidence of coverage.
"Health Service" means those services, supplies or items that a health care provider is licensed, equipped and staffed to provide and which he/she/it customarily provides to or arranges for individuals.
"Medically Necessary" or "Medical Necessity" means the definition as set forth in the applicable Participation Attachment(s).
"Member" means any individual who is eligible, as determined by Plan, to receive Covered Services under a Health Benefit Plan. For all purposes related to this Agreement, including all schedules, attachments, exhibits, provider manual(s), notices and communications related to this Agreement, the term "Member" may be used interchangeably with the terms Insured, Covered Person, Covered Individual, Enrollee, Subscriber, Dependent Spouse/Domestic Partner, Child, Beneficiary or Contract Holder, and the meaning of each is synonymous with any such other.
"Network" means a group of providers that support, through a direct or indirect contractual relationship, one or more product(s) and/or program(s) in which Members are enrolled.
"Other Payors" means persons or entities, pursuant to an agreement with Anthem or an Affiliate, that access the rates, terms or conditions of this Agreement with respect to certain Network(s), excluding Government Programs unless otherwise set forth in any Participation Attachment(s) for Government Programs. Other Payors include, without limitation, other Blue Cross and/or Blue Shield Plans that are not Affiliates, and employers or insurers providing Health Benefit Plans pursuant to partially or wholly insured, self-administered or self-insured programs.
"Participating Provider" means a person or entity, or an employee or subcontractor of such person or entity, that is party to an agreement to provide Covered Services to Members that has met all applicable Plan credentialing requirements, standards of participation and accreditation requirements for the services the Participating Provider provides, and that is designated by Plan to participate in one or more Network(s).
"Participation Attachment(s)" means the document(s) attached hereto and incorporated herein by reference, and which identifies the additional duties and/or obligations related to Network(s), Government Program(s), Health Benefit Plan(s), and/or Plan programs such as quality and/or incentive programs. The Provider Networks Attachment in each State Specific Provisions Attachment identifies the Networks and programs to
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 3 | 1841672798 #1350526454 |
which the Provider participates for a particular Anthem Entity, subject to the terms and conditions of this Agreement, including the terms set forth in such Participation Attachment.
"Plan" means the applicable Anthem Entity, an Affiliate, and/or an Other Payor. For purposes of this Agreement, when the term "Plan" applies to an entity other than Anthem, "Plan" shall be construed to only mean such entity (i.e., the financially responsible Affiliate or Other Payor under the Member's Health Benefit Plan). When the term Anthem or Anthem Entity is used herein, it shall mean only the applicable Anthem Entity that is financially responsible. Each Plan shall be solely responsible and liable for their respective obligations created under this Agreement and in no case shall any of them be responsible for any obligations of each other.
"Plan Compensation Schedule" ("PCS") means the document(s) attached hereto and incorporated herein by reference, and which sets forth the Anthem Rate(s) and compensation related terms for the Network(s) in which Provider participates. The PCS may include additional Provider obligations and specific Anthem compensation related terms and requirements.
"Regulatory Requirements" means any requirements, as amended from time to time, imposed by applicable federal, state or local laws, rules, regulations, guidelines, instructions, Government Contract, or otherwise imposed by an Agency or government regulator in connection with the procurement, development or operation of a Health Benefit Plan, or the performance required by either party under this Agreement. The omission from this Agreement of an express reference to a Regulatory Requirement applicable to either party in connection with their duties and responsibilities shall in no way limit such party's obligation to comply with such Regulatory Requirement.
"State Specific Provisions Attachment" means the document(s), if any, attached hereto, which identifies provisions specific to the individual state and are required by the Plan, by statute, or by regulation. The State Specific Provisions Attachment contains the Provider Networks Attachment that identifies the Networks and programs to which the Provider participates for a particular Anthem Entity, subject to the terms and conditions of this Agreement, including the terms set forth in any applicable Participation Attachment.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 4 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 5 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 6 | 1841672798 #1350526454 |
In addition to and separate from Networks that support some or all of Plan's products and/or programs (e.g., HMO, PPO and Indemnity products), Provider further acknowledges that certain Health Services, including by way of example only, laboratory or behavioral health services, may be provided exclusively by designated Participating Providers (a "Health Services Designated Network"), as determined by Plan. Provider agrees to refer Members to such designated Participating Providers in a Health Services Designated Network for the provision of certain Health Services, even if Provider performs such services. Notwithstanding any other provision in this Agreement, if Provider provides a Health Service to a Member for which Provider is not a designated Participating Provider in a Health Services Designated Network, then Provider agrees that he/she/it shall not be reimbursed for such services by Anthem, Plan or the Member, unless Provider was authorized to provide such Health Service by Plan.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 7 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 8 | 1841672798 #1350526454 |
ARTICLE III
CONFIDENTIALITY/RECORDS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 9 | 1841672798 #1350526454 |
ARTICLE IV
INSURANCE
ARTICLE V
RELATIONSHIP OF THE PARTIES
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 10 | 1841672798 #1350526454 |
ARTICLE VI
INDEMNIFICATION AND LIMITATION OF LIABILITY
ARTICLE VII
DISPUTE RESOLUTION AND ARBITRATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 11 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 12 | 1841672798 #1350526454 |
ARTICLE VIII
TERM AND TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 13 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 14 | 1841672798 #1350526454 |
ARTICLE IX
GENERAL PROVISIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 15 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 16 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 17 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 18 | 1841672798 #1350526454 |
ARTICLE X
BCBSA REQUIREMENTS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 19 | 1841672798 #1350526454 |
Each party warrants that it has full power and authority to enter into this Agreement and the person signing this Agreement on behalf of either party warrants that he/she has been duly authorized and empowered to enter into this Agreement. Each Anthem Entity is deemed to be a party to this Agreement as to the Networks and programs set forth on the Provider Networks Attachment, each of which has an independent relationship with Provider, and each Anthem Entity shall be solely responsible and liable for its respective obligations created under this Agreement, and in no case shall any of them be responsible for any obligations of each other.
THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION WHICH MAY BE ENFORCED BY THE PARTIES
Provider shall be designated as a Participating Provider in the Networks set forth on the Provider Network Attachment on the later of: (1) the Effective Date of this Agreement or; (2) as determined by Plan in its sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements.
PROVIDER LEGAL NAME: Online Care Group, P.C.
By: | /s/ Bradford Gay |
| November 16, 2022 |
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Printed: | Bradford Gay |
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Address: | 75 State Street, 26th Floor |
| Boston, MA 02109 | ||||
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Tax Identification Number (TIN): | 541237939 |
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(Note: If any of the following is not applicable, please leave blank) |
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Phone Number: |
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Rocky Mountain Hospital and Medical Service, Inc., doing business as Anthem Blue Cross and Blue Shield and HMO Colorado, Inc. doing business as HMO Colorado, Anthem Health Plans, Inc. doing business as Anthem Blue Cross and Blue Shield, Anthem Insurance Companies, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. d/b/a Anthem Blue Cross and Blue Shield, Anthem Insurance Companies, Inc. doing business as Anthem Blue Cross and Blue Shield, Anthem Health Plans of Kentucky, Inc. d/b/a Anthem Blue Cross and Blue Shield, Anthem Health Plans of Maine, Inc. doing business as Anthem Blue Cross and Blue Shield, RightCHOICE Managed Care, Inc., Anthem Health Plans of New Hampshire, Inc. doing business as Anthem Blue Cross and Blue Shield and Matthew Thornton Health Plan, Inc., Rocky Mountain Hospital and Medical Service, Inc. doing business as Anthem Blue Cross and Blue Shield and HMO Colorado, Inc. doing business as HMO Nevada, Empire HealthChoice HMO, Inc. (d/b/a Empire BlueCross BlueShield HMO or Empire Blue Cross HMO) and Empire HealthChoice Assurance, Inc. (d/b/a Empire BlueCross BlueShield or Empire Blue Cross), Community Insurance Company doing business as Anthem Blue Cross and Blue Shield, Anthem Health Plans of Virginia, Inc. doing business as Anthem Blue Cross and Blue Shield, Blue Cross Blue Shield of Wisconsin doing business as Anthem Blue Cross and Blue Shield
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 20 | 1841672798 #1350526454 |
ANTHEM INTERNAL USE ONLY THE EFFECTIVE DATE OF THIS AGREEMENT IS: January 1, 2023
By: | /s/ Thomas Golias |
| 11/28/2022 | ||
| Signature, Authorized Representative of Anthem |
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Printed: | Tom Golias |
| VP, Enterprise National Contracting | ||
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As of the Effective Date of this Agreement, Provider will be designated as Network/Participating Provider in the following:
For a specific listing of the applicable Network(s)/products(s) in each state please refer to the applicable State Specific Provisions Attachment for that state.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 21 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
This is a Commercial Business Participation Attachment ("Attachment") to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
ARTICLE I
DEFINITIONS
The following definitions shall apply to this Attachment. Terms not otherwise defined in this Attachment shall carry the meaning set forth in the Agreement.
"Commercial Business" means certain Health Benefit Plans, including individual and employer groups, partially or wholly insured or administered by Plan, under which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers. Commercial Business does not include Government Programs as defined in the Agreement, but does include the FEHBP as well as state and local government employer programs.
"Commercial Business Covered Services" means, for purposes of this Attachment, only those Covered Services provided under Plan's Commercial Business products.
"Commercial Business Member" means, for purposes of this Attachment, a Member who is covered under one of Plan's Commercial Business products.
"Complete Claim" means, unless applicable law otherwise requires, an accurate Claim submitted pursuant to this Agreement, for which all information necessary to process such Claim and make a benefit determination is included.
"Medically Necessary" or "Medical Necessity" means the definition set forth in the Health Benefit Plan, unless a different definition is required by Regulatory Requirements.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 22 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 23 | 1841672798 #1350526454 |
ARTICLE III
TERMINATION
3.2.1 Any provisions required in order to comply with Regulatory Requirements.
ARTICLE IV
GENERAL PROVISIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 24 | 1841672798 #1350526454 |
MEDICARE ADVANTAGE PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
This is a Medicare Advantage Participation Attachment ("Attachment") to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
ARTICLE I DEFINITIONS
The following definitions shall apply to this Attachment. Terms not otherwise defined in this Attachment shall carry the meaning set forth in the Agreement.
"Clean Claim" means a Claim that has no defect or impropriety, including a lack of required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payment from being made on the Claim. A Claim is clean even though Plan refers it to a medical specialist within Plan for examination. If additional documentation (e.g., a medical record) involves a source outside Plan, then the Claim is not considered clean.
"CMS" is defined as set forth in Article I of the Agreement.
"Downstream Entity(ies)" means any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit, below the level of the arrangement between Anthem and a First Tier Entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.
"Emergency Condition" is defined as set forth in the PCS. "Emergency Services" is defined as set forth in the PCS.
"First Tier Entity(ies)" means any party that enters into a written agreement, acceptable to CMS, with Anthem to provide administrative services or health care services for a Medicare eligible Member under the Medicare Advantage Program.
"Medically Necessary" or "Medical Necessity" means care for which CMS determines is reasonable and necessary under Medicare for services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of MA Member's medical condition and meet accepted standards of medical practice.
"Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Act, as then constituted or later amended.
"Medicare Advantage Covered Services ("MA Covered Services")" means, for purposes of this Attachment, only those Covered Services provided under Plan's Medicare Advantage Program.
"Medicare Advantage Member ("MA Member")" means, for purposes of this Attachment, a Member who is covered under a Medicare agreement between CMS and Plan under Part C of Title XVIII of the Social Security Act ("Medicare Advantage Program") and for Plan's DSNP Medicare Program, the beneficiary is also entitled to Medicaid under Title XIX of the Social Security Act, see 42 USC §1396 et seq..
"Medicare Advantage Network" means Network of Providers that provides MA Covered Services to MA Members.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 25 | 1841672798 #1350526454 |
"Related Entity(ies)" means any entity that is related to Anthem by common ownership or control and (1) performs some of Anthem's management functions under contract or delegation; (2) furnishes services to MA Member under an oral or written agreement; or (3) leases real property or sells materials to Anthem at a cost of more than twenty-five hundred dollars ($2,500) during a contract period.
"Urgently Needed Care" means MA Covered Services provided when a MA Member is either: (1) temporarily absent from Plan's Medicare Advantage service area and such MA Covered Services are Medically Necessary and immediately required: (a) as a result of an unforeseen illness, injury, or condition; and (b) it was not reasonable, given the circumstances, to obtain the services through Plan's Medicare Advantage Network; or
(2) under unusual and extraordinary circumstances, the MA Member is in the service area but Plan's Network is temporarily unavailable or inaccessible and such MA Covered Services are Medically Necessary and immediately required: (a) as a result of an unforeseen illness, injury, or condition; and (b) it was not reasonable, given the circumstances, to obtain the services through Plan's Medicare Advantage Network.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 26 | 1841672798 #1350526454 |
ARTICLE III
ACCESS: RECORDS/FACILITIES
ARTICLE IV
ACCESS: BENEFITS AND COVERAGE
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 27 | 1841672798 #1350526454 |
(24) hour per day, seven (7) day a week basis to assure availability, adequacy and continuity of care to MA Member. In the event Provider is not one of the foregoing described providers, then Provider shall provide Health Services to MA Member on a twenty-four (24) hour per day, seven (7) day a week basis or at such times as Health Services are typically provided by similar providers to assure availability, adequacy, and continuity of care to MA Member. If Provider is unable to provide Health Services as described in the previous sentence, Provider will arrange for another Participating Provider to cover Provider's patients in Provider's absence.
ARTICLE V
BENEFICIARY PROTECTIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 28 | 1841672798 #1350526454 |
5.6.1 Dual Eligibles. Provider further agrees that for MA Members who are dual eligible beneficiaries for Medicare and Medicaid, that Provider will ensure he/she/it will not bill the MA Member for Cost Sharing that is not the MA Member's responsibility and such MA Members will not be held liable for Medicare Parts A and B Cost Sharing when the State is liable for the Cost Sharing. In addition, Provider agrees to accept Plan payment as payment in full or Provider should bill the appropriate state source.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 29 | 1841672798 #1350526454 |
ARTICLE VI
COMPENSATION AND AUDIT
ARTICLE VII
REPORTING AND DISCLOSURE REQUIREMENTS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 30 | 1841672798 #1350526454 |
(iv) containing the same procedural information as the supplemental data identified through the retrospective medical chart review or other processes. Plan requires submission of the original Claim prior to the submission of supplemental data to ensure the two (2) can be linked.
Supplemental diagnosis data shall be submitted in a format specified by Plan. If Provider reasonably determines that a Provider is unable to meet these requirements, then Provider must inform Plan within a reasonable time, but no later than thirty (30) days after receiving knowledge, actual or constructive of such inability, and Plan shall have the right to validate the data by auditing medical records and/or data generation processes, or by requesting additional data and/or documentation from Provider to confirm the acceptability of the data. For purposes of clarity, Provider shall cooperate with any such requests by Plan or on Plan's behalf, as set forth in this Agreement. If Provider identifies data corrections (e.g., prior data submissions not supported in the medical record), then Provider shall promptly inform Plan and submit data corrections to Plan in a format specified by Plan as soon as reasonably possible, but in no event later than thirty (30) days after identifying.
ARTICLE VIII
QUALITY ASSURANCE/QUALITY IMPROVEMENT REQUIREMENTS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 31 | 1841672798 #1350526454 |
(3) are developed in consultation with participating physicians; (4) are reviewed and updated periodically; and
(5) are communicated to providers and, as appropriate, to MA Member. Plan also agrees to ensure that decisions with respect to utilization management, MA Member education, coverage of Health Services, and other areas in which the guidelines apply are consistent with the guidelines.
ARTICLE IX
COMPLIANCE
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 32 | 1841672798 #1350526454 |
6.3 Federal Funds. Provider acknowledges that payments Provider receives from Plan to provide MA Covered Services to MA Members are, in whole or part, from federal funds. Therefore, Provider and any of his/her/its subcontractors are subject to certain Regulatory Requirements that are applicable to Members and entities receiving federal funds, which may include but is not limited to, Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR Part 84; the Age Discrimination Act of 1975 as implemented by 45 CFR Part 91; the Americans with Disabilities Act; lobbying restrictions as implemented by 45 CFR Part 93 and 31 USC 1352 and any other regulations applicable to recipients of federal funds.
ARTICLE X
MARKETING
10.1 Approval of Materials. Both parties agree to comply, and to require any of his/her/its subcontractors to comply, with all applicable Regulatory Requirements, CMS instructions, and marketing activities under this Agreement, including but not limited to, the Medicare Marketing Guidelines for Medicare Managed Care Plans and any requirements for CMS prior approval of materials. Any printed materials, including but not limited to letters to Plan MA Members, brochures, advertisements, telemarketing scripts, packaging prepared or produced by Provider or any of his/her/its subcontractors pursuant to this Agreement must be submitted to Plan for review and approval at each planning stage (i.e., creative, copy, mechanicals, blue lines, etc.) to assure compliance with Regulatory Requirements, and Blue Cross/Blue Shield Association guidelines. Plan agrees its approval will not be unreasonably withheld or delayed.
ARTICLE XI
TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 33 | 1841672798 #1350526454 |
ARTICLE XII
GENERAL PROVISIONS
(4) dated signatures of all the parties to the subcontract.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 34 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement Medicare Adv.Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 35 | 1841672798 #1350526454 |
PLAN COMPENSATION SCHEDULE ("PCS")
The definitions set forth below shall apply with respect to all of the terms outlined in this PCS. Terms not otherwise defined in this PCS and defined elsewhere in the Agreement shall carry the meanings set forth in the Agreement.
"Anthem Medicaid Fee Schedule(s)/Rate(s)/Methodologies" means the Anthem Rate(s) that is a proprietary rate that is based on the applicable state Medicaid Fee Schedule(s)/Rate(s)/Methodologies, which could be enhanced by additional Covered Services included in the Government Contract.
"Anthem Medicare Advantage Rate" shall mean the Anthem Rate that is used for Medicare Advantage.
"Capitation" means the amount paid by Anthem to a provider or management services organization on a per member per month basis for either specific services or the total cost of care for Covered Services.
"Case Rate" means the all-inclusive Anthem Rate for an entire admission or one outpatient encounter for Covered Services.
"Coded Service Identifier(s)" means a listing of descriptive terms and identifying codes, updated from time to time by CMS or other industry source, for reporting Health Services on the CMS 1500 or CMS 1450/UB-04 claim form or its successor as applicable based on the services provided. The codes include but are not limited to, American Medical Association Current Procedural Terminology ("CPT®-4"), CMS Healthcare Common Procedure Coding System ("HCPCS"), International Classification of Diseases, 10th Revision ("ICD- 10"), National Uniform Billing Committee ("Revenue Code") and National Drug Code ("NDC") or their successors.
"Diagnosis-Related Group" ("DRG") means Diagnosis Related Group or its successor as established by CMS or other grouper, including but not limited to, a state mandated grouper or other industry standard grouper.
"DRG Rate" means the all-inclusive dollar amount which is multiplied by the appropriate DRG Weight to determine the Anthem Rate for Covered Services.
"DRG Weight" means the weight applicable to the specific DRG methodology set forth in this PCS, including but not limited to, CMS DRG weights as published in the Federal Register, state agency weights, or other industry standard weights.
"Eligible Charges" means those Provider Charges that meet Anthem's conditions and requirements for a Health Service to be eligible for reimbursement. These conditions and requirements include but are not limited to: Member program eligibility, Provider program eligibility, benefit coverage, authorization requirements, provider manual specifications, Anthem administrative, clinical and reimbursement policies and methodologies, code editing logic, coordination of benefits, Regulatory Requirements, and this Agreement. Eligible Charges do not include Provider Charges for any items or services that Provider receives and/or provides free of charge.
"Emergency Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the health of the individual, or in the case of a pregnant woman, the health of the woman or her unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 36 | 1841672798 #1350526454 |
"Emergency Services" means those Covered Services furnished by a provider qualified to furnish emergency services, and which are needed to evaluate or treat an Emergency Condition.
"Encounter Data" means Claim information and any additional information submitted by a provider under capitated or risk-sharing arrangements for Health Services rendered to Members.
"Encounter Rate" means the Anthem Rate that is all-inclusive of professional, technical and facility charges including evaluation and management, pharmaceuticals, routine surgical and therapeutic procedures, and diagnostic testing (including laboratory and radiology) capable of being performed on site.
"Fee Schedule(s)" means the complete listing of Anthem Rate(s) for specific services that is payment for each unit of service allowed based on applicable Coded Service Identifier(s) for Covered Services.
"Global Case Rate" means the all-inclusive Anthem Rate which includes facility, professional and physician services for specific Coded Service Identifier(s) for Covered Services.
"Inpatient Services" means Covered Services provided by a facility to a Member who is admitted and treated as a registered inpatient, is assigned a licensed bed within the facility, remains assigned to such bed and for whom a room and board charge is made.
"Outpatient Services" means Covered Services provided by a facility to a Member who is admitted and treated as a registered outpatient within the facility.
"Percentage Rate" means the Anthem Rate that is a percentage of Eligible Charges billed by a provider for Covered Services.
"Per Diem Rate" means the Anthem Rate that is the all-inclusive fixed payment for Covered Services rendered on a single date of service.
"Per Hour Rate" means the Anthem Rate that is payment based on an increment of time for Covered Services.
"Per Relative Value Unit" ("RVU") means the Anthem Rate for each unit of service based on the CMS, State Agency or other (e.g., American Society of Anesthesiologists (ASA)) defined Relative Value Unit (RVU).
"Per Service Rate" means the Anthem Rate that is payment for each service allowed based on applicable Coded Service Identifier(s) for Covered Services.
"Per Unit Rate" means the Anthem Rate that is payment for each unit of service allowed based on applicable Coded Service Identifier(s) for Covered Services.
"Per Visit Rate" means the Anthem Rate that is the all-inclusive fixed payment for one encounter for Covered Services.
"Provider Charges" means the regular, uniform rate or price Provider determines and submits to Anthem as charges for Health Services provided to Members. Such Provider Charges shall be no greater than the rate or price Provider submits to any person or other health care benefit payor for the same Health Services provided, regardless of whether Provider agrees with such person or other payor to accept a different rate or price as payment in full for such services.
"State Medicaid Rate(s)/Fee Schedule(s)/Methodologies" means the Anthem Rate for the applicable state Medicaid Rate(s) /Fee Schedule(s)/Methodologies in effect on the date of service for the provider type(s)/service(s) identified herein for the applicable Medicaid Program(s).
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 37 | 1841672798 #1350526454 |
Billing Form and Claims Reporting Requirements. Provider shall submit all Claims on a CMS 1500 or CMS 1450/UB-04 claim form or its successor form(s) as applicable based on the Health Services provided in accordance with Policies or applicable Regulatory Requirements. Provider shall report all Health Services in accordance with the Coded Service Identifier(s) reporting guidelines and instructions using HIPAA compliant billing codes. In addition, Plan shall not pay any Claim(s) nor accept any Encounter Data submitted using non-compliant codes. Plan audits that result in identification of Health Services that are not reported in accordance with the Coded Service Identifier(s) guidelines and instructions, will be subject to recovery through remittance adjustment or other recovery action as may be set forth in the provider manual(s).
Claim Submissions for Pharmaceuticals. Each Claim submitted for a pharmaceutical product must include standard Coded Service Identifier(s), a National Drug Code ("NDC") number of the covered medication, a description of the product, and dosage and units administered. Unless otherwise required under Regulatory Requirements, Plan shall not reimburse for any pharmaceuticals that are not administered to the Member and/or deemed contaminated and/or considered waste.
Coding Updates. Coded Service Identifier(s) used to define specific rates are updated from time to time to reflect new, deleted or replacement codes. Anthem shall use commercially reasonable efforts to update all applicable Coded Service Identifiers within sixty (60) days of release by CMS or other applicable authority. When billing codes are updated, Provider is required to use appropriate replacement codes for Claims for Covered Services, regardless of whether this Agreement has been amended to reflect changes to standard billing codes. If Provider bills a revised code prior to the effective date of the revised code, the Claim will be rejected or denied and Provider shall resubmit Claim with correct code. In addition, Claims with codes which have been deleted will be rejected or denied.
Coding Software. Updates to Anthem's Claims processing filters, code editing software, pricers, and any edits related thereto, as a result of changes in Coded Service Identifier(s) reporting guidelines and instructions, shall take place automatically and do not require any notice, disclosure or amendment to Provider.
Modifiers. All appropriate modifiers must be submitted in accordance with Regulatory Requirements, industry standard billing guidelines and Policies. If appropriate modifiers are not submitted, Claims may be rejected or denied.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 38 | 1841672798 #1350526454 |
New/Expanded Service or New/Expanded Technology. In accordance with the Scope/Change in Status section of the Agreement, as of the Effective Date of this Agreement, any New/Expanded Service or New/Expanded Technology (defined below) is not reimbursable under this Agreement. Notwithstanding the foregoing, Provider may submit the following documentation to Anthem at least sixty (60) days prior to the implementation of any New/Expanded Service or New/Expanded Technology for consideration as a reimbursable service: (1) a description of the New/Expanded Service or New/Expanded Technology; (2) Provider's proposed charge for the New/Expanded Service or New/Expanded Technology; (3) such other reasonable data and information required by Anthem to evaluate the New/Expanded Service or New/Expanded Technology. In addition, Anthem may also need to obtain approval from applicable Agency prior to Anthem making determination that New/Expanded Service or New/Expanded Technology can be considered a reimbursable service. If Anthem agrees that the New/Expanded Service or New/Expanded Technology may be reimbursable under this Agreement, then Anthem shall notify Provider, and both parties agree to negotiate in good faith, a new Anthem Rate for the New/Expanded Service or New/Expanded Technology within sixty (60) days of Anthem's notice to Provider. If the parties are unable to reach an agreement on a new Anthem Rate for the New/Expanded Service or New/Expanded Technology before the end of the sixty (60) day period, then such New/Expanded Service or New/Expanded Technology shall not be reimbursed by Anthem, and the Payment in Full and Hold Harmless provision of this Agreement shall apply.
Non-Priced Codes for Covered Services. Anthem reserves the right to establish a rate for codes that are not priced in this PCS or in the Fee Schedule(s), including but not limited to, Not Otherwise Classified Codes ("NOC"), Not Otherwise Specified ("NOS"), Miscellaneous, Individual Consideration Codes ("IC"), and By Report ("BR") (collectively "Non-Priced Codes"). Anthem shall only reimburse Non-Priced Codes for Covered Services in the following situations: (i) the Non-Priced Code does not have a published dollar amount on the then current applicable Plan, State or CMS Fee Schedule, (ii) the Non-Priced Code has a zero dollar amount listed, or (iii) the Non-Priced Code requires manual pricing. In such situations, such Non-Priced Code shall be reimbursed at a rate established by Anthem for such Covered Service. Notwithstanding the foregoing, Anthem shall not price Non-Priced Codes that are not Covered Services under the Members Health Benefit Plan. Anthem may require the submission of medical records, invoices, or other documentation for Claims payment consideration.
Reimbursement for Anthem Rate Based on Eligible Charges. Notwithstanding any reimbursement amount set forth herein, Provider shall only be allowed to receive such reimbursement if such reimbursement is for an Eligible Charge. In addition, if Provider reimbursement is under one or more of the following methodologies: Capitation, Case Rate, DRG Rate, Encounter Rate, Global Case Rate, Per Diem Rate, Per Relative Value Unit (RVU), and Per Visit Rate, then individual services billed shall not be reimbursed separately, unless otherwise specified in Article IV of this PCS.
Reimbursement for Subcontractors. Plan shall not be liable for any reimbursement in addition to the applicable Anthem Rate as a result of Provider's use of a subcontractor. Provider shall be solely responsible to pay subcontractors for any Health Services, and shall via written contract, contractually prohibit such subcontractors from billing, collecting or attempting to collect from Anthem, Plan or Members. Notwithstanding the foregoing, if Anthem has a direct contract with the subcontractor, the direct contract shall prevail over this Agreement and the subcontractor shall bill Anthem under the direct contract for any
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 39 | 1841672798 #1350526454 |
subcontracted services, with the exception of nursing services provided for Home Infusion Therapy, or unless otherwise agreed to by the parties.
Tax Assessment and Penalties. The Anthem Rates in this Agreement include all sales and use taxes and other taxes on Provider revenue, gross earnings, profits, income and other taxes, charges or assessments of any nature whatsoever (together with any related interest or penalties) now or hereafter imposed against or collectible by Provider with respect to Covered Services, unless otherwise required by Agency pursuant to Regulatory Requirements. Neither Provider nor Plan shall add any amount to or deduct any amount from the Anthem Rates, whether on account of taxes, assessments, tax penalties or tax exemptions.
Updates to Anthem Rate(s) Based on External Sources. Unless otherwise required by Regulatory Requirements, and notwithstanding any proprietary fee schedule(s)/rate(s)/methodologies, Anthem shall use commercially reasonable efforts to update the Anthem Rate(s) based on External Sources, which include but are not limited to, i) CMS Medicare fee schedule(s)/rate(s)/methodologies; ii) Medicaid or State Agency fee schedule(s)/rate(s)/methodologies; iii), vendor fee schedule(s)/rate(s)/methodologies; or iv) or any other entity's published fee schedule(s)/rate(s)/methodologies ("External Sources") no later than sixty (60) days after Anthem's receipt of the final fee schedule(s)/rate(s)/methodologies change from such External Sources, or on the effective date of such final fee schedule(s)/rate(s)/methodologies change, whichever is later. The effective date of such final fee schedule(s)/rate(s)/methodologies change shall be the effective date of the change as published by External Sources. Claims processed prior to the implementation of the new Anthem Rate(s) in Anthem's payment system shall not be reprocessed, however, if reprocessing is required by Regulatory Requirements, and such reprocessing could result in a potential under and/or over payment to a Provider, then Plan may reconcile the Claim adjustments to determine the remaining amount Provider owes Plan, or that Plan owes to Provider. Any resultant overpayment recoveries (i.e. Provider owes Plan) shall occur automatically without advance notification to Provider. Unless otherwise required by Regulatory Requirements, Anthem shall not be responsible for interest payments that may be the result of a late notification by External Sources to Anthem of fee schedule(s)/rate(s)/methodologies change.
"Specialty Physician Group" means one or more licensed or certified medical practitioners who have specialized education, training or experience in accordance with the Regulatory Requirements of the state in which Health Services are rendered.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
"Specialty Provider Group (Non-MD or DO)" means one or more licensed or certified medical practitioner who has specialized education, training or experience in accordance with the Regulatory Requirements of the state in which Health Services are rendered.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
For Covered Services provided by or on behalf of Provider to a Member who is enrolled in a product and/or program that is supported by a Network designated in this Agreement, Provider agrees to accept as the Anthem Rate, the lesser of Eligible Charges or the compensation as set forth below.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 40 | 1841672798 #1350526454 |
Reimbursement Rates | ||
CPT Code & Description | Rate per Visit - 2023 | Rate per Visit - 1/1/2024 to 12/31/2025 |
Commercial | ||
99422 NON-FACE TO FACE NEW & ESTABLISHED URGENT/ACUTE VISIT | [**] | [**] |
99423-GQ ASYNCHRONOUS NEW & ESTABLISHED DERM VISIT | [**] | [**] |
99213-GT OFFICE/OUTPATIENT VISIT EST - PSYCH | [**] | [**] |
99204 OFFICE/OUTPATIENT VISIT NEW - PSYCH | [**] | [**] |
99204-GQ OFFICE/OUTPATIENT VISIT NEW - SLEEP SPEC | [**] | [**] |
99214-GT OFFICE/OUTPATIENT VISIT EST - PSYCH | [**] | [**] |
99214 OFFICE/OUTPATIENT VISIT EST - SLEEP SPEC | [**] | [**] |
95806 SLEEP STUDY UNATT & RESP EFFT | [**] | [**] |
90834 BH THERAPY -MIDLEVEL | [**] | [**] |
90834 BH THERAPY -MD/PHD | [**] | [**] |
0488T DIABETES PREVENTION PROGRAM - 0488T 5% weight loss - 0488T after 1st visit with Provider - 0488T after 4th visit with Provider - 0488T after 8th visit with Provider | [**] | [**] |
MUSCULOSKELETAL SERVICES 98975 - Milestone 1 - 1st visit with Provider-Tech Kit & Marketing Engagement services - Milestone 2 - 3 exercises modules with digital platform & unlimited chat with PT coach Platform - Milestone 3 – 6exercise modules with the digital platform & unlimited chat with PT coach 97161 | Milestone 1 - [**]
Milestone 2 & 3 - [**] | Milestone 1 - [**] Milestone 2 & 3 - [**] |
Medicare Advantage | ||
99422 NON-FACE TO FACE NEW & ESTABLISHED URGENT/ACUTE VISIT | [**] | [**] |
90834 BH THERAPY -MIDLEVEL | [**] | [**] |
90834 BH THERAPY -MD/PHD | [**] | [**] |
99213-GT OFFICE/OUTPATIENT VISIT EST - PSYCH | [**] | [**] |
99204 OFFICE/OUTPATIENT VISIT NEW - PSYCH | [**] | [**] |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
41
*The Anthem Rate for acute care/urgent care services (currently defined as CPT 99422 but includes any successor code) will be reviewed for a potential rate/visit change , beginning March 1, 2024. The review of the Anthem Rate for acute care/urgent care services will be done March 1, 2024, through April 30, 2024, for an effective date of a potential rate/visit change commencing January 1, 2025. The review will consider a variety of factors, including market conditions, to determine any mutually agreed upon change to the Anthem Rate for acute care/urgent care services as defined above. Any change as in the Anthem Rate, a result of the review, will be subject to mutual consent. If by June 1, 2024, the parties cannot agree to a change, the Anthem Rate will increase to [**]per visit effective January 1, 2025.
Provider Access Fee In consideration of the payment of Access Fees (as set forth below), Provider shall provide, and ensure that Members gain prioritized access to Covered Services provided by Participating Providers via Live Health Online, a web-based communications system (“Platform”). Specifically, Provider shall ensure that Participating Providers provide, the following services: 1.1 Availability of Participating Providers. Provider shall make available its Participating Providers to Anthem in order to provide Covered Services to Members on the Platform on a 24/7/365 basis during the term of this Agreement. 1.2 Qualifications of Participating Providers. Throughout the term of this Agreement, all Participating Providers will be: (i) licensed in the state in which the patient receiving Covered Services is located; (ii) certified by one or more of the American Board of Medical Specialties (ABMS) or the AOA in Internal Medicine, Family Medicine, Pediatrics, Emergency Medicine, or other specialties as may be agreed upon by the parties; (iii) maintain levels of medical malpractice insurance as required by law to provide Covered Services; (iv) credentialed in accordance with NCQA’s CR1-8 standards, including verification of the Participating Provider’s licensure, board certification, malpractice history, controlled substances registration, disciplinary actions, education, work history, Medicare provider status, and other criteria as may be agreed upon from time to time by the parties, (v) hold any state or federal registrations necessary to issue prescriptions; and (vi) trained in the provision of professional medical services in an online setting. 1.3 Standards and Requirements. Throughout the term of this Agreement, Provider shall require Participating Providers to: (i) provide Covered Services in a manner consistent with all accepted standards of professional practice; (ii) adhere to all ethical standards and requirements, local, state and federal laws and regulations; (iii) adhere to all terms of use applicable to use of the Platform; (iv) dress professionally and be located in a physical environment conducive to an effective, private conversation when providing the Covered Services; and (v) maintain access to a supported computer and web browser, a high-speed internet connection (DSL, cable modem, T1) and web camera, all in accordance with the Platform’s requirements.
Anthem will pay an annual access fee to the Provider for each calendar year of the term of this Agreement in the amounts set forth below. These payments shall be paid annually in advance on the dates set forth below. | ||
Year | Payment Date | Payment Amount |
|
|
|
2023 | December 15, 2022 | [**] |
|
|
|
2024 | December 15, 2023 | [**] |
2025 | December 15, 2024 | [**] |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
42
In addition to timely access requirements of the BCC Health Plan, which may be in this Agreement, the provider manual, or Policies the following requirements shall apply. In the event of a conflict, the strictest requirement shall apply.
Provider Access Requirements Provider agrees to provide monthly and quarterly supporting reporting for all provider access requirements, subject to audit by Anthem.
Urgent care/acute care Visits: • [**] of services under [**]wait (not including requested Providers), for Commercial and Medicare Advantage, calculated separately • Average wait time to equal [**]or less for Commercial and Medicare Advantage, calculated separately • Member drop off percentages: no more than [**]of total connections for Commercial and Medicare Advantage after [**] of wait time |
Provider access requirements will be reported monthly by the Provider to Anthem. If any of the Provider access requirements are not met for two consecutive months, Provider will credit a [**] reduction in the provider access fee on a pro-rated monthly basis which will be applied to the following Dec 15th access fee payment. For Year 2024, the Penalty will be reimbursed to Health Plan, if no Fee is scheduled to be paid December 2024.
Example: If 3 (three) requirements are missed two months in a row for the year, it would be [**]= Penalty
Example: If 1 (one) requirement are missed two months in a row for the year, it would be [**]= Penalty
Behavioral Health Visits:
Provider satisfaction measure: Provider will maintain a patient rated score of their satisfaction with the terapist, or Psychologist for therapy, and Psychiatrist for medical Visits at a minimum score of [**]
Unless otherwise mutually agreed to beyond the initial term, the parties hereto agree that all Provider access fees in place for the previous calendar year of the Agreement shall apply with respect to subsequent one (1) year renewals.
For clarity and notwithstanding anything set forth herein, the parties hereto agree that it shall not constitute a breach of the Agreement to the extent that Provider does not meet the Urgent care/acute care Visits Provider access requirements and Behavioral Health Visit Provider access requirements set forth above. Instead, if Provider is unable to meet those obligations on a monthly or quarterly basis, the parties will meet and Provider shall present a plan designed to meet these obligations on a going forward basis.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
43
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
CO STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern.
These provisions are specific to the state of Colorado and are required either by Plan, by statute, or by regulation.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 44 | 1841672798 #1350526454 |
ARTICLE II
SERVICES/OBLIGATIONS
ARTICLE VII
DISPUTE RESOLUTION AND ARBITRATION
7.1 Dispute Resolution. All disputes between Anthem and Provider arising out of or related in any manner to this Agreement shall be resolved using the dispute resolution and arbitration procedures as set forth below. Provider shall exhaust any other applicable provider appeal/provider dispute resolution procedures under this Agreement and any applicable exhaustion requirements imposed by Regulatory Requirements as a condition precedent to Provider's right to pursue the dispute resolution and arbitration procedures as set
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 45 | 1841672798 #1350526454 |
forth below. In the resolution of any dispute, there shall be available those remedies at law, in equity, and including injunctive relief.
7.1.1 In order to invoke the dispute resolution procedures in this Agreement, a party first shall send to the other party a written demand letter that contains a detailed description of the dispute and all relevant underlying facts, a detailed description of the amount(s) in dispute and how they have been calculated and any other information that the Anthem provider manual(s) may require Provider to submit with respect to such dispute. If the total amount in dispute as set forth in the demand letter is less than two hundred thousand dollars ($200,000), exclusive of interest, costs, and attorneys' fees, then within twenty (20) days following the date on which the receiving party receives the demand letter, representatives of each party's choosing shall meet to discuss the dispute in person or telephonically in an effort to resolve the dispute. If the total amount in dispute as set forth in the demand letter is two hundred thousand dollars ($200,000) or more, exclusive of interest, costs, and attorneys' fees, then within ninety (90) days following the date of the demand letter, the parties shall engage in non-binding mediation in an effort to resolve the dispute unless both parties agree in writing to waive the mediation requirement. The parties shall mutually agree upon a mediator, and failing to do so, Judicial Arbitration and Mediation Services ("JAMS") shall be authorized to appoint a mediator.
ARTICLE VIII
TERM AND TERMINATION
8.2 Termination Without Cause. Either party may terminate this Agreement without cause at any time by giving at least ninety (90) days prior written notice of termination to the other party. Notwithstanding the foregoing, should a Participation Attachment(s) contain a longer without cause termination period, the Agreement shall continue in effect only for such applicable Participation Attachment(s) until the termination without cause notice period in the applicable Participation Attachment(s) ends.
ARTICLE IX
GENERAL PROVISIONS
9.1 Amendment. Except as otherwise provided for in this Agreement or as otherwise required by CRS 25-37-101, Anthem retains the right to amend this Agreement, the Anthem Rate, any attachments or addenda by making a good faith effort to provide notice to Provider at least ninety (90) days in advance of the effective date of the amendment. Except to the extent that Anthem determines an amendment is necessary to effectuate Regulatory Requirements, if Provider objects to the amendment prior to its effective date, then Provider has the right to terminate this Agreement, and such termination shall take effect on the later of the amendment effective date identified by Anthem or ninety (90) days from the date Provider has provided notice of his/her/its intention to terminate the Agreement pursuant to this section. Failure of Provider to provide such notice to Anthem within the time frames described herein will constitute acceptance of the amendment by Provider. Notwithstanding anything herein, and where permitted by Regulatory Requirements, any other amendment to this Agreement may be accomplished upon thirty (30) days written notice to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 46 | 1841672798 #1350526454 |
9.5 Entire Agreement. This Agreement, exhibits, attachments, appendices, and amendments hereto, and the provider manual(s), together with any items incorporated herein by reference, constitute the entire understanding between the parties and supersedes all prior oral or written agreements between them with respect to the matters provided for herein. If there is an inconsistency between any of the provisions of this Agreement and the provider manual(s), then this Agreement shall govern. In addition, if there is an inconsistency between the terms of this Agreement and the terms provided in any attachment to this Agreement, then the terms provided in that attachment shall govern. The summary disclosure form is for
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 47 | 1841672798 #1350526454 |
informational purposes only, is not an attachment to this Agreement and does not constitute a term and condition of this Agreement.
9.13 Waiver. Neither the waiver by either of the parties of a breach of any of the provisions of this Agreement, nor the failure of either of the parties, on one or more occasion, to enforce any of the provisions of this Agreement, shall thereafter be construed as a waiver of any subsequent breach of any of the provisions of this Agreement.
9.13.1 Waiver of Law. This Agreement shall not require as a condition of contracting that Provider waive or forego any right or benefit to which the Provider may be entitled. [Required by 25-37-109]
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 48 | 1841672798 #1350526454 |
PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the following Networks on the later of: 1) the Effective Date of this Agreement or; 2) as determined by Plan in its sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements:
Commercial lines of business:
Health Benefit Plans in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status or funding source. Provider participates in Networks which support such Health Benefit Plans including but not limited to the following:
Government Programs:
Health Benefit Plans issued pursuant to an agreement between Plan and Agency in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status. Provider participates in the following Networks which support such Health Benefit Plans:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 49 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION
ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD
PROVIDER AGREEMENT
ARTICLE I
DEFINITIONS
"Clean Claim" unless, otherwise set forth in the Health Benefit Plan, shall have the meaning set forth in 10- 16-106.5(2), C.R.S. and related regulations, as amended from time to time.
"Material Change" means a change to this Attachment for Commercial Business, including any referenced document incorporated herein, that decreases the health care provider's payment or compensation, changes the administrative procedures in a way that may reasonably be expected to significantly increase the provider's administrative expense, replaces the maximum allowable cost list used with a new and different maximum allowable cost list by a person or entity for reimbursement of generic prescription drug claims, or adds a new category of coverage. A Material Change does not include:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 50 | 1841672798 #1350526454 |
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or programs offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 51 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 52 | 1841672798 #1350526454 |
2.13.1 Provider shall not be subjected to financial disincentives by Anthem based on the number of referrals made to Participating Providers in a Commercial Business Member's Health Benefit Plan for Commercial Business Covered Services, so long as Provider adheres to Anthem's utilization review policies and procedures.
ARTICLE III
TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 53 | 1841672798 #1350526454 |
ARTICLE IV
GENERAL PROVISIONS
4.1 This provision intentionally left blank.
4.3 Material Change. Anthem reserves the right to amend its policies and procedures (incorporated by reference herein) for Commercial Business by providing Provider with a written description of the Material Change at least ninety (90) days prior to the date that the Material Change becomes effective (the "Notice Period") on a form entitled "Notice of Material Change to Contract." The date that Anthem sends the material change notice by U.S. mail shall be referred to as the "Notice Date," and it shall mark the beginning of the Notice Period.
If the Provider does not object to this Material Change, in the manner described below, the Material Change will become effective at the end of the Notice Period. However, if Provider objects to the Material Change, Provider may terminate this Agreement rather than complying with the Material Change terms.
If the Provider objects in writing to the Material Change within fifteen (15) days and there is no resolution of the objection either party may terminate the contract upon written notice of termination provided to the other party not later than sixty (60) days before the effective date of the Material Change.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 54 | 1841672798 #1350526454 |
If Provider gives Anthem notice of Provider's intent to terminate the Agreement, as described above, Anthem has the right to notify Provider that Anthem will not implement the Material Change as to Provider. If Anthem chooses to exercise this option, its notice to Provider must be in writing and given within sixty (60) days of the Notice Date. If Anthem gives Provider this notice, then this Agreement will not terminate, and the Material Change will not be applied to Provider.
If a change to the contract is administrative only and is not a Material Change, the change shall be effective upon at least fifteen (15) days' notice to the Provider. All other notices shall be provided pursuant to the contract.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 55 | 1841672798 #1350526454 |
PLAN COMPENSATION SCHEDULE ("PCS")
I. DEFINITIONS
"Emergency Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy to the health of the individual (or unborn child); (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.
"Emergency Services" means those services necessary to screen for, diagnose or stabilize an Emergency Condition. Anthem shall compensate Provider for Emergency Services, if at all, according to the Member's Health Benefit Plan.
Specialty Physician Group Obligations. Provider will use his or her best efforts to require any non-participating Network health care provider to whom a Member is referred to abide by the terms of this Agreement. Provider must provide for the availability of emergency services twenty-four (24) hours, seven (7) days a week and to arrange for coverage by another provider when absent from his or her practice and, if such covering health care provider is not a Participating Provider, to use Provider's best efforts to cause such covering health care provider to abide by the terms of this Agreement.
Unless Anthem explicitly agrees otherwise, Provider acknowledges he or she is a Participating Provider at ALL locations and under ALL tax identification numbers. Furthermore, Provider agrees to notify Anthem in writing of each separate tax identification number under which Provider received compensation.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Anthem will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Specialty Provider Group (Non-MD or DO) Obligations. Provider will use his or her best efforts to require any non-participating Network health care provider to whom a Member is referred to abide by the terms of this Agreement. Provider must provide for the availability of emergency services twenty-four (24) hours, seven (7) days a week and to arrange for coverage by another provider when absent from his or her practice and, if such covering health care provider is not a Participating Provider, to use Provider's best efforts to cause such covering health care provider to abide by the terms of this Agreement.
Unless Anthem explicitly agrees otherwise, Provider acknowledges he or she is a Participating Provider at ALL locations and under ALL tax identification numbers. Furthermore, Provider agrees to notify Anthem in writing of each separate tax identification number under which Provider received compensation.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Anthem will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement PCS © 2022 July - RockyMountain Hospital and Medical Services, Inc. © 2022 July - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 56 | 1841672798 #1350526454 |
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or a Fee Schedule based on one hundred percent (100%) of the CMS Medicare fee schedules.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement PCS © 2022 July - RockyMountain Hospital and Medical Services, Inc. © 2022 July - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 57 | 1841672798 #1350526454 |
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
ColoradoProvider Agreement PCS © 2022 July - RockyMountain Hospital and Medical Services, Inc. © 2022 July - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 58 | 1841672798 #1350526454 |
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
CT STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern
The following provisions shall apply to all Health Benefit Plans issued in the State of Connecticut, unless otherwise set forth by statute or regulation unless otherwise indicated in this Agreement.
ARTICLE I
DEFINITIONS
"Plan" means Anthem, an Affiliate, and/or an Other Payor, as applicable.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 59 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 60 | 1841672798 #1350526454 |
ARTICLE III
CONFIDENTIALITY/RECORDS
3.1 Proprietary and Confidential Information. Except as otherwise provided herein, all information and material provided by either party in contemplation of or in connection with this Agreement remains proprietary and confidential to the disclosing party. This Agreement, including but not limited to the Anthem Rates, is Anthem's proprietary and confidential information. Neither party shall disclose any information proprietary or confidential to the other, or use such information or material except: (1) as otherwise set forth in this Agreement; (2) as may be required to perform obligations hereunder; (3) as required to deliver Health Services or administer a Health Benefit Plan; (4) to Plan or its designees; (5) upon the express written consent of the parties; or (6) as required or allowed by Regulatory Requirements. Notwithstanding the foregoing, either party may disclose such information to its legal advisors, lenders and business advisors, provided that such legal advisors, lenders and business advisors agree to maintain confidentiality of such information. Provider and Anthem shall each have a system in place that meets all applicable Regulatory Requirements to protect all records and all other documents relating to this Agreement which are deemed confidential by law. Any disclosure or transfer of proprietary or confidential information by Provider or Anthem will be in accordance with applicable Regulatory Requirements. Provider shall immediately notify Anthem if Provider is required to disclose any proprietary or confidential information at the request of an Agency or pursuant to any federal or state freedom of information act request.
3.3 Network Provider/Patient Discussions. Notwithstanding any other provision in this Agreement and regardless of any benefit or coverage exclusions or limitations associated with a Health Benefit Plan, Provider shall not be prohibited from discussing fully with a Member any issues related to the Member's health including recommended treatments, treatment alternatives, treatment risks and the consequences of any benefit coverage or payment decisions made by Plan or any other party. Plan shall not refuse to allow or to continue the participation of any otherwise eligible provider, or refuse to compensate Provider in connection with services rendered, solely because Provider has in good faith communicated with one or more of his/her/its current, former or prospective patients regarding the provisions, terms or requirements of a Health Benefit Plan as they relate to the health needs of such patient. In addition, nothing in this Agreement shall be construed to create any financial incentive for Provider to withhold Covered Services.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 61 | 1841672798 #1350526454 |
ARTICLE VIII
TERM AND TERMINATION
Provider may waive, in writing, the due process procedures as set forth herein, but Anthem shall not require Provider to waive his/her rights to due process as a condition of this Agreement.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 62 | 1841672798 #1350526454 |
ARTICLE IX
GENERAL PROVISIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 63 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 64 | 1841672798 #1350526454 |
PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the Networks: 1) when participation is determined by Plan in its sole discretion according to applicable law; or, 2) where there is no applicable law, on the later of the Effective Date of this Agreement or the date Provider has met Plan's applicable credentialing requirements, standards of participation and accreditation requirements:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 65 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION
ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD
PROVIDER AGREEMENT
ARTICLE I
DEFINITIONS
"Clean Claim" means a bill for Covered Services or a line item of goods or services contained on one bill, which bill can be processed without obtaining additional information from the provider of service(s) or a third party and which bill otherwise meets Anthem's billing requirements. A Clean Claim does not include a Claim from a provider who is under investigation for fraud or abuse, or a Claim under review for Medical Necessity.
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or programs offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Connecticut ProviderAgreement Commercial Attachment © 2022 Mar AnthemHealth Plans, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 66 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Connecticut ProviderAgreement Commercial Attachment © 2022 Mar AnthemHealth Plans, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 67 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Connecticut ProviderAgreement Commercial Attachment © 2022 Mar AnthemHealth Plans, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 68 | 1841672798 #1350526454 |
ARTICLE III
TERMINATION
ARTICLE IV
GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Connecticut ProviderAgreement Commercial Attachment © 2022 Mar AnthemHealth Plans, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 69 | 1841672798 #1350526454 |
PLAN COMPENSATION SCHEDULE ("PCS")
I. DEFINITIONS
"Emergency" or "Emergency Services" means the onset of a serious illness or injury which requires Emergency medical treatment; or the onset of symptoms of sufficient severity that a prudent layperson, acting reasonably, believes that Emergency medical treatment is needed.
Specialty Physician Group Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Anthem will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Specialty Provider Group (Non-MD or DO) Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Anthem will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Connecticut ProviderAgreement PCS © 2022 JulyAnthem Health Plans, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 70 | 1841672798 #1350526454 |
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or the amount(s) set forth on Anthem's Medicare Advantage Fee Schedule(s).
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules, or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment, or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Connecticut ProviderAgreement PCS © 2022 JulyAnthem Health Plans, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 71 | 1841672798 #1350526454 |
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
GA STATE SPECIFIC PROVISIONS
ARTICLE II
SERVICES/OBLIGATIONS
2.2 Provider Non-discrimination. Provider will not differentiate, or discriminate against any Member as a result of his/her enrollment in a Health Benefit Plan, or because of race, color, creed, national origin, ancestry, religion, sex, marital status, age, disability, payment source, state of health, need for Health Services, status as a litigant, status as a Medicare or Medicaid beneficiary, sexual orientation, gender identity, or any other basis prohibited by law. Provider shall not be required to provide any type, or kind of Health Service to Members that he/she/it does not customarily provide to others. Additional requirements may be set forth in the applicable Participation Attachment(s).
ARTICLE IX
GENERAL PROVISIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 72 | 1841672798 #1350526454 |
9.5 Entire Agreement. This Agreement, exhibits, attachments, appendices, and amendments hereto, together with any items incorporated herein by reference, constitute the entire understanding between the parties and supersedes, replaces and terminates all prior oral or written agreements between them, and between individual Participating Providers (contracted or employed by Provider) and Plan, including any agreements arising out of or relating to any other Network(s), products, or matters of participation. If there is an inconsistency between any of the provisions of this Agreement and the provider manual(s), then, this Agreement shall govern. In addition, if there is an inconsistency between the terms of this Agreement and the terms provided in any attachment to this Agreement, then the terms provided in that attachment shall govern.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 73 | 1841672798 #1350526454 |
PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the Networks set forth below on the later of: (1) the Effective Date of this Agreement or; (2) the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements:
PROVIDER LOCATIONS
Name | Street Address | City | State | Zip |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 74 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or programs offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
GeorgiaProvider Agreement Commercial Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. © 2022 Mar - BlueCross Blue Shield Healthcare Plan of Georgia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 75 | 1841672798 #1350526454 |
ARTICLE III TERMINATION
The Commercial Business Member shall not have the right to the continuation provision in this section if Provider is terminated as a result of the suspension or revocation of its license pursuant to section 8.4 of the Agreement, or if Anthem determines that provider poses a threat to the health, safety, or welfare of the Commercial Business Member.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
GeorgiaProvider Agreement Commercial Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. © 2022 Mar - BlueCross Blue Shield Healthcare Plan of Georgia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 76 | 1841672798 #1350526454 |
ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
GeorgiaProvider Agreement Commercial Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. © 2022 Mar - BlueCross Blue Shield Healthcare Plan of Georgia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 77 | 1841672798 #1350526454 |
MEDICARE ADVANTAGE PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE VI COMPENSATION AND AUDIT
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
GeorgiaProvider Agreement Medicare Adv. Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc. © 2022 Mar - BlueCross Blue Shield Healthcare Plan of Georgia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 78 | 1841672798 #1350526454 |
PLAN COMPENSATION SCHEDULE ("PCS")
I. DEFINITIONS
"Emergency Condition" is defined as a condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson possessing average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to obtain immediate medical care could result in: (1) placing the Member's health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction to any bodily organ or part; or (4) other serious medical consequences.
"Emergency Services" means those Covered Services provided to Members to treat an Emergency Condition only.
Specialty Physician Group Obligations. Provider is authorized pursuant to this Agreement to participate in Networks as a Specialty Physician. Provider is authorized to provide only those Covered Services which are customarily rendered by physician specialists who are board certified or board eligible in the medical specialty area(s) for which Provider has been approved by Plan. Provider agrees to provide Covered Services to Members in accordance with the terms of this Agreement and all attachments and appendices hereto.
Provider understands and agrees that Plan may require Members to select a Primary Care Physician ("PCP") at the time of enrollment in a Health Benefit Plan. Provider further agrees to provide Covered Services to those Members when referred to him/her by a PCP, or as otherwise permitted by this Agreement. Provider shall render Covered Services to Members as permitted by Provider's patient load and appointment calendar and shall accept Members as new patients as long as Provider is accepting non-Members as new patients.
Provider shall ensure that services provided are made available and accessible to Members promptly and in a manner that assures continuity of care (including coordinating overall health care and exchanging health records) and agrees to forward all clinical information in a timely manner to other Participating Providers engaged in treatment of Members. Provider agrees to provide Covered Services only when Medically Necessary, and only in such settings as is appropriate in the context of good patient care; this means that the Provider agrees to render such Covered Services in the most cost effective manner in the least costly setting required for the appropriate treatment of the condition for which treatment is required in the provision of safe quality care.
Provider shall make necessary and appropriate arrangements with other Specialty Physicians to assure the availability of Covered Services on a twenty-four (24) hours per day, seven (7) days per week basis, including arrangements to assure coverage of a Member referred by a PCP after hours or when Provider is otherwise absent. For Covered Services rendered by any covering Specialty Physician on behalf of Provider, it shall be Provider's sole responsibility to make suitable arrangements with the covering Specialty Physician regarding the manner in which said provider will be reimbursed or otherwise compensated; provided, however, that Provider shall ensure that the covering provider will not, under any circumstances, bill a Member or Plan for Covered Services rendered by a Specialty Physician who is covering on behalf of Provider. If Provider or a Specialty Physician providing alternative coverage cannot be reached within a reasonable period of time, then Plan is automatically authorized to make any necessary arrangements for a Member's medical care.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
GeorgiaProvider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. © 2022 July - BlueCross Blue Shield Healthcare Plan of Georgia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 79 | 1841672798 #1350526454 |
Provider agrees to abide by the referral management policies and procedures promulgated by Plan. It is understood and agreed that Provider will refer, with a Member's PCP's concurrence, Members to other Participating Providers, except in an emergency, when no such Participating Provider is available (in which case approval must be obtained from Plan prior to referral except in an emergency), or as otherwise permitted by Member's Health Benefit Plan. Upon referral, and with a Member's consent, Provider shall furnish such providers with complete information on treatment, procedures and diagnostic tests performed on Member prior to such referral.
Provider agrees that he/she will have and maintain active staff privileges with at least one participating hospital within the Anthem Network during the term of this Agreement. Provider agrees to admit Members or arrange for their admission within the participating hospital, unless Covered Services cannot be provided within the participating hospital or unless there is an emergency.
Provider agrees to ensure that all facilities and equipment used for and in the delivery of health care services which are required to be licensed and/or certified by law, shall be so licensed and/or certified. Provider agrees to provide a functional, sanitary, and comfortable environment for Members, personnel and the public. There shall be an adequate amount of space for services provided and disabilities treated, including waiting and reception areas, staff space, examining rooms, treatment areas, and storage. Plan reserves the right to audit Provider for compliance with this provision and other Policies and procedures, at any time during Provider's regular business hours following twenty-four (24) hours prior notice to Provider.
Provider agrees that he/she shall maintain in good standing: (1) a nonrestricted license to practice medicine in Georgia; and (2) a current Drug Enforcement Administration ("DEA") Certificate valid in the State of Georgia. Evidence of licenses shall be submitted to Anthem upon request and shall be kept on file with Anthem. Provider warrants that he/she does now and shall at all times during the term of this Agreement, comply with all applicable Regulatory Requirements relating to the ownership and operation of Provider's practice and related services and entities.
Provider shall cooperate with Plan in developing and implementing innovative methods for delivering services that promote cost effectiveness, quality care and superior customer service, as set forth in provider manual(s) and Policies.
Provider shall provide and encourage Member participation in appropriate preventive health education to promote achieving and maintaining a healthy lifestyle, as set forth in provider manual(s) and Policies.
Provider, in cooperation with Plan and various committees that may be established by Plan, shall establish, maintain, and, from time to time, review methods, procedures, and details of coverage and systems to ensure adequate Member coverage and quality of care at all times.
Provider agrees that Plan retains the right to change, revise, modify or alter the form and content of any Health Benefit Plan without prior notice to or approval by Provider.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Anthem will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
GeorgiaProvider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. © 2022 July - BlueCross Blue Shield Healthcare Plan of Georgia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 80 | 1841672798 #1350526454 |
or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows, unless otherwise addressed in the Member's Health Benefit Plan documents:
Provider agrees to provide at no cost to Anthem, Plan or the Member, all information necessary for Plan or Anthem to determine its payment liability. Once Anthem determines Plan has any payment liability, all Complete/Clean Claims will be paid in accordance with the terms and conditions of a Member's Health Benefit Plan and Agreement.
MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or a Fee Schedule based on of the CMS Medicare fee schedules.
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
GeorgiaProvider Agreement PCS © 2022 July - Anthem Insurance Companies, Inc. © 2022 July - BlueCross Blue Shield Healthcare Plan of Georgia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 81 | 1841672798 #1350526454 |
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
IN STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern.
The following provisions are required terms and conditions for the certain Health Benefit Plans that are issued in the State of Indiana.
ARTICLE VII
DISPUTE RESOLUTION AND ARBITRATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 82 | 1841672798 #1350526454 |
ARTICLE VIII
TERM AND TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ARTICLE IX GENERAL PROVISIONS
9.1 Amendment. Except as otherwise provided for in this Agreement, Anthem retains the right to amend this Agreement, the Anthem Rate, any attachments or addenda by providing notice to Provider at least forty five
(45) days in advance of the effective date of the amendment. Except to the extent that Anthem determines an amendment prior to its effective date is necessary to effectuate Regulatory Requirements, if Provider objects to the amendment, prior to its effective date, then Provider has the right to terminate this Agreement, and such termination shall take effect on the later of the amendment effective date identified by Anthem or one hundred eighty (180) days from the date Provider has provided notice of his/her/its intention to terminate the Agreement pursuant to this section. Failure of Provider to provide such notice to Anthem within the time frames described herein will constitute acceptance of the amendment by Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the Networks set forth on the Provider Network Attachment on the later of: (1) the Effective Date of this Agreement or; (2) as determined by Plan in its sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements.
Commercial lines of business:
Governmental lines of business:
Other Plan Programs:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or programs offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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KENTUCKY PATHWAY TRANSITION HMO NETWORK PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
This is an Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem on behalf of its affiliate, Anthem Health Plans of Kentucky, Inc. doing business as Anthem Blue Cross and Blue Shield (hereinafter "Anthem Kentucky") and Provider and is incorporated into the Agreement.
This Attachment applies solely to Anthem Kentucky's Pathway Transition/Pathway X Transition HMO Network and Provider agrees to participate as a Participating Provider in Anthem's Pathway Transition/Pathway X Transition HMO Network ("the Transition Network").
Provider understands that the Anthem Pathway Transition/Pathway X Transition HMO Network supports Individual and Small Group Products or Plans effective January 1, 2018 and later for sale on and off the Exchange. Provider acknowledges that the Anthem Pathway Transition/Pathway X Transition HMO Network and the products it supports are subject to Regulatory Requirements, and Provider agrees to abide by all applicable Regulatory Requirements and other requirements as they exist and may be amended or changed from time to time.
Provider agrees to accept the Anthem Rate as set forth in the PCS as payment in full, in all circumstances, the applicable Anthem Rate for Covered Services provided to Members covered by Health Benefit Plans supported by the Anthem Pathway Transitions/Pathway X Transition HMO Network.
Provider shall refer Members only to Anthem Pathway Transition/Pathway X Transition HMO Participating Providers who participate in the Anthem Pathway Transition/Pathway X Transition HMO Network. In the event necessary Health Services are not available from an Anthem Pathway Transition/Pathway X Transition HMO Network Provider, prior to such admittance/referral to a non-Participating Provider, Provider will obtain Anthem's approval.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Indiana Provider AgreementKY Pthwy Trans Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 87 | 1841672798 #1350526454 |
KENTUCKY WORKERS' COMPENSATION PARTICIPATION ATTACHMENT TO THE ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
This is a Workers' Compensation Participation Attachment (the "Attachment") to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement") entered into by and between Anthem and Provider and is incorporated into the Agreement.
ARTICLE I
DEFINITIONS
The following definitions shall apply to this Attachment. Terms not otherwise defined in this Attachment shall carry the meaning set forth in the Agreement or a Participation Attachment(s) as applicable:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ARTICLE II
SERVICES/OBLIGATIONS
Kentucky's workers' compensation laws and regulations. Provider shall provide and maintain Injured Worker(s) continuity of care, including timely referral of Injured Worker(s) to specialists within the Anthem Workers' Compensation Network.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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Provider agrees that when the Anthem Workers' Compensation Network is utilized by an Affiliate or Other Payor, Provider agrees to provide services to Injured Workers including those covered by workers' compensation carriers of that Affiliate or Other Payor in accordance with the terms of this Attachment. Anthem agrees to pre-qualify Other Payors with respect to determining their ability to pay Claims in accordance with the rates as set forth in this Attachment. In all events, however, Provider shall look for payment only to the particular Affiliate or Other Payor that covers the particular services for which Provider seeks to be compensated (except for applicable Cost Shares or other obligations of Injured Workers.) Anthem shall use its best efforts to assure Other Payors compensate Provider in accordance with the rates as set forth in this Attachment. In the event any such Other Payor fails to make required payments, Provider may seek payment from the Injured Worker (up to the rates specified herein) unless prohibited by applicable law. When an Other Payor utilizes the Anthem Workers' Compensation Network, Provider shall follow such Other Payor's specified utilization review requirements.
ARTICLE III GENERAL PROVISIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Indiana Provider AgreementKY Pthwy Trans Attachment © 2022 Mar - Anthem InsuranceCompanies, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 90 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ARTICLE IV
TERM AND TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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PLAN COMPENSATION SCHEDULE ("PCS")
"Per Relative Value Unit" ("RVU") means the Anthem Rate for each unit of service based on the CMS, Agency or other (e.g., American Society of Anesthesiologists (ASA)) defined Relative Value Unit (RVU).
Coding Updates. Coded Service Identifier(s) used to define specific rates are updated from time to time to reflect new, deleted or replacement codes. Anthem shall use commercially reasonable efforts to update all applicable Coded Service Identifiers within sixty (60) days of release by CMS or other applicable authority. When billing codes are updated, Provider is required to use appropriate replacement codes for Claims for Covered Services, regardless of whether this Agreement has been amended to reflect changes to standard billing codes. If Provider bills a new, replacement or revised code prior to the effective date of such code, the Claim will be rejected or denied and the Provider shall resubmit Claim with correct code. In addition, Claims with codes which have been deleted will be rejected or denied.
Reimbursement for Subcontractors. If Anthem has a direct contract with the subcontractor, the direct contract shall prevail over this Agreement and the subcontractor shall bill Anthem under the direct contract for any subcontracted services, with the exception of nursing services provided for Home Infusion Therapy, or unless otherwise agreed to by the parties. The subcontracted entity shall bill Anthem directly under the subcontracted entity's Anthem agreement for the subcontracted services. Provider shall not bill Anthem for such subcontracted entity's services. Provider acknowledges and agrees that the reimbursement Anthem has agreed to pay the subcontracted entity as set forth in the subcontracted entity's agreement shall represent payment in full for such subcontracted entity's services.
Specialty Physician Group Obligations. Provider is designated as a Specialty Care Provider ("SCP" or "Specialty Care Provider") for those Network(s) designated on the Provider Networks Attachment of the Agreement.
Except in case of an Emergency, or as otherwise set forth in the Member's Health Benefit Plan, or required by Regulatory Requirements, prior to treating a Member, Specialty Care Provider agrees to obtain a referral, in accordance with Member's Health Benefit Plan, from a Primary Care Provider ("PCP") who is primarily responsible for providing or authorizing the professional services as set forth in the Health Benefit Plan.
A Provider who is a Primary Care Provider, or a gynecologist or obstetrician, shall provide Health Services or make arrangements for the provision of Health Services to Members on a twenty-four (24) hour per day, seven
(7) day a week basis to assure availability, adequacy, and continuity of care to Members. In the event a Provider is not one of the foregoing described Providers, then Provider shall provide Health Services to Members on a twenty-four (24) hour per day, seven (7) day a week basis or at such times as Health Services are typically provided by similar providers to assure availability, adequacy, and continuity of care to Members. If Provider is unable to provide Health Services as described in the previous sentence, Provider will arrange for another Network Provider to cover Provider's patients in Provider's absence.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Indiana ProviderAgreement PCS © 2022 July - Anthem Insurance Companies, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 93 | 1841672798 #1350526454 |
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
MEDICARE ADVANTAGE
Provider shall be compensated at one hundred percent (100%) of the current Anthem Medicare Advantage Rate in effect at the time the Medicare Advantage Covered Service is rendered. The Anthem Medicare Advantage Rates may be amended from time to time as to apply changes in rates or methodology.
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
INDIANA MEDICAID PROGRAM(S)
Healthy Indiana Plan (HIP):
Rates are based on one hundred percent (100%) of the CMS Medicare Fee Schedule or one hundred thirty percent (130%) of the Indiana State Medicaid Fee Schedule if the service does not have a Medicare reimbursement rate, except for those Coded Service Identifiers set forth in the attached Government Program(s) PCS Attachment or Provider's Charges, whichever is less. Payment for Medicaid Covered Services submitted with the Coded Service Identifier(s) set forth in the attached Government Program(s) PCS Attachment, will be reimbursed based on the Anthem Rate corresponding to the Coded Service Identifier(s).
Provider acknowledges that reimbursement for some Medicaid Covered Services may first be made from the HIP Member's POWER Account, with any remaining balance payable by Anthem. Provider agrees that under no circumstances shall he/she/it balance bill the HIP Member. For purposes of this Attachment, "POWER Account" means an individual health care account funded by, at a minimum, the State of Indiana and the HIP Member and used by that Member to purchase Medicaid Covered Services before their deductible is met.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Indiana ProviderAgreement PCS © 2022 July - Anthem Insurance Companies, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 95 | 1841672798 #1350526454 |
Nothing in this Attachment shall be interpreted as interfering with Provider's ability to hold HIP Members liable for the Emergency Services copayment or payment of Medicaid Covered Services with POWER Account funds before the HIP Member's deductible has been met.
Government Program(s) PCS Attachment
Healthy Indiana Plan (HIP) | |
Coded Service Identifier(s)/Provider Type(s) | Anthem Rate |
Advance Practice Nurse and/or Physician Assistant working as a Primary Care Provider (PCP) – billing with the NPI assigned to the Advance Practice Nurse or Physician Assistant | [**]of the HIP Anthem Rate [**]of the HIP Anthem Rate for the following Covered Services billed with the applicable codes: Radiology (70010 – 79999) Pathology and Lab (80048 – 89399) Immunizations (90281-90799) Level II HCPC codes (A0021-A9999,B4034- B9999, C1010-C9711, D0120-D9999, EE0100- E2599, G0001-G9016, J0120-J9999, K0001- K0620, L0100-L9900, P2028-P9615, Q0035- Q4077, R0070-R0076, and S0012-S9999) |
Advance Practice Nurse and/or Physician Assistant working as a Specialty Care Provider (SCP) - when billing with NPI assigned to Advance Practice Nurse or Physician Assistant | [**]of the HIP Anthem Rate - Other codes set forth on this Exhibit A shall be reimbursed in accordance with the applicable Anthem Rate identified. Radiology (70010 – 79999) Pathology and Lab (80048 – 89399) Immunizations (90281-90799) Level II HCPC codes (A0021-A9999,B4034- B9999, C1010-C9711, D0120-D9999, EE0100- E2599, G0001-G9016, J0120-J9999, K0001- K0620, L0100-L9900, P2028-P9615, Q0035- Q4077, R0070-R0076, and S0012-S9999) |
Advance Practice Nurse and/or Physician Assistant working as a Specialty Care Physician (SCP) employed by and billing with the NPI assigned to a supervising physician using the modifier SA, HN or HO, as applicable | [**]of the HIP Anthem Rate - Other codes set forth on this Exhibit A shall be reimbursed in accordance with the applicable Anthem Rate identified. |
All other provider types not specifically identified otherwise | [**] of the HIP Anthem Rate |
KENTUCKY WORKERS' COMPENSATION
For Medically Necessary Compensable Medical Care provided to Injured Worker(s), Provider agrees to accept the lesser of (i) the Anthem Indiana Workers' Compensation Plan Fee Schedule Rate, (ii) Bill Review Allowed or (iii) Provider's Eligible Charges.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
96
INDIANA WORKERS' COMPENSATION
For Medically Necessary Compensable Medical Care provided to Injured Worker(s) Provider agrees to accept the lesser of (i) the Anthem Indiana Workers' Compensation Plan Fee Schedule Rate, ii) Bill Review Allowed or (iii) Provider's Eligible Charges.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
97
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
KY STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern.
The following provisions are required terms and conditions for certain fully insured Health Benefit Plans that are issued in the Commonwealth of Kentucky.
ARTICLE II
SERVICES/OBLIGATIONS
2.5 Submission and Adjudication of Claims. Provider shall submit, and Plan shall adjudicate, Claims in accordance with the applicable Participation Attachment(s), the PCS, the provider manual(s) and Regulatory Requirements. If Provider submits Claims prior to receiving notice of Anthem's approval pursuant to section 2.13, and/or approval of any requested change of status pursuant to section 9.3, then such Claims shall be processed as out of network and Anthem shall not make retroactive adjustments with respect to such Claims.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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2.11 Networks and Provider Panels. Provider shall be eligible to participate in those Networks designated on the Provider Networks Attachment of this Agreement. Provider shall not be recognized as a Participating Provider in such Networks until the later of: 1) the Effective Date of this Agreement or; 2) Provider has met Plan's applicable credentialing requirements, standards of participation and accreditation requirements. Provider acknowledges that Plan may develop, discontinue, or modify new or existing Networks, products and/or programs. In addition to those Networks designated on the Provider Networks Attachment, Anthem may also identify Provider as a Participating Provider in additional Networks, products and/or programs designated in writing from time to time by Anthem. The terms and conditions of Provider's participation as a Participating Provider in such additional Networks, products and/or programs shall be on the terms and conditions as set forth in this Agreement unless otherwise agreed to in writing by Provider and Anthem.
In addition to and separate from Networks that support some or all of Plan's products and/or programs (e.g., HMO, PPO and Indemnity products), Provider further acknowledges that certain Health Services, including by way of example only, laboratory or behavioral health services, may be provided exclusively by designated Participating Providers (a "Health Services Designated Network"), as determined by Plan. Provider agrees to refer Members to such designated Participating Providers in a Health Services Designated Network for the provision of certain Health Services, even if Provider performs such services. Notwithstanding any other provision in this Agreement, if Provider provides a Health Service to a Member for which Provider is not a designated Participating Provider in a Health Services Designated Network, then Provider agrees that he/she/it shall not be reimbursed for such services by Anthem, Plan or the Member, unless Provider was authorized to provide such Health Service by Plan.
2.14 Adjustment Requests. If Provider believes a Claim has been improperly adjudicated for Covered Service for which Provider timely submitted a Clean Claim to Plan, Provider must submit a request for an adjustment to Plan per the requirements set forth in the provider manual(s) or applicable Participation Attachment(s). Adjustment requests submitted that do not comply with such requirements may be denied for payment, and Provider shall not be permitted to bill Anthem, Plan, or the Member for those Covered Services for which payment was denied.
2.18 Request for Fees. Upon request by Provider, Plan shall provide Provider with the payment or fee schedules or other information sufficient to enable Provider to determine the amount and manner of payments under the Agreement for Provider's services. This does not prohibit Plan from making any part of the information requested available electronically or via a web site.
ARTICLE VIII
TERM AND TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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8.2 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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8.7 Continuation of Care Upon Termination. If this Agreement or any Participation Attachment terminates for any reasons other than one of the grounds set forth in the "Immediate Termination" section, then Provider shall at Anthem's discretion, continue to provide Covered Services to Members under this Agreement or any terminating Participation Attachment as applicable, in accordance with Regulatory Requirements. During such continuation period, Provider agrees to: (i) accept reimbursement from Anthem for all Covered Services furnished hereunder in accordance with this Agreement and at the rates set forth in the PCS attached hereto; and (ii) adhere to Anthem's Policies, including but not limited to, Policies regarding quality assurance requirements, referrals, pre-authorization and treatment planning.
ARTICLE IX GENERAL PROVISIONS
9.1 Amendment. Except as otherwise provided for in this Agreement, Anthem retains the right to amend this Agreement, the Anthem Rate, any attachments or addenda by making a good faith effort to provide notice to Provider at least thirty (30) days in advance of the effective date of the amendment. Except to the extent that Anthem determines an amendment is necessary to effectuate Regulatory Requirements, if Provider objects to the amendment, prior to its effective date, then Provider has the right to terminate this Agreement, and such termination shall take effect on the later of the amendment effective date identified by Anthem or one hundred eighty (180) days from the date Provider has provided notice of his/her/its intention to terminate the Agreement pursuant to this section. Failure of Provider to provide such notice to Anthem within the time frames described herein will constitute acceptance of the amendment by Provider.
9.1.1 Except as otherwise provided for in this Agreement, for Networks, products and/or programs that are subject to state law, Anthem retains the right to amend this Agreement, the provider manual, any attachments or addenda. If such an amendment results in a material change as that term is defined under KRS 304.17A-235, Anthem shall provide notice of such amendment at least ninety (90) days before the proposed effective date of the amendment. If the Provider objects to the amendment, the Provider must provide written notice of the objection within thirty (30) days of receipt of the notice of the Amendment. If the parties cannot reach an agreement, the Provider may terminate this Agreement pursuant to its original terms within thirty (30) days prior to the proposed effective date of the Amendment. If the Provider fails to timely object to the proposed Amendment, the Amendment shall become effective as to that Provider. If the Amendment relates to the Provider's inclusion in any new or modified insurance product or proposes changes to the Provider's network membership, the amendment shall only take effect upon the Provider's acceptance as evidenced by the Provider's signature.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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9.5 Entire Agreement. This Agreement, exhibits, attachments, appendices, and amendments hereto, together with any items incorporated herein by reference, constitute the entire understanding between the parties and supersedes all prior oral or written agreements between them with respect to the matters provided for herein. If there is an inconsistency between any of the provisions of this Agreement and the provider manual(s) or Policies, then this Agreement shall govern. In addition, if there is an inconsistency between
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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the terms of this Agreement and the terms provided in any attachment to this Agreement, then the terms provided in that attachment shall govern.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 103 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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2.8 Use of Subcontractors. Provider and Plan may fulfill some of their duties under this Agreement through subcontractors. Provider shall provide Anthem with at least ninety (90) days prior notice of any Health Services subcontractors with which Provider may contract to perform Provider's duties and obligations under this Agreement. Provider shall provide Anthem with a sample contract of any agreement between Provider and such subcontractors at least ninety (90) days prior to the commencement of such subcontractor(s)' services, for the purpose of Anthem's filing such agreement with the Kentucky Department of Insurance, as required by KRS 304.17A-527(1)(e). Provider shall require such subcontractors to abide by the terms and conditions of this Agreement, including the provisions of KRS 304.17A, and shall indemnify Anthem, Plan, and Commercial Business Members for any failure of any subcontractor to so comply. Provider agrees that Anthem may contract directly with any Health Services providers rather than relying on the subcontracting arrangements entered by Provider. If Anthem has a direct contract with the subcontractor ("direct contract"), the direct contract shall prevail over this Agreement.
ARTICLE III TERMINATION
3.1 Termination-Commercial Business Attachment and/or Network(s). At any time, Provider may terminate, without cause, Provider's participation in one or more Commercial Network(s) designated on the Provider Networks Attachment, or this Attachment by giving at least one hundred eighty (180) days prior written notice of termination to Anthem. Following any termination as described herein, the remainder of the Agreement shall remain in full force and effect, if applicable.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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INDIANA WORKERS' COMPENSATION PARTICIPATION ATTACHMENT TO THE ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
This is a Workers' Compensation Participation Attachment (the "Attachment") to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement") entered into by and between Anthem and Provider and is incorporated into the Agreement.
ARTICLE I
DEFINITIONS
The following definitions shall apply to this Attachment. Terms not otherwise defined in this Attachment shall carry the meaning set forth in the Agreement or a Participation Attachment(s) as applicable.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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Provider agrees that when the Anthem Workers' Compensation Network is utilized by an Affiliate or Other Payor, Provider agrees to provide services to Injured Workers including those covered by workers' compensation carriers of that Affiliate or Other Payor in accordance with the terms of this Attachment. Anthem agrees to pre-qualify Other Payors with respect to determining their ability to pay Claims in accordance with the rates as set forth in this Attachment. In all events, however, Provider shall look for payment only to the particular Affiliate or Other Payor that covers the particular services for which Provider seeks to be compensated (except for services deemed non-compensable). Anthem shall use its best efforts to assure Other Payors compensate Provider in accordance with the rates as set forth in this Attachment. In the event any such Other Payor fails to make required payments, Provider may seek payment from the Injured Worker (up to the rates specified herein) unless prohibited by applicable law. When an Other Payor utilizes the Anthem Workers' Compensation Network, Provider shall follow such Other Payor's specified utilization review requirements.
ARTICLE III GENERAL PROVISIONS
ARTICLE IV
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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TERM AND TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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OHIO BLUE CONNECTION HMO NETWORK PARTICIPATION ATTACHMENT TO THE ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement (the "Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
Provider agrees to participate as a Network/Participating Provider in Anthem's Blue Connection HMO Network.
Provider understands that the Anthem Blue Connection HMO Network supports Group Products or Plans effective January 1, 2020 and later. Provider acknowledges that the Anthem Blue Connection HMO Network and the products or Plan Programs it supports are subject to federal and state regulatory requirements, and Provider agrees to abide by all applicable rules, regulations and other requirements as they exist and may be amended or changed from time to time.
Provider agrees to accept the Anthem Blue Connection HMO Network Rate ("Anthem Rate") as set forth in the Plan Compensation Schedule ("PCS") as payment in full, in all circumstances, the applicable Anthem Rate for Covered Services provided to Members covered by Health Benefit Plans supported by the Anthem Blue Connection HMO Network.
Provider shall refer Members only to Anthem Blue Connection HMO Network/Participating Providers who participate in the Anthem Blue Connection HMO Network. In the event necessary Health Services are not available from an Anthem Blue Connection HMO Network Provider, prior to such admittance/referral to a non- network provider, Provider will obtain Anthem's approval.
Provider and Anthem are dedicated to the development of a more effective health care delivery system which emphasizes continuous improvement and increased patient access to high quality, cost-effective care. Provider agrees to cooperate and comply with the quality programs that are established and implemented by Anthem. Anthem will monitor Provider's performance and work collaboratively with Provider to implement a performance improvement plan if Provider fails to meet quality program standards.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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PLAN COMPENSATION SCHEDULE ("PCS")
"Anthem Medicaid Rate(s)/Fee Schedule(s)/Methodologies" means the Anthem Rate for the applicable KY Medicaid Rate(s) /Fee Schedule(s)/ in effect on the date of service for the provider type(s)/service(s) identified herein for the applicable Medicaid Program(s).
"Anthem Proprietary Medicaid Fee Schedule(s)" means the Anthem Rate(s) which is based on the applicable proprietary Medicaid Fee Schedule(s), and which could be enhanced by additional Covered Services included in the Government Contract.
"Case Rate" means the all-inclusive Anthem Rate for an entire admission or one outpatient encounter for Covered Services. Individual services billed shall not be reimbursed separately.
"Emergency Condition" is defined as a medical condition that manifests itself by such acute symptoms of sufficient severity, including severe pain, that a prudent layperson could reasonably expect the absence of immediate medical attention to result in any of the following: (1) placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. With respect to a pregnant woman who is having contractions, "Emergency" means: (1) a situation in which there is inadequate time to effect a safe transfer to another hospital before delivery; or (2) a situation in which transfer may pose a threat to the health or safety of the woman or the unborn child.
"Emergency Services" means those Covered Services provided in connection with an Emergency Condition.
New/Expanded Service or New/Expanded Technology. In accordance with the Scope/Change in Status section of the Agreement, as of the Effective Date of this Agreement, any New/Expanded Service or New/Expanded Technology (defined below) is not reimbursable under this Agreement. Notwithstanding the foregoing, Provider may submit the following documentation to Anthem at least sixty (60) days prior to the implementation of any New/Expanded Service or New/Expanded Technology for consideration as a reimbursable service: (1) a description of the New/Expanded Service or New/Expanded Technology; (2) Provider's proposed charge for the New/Expanded Service or New/Expanded Technology; (3) such other reasonable data and information required by Anthem to evaluate the New/Expanded Service or New/Expanded Technology. In addition, Anthem may also need to obtain approval from applicable Agency prior to Anthem making determination that New/Expanded Service or New/Expanded Technology can be considered a reimbursable service. If Anthem agrees that the New/Expanded Service or New/Expanded Technology may be reimbursable under this Agreement, then Anthem shall notify Provider, and both parties agree to negotiate in good faith, a new Anthem Rate for the New/Expanded Service or New/Expanded Technology within sixty (60) days of Anthem's notice to Provider. If the parties are unable to reach an agreement on a new Anthem Rate for the New/Expanded Service or New/Expanded Technology before the end of the sixty (60) day period, then such New/Expanded Service or New/Expanded Technology shall not be reimbursed by Anthem, and the Payment in Full and Hold Harmless provision of this Agreement shall apply.
Reimbursement for Anthem Rate Based on Eligible Charges. Notwithstanding any reimbursement amount set forth herein, Provider shall only be allowed to receive such reimbursement if such reimbursement is for
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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an Eligible Charge. In addition, if Provider reimbursement is under one or more of the following methodologies: Capitation, Case Rate, DRG Rate, Encounter Rate, Global Case Rate, Per Diem Rate, Per Relative Value Unit, Per Service Rate, and Per Visit Rate, then individual services billed shall not be reimbursed separately, unless otherwise specified in Article IV of this PCS.
Specialty Physician Group Obligations. Provider is designated as a Specialty Care Provider ("SCP" or "Specialty Care Provider") for those Network(s) designated on the Provider Networks Attachment of the Agreement.
Except in case of an Emergency, or as otherwise set forth in the Member's Health Benefit Plan, or required by Regulatory Requirements, prior to treating a Member, Specialty Care Provider agrees to obtain a referral, in accordance with Member's Health Benefit Plan, from a Primary Care Provider ("PCP") who is primarily responsible for providing or authorizing the professional services as set forth in the Health Benefit Plan.
A Provider who is a Primary Care Provider, or a gynecologist or obstetrician, shall provide Health Services or make arrangements for the provision of Health Services to Members on a twenty-four (24) hour per day, seven
(7) day a week basis to assure availability, adequacy, and continuity of care to Members. In the event a Provider is not one of the foregoing described Providers, then Provider shall provide Health Services to Members on a twenty-four (24) hour per day, seven (7) day a week basis or at such times as Health Services are typically provided by similar providers to assure availability, adequacy, and continuity of care to Members. If Provider is unable to provide Health Services as described in the previous sentence, Provider will arrange for another Network Provider to cover Provider's patients in Provider's absence.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
MEDICARE ADVANTAGE
Provider shall be compensated at the current Anthem Medicare Advantage Rate in effect at the time the Medicare Advantage Covered Service is rendered. The Anthem Medicare Advantage Rates may be amended from time to time as to apply changes in rates or methodology. Anthem shall provide a copy of the Anthem Medicare Advantage Rate upon request from Provider.
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
KENTUCKY WORKERS' COMPENSATION
For Medically Necessary Compensable Medical Care provided to Injured Worker(s), Provider agrees to accept the lesser of (i) the Anthem Blue Access Plan Fee Schedule Rate, (ii) Bill Review Allowed or (iii) Provider's Eligible Charges.
INDIANA WORKERS' COMPENSATION
For Medically Necessary Compensable Medical Care provided to Injured Worker(s) Provider agrees to accept the lesser of (i) the Anthem Indiana Workers' Compensation Plan Fee Schedule Rate, ii) Bill Review Allowed or (iii) Provider's Eligible Charges.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ME STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern.
These provisions are specific to the State of Maine and are required either by the Plan, by statute, or by regulation.
ARTICLE II
SERVICES/OBLIGATIONS
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2.11 Networks and Provider Panels. Provider shall be eligible to participate only in those Networks designated on the Provider Networks Attachment of this Agreement. Provider shall not be recognized as a Participating Provider in such Networks until: 1) participation is determined by Plan in its sole discretion according to applicable Regulatory Requirements; or, 2) where there is no applicable Regulatory Requirements, the later of the Effective Date of this Agreement or the date Provider has met Plan's applicable credentialing requirements, standards of participation and accreditation requirements. Provider acknowledges that Plan may develop, discontinue, or modify new or existing Networks, products and/or programs. In addition to those Networks designated on the Provider Networks Attachment, Anthem may also identify Provider as a Participating Provider in additional Networks, products and/or programs designated in writing from time to time by Anthem. The terms and conditions of Provider's participation as a Participating Provider in such
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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additional Networks, products and/or programs shall be on the terms and conditions as set forth in this Agreement unless otherwise agreed to in writing by Provider and Anthem.
In addition to and separate from Networks that support some or all of Plan's products and/or programs (e.g., HMO, PPO and Indemnity products), Provider further acknowledges that certain Health Services, including by way of example only, laboratory or behavioral health services, may be provided exclusively by designated Participating Providers (a "Health Services Designated Network"), as determined by Plan. Provider agrees to refer Members to such designated Participating Providers in a Health Services Designated Network for the provision of certain Health Services, even if Provider performs such services. Notwithstanding any other provision in this Agreement, if Provider provides a Health Service to a Member for which Provider is not a designated Participating Provider in a Health Services Designated Network, then Provider agrees that he/she/it shall not be reimbursed for such services by Anthem, Plan or the Member, unless Provider was authorized to provide such Health Service by Plan.
ARTICLE V RELATIONSHIP OF THE PARTIES
5.1 Relationship of the Parties. For purposes of this Agreement, Anthem and Provider are and will act at all times as independent contractors. Nothing in this Agreement shall be construed, or be deemed to create, a relationship of employer or employee or principal and agent, partnership, joint venture, or any relationship other than that of independent entities contracting with each other for the purposes of effectuating this Agreement. In accordance with 24-A M.R.S.A. Section 4303(3), Provider may freely communicate with Members regarding the treatment options available to them, including medication treatment options, regardless of benefit coverage limitations.
ARTICLE VIII
TERM AND TERMINATION
8.2 Termination Without Cause. Either party may terminate this Agreement without cause at any time by giving at least ninety (90) days prior written notice of termination to the other party. Notwithstanding the foregoing, should a Participation Attachment(s) contain a longer without cause termination period, the Agreement shall continue in effect only for such applicable Participation Attachment(s) until the termination without cause notice period in the applicable Participation Attachment(s) ends.
8.4 Immediate Termination. This Agreement may be terminated automatically and immediately by Anthem at any time upon written notice to Provider in cases involving imminent harm to patient care, a final determination of fraud by a governmental agency, or a final disciplinary action by a state licensing board or other governmental agency that impairs the ability of Provider to comply with the terms of this Agreement or to provide Covered Services to Members.
ARTICLE IX GENERAL PROVISIONS
9.1 Amendment. Except as otherwise provided for in this Agreement, Anthem retains the right to amend this Agreement, the Anthem Rate, any attachments or addenda by providing notice to Provider at least sixty (60) days in advance of the effective date of the amendment. Except to the extent that Anthem determines an amendment is necessary to effectuate Regulatory Requirements, if Provider objects to the amendment prior to its effective date, then Provider has the right to terminate this Agreement, and such termination shall take effect on the earlier of the amendment effective date identified by Anthem or ninety (90) days from the date Provider has provided notice of his/her/its intention to terminate the Agreement pursuant to this section. Failure of Provider to provide such notice to Anthem within the time frames described herein will constitute acceptance of the amendment by Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the Networks: 1) when participation is determined by Plan in its sole discretion according to applicable Regulatory Requirements; or, 2) where there is no applicable Regulatory Requirements, on the later of the Effective Date of this Agreement or the date Provider has met Plan's applicable credentialing requirements, standards of participation and accreditation requirements:
Commercial lines of business:
Health Benefit Plans in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status or funding source. Provider participates in Networks which support such Health Benefit Plans including but not limited to the following:
Notwithstanding the foregoing, if Provider's office(s) is physically located outside the State of Maine, Provider will not be considered a Participating Provider in the FEP program (PPO).
Governmental lines of business:
Health Benefit Plans issued pursuant to an agreement between Plan and Agency in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status. Provider participates in Networks which support such Health Benefit Plans including but are not limited to the following:
Narrow Networks lines of business:
Health Benefit Plans in which Members have access to a limited network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers. The Narrow Networks for which Provider is participating includes only the following:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE I
DEFINITIONS
"Complete Claim" means, unless otherwise set forth in the Health Benefit Plan, the definition in Title 24-A M.R.S.A., Section 2436, 2-A.
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or program offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all applicable Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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2.8 Retroactive Denials Prohibited; Exceptions. For Claims governed by Maine law, the parties shall comply with Title 24-A, M.R.S.A. Section 4303 (10).
ARTICLE III TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Maine ProviderAgreement Attachment © 2022 Mar - Anthem HealthPlans of Maine, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 121 |
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PLAN COMPENSATION SCHEDULE ("PCS")
I. DEFINITIONS
"Emergency Condition" means, unless otherwise set forth in the Health Benefit Plan, the definition set forth in Maine Bureau of Insurance Rule Chapter 850, Section 5, "O".
"Emergency Service" means unless otherwise set forth in the Health Benefit Plan, the definition set forth in Maine Bureau of Insurance Rule Chapter 850, Section 5, "P".
Specialty Physician Group Obligations. To the extent required by law or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of an individual Network participation. Anthem reserves the right to notify its Members of Provider's termination. Notification by Anthem shall not relieve the Provider from his or her responsibility to give notification as required above.
Specialty Provider Group (Non-MD or DO) Obligations. To the extent required by law or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of an individual Network participation. Anthem reserves the right to notify its Members of Provider's termination. Notification by Anthem shall not relieve the Provider from his or her responsibility to give notification as required above.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Maine ProviderAgreement PCS © 2022 July - Anthem HealthPlans of Maine, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 122 |
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product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Maine ProviderAgreement PCS © 2022 July - Anthem HealthPlans of Maine, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 123 |
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MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or a Fee Schedule based on one hundred percent (100%) of the CMS Medicare fee schedules.
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules, or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment, or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Maine ProviderAgreement PCS © 2022 July - Anthem HealthPlans of Maine, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 124 |
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STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
MO STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
These provisions are specific to Covered Services provided to Members enrolled under Health Benefit Plans issued in the State of Missouri by RightCHOICE Managed Care, Inc. (hereinafter "Company") and are required terms and conditions for any Provider located in either the State of Missouri or the State of Illinois. Neither HealthLink, Inc. nor HealthLink HMO, Inc. will be considered a party to this Agreement or an Affiliate as defined in the Agreement.
ARTICLE I
DEFINITIONS
"Company Rate" means the lesser of one hundred percent (100%) of Eligible Provider's Charges for Covered Services, or the total reimbursement amount that Provider and Company have agreed upon as set forth in the PCS. The Company Rate includes applicable Cost Shares, and shall represent payment in full to Provider for Covered Services.
"Audit" means a post-payment review of the Claim(s) and supporting clinical information reviewed by Company to ensure payment accuracy. The review ensures Claim(s) comply with all pertinent aspects of submission and payment including, but not limited to, contractual terms, Regulatory Requirements, Coded Service Identifiers (as defined in the Plan Compensation Schedule ("PCS") guidelines and instructions, Company medical policies and clinical utilization management guidelines, reimbursement policies, and generally accepted medical practices. Audit does not include medical record review for quality and risk adjustment initiatives, or activities conducted by Company's Special Investigation Unit ("SIU").
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 125 |
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2.16 Coordination of Benefits. Subject to Regulatory Requirements, Provider agrees to cooperate with Plan regarding coordination of benefits, as set forth in Policies and the provider manual(s), and to notify Plan promptly after receipt of information regarding any Member who may have a Claim involving coordination of benefits.
ARTICLE VIII
TERM AND TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 126 |
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Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 127 |
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ARTICLE IX GENERAL PROVISIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 128 |
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9.16 Review. Provider hereby acknowledges that Provider was allowed at least thirty (30) days to review this Agreement prior to Provider's execution hereof.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 129 |
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PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the following Networks and substantially equivalent successor Networks set forth below on the later of: (1) the Effective Date of this Agreement or; (2) as determined by Plan in its sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 130 |
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COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
This is a Commercial Business Participation Attachment ("Attachment") to the Company Provider Agreement ("Agreement"), entered into by and between Company and Provider and is incorporated into the Agreement.
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Company's Pathway/Pathway X Network, which will support Company's Individual Business, both with respect to products or programs offered by Company on state-based, regional or federal health insurance exchanges ("Exchanges") established by Patient Protection and Affordable Care Act ("PPACA"), and with respect to products or programs offered by Company outside of Exchanges. Provider acknowledges and understands that the Pathway/Pathway X Network and certain products or programs it supports are subject to Regulatory Requirements; and Provider agrees to abide by all applicable rules, regulations and other requirements of the Exchanges as they exist and as they may be amended or changed from time to time. For purposes of this subsection 2.1.2, Individual Business means certain Health Benefit Plans sold by Company directly to Commercial Business Members and not through an employer group, as determined by Company. Individual Business does not include Commercial Business Members covered under The Consolidated Omnibus Budget Reconciliation Act ("COBRA"), Company's Medicare Advantage, Medicare Supplement or short-term medical products, or Company's Federal Employee Program. "Grandfathered" Health Benefit Plans, as defined by PPACA, do not constitute Individual Business.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Missouri ProviderAgreement Commercial Attachment © 2022 Mar - RightCHOICE Managed Care, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 131 |
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ARTICLE III TERMINATION
(ii) the date on which the Commercial Business Member is discharged from an inpatient facility, or (iii) the expiration of such other period as may be required by Regulatory Requirements applicable to Company, a Plan, the Health Benefit Plan or the Commercial Business Member, whichever is greater. This provision will be construed in favor of a Commercial Business Member and supersedes any oral or written contrary agreement between Provider and a Commercial Business Member or the representative of a Commercial Business Member if the contrary agreement is inconsistent with this provision and the provisions of the Agreement regarding the continuation of care after termination. This provision shall survive termination of this Attachment.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Missouri ProviderAgreement Commercial Attachment © 2022 Mar - RightCHOICE Managed Care, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 132 |
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ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Missouri ProviderAgreement Commercial Attachment © 2022 Mar - RightCHOICE Managed Care, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 133 |
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PLAN COMPENSATION SCHEDULE ("PCS")
I. DEFINITIONS
"Company Medicare Advantage Rate" shall mean the Company Rate that is used for Medicare Advantage.
"Emergency Condition", the sudden and, at the time, unexpected onset of a health condition that manifests itself by symptoms of sufficient severity that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that immediate medical care is required, which may include, but shall not be limited to: (a) Placing the person's health in significant jeopardy; (b) Serious impairment to a bodily function; (c) Serious dysfunction of any bodily organ or part; (d) Inadequately controlled pain; or (e) With respect to a pregnant woman who is having contractions: (a) that there is inadequate time to effect a safe transfer to another hospital before delivery; or (b) that transfer to another hospital may pose a threat to the health or safety of the woman or unborn child.
"Emergency Services" means those Covered Services furnished or required to evaluate and treat an Emergency Condition, which may include, but shall not be limited to, Covered Services that are provided in a licensed hospital's emergency facility by an appropriate provider.
Specialty Physician Group Obligations. Provider is designated as a Specialty Care Provider ("SCP" or "Specialty Care Provider") for those Network(s) designated on the signature page of the Agreement.
Except in case of an Emergency, or as otherwise set forth in the Member's Health Benefit Plan, or required by statute or regulation, prior to treating a Member, Specialty Care Provider agrees to obtain a referral, in accordance with Member's Health Benefit Plan, from a Primary Care Provider ("PCP") who is primarily responsible for providing or authorizing the professional services as set forth in the Health Benefit Plan.
A Provider who is a Specialty Care Provider, such as a gynecologist or obstetrician shall provide Health Services to Members on a twenty-four (24) hour per day, seven (7) day a week basis or at such times as Health Services are typically provided by similar providers to assure availability, adequacy, and continuity of care to Members. If Provider is unable to provide Health Services as described in the previous sentence, Provider will arrange for another Participating Provider to cover Provider's patients in Provider's absence.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of an individual Network participation.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Company's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for state and federal health programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Missouri ProviderAgreement PCS © 2022 July - RightCHOICE Managed Care, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 134 |
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If a Member is required to obtain Covered Services through a Participating Provider or a provider participating in a separate provider network to receive the highest level of benefits, and Provider is not a Participating Provider or a provider participating in the separate provider network, but Provider participates in a Network for an equivalent Company product issued in the state compared to the Member's product, Provider shall accept the applicable Company Rate for the equivalent Network in which the Provider participates. For example, if a Provider participates in the Blue Access Program and has a Plan Compensation Schedule for the Blue Access Program, but the Provider does not participate in the Blue Access Choice Program as a Participating Provider and there is no specific Plan Compensation Schedule for the Blue Access Choice Program attached to the Agreement, the Plan Compensation Schedule for the Blue Access Program shall be used to determine the "Allowed Amount" for Covered Services provided by the Provider to Members in the Blue Access Choice Program. Provider shall bill, collect and accept reimbursement for services from Members for Cost Shares. If Provider's participation is limited to an indemnity product that does not include incentives for the Member to use a Participating Provider ("Traditional Network"), or Provider does not participate in a Network for an equivalent Company product issued in the state compared to the Member's product, Provider shall accept the Company Rate for the Traditional Network as set forth on the Fee Schedule. Provider shall bill, collect and accept reimbursement for Cost Shares.
Request for Representative Fee Schedule. Upon Provider's written request, Company will provide Provider with a representative sample of the fees then in effect under a Fee Schedule applicable to a particular Network.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Missouri ProviderAgreement PCS © 2022 July - RightCHOICE Managed Care, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 135 |
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MEDICARE ADVANTAGE
For Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept the lesser of Provider Charges or a Fee Schedule based on of the CMS Medicare fee schedules.
When determining the Company Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Company Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Company notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Missouri ProviderAgreement PCS © 2022 July - RightCHOICE Managed Care, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 136 |
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STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
NH STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern.
The following provisions are required terms and conditions for certain Health Benefit Plans that are issued in the State of New Hampshire.
ARTICLE II
SERVICES/OBLIGATIONS
2.9 Compliance with Provider Manual(s) and Policies, Programs and Procedures. Provider agrees to cooperate and comply with, Anthem provider manual(s), and all other policies, programs and procedures (collectively "Policies") established and implemented by Plan applicable to the Network(s) in which Provider participates. Anthem or its designees may modify the provider manual(s) and its Policies by making a good faith effort to provide notice to Provider at least sixty (60) days in advance of the effective date of material modifications for Commercial Business subject to New Hampshire state law, and at least thirty (30) days in advance of the effective date of material modifications for all other lines of business thereto.
2.17 Cost Effective Care. Provider shall provide Covered Services in the most cost effective, clinically appropriate setting and manner. In addition, in accordance with the provider manual(s) and Policies, Provider shall utilize Participating Providers, and when Medically Necessary or appropriate, refer and transfer Members to Participating Providers for all Covered Services, including but not limited to specialty, laboratory, ancillary and supplemental services.
2.17.1 In accordance with New Hampshire RSA 420-J:8,XIV, and to the extent that the law is applicable, no provider employed by a hospital or any affiliate is required or in any way obligated to refer Members to providers also employed or under contract with a hospital or any affiliate.
ARTICLE IX GENERAL PROVISIONS
9.1 Amendment. Except as otherwise provided for in this Agreement, Anthem retains the right to amend this Agreement, the Anthem Rate, any attachments or addenda by making a good faith effort to provide notice to Provider at least sixty (60) days in advance of the effective date of the amendment. Except to the extent that Anthem determines an amendment is necessary to effectuate Regulatory Requirements, if Provider objects to the amendment prior to its effective date, then Provider has the right to terminate this Agreement, and such termination shall take effect on the later of the amendment effective date identified by Anthem or one hundred eighty (180) days from the date Provider has provided notice of his/her/its intention to terminate the Agreement pursuant to this section. Failure of Provider to provide such notice to Anthem within the time frames described herein will constitute acceptance of the amendment by Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 137 |
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Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 138 |
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Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 139 |
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PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the following Networks on the later of: 1) the Effective Date of this Agreement or; 2) as determined by Plan in its sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements:
Notwithstanding the foregoing, if Provider's office(s) is physically located outside the state of New Hampshire, Provider will not be considered a Participating Provider in the FEP program (PPO) or any Indemnity/Traditional/Standard Health Benefit Plans.
Other Plan Programs:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 140 |
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COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
New Hampshire ProviderAgreement Commercial Attachment © 2022 Mar - Anthem HealthPlans of New Hampshire, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 141 |
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ARTICLE III TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
New Hampshire ProviderAgreement Commercial Attachment © 2022 Mar - Anthem HealthPlans of New Hampshire, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 142 |
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ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
New Hampshire ProviderAgreement Commercial Attachment © 2022 Mar - Anthem HealthPlans of New Hampshire, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - Anthem InsuranceCompanies, Inc. NY Only (07/15/2019), DOH ID# 1291 11/09/2022 | 143 |
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PLAN COMPENSATION SCHEDULE ("PCS")
I. DEFINITIONS
"Emergency Condition" as set forth in New Hampshire RSA 417-F:1, I, means a medical condition with sudden onset that manifests itself by symptoms of sufficient severity that the absence of immediate medical attention could be expected to result in any of the following: (a) serious jeopardy to the patient's health; (b) serious impairment to bodily functions; (c) serious dysfunction of any bodily organ or part. "Emergency Services" means those Covered Services provided in connection with an Emergency Condition.
Specialty Physician Group Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Anthem will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Specialty Provider Group (Non-MD or DO) Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Anthem will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
New Hampshire ProviderAgreement PCS © 2022 July - Anthem Health Plans of New Hampshire, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 144 |
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Maximum Allowable Benefit ("MAB"). Anthem shall establish, and amend from time to time, a Maximum Allowable Benefit ("MAB"), which is the maximum level of reimbursement up to which Anthem shall allow for Covered Services provided to Members. Such amendments to MAB shall reflect market demands and consider Resource Based Relative Values ("RBRVS") and other relevant criteria designated by Anthem at Anthem's sole discretion.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
New Hampshire ProviderAgreement PCS © 2022 July - Anthem Health Plans of New Hampshire, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 145 |
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MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or a Fee Schedule based on one hundred percent (100%) of the CMS Medicare fee schedules.
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
New Hampshire ProviderAgreement PCS © 2022 July - Anthem Health Plans of New Hampshire, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 146 |
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STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
NV STATE SPECIFIC PROVISIONS
These provisions are specific to the state of Nevada and are required either by Plan, by statute, or by regulation.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ARTICLE VIII
TERM AND TERMINATION
8.2 Termination Without Cause. Either party may terminate this Agreement without cause at any time by giving at least one hundred twenty (120) days prior written notice of termination to the other party. Notwithstanding the foregoing, should a Participation Attachment(s) contain a longer without cause termination period, the Agreement shall continue in effect only for such applicable Participation Attachment(s) until the termination without cause notice period in the applicable Participation Attachment(s) ends.
ARTICLE IX GENERAL PROVISIONS
9.1.1 Amendment To Anthem Rate. Except as otherwise provided for in this Agreement, Anthem retains the right to amend the Anthem Rate upon at least forty-five (45) days' written notice in advance of
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 148 |
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the effective date of the amendment. If Provider objects in writing to the Anthem Rate change within the forty-five (45) day period, the change will not become effective unless agreed to in writing by the parties. However, if Provider fails to object in writing to the Anthem Rate change within the forty-five
(45) day period, then the Anthem Rate change will be effective at the end of that period.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 149 |
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PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the Networks set forth below on the later of: (1) the Effective Date of this Agreement or; (2) the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements:
Commercial lines of business:
Health Benefit Plans in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status or funding source. Provider participates in Networks which support such Health Benefit Plans including but not limited to the following:
Governmental lines of business:
Health Benefit Plans issued pursuant to an agreement between Plan and Agency in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status. Provider participates in the following Networks which support such Health Benefit Plans:
Other Plan Programs:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem Insurance Companies,Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 150 |
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COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE I
DEFINITIONS
"Clean Claim" means either the uniform bill form or electronic submission form in the format prescribed by Anthem submitted for payment by a provider for Covered Services rendered to a Member which includes all information necessary to process the Claim. "Clean Claim" does not include a Claim for payment of expenses incurred during a period of time for which premiums are delinquent, except to the extent otherwise required by applicable Regulatory Requirements.
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or programs offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
Anthem shall approve or deny Clean Claims within thirty (30) calendar days of receipt. If a Clean Claim is payable, payment shall be made within thirty (30) days after it is approved. If a Clean Claim is payable, and Anthem does not pay the Claim with thirty (30) days of approval, Anthem shall pay Provider interest on the amount owed at a rate equal to the prime rate at the largest bank in Nevada, as ascertained by the commissioner of financial institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus six percent (6%). In the event additional information is required to appropriately process a Claim, Anthem shall notify Provider of its request for additional information within twenty (20) days after receipt of the Claim. Anthem shall approve or deny the Claim within thirty (30) days after receiving the additional information. If the Claim is approved, Anthem shall pay the Claim within thirty (30) days after it receives the additional information. If Anthem fails to pay the approved Claim within that time frame, it shall pay interest to Provider as stated above from thirty (30) days after the date on which the Claim was approved until the date on which the Claim is paid.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
NevadaProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 151 |
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ARTICLE III TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
NevadaProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 152 |
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The above provisions shall be construed in favor of the Commercial Business Member and shall supersede any oral or written contrary agreement between Provider and the Commercial Business Member or the Commercial Business Member's representative if the contrary agreement is inconsistent with the above provisions.
ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
NevadaProvider Agreement Commercial Attachment © 2022 Mar - RockyMountain Hospital and Medical Services,Inc. © 2022 Mar - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 153 |
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PLAN COMPENSATION SCHEDULE ("PCS")
Specialty Physician Group Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of an individual Network participation.
Specialty Provider Group (Non-MD or DO) Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of an individual Network participation.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Anthem out-of-network maximum benefit allowance compensation rate, but based on the Member's Health Benefit Plan, Plan may have no liability for services rendered. In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem out-of-network maximum benefit allowance compensation rate, but based on the Member's Health Benefit Plan, Plan may have no liability for services rendered. In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
NevadaProvider Agreement PCS © 2022 July- Rocky Mountain Hospitaland MedicalServices, Inc. © 2022 July - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 154 |
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MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or a Fee Schedule based on of the CMS Medicare fee schedules.
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
NevadaProvider Agreement PCS © 2022 July- Rocky Mountain Hospitaland MedicalServices, Inc. © 2022 July - HMOColorado, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 155 |
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STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
NY STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern.
The following provisions are required terms and conditions for certain Health Benefit Plans that are issued in the State of New York.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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2.11 Networks and Provider Panels. Provider shall be eligible to participate only in those Networks designated on the Provider Networks Attachment of this Agreement. Provider shall not be recognized as a Participating Provider in such Networks until the later of: 1) the Effective Date of this Agreement or; 2) as determined by Plan in its sole discretion, the date Provider has met Plan's applicable credentialing requirements, standards of participation and accreditation requirements. Provider acknowledges that Plan may develop, discontinue,
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 157 |
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or modify new or existing Networks, products and/or programs. In addition to those Networks designated on the Provider Networks Attachment, Empire may also identify Provider as a Participating Provider in additional Networks, products and/or programs designated in writing from time to time by Empire. The terms and conditions of Provider's participation as a Participating Provider in such additional Networks, products and/or programs shall be on the terms and conditions as set forth in this Agreement unless otherwise agreed to in writing by Provider and Empire.
In addition to and separate from Networks that support some or all of Plan's products and/or programs (e.g., HMO, PPO and Indemnity products), Provider further acknowledges that certain Health Services, including by way of example only, laboratory or behavioral health services, may be provided exclusively by designated Participating Providers (a "Health Services Designated Network"), as determined by Plan. Provider agrees to refer Members to such designated Participating Providers in a Health Services Designated Network for the provision of certain Health Services, even if Provider performs such services. Notwithstanding any other provision in this Agreement, if Provider provides a Health Service to a Member for which Provider is not a designated Participating Provider in a Health Services Designated Network, then Provider agrees that he/she/it shall not be reimbursed for such services by Empire, Plan or the Member, unless Provider was authorized to provide such Health Service by Plan. Notwithstanding the foregoing, Provider expressly acknowledges and agrees that they shall not be participating in any applicable Medicare Advantage HMO Special Needs Plan ("SNP") or Medicare Advantage HMO products or other Medicare Advantage products that are administered or managed by CareMore IPA of New York, LLC. In addition and notwithstanding anything to the contrary in the Agreement, this Agreement shall not apply to the products issued by HealthPlus HP, LLC d/b/a Empire BlueCross BlueShield HealthPlus unless otherwise notified by Empire.
2.13 Provider Credentialing, Standards of Participation and Accreditation. Provider warrants that he/she/it meets all applicable Plan credentialing requirements, standards of participation, and accreditation requirements for the Networks in which Provider participates. A description of the applicable credentialing requirements, standards of participation, and accreditation requirements, are set forth in the provider manual(s) and/or in the PCS. Provider acknowledges that until such time as Provider has been determined to have fully met Plan's credentialing requirements, standards of participation, and accreditation requirements, as applicable, Provider shall not be entitled to the benefits of participation under this Agreement, including without limitation the Empire Rates set forth in the PCS attached hereto.
2.18 Multiple Office Sites. Provider understands and agrees that this Agreement constitutes Provider's agreement to participate in the Networks under all tax identification numbers and at all office locations, regardless of area of practice, unless Empire elects to limit participation to certain office locations or tax identification numbers. Provider is hereby prohibited from restricting participation to certain office locations or tax identification numbers when Provider maintains multiple offices or tax identification numbers. Provider shall provide thirty
(30) days advance written notice to Empire of the addition or deletion of any Provider office locations or tax identification numbers. In the event that Provider closes or no longer practices at a particular office location, Provider further agrees to provide written notice to Members who are existing patients of Provider setting forth Provider's remaining office locations where such Members may continue to access Covered Services.
ARTICLE VII
DISPUTE RESOLUTION AND ARBITRATION
7.1 Dispute Resolution. All disputes between Empire and Provider arising out of or related in any manner to this Agreement shall be resolved using the dispute resolution and arbitration procedures as set forth below. Provider shall exhaust any other applicable provider appeal/provider dispute resolution procedures and any applicable state law exhaustion requirements imposed by Regulatory Requirements as a condition precedent to Provider's right to pursue the dispute resolution and arbitration procedures as set forth below.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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The parties agree that external appeal decisions issued by an independent review organization contracted with a state Agency for medical necessity or investigational disputes are final and binding on the parties, and Provider may not pursue further dispute resolution or arbitration as further set forth in this Article VII below with respect to such disputes.
7.1.1 Except as otherwise specified in section 7.1 above, in order to invoke the dispute resolution procedures in this Agreement, a party first shall send to the other party a written demand letter that contains a detailed description of the dispute and all relevant underlying facts, a detailed description of the amount(s) in dispute and how they have been calculated and any other information that the Empire provider manual(s) may require Provider to submit with respect to such dispute. If the total amount in dispute as set forth in the demand letter is less than two hundred thousand dollars ($200,000), exclusive of interest, costs, and attorneys' fees, then within twenty (20) days following the date on which the receiving party receives the demand letter, representatives of each party's choosing shall meet to discuss the dispute in person or telephonically in an effort to resolve the dispute. If the total amount in dispute as set forth in the demand letter is two hundred thousand dollars ($200,000) or more, exclusive of interest, costs, and attorneys' fees, then within ninety (90) days following the date of the demand letter, the parties shall engage in non-binding mediation in an effort to resolve the dispute unless both parties agree in writing to waive the mediation requirement. The parties shall mutually agree upon a mediator, and failing to do so, Judicial Arbitration and Mediation Services ("JAMS") shall be authorized to appoint a mediator.
ARTICLE VIII
TERM AND TERMINATION
Notwithstanding the foregoing, Empire may nonrenew Provider's participation in one or more Network(s) designated on the Provider Networks Attachment by giving Provider written notice at least sixty (60) days prior to the start of the calendar year. Following any nonrenewal of Provider's participation in one or more Network(s), the remainder of the Agreement shall remain in full force and effect. Should a Participation Attachment(s) contain a longer notice period, the Agreement shall continue in effect only for such applicable Participation Attachment(s) until the notice period in the applicable Participation Attachment(s) ends.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ARTICLE IX GENERAL PROVISIONS
9.1 Amendment. Except as otherwise provided for in this Agreement, Empire retains the right to amend this Agreement, the Empire Rate, any attachments or addenda by making a good faith effort to provide notice to Provider at least forty-five (45) days in advance of the effective date of the amendment.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 160 |
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Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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9.16 Regulatory Approval. To the extent Provider participates in Networks under this Agreement, which are subject to review by the New York State Department of Health, this Agreement is subject to the approval of the New York State Department of Health as to form. If this Agreement is implemented prior to such approval, the parties agree to incorporate into this Agreement any and all modifications required by the Department of Health for approval or, alternatively, to terminate this Agreement if so directed by the Department of Health. The "New York State Department of Health Standard Clauses for Managed Care Provider/IPA/ACO Contracts", attached to the Agreement as Attachment A, are expressly incorporated into this Agreement and are binding upon the Article 44 plans and providers that contract with such plans, and who are a party to this Agreement. In the event of any inconsistent or contrary language between the Standard Clauses and any other part of the Agreement, including but not limited to appendices, amendments, exhibits, the parties agree that the provisions of the Standard Clauses shall prevail, except to the extent applicable law requires otherwise and/or to the extent a provision of the Agreement exceeds the minimum requirements of the Standard Clauses.
ARTICLE X BCBSA REQUIREMENTS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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10.2 Blue Cross Blue Shield Out of Area Program. Provider agrees to provide Covered Services to any person who is covered under another BCBSA out of area or reciprocal program, and to submit Claims for payment in accordance with current BCBSA Claims filing guidelines. Provider agrees to accept payment by Plan at the Empire Rate for the equivalent Network as payment in full except Provider may bill, collect and accept compensation for Cost Shares. The provisions of this Agreement shall apply to Eligible Charges as defined in the PCS for Covered Services under the out of area or reciprocal programs. Provider further agrees to comply with other similar programs of the BCBSA. For Members who are enrolled under BCBSA out of area or reciprocal programs, Provider shall comply with the applicable Plan's utilization management policies. Each Plan utilizes its own utilization management criteria as guideline for Medical Necessity decisions. To the extent Provider is seeking precertification for a person who is covered under another BCBSA out of area reciprocal program, the Provider shall have the right to request the utilization management criteria utilized or to be utilized for the Medical Necessity determination from the applicable Plan. In addition, if the Provider renders services to a person who is covered under another BCBSA out of area reciprocal program and the service is denied as not being Medically Necessary, Provider shall have the right to request that Empire shall obtain the utilization management criteria utilized for the Medical Necessity determination from the applicable Plan.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the following Networks on the later of: 1) the Effective Date of this Agreement or; 2) as determined by Plan in its sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
(120) day period referenced in section 2.3 above, whichever is longer.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ARTICLE III TERMINATION
3.1 Termination for Adverse Reimbursement Change. If there is an Adverse Reimbursement Change (as defined below) to the Agreement and the Provider is a licensed health care professional under Title 8 of the New York State Education law, Provider shall have the right to terminate all Networks, listed on the Provider Networks Attachment, which support Commercial Business and this Attachment by giving written notice to Empire sixty
(60) days prior to the effective date of the Adverse Reimbursement Change. For purposes of this section, "Adverse Reimbursement Change" shall be defined as a change in the Empire Rate that can reasonably be expected to have a material impact on the aggregate level of payment to an individual health care professional.
ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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PLAN COMPENSATION SCHEDULE ("PCS")
"Emergency Condition" means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent lay person possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (1) placing the health of the individual afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such individual or others in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part of such individual; or (4) serious disfigurement of such individual.
"Emergency Services" means those Covered Services provided in connection with an Emergency Condition. "Empire Medicare Advantage Rate" shall mean the Empire Rate that is used for Medicare Advantage.
Coding Software. Updates to Empire's Claims processing filters, code editing software, pricers, and any edits related thereto, as a result of changes in Coded Service Identifier(s) reporting guidelines and instructions, shall take place automatically and do not require any notice, disclosure or amendment to Provider. Empire reserves the right to use a code editing software as reasonably required by Empire to ensure Claims adjudication in accordance with industry standards, including, but not limited to, determining which services are considered part of, incidental to, or inclusive of the primary procedure and ensuring medically appropriate age, gender, diagnosis, frequency, and units billed.
Reimbursement for Anthem Rate Based on Eligible Charges. Notwithstanding any reimbursement amount set forth herein, Provider shall only be allowed to receive such reimbursement if such reimbursement is for an Eligible Charge. In addition, if Provider reimbursement is under one or more of the following methodologies: Capitation, Case Rate, DRG Rate, Encounter Rate, Global Case Rate, Per Diem Rate, Per Relative Value Unit (RVU), Per Service Rate, and Per Visit Rate, then individual services billed shall not be reimbursed separately, unless otherwise specified in Article IV of this PCS.
Specialty Physician Group Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Empire will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Specialty Provider Group (Non-MD or DO) Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Empire will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Accessing Fee Schedules. Provider may access Fee Schedules by following the instructions outlined in the "Empire's Online Services" section of the provider manual.
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Empire's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Empire Rate. Provider agrees to accept the Indemnity/Traditional/Standard Empire Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Empire Rate. Provider agrees to accept the Indemnity/Traditional/Standard Empire Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Empire Rate established for the Network and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Empire Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or Plan's Fee Schedule.
When determining the Empire Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules, or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Empire Medicare Advantage Rate shall not include any bonus payment, or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Empire notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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OHIO SUMMARY DISCLOSURE FORM
Anthem Blue Cross and Blue Shield Provider Agreement
Provider Name: Online Care Group Tax ID#: 541237939 Date: 11/09/2022
1. Compensation Terms |
Manner of Payment: Fee for Service
Fee Schedule, reimbursement policies, and edits are available at: www.availity.com. (You will need to Register or Log In to the Provider Portal via Availity in order to access this information.) |
2. List of products or networks covered by this contract | Blue Access - OH II-Tier 1, Blue Access - OH II-Tier 2, Blue Access- OH I-Tier 1, Blue Access- OH I-Tier 2, Blue Access/Access, Blue Connection, Blue Preferred Primary Plus/Primary Plus, Blue Preferred Primary/Preferred Primary, Blue Traditional/Traditional, Medicare Advantage HMO, Medicare Advantage PPO, Pathway, Pathway Essentials, Pathway Group HMO, Pathway HMO, Pathway X HMO |
3. Term of this contract |
Please refer to Article VIII, 8.1 Term of Agreement and the Signature Page of the Agreement. |
4. Contracting entity or payer responsible for processing payment | Anthem and/or Anthem’s Affiliate’s. Please refer to the list of Affiliate’s located under Other Affiliate Information at www.anthem.com |
5. Internal mechanism for resolving disputes regarding contract terms | Please refer to Article VII, 7.1 Dispute Resolution |
6. Addenda to contract |
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7. Telephone number to access a readily available mechanism, such as a specific web site address, to allow a participating provider to receive the information in (1) through (6) from the payer | Akron/Canton 330-493-2354 Cincinnati 513-770-7607 Cleveland 216-573-4440 Columbus 614-438-3400 Dayton 937-428-8808 |
The information provided in this Summary Disclosure Form is a guide to the attached Health Care Contract as defined in section 3963.01 of the Ohio Revised Code. The Summary Disclosure Form does not constitute a part of the Health Care Contract. The terms and conditions of the attached Health Care Contract constitute the contract rights of the parties.
In the event of a conflict between the terms stated in the Health Care Contract and the terms stated in this Summary Disclosure Form, the terms of the Health Care Contract shall govern.
Reading this Summary Disclosure Form is not a substitute for reading the entire Health Care Contract. When you sign the Health Care Contract, you will be bound by its terms and conditions. These terms and conditions may be amended over time pursuant to section 3963.04 of the Ohio Revised Code. You are encouraged to read any proposed amendments that are sent to you after execution of the Health Care Contract.
Nothing in this Summary Disclosure Form creates any additional rights or causes of action in favor of either party.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
OH STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern.
These provisions are specific to the state of Ohio and are required either by Plan, by stature, or by regulation.
ARTICLE I
DEFINITIONS
"Material Amendment", for those providers defined in O.R.C. §3963.01 unless otherwise set forth by law, regulation or the Member's Health Benefit Plan, means a change to the Agreement that decreases the Provider's overall reimbursement or changes the contractual obligations in a way that may reasonably be expected to significantly increase the Provider's administrative expenses. The term Material Amendment shall be construed in a manner consistent with the definition in O.R.C. section 3963.01 et.seq.
ARTICLE II
SERVICES/OBLIGATIONS
2.9 Compliance with Provider Manual(s) and Policies, Programs and Procedures. Provider agrees to cooperate and comply with, Anthem provider manual(s), and all other policies, programs and procedures (collectively "Policies") established and implemented by Plan applicable to the Network(s) in which Provider participates. Anthem or its designees may modify the provider manual(s) and its Policies by making a good faith effort to provide notice to Provider at least ninety (90) days in advance of the effective date of material modifications thereto.
ARTICLE IX GENERAL PROVISIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 170 | 1841672798 #1350526454 |
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 171 | 1841672798 #1350526454 |
PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the following Networks on the later of: 1) the Effective Date of this Agreement or; 2) as determined by Plan in its sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements:
Commercial lines of business:
Health Benefit Plans in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status or funding source. Provider participates in Networks which support such Health Benefit Plans including but not limited to the following:
• Indemnity/Traditional/Standard | (includes | indemnity/traditional/standard | products | such | as: | Blue |
Traditional/Traditional) • Blue Connection • Pathway • Pathway Essentials |
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Governmental lines of business:
Health Benefit Plans issued pursuant to an agreement between Plan and Agency in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status. Provider participates in the following Networks which support such Health Benefit Plans:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-State ProviderAgreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 172 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or programs offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Ohio ProviderAgreement Commercial Attachment © 2022 Mar - Community Insurance Company AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 173 | 1841672798 #1350526454 |
ARTICLE III TERMINATION
ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Ohio ProviderAgreement Commercial Attachment © 2022 Mar - Community Insurance Company AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 174 | 1841672798 #1350526454 |
PLAN COMPENSATION SCHEDULE ("PCS")
I. DEFINITIONS
"Emergency Condition" is defined as a medical condition that manifests itself by such acute symptoms of sufficient severity, including severe pain, such 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: (1) placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.
Specialty Physician Group Obligations. Provider is designated as a Specialty Care Provider ("SCP" or "Specialty Care Provider") for those Network(s) designated on the Provider Networks Attachment of the Agreement.
Except in case of an Emergency, or as otherwise set forth in the Member's Health Benefit Plan, or required by Regulatory Requirements, prior to treating a Member, Specialty Care Provider agrees to obtain a referral, in accordance with Member's Health Benefit Plan, from a Primary Care Provider ("PCP") who is primarily responsible for providing or authorizing the professional services as set forth in the Health Benefit Plan.
A Provider who is a Primary Care Provider, or a gynecologist or obstetrician, shall provide Health Services or make arrangements for the provision of Health Services to Members on a twenty-four (24) hour per day, seven
(7) day a week basis to assure availability, adequacy, and continuity of care to Members. In the event a Provider is not one of the foregoing described Providers, then Provider shall provide Health Services to Members on a twenty-four (24) hour per day, seven (7) day a week basis or at such times as Health Services are typically provided by similar providers to assure availability, adequacy, and continuity of care to Member. If Provider is unable to provide Health Services as described in the previous sentence, Provider will arrange for another Network Provider to cover Provider's patients in Provider's absence.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Specialty Provider Group (Non-MD or DO) Obligations. For those Providers who participate in a HMO/HIC Network, Provider agrees to accept a minimum of one hundred (100) Members in his/her/its practice and will notify Plan when Provider no longer accepts new patients. If Provider is in a group, then each individual Provider in the group shall abide by this section. Provider agrees not to close his/her practice and/or business to Members if Provider is offering Health Services to new non-Plan members. Provider shall give Plan sixty
(60) days prior written notice when Provider no longer accepts new patients.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Standard Anthem Rate. Provider agrees to accept the Indemnity/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on one hundred percent (100%) of the Indemnity/Standard Anthem Rate and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the local Ohio PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services. Notwithstanding any contrary provision contained herein, if Provider is not a Network/Participating Provider in Anthem Pathway Networks/products, Provider shall accept one hundred percent (100%) of the CMS rate as payment in full. Anthem Pathway Networks/products, as designated by Anthem, are On and Off Exchange individual products and off Exchange group products offered by Anthem.
MEDICARE ADVANTAGE
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or a Fee Schedule based on one hundred percent (100%) of the CMS Medicare fee schedules.
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Ohio ProviderAgreement - PCS © 2022 July - Community Insurance Company AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 176 | 1841672798 #1350526454 |
the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Ohio ProviderAgreement - PCS © 2022 July - Community Insurance Company AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 177 | 1841672798 #1350526454 |
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
VA STATE SPECIFIC PROVISIONS
These provisions are specific to the state of Virginia and are required either by Plan, by statute, or by regulation.
ARTICLE I
DEFINITIONS
"Government Contract" means the contract between Anthem or HMO and an applicable party, such as an Agency, which governs the delivery of Health Services by Anthem or HMO to Member(s) pursuant to a Government Program.
"HMO" means HealthKeepers, Inc.
ARTICLE II
SERVICES/OBLIGATIONS
The Provider further agrees that (1), this section shall survive the termination of this Provider Agreement regardless of the cause giving rise to such termination and shall be construed to be for the benefit of the Plan's Members, and (2), this section supersedes any oral or written agreement to the contrary now existing or hereafter entered into between the Provider and the Member or persons acting on the Member's behalf.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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In the event of nonpayment and/or insolvency of a Plan that is not underwritten by Anthem or an Affiliate, Provider further agrees that it shall not seek compensation from or have any other recourse against Anthem or an Affiliate.
For purposes of this provision, Provider shall include all subcontractors of the Provider. The Provider will make no charge and render no bill to any Plan, the Member, or the Member's guarantor for any services unless such services are certified as Medically Necessary and not Investigational* according to the terms of the utilization management program, a copy of which is included in the provider manual. The Provider also agrees that it will make no charge and render no bill to any Plan, the Member, or the Member's guarantor for any penalty or reduction in benefits required under a Member's Health Benefit Plan for failure to request Medical Necessity pre-authorization or pre- certification of services or extension of such services.
Notwithstanding any other section of the above paragraphs, in the event that any Plan notifies a Member and the Provider in writing that a service is not considered Medically Necessary, or is considered Investigational and therefore non-Covered, the Provider may bill such Member for such service if and only if: (a) the Member is notified, in writing, by the Provider that the services are not Medically Necessary or are Investigational (as applicable) in Plan's opinion and, therefore will not be covered; (b) following such notice, the Member acknowledges, in advance of receiving such services, his/her consent to receive or continue to receive such services and accept responsibility for payment; and (c) such notice and acknowledgment shall be in writing and contain, at a minimum, the date, time, description of the services to be rendered, the estimated cost of the services to be rendered, and the Member's signature. The Provider shall make such written notice/acknowledgement a part of the Member's medical record. Upon request, copies of the written notice/acknowledgement to the Member by the Provider shall be provided to Plan by the Provider. Nothing in the preceding sentences shall permit the Provider to bill any Plan for any such services. Any such written notice/acknowledgement must be obtained on a case-by-case basis.
To the extent that the Payment in Full and Hold Harmless provisions above are prohibited by law, they shall be inapplicable.
*Investigational means any service or supply that is judged to be Investigational at Anthem's sole discretion. Services which do not meet each of the following criteria will be excluded from coverage as Investigational:
Any supply or drug used must have received final approval to market by the U.S. Food and Drug Administration ("FDA") for the particular indication or application in question. Moreover, quantities of any drug or medication used, except those drugs used in the treatment of cancer pain and prescribed in compliance with established statutes pertaining to patients with intractable cancer pain, must be within recommended maximum daily dose or duration established by the FDA or any of the standard reference compendia defined below. There are two (2) exceptions which apply when a drug has received final approval to market by the FDA, but not for the particular indication or application in question.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
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ii In substantially accepted peer-reviewed medical literature. Peer-reviewed medical literature means a scientific study published only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased independent experts. This study must appear in a journal that has been determined by the International Committee of Medical Journal Editors to have met the Uniform Requirements for Manuscripts submitted to biomedical journals. Peer-reviewed medical literature does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier; or
There must be enough information in the peer-reviewed medical and scientific literature to let Anthem judge the safety and efficacy.
The service or supply must be as safe and effective outside a research setting as current diagnostic or therapeutic options.
New technologies are evaluated against these criteria to determine if services should be included as a Covered Service or considered Investigational.
Hold Harmless for Non-Covered Services Rendered to HMO Members. In the event that the Provider provides non-Covered Services of any type to a Member enrolled in a Plan that is a health maintenance organization, the Provider shall, prior to the provision of such non-Covered Services, notify such Member in writing: (i) of the services to be provided, (ii) that no Plan will pay for or be liable for said services, and (iii) that the Member will be financially liable for such services. Such notice must also contain the date and time such services are to be rendered as well as a description and an estimate of cost of such services. The Provider shall have the Member sign an acknowledgement that he or she understands these terms contained in the notice. If such Member is so advised and the notice and acknowledgement is signed, the Provider may bill such Member for such services. If the Member is not so advised or if the notice/acknowledgement is not signed by the Member, then the Provider may not bill the Member for such services. The Provider shall make such written notice/acknowledgement a part of the Member's medical record. Upon request, copies of the written notice/acknowledgement shall be provided to Plan by the Provider. Nothing in the preceding sentences shall permit the Provider to bill any Plan for any such services. Any such written notice/acknowledgement must be obtained on a case-by-case basis.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 180 | 1841672798 #1350526454 |
In any subcontract or delegation agreement entered into between Provider and any other entity for the provision of services to Members, Provider shall include the following hold harmless section:
[Subcontractor] hereby agrees that in no event, including but not limited to, non-payment by Plan or Provider, Plan or Provider insolvency or breach of this Agreement, shall [Subcontractor] bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members or persons other than Plan or Provider for services provided pursuant to the Agreement. This section shall not prohibit collection of any applicable Cost Shares billed in accordance with the terms of the Member agreement for the Plan.
[Subcontractor] further agrees that (1) this section shall survive the termination of this Agreement regardless of the cause giving rise to such termination and shall be construed to be for the benefit of the Plan's Members and (2) this section supersedes any oral or written agreement to the contrary now existing or hereafter entered into between [Subcontractor] and the Members or persons acting on the Member's behalf.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 181 | 1841672798 #1350526454 |
In addition to and separate from Networks that support some or all of Plan's products and/or programs (e.g., HMO, PPO and Indemnity products), Provider further acknowledges that certain Health Services, including by way of example only, laboratory services, may be provided exclusively by designated Participating Providers (a "Health Services Designated Network"), as determined by Plan. Provider agrees to refer Members to such designated Participating Providers in a Health Services Designated Network for the provision of certain Health Services, even if Provider performs such services. Notwithstanding any other provision in this Agreement, if Provider provides a Health Service to a Member for which Provider is not a designated Participating Provider in a Health Services Designated Network then Provider agrees that he/she/it shall not be reimbursed for such services by Anthem, Plan or the Member, unless Provider was authorized to provide such Health Service by Plan.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 182 | 1841672798 #1350526454 |
ARTICLE III
CONFIDENTIALITY/RECORDS
3.3 Network Provider/Patient Discussions. Notwithstanding any other provision in this Agreement and regardless of any benefit or coverage exclusions or limitations associated with a Health Benefit Plan, Provider shall fully discuss medical treatment options with a Member, including any issues related to the Member's health such as treatment alternatives, treatment risks and the consequences of any benefit coverage or payment decisions made by Plan or any other party. In addition, nothing in this Agreement shall be construed to create any financial incentive for Provider to withhold Covered Services, or prohibit Provider from disclosing to the Member the general methodology by which Provider is compensated under this Agreement, such as for example, whether Provider is paid on a fee for service, capitation or Percentage Rate basis. Plan shall not refuse to allow or to continue the participation of any otherwise eligible provider, or refuse to compensate Provider in connection with services rendered, solely because Provider has in good faith communicated with one or more of his/her/its current, former or prospective patients regarding the provisions, terms or requirements of a Health Benefit Plan as they relate to the health needs of such patient. Nothing in this section shall be construed to permit Provider to disclose Anthem Rates or specific terms of the compensation arrangement under this Agreement.
ARTICLE VI
INDEMNIFICATION AND LIMITATION OF LIABILITY
6.3 Period of Limitations. Unless otherwise provided for in this Agreement, a Health Benefit Plan, the provider manual(s), Policies, or Participation Attachment(s), neither party shall commence any action at law or equity against the other to recover on any legal or equitable claim arising out of this Agreement more than two (2) years after the events which gave rise to such claim provided, however, this two (2) year limitation shall not apply to actions by Anthem against Provider related to fraud, waste or abuse. The deadline for initiating an action shall not be tolled by the appeal process, or any other administrative process.
ARTICLE VIII
TERM AND TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 183 | 1841672798 #1350526454 |
ARTICLE IX GENERAL PROVISIONS
9.1 Amendment. Anthem retains the right to amend this Agreement, the Anthem Rate, or any attachments or addenda or the provider manual by providing Provider with a written copy of the applicable portion of the
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 184 | 1841672798 #1350526454 |
amendment. If Provider is unwilling to accept the amendment, Provider may terminate this Agreement by giving Anthem written notice of termination within forty (40) calendar days after the marked date associated with the corresponding delivery method of the amendment, and such termination shall become effective sixty
(60) calendar days after the expiration of this forty (40) calendar day period without the amendment taking effect. If Provider does not give Anthem notice of termination within this forty (40) calendar day period, then the amendment will become effective sixty (60) calendar days after the expiration of this forty (40) calendar day period.
9.4 Definitions. Unless otherwise specifically noted, the definitions as set forth in Article I of this Agreement will have the same meaning when used in any attachment the provider manual(s), and Policies.
9.11 Notice. Any notice required to be given pursuant to the terms and provisions of this Agreement shall be in writing and shall be delivered by hand, facsimile, electronic mail, or mail. Notice shall be deemed to be effective: (a) when delivered by hand, (b) upon transmittal when transmitted by facsimile transmission or by electronic mail, (c) upon receipt by registered or certified mail, postage prepaid, (d) on the next business day if transmitted by national overnight courier, or (e) if sent by regular mail, five (5) days from the date set forth on the correspondence. Unless specified otherwise in writing by a party, Anthem shall send Provider notice to an address that Anthem has on file for Provider, and Provider shall send Anthem notice to Anthem's address as set forth on the signature page.
ARTICLE X BCBSA REQUIREMENTS
10.2 Blue Cross Blue Shield Out of Area Program. Provider agrees to provide Covered Services to any person who is covered under another BCBSA out of area or reciprocal program, and to submit Claims to Anthem for payment or as otherwise instructed in the provider manual. Provider agrees to accept payment by Plan at the Anthem Rate for the equivalent Network as payment in full except Provider may bill, collect and accept compensation for Cost Shares. The provisions of this Agreement shall apply to Eligible Charges as defined in the PCS for Covered Services under the out of area or reciprocal programs. Provider further agrees to comply with other similar programs of the BCBSA. For Members who are enrolled under BCBSA out of area or reciprocal programs, Provider shall comply with the applicable Plan's utilization management policies.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 185 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE I
DEFINITIONS
"Medically Necessary" or "Medical Necessity" means the health care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors." The above definition of "Medically Necessary"/"Medical Necessity" shall be inapplicable to the extent that a different definition is required by Government Contract, or where any Regulatory Requirement requires a different definition.
"Physician Specialty Society" means a United States medical specialty society that represents diplomats certified by a board recognized by the American Board of Medical Specialties.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Virginia Provider Agreement Commercial Attachment © 2022 Mar - Anthem HealthPlans of Virginia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 186 | 1841672798 #1350526454 |
ARTICLE III TERMINATION
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Virginia Provider Agreement Commercial Attachment © 2022 Mar - Anthem HealthPlans of Virginia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 187 | 1841672798 #1350526454 |
3.1 This provision intentionally left blank.
ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Virginia Provider Agreement Commercial Attachment © 2022 Mar - Anthem HealthPlans of Virginia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 188 | 1841672798 #1350526454 |
MEDICARE ADVANTAGE PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
2.1 Participation-Medicare Advantage. As a participant in Plan's Medicare Advantage Network, Provider will render MA Covered Services to MA Members enrolled in Plan's Medicare Advantage Program in accordance with the terms and conditions of the Agreement and this Attachment. Except as set forth in this Attachment, or in the PCS, all terms and conditions of the Agreement will apply to Provider's participation in Plan's Medicare Advantage Program(s). The terms and conditions set forth in this Attachment are limited to the provision of and payment for Health Services provided to MA Members. This Agreement does not apply to any of Plan's Medicare Advantage Private Fee for Service or Medical Savings Account Programs or Medicare Advantage plans managed or administered by CareMore, LLC unless otherwise agreed to by the parties and set forth in the PCS. If Plan contracts with a third party to manage all or any portion of its Medicare Advantage Network, then Provider shall be required to contract separately with such third party to maintain its status as a Participating Provider for such Network(s).
2.1.1 New Programs. Provider acknowledges that Plan has or may develop Medicare Advantage Networks that support certain products, programs or plans with specific participation criteria that may include but are not limited to, quality and/or cost of care metrics. Pursuant to this Agreement, Provider shall be a Participating Provider in any such Network unless Anthem notifies Provider in writing to the contrary. Plan shall notify Provider sixty (60) days in advance of any specific Network participation criteria. Any notice of non-inclusion in any of Plan's Medicare Advantage Network(s) shall be provided in writing sixty (60) days in advance.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Virginia Provider Medicare Adv.Attachment © 2022 Mar - Anthem HealthPlans of Virginia, Inc AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 189 | 1841672798 #1350526454 |
PLAN COMPENSATION SCHEDULE ("PCS")
"Emergency Condition" the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment of the individual's bodily functions, (iii) serious dysfunction of any of the individual's bodily organs, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus.
Open Access Member. Members who are enrolled under an HMO Health Benefit Plan that does not require the Member to obtain a referral from his/her Provider in order to receive Covered Services from Participating Providers.
Specialty Physician Group Obligations. Provider is designated as a Specialty Physician for those Network(s) indicated on the signature page of the Agreement for which Provider did not opt-out.
Provider agrees to provide within the scope of his/her practice Covered Services to Members subject to any applicable referral and/or authorization requirements in Member's Health Benefit Plan or in this Agreement.
Except in case of an emergency, or as otherwise set forth in the Member's Health Benefit Plan, or required by statue or regulation, prior to treating a Member, Provider agrees to obtain a referral, in accordance with Member's Health Benefits Plan, from the Primary Care Physician ("PCP") who is primarily responsible for providing or authorizing the professional services as set forth in the Health Benefit Plan. For Members who are covered by an HMO Health Benefits Plan, Health Services provided by Provider without proper referral or prior authorization from the HMO shall not be considered Covered Services. Also, in the event that services required by a Member covered by an HMO Health Benefits Plan, including an open access Member, are not available from Participating Providers, other providers may be utilized with the prior authorization of the HMO. Should Provider refer a Member to another provider, whether that provider is a Participating Provider or not, without the prior authorization of the Member's PCP or the HMO, as specified above, the HMO may elect to pay the Member for the Covered Service or to pay the provider of the service and to deduct the amount paid in such cases from any payment due Provider.
Provider agrees to make necessary and appropriate arrangements to ensure the availability of Health Services to Members on a twenty-four (24) hour per day, seven (7) day per week basis, including arrangements to ensure coverage for Members after hours or when Provider is otherwise absent. Provider will use best efforts to ensure that covering providers participate with the Network specified in the Members Health Benefit Plan. Additionally, Provider agrees to (i) ensure the availability of routine appointments for non-emergency or non- urgent care within two (2) weeks of the Member's request and preventive care appointments, including routine physical examinations, within sixty (60) days of the Member's request; and (ii) provide clear notice to Members of provisions for urgent care or emergency services when Provider is not available after hours.
HMO may contract with a limited number of laboratory services providers to provide outpatient lab services. Provider agrees to use any laboratory designated by HMO for HMO Members. Member. If Provider sends laboratory specimens to any laboratory services provider – other than the one(s) designated by HMO for HMO Members – without the authorization of HMO, then Provider shall be in breach of this Agreement and
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Virginia Provider Agreement PCS © 2022 July- Anthem Health Plans ofVirginia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 190 | 1841672798 #1350526454 |
shall be responsible for any damages that may be sustained by HMO or its Members. . HMO will reimburse for a limited list of lab services when performed in Provider's office. These lab codes and the related reimbursement are included in this PCS Attachment. Provider further agrees not to bill Members for covered lab services that are determined as ineligible for compensation to Provider by HMO.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of an individual Network participation. As required by Virginia Code Section 38.2-3407.10D, if Provider terminates this Agreement for any reason, Provider must furnish reasonable notice of such termination to Provider's patients who are Members.
Specialty Provider Group (Non-MD or DO) Obligations. Provider is designated as a Specialty Physician for those Network(s) indicated on the signature page of the Agreement for which Provider did not opt-out.
Provider agrees to provide within the scope of his/her practice Covered Services to Members subject to any applicable referral and/or authorization requirements in Member's Health Benefit Plan or in this Agreement.
Except in case of an emergency, or as otherwise set forth in the Member's Health Benefit Plan, or required by statue or regulation, prior to treating a Member, Provider agrees to obtain a referral, in accordance with Member's Health Benefits Plan, from the Primary Care Physician ("PCP") who is primarily responsible for providing or authorizing the professional services as set forth in the Health Benefit Plan. For Members who are covered by an HMO Health Benefits Plan, Health Services provided by Provider without proper referral or prior authorization from the HMO shall not be considered Covered Services. Also, in the event that services required by a Member covered by an HMO Health Benefits Plan, including an open access Member, are not available from Participating Providers, other providers may be utilized with the prior authorization of the HMO. Should Provider refer a Member to another provider, whether that provider is a Participating Provider or not, without the prior authorization of the Member's PCP or the HMO, as specified above, the HMO may elect to pay the Member for the Covered Service or to pay the provider of the service and to deduct the amount paid in such cases from any payment due Provider.
Provider agrees to make necessary and appropriate arrangements to ensure the availability of Health Services to Members on a twenty-four (24) hour per day, seven (7) day per week basis, including arrangements to ensure coverage for Members after hours or when Provider is otherwise absent. Provider shall use best efforts to ensure that covering providers participate with the Network specified in the Members Health Benefit Plan. Additionally, Provider agrees to (i) ensure the availability of routine appointments for non-emergency or non- urgent care within two (2) weeks of the Member's request and preventive care appointments, including routine physical examinations, within sixty (60) days of the Member's request; and (ii) provide clear notice to Members of provisions for urgent care or emergency services when Provider is not available after hours.
HMO may contract with a limited number of laboratory services providers to provide outpatient lab services. Provider agrees to use any laboratory designated by HMO for HMO Members . If Provider sends laboratory specimens to any laboratory services provider – other than the one(s) designated by HMO for HMO Members
– without the authorization of HMO, then Provider shall be in breach of this Agreement and shall be responsible for any damages that may be sustained by HMO or its Members. HMO shall reimburse for a limited list of lab services when performed in Provider's office. These lab codes and the related reimbursement are included in this PCS Attachment. Provider further agrees not to bill Members for covered lab services that are determined as ineligible for compensation to Provider by HMO.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider shall provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of an individual Network participation. As required by Virginia Code Section 38.2-3407.10D,
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Virginia Provider Agreement PCS © 2022 July- Anthem Health Plans ofVirginia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 191 | 1841672798 #1350526454 |
if Provider terminates this Agreement for any reason, Provider must furnish reasonable notice of such termination to Provider's patients who are Members.
Provider shall be compensated at one hundred percent Provider shall be compensated at one hundred percent [100%) of the current Anthem Medicare Advantage Rate in effect at the time the Medicare Advantage Covered Service is rendered. The Anthem Medicare Advantage Rates may be amended from time to time as to apply changes in rates or methodology.
When determining the applicable Fee Schedule, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules, or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The applicable Fee Schedule shall not include any bonus payment, or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
MEDICAID PROGRAM(S)
Notwithstanding any other provision in the Agreement, HMO will pay Provider the Medicaid HMO Allowance for each Medically Necessary Covered Service that Provider provides to a Medicaid Member, less authorized Cost Shares, which shall be the responsibility of the Medicaid Member.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Virginia Provider Agreement PCS © 2022 July- Anthem Health Plans ofVirginia, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 192 | 1841672798 #1350526454 |
STATE SPECIFIC PROVISIONS ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
WI STATE SPECIFIC PROVISIONS
This is a Participation Attachment to the Anthem Blue Cross and Blue Shield Provider Agreement ("Agreement"), entered into by and between Anthem and Provider and is incorporated into the Agreement.
The provisions in this State Specific Provisions Attachment shall replace the similarly-titled provisions in the Agreement. Notwithstanding the foregoing, there may be other provisions in this State Specific Provisions Attachment that are not set forth in the Agreement, but which shall apply for this state. If there is a conflict between the terms of this State Specific Provisions Attachment and the terms of the Agreement (outside of this State Specific Provisions Attachment), the terms of this State Specific Provisions Attachment shall govern
These provisions are specific to the State of Wisconsin and are required either by Plan, by statute, or by regulation.
ARTICLE II
SERVICES/OBLIGATIONS
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 193 | 1841672798 #1350526454 |
2.11 Networks and Provider Panels. Provider shall be eligible to participate only in those Networks designated on the Provider Networks Attachment of this Agreement. Provider shall not be recognized as a Participating Provider in such Networks until the later of: 1) the Effective Date of this Agreement or; 2) as determined by Plan in its sole discretion, the date Provider has met Plan's applicable credentialing requirements, standards of participation and accreditation requirements. Provider acknowledges that Plan may develop, discontinue, or modify new or existing Networks, products and/or programs. In addition to those Networks designated on the Provider Networks Attachment, Anthem may also identify Provider as a Participating Provider in additional Networks, products and/or programs designated in writing from time to time by Anthem. The terms and conditions of Provider's participation as a Participating Provider in such additional Networks, products and/or programs shall be on the terms and conditions as set forth in this Agreement unless otherwise agreed to in writing by Provider and Anthem.
In addition to and separate from Networks that support some or all of Plan's products and/or programs (e.g., HMO, PPO and Indemnity products), Provider further acknowledges that certain Health Services, including by way of example only, laboratory or behavioral health services, may be provided exclusively by designated Participating Providers (a "Health Services Designated Network"), as determined by Plan. Provider agrees to refer Members to such designated Participating Providers in a Health Services Designated Network for the provision of certain Health Services, even if Provider performs such services. Notwithstanding any other provision in this Agreement, if Provider provides a Health Service to a Member for which Provider is not a designated Participating Provider in a Health Services Designated Network, then Provider agrees that he/she/it shall not be reimbursed for such services by Anthem, Plan or the Member, unless Provider was authorized to provide such Health Service by Plan.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 194 | 1841672798 #1350526454 |
ARTICLE IX GENERAL PROVISIONS
9.1 Amendment. Except as otherwise provided for in this Agreement, Anthem retains the right to amend this Agreement, the Anthem Rate, any attachments or addenda by making a good faith effort to provide notice to Provider at least forty five (45) days in advance of the effective date of the amendment. Except to the extent that Anthem determines an amendment is necessary to effectuate Regulatory Requirements, if Provider objects to the amendment prior to its effective date, then Provider has the right to terminate this Agreement, and such termination shall take effect on the later of the amendment effective date identified by Anthem or one hundred eighty (180) days from the date Provider has provided notice of his/her/its intention to terminate the Agreement pursuant to this section. Failure of Provider to provide such notice to Anthem within the time frames described herein will constitute acceptance of the amendment by Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 195 | 1841672798 #1350526454 |
PROVIDER NETWORKS ATTACHMENT
Provider shall be designated as a Participating Provider in the Networks: 1) when participation is determined by Plan in its sole discretion according to applicable law; or, 2) where there is no applicable law, on the later of the Effective Date of this Agreement or the date Provider has met Plan's applicable credentialing requirements, standards of participation and accreditation requirements:
Commercial lines of business:
Health Benefit Plans in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status or funding source. Provider participates in Networks which support such Health Benefit Plans including but not limited to the following:
Government Programs:
Health Benefit Plans issued pursuant to an agreement between Plan and Agency in which Members have access to a network of providers and receive an enhanced level of benefits when they obtain Covered Services from Participating Providers regardless of product licensure status. Provider participates in the following Networks which support such Health Benefit Plans:
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Enterprise Multi-State Provider Agreement © 2022 Mar - Anthem InsuranceCompanies, Inc. AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 196 | 1841672798 #1350526454 |
COMMERCIAL BUSINESS PARTICIPATION ATTACHMENT TO THE
ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER AGREEMENT
ARTICLE II
SERVICES/OBLIGATIONS
2.1.2 Provider agrees to participate in Anthem's exchange network(s) set forth on the Provider Networks Attachment, which may support both products or programs offered by Anthem through state-based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should Anthem change the name of the exchange network(s) set forth on the Provider Networks Attachment, it shall notify Provider.
2.4 Plan Payment Time Frames. To the extent a Complete Claim is subject to Wis. Stat. § 628.46, such Complete Claim shall be paid within thirty (30) days as provided for under the terms of Sec. 628.46.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Wisconsin Provider Agreement Commercial Attachment © 2022 Mar - Blue Cross Blue Shield of Wisconsin AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 197 | 1841672798 #1350526454 |
ARTICLE III TERMINATION
Provider shall, upon termination of this Agreement for reasons other than the grounds set forth in the Immediate Termination section of this Agreement, pursuant to 609.24, Wis. Stats., continue to provide and be compensated for Commercial Business Covered Services rendered to Commercial Business Members under the terms and conditions of this Agreement until the earlier of such time that: (1) the Commercial Business Member has completed the course of treatment; or (2) reasonable and medically appropriate arrangements have been made for a Participating Provider to render Health Services to the Commercial Business Member. Provider shall comply with the notice posting requirements of INS 9.35(1m) (if applicable).
ARTICLE IV GENERAL PROVISIONS
4.1 This provision intentionally left blank.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Wisconsin Provider Agreement Commercial Attachment © 2022 Mar - Blue Cross Blue Shield of Wisconsin AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 198 | 1841672798 #1350526454 |
PLAN COMPENSATION SCHEDULE ("PCS")
"State Medicaid Rate(s)/Fee Schedule(s)/Methodologies" means the Anthem Rate for the applicable state Medicaid Rate(s) /Fee Schedule(s)/Methodologies in effect on the date of service for the provider type(s)/service(s) identified herein for the applicable Medicaid Program(s).
Billing Form and Claims Reporting Requirements. Provider shall report all Health Services in accordance with the Coded Service Identifier(s) reporting guidelines and instructions using HIPAA compliant billing codes. In addition, Plan shall not pay any Claim(s) nor accept any Encounter Data submitted using non-compliant codes. Plan audits that result in identification of Health Services that are not reported in accordance with the Coded Service Identifier(s) guidelines and instructions, will be subject to recovery through remittance adjustment or other recovery action as may be set forth in the provider manual(s).
Specialty Physician Group Obligations. Provider is designated as a Specialty Care Provider ("SCP" or "Specialty Care Provider") for those Network(s) designated on the Provider Networks Attachment of the Agreement.
Except in case of an Emergency, or as otherwise set forth in the Member's Health Benefit Plan, or required by Regulatory Requirements, prior to treating a Member, Specialty Care Provider agrees to obtain a referral, if necessary, in accordance with Member's Health Benefit Plan, from a Primary Care Provider ("PCP") who is primarily responsible for providing or authorizing the professional services set forth in the Health Benefit Plan.
A Provider who is a gynecologist or obstetrician, shall provide Health Services or make arrangements for the provision of Health Services to Members on a twenty-four (24) hour per day, seven (7) day a week basis to assure availability, adequacy, and continuity of care to Members. In the event a Provider is not one of the foregoing described Providers, then Provider shall provide Health Services to Members on a twenty-four (24) hour per day, seven (7) day a week basis or at such times as Health Services are typically provided by similar providers to assure availability, adequacy, and continuity of care to Members. If Provider is unable to provide Health Services as described in the previous sentence, Provider will arrange for another Participating Provider to cover Provider's patients in Provider's absence.
To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Specialty Provider Group (Non-MD or DO) Obligations. To the extent required by Regulatory Requirements or an accrediting body, upon termination without cause, Provider will provide timely, sixty (60) day, notice to affected Member(s) of termination of this Agreement or termination of individual Network participation.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Wisconsin Provider Agreement PCS © 2022 July - Blue Cross Blue Shield of Wisconsin AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 199 | 1841672798 #1350526454 |
Allowances for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. Plan shall automatically update its allowance for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in this PCS. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to Anthem's fee allowances and payment responsibility.
Commercial Billing Form. Provider shall submit all Claims on a CMS 1500 claim form or its successor form(s) as applicable based on the services provided in accordance with Policies or applicable Regulatory Requirements.
Out-of-Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows:
Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share.
Except for Emergency Services, if the Member's Health Benefit Plan requires authorization by the Plan or a Provider for out of Network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Health Benefit Plan does not have out-of-network benefits unless authorized by the Plan or Provider, Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered.
Except for Emergency Services, if the Member's Health Benefit Plan has out-of-network benefits without authorization being required by the Plan or Provider, and no authorization has been given, then Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or product that supports the Member's Health Benefit Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Plan and the Member exceed Provider's Charge for such Covered Services.
MEDICARE ADVANTAGE
Medicare Billing Form. Provider shall submit all Claims on a CMS 1500 or CMS 1450/UB-04 claim form or its successor form(s) as applicable based on the services provided in accordance with Policies or applicable Regulatory Requirements.
For MA Covered Services provided by or on behalf of Provider to a Medicare Advantage Member, Provider agrees to accept, as the Anthem Medicare Advantage Rate, the lesser of Eligible Charges or a Fee Schedule based on of the CMS Medicare fee schedules.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Wisconsin Provider Agreement PCS © 2022 July - Blue Cross Blue Shield of Wisconsin AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 200 | 1841672798 #1350526454 |
When determining the Anthem Medicare Advantage Rate, any reimbursement terms in this Agreement that are based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS, shall refer to the per claim payment amounts that CMS and a Medicare beneficiary would directly pay to Provider for the same items or services under fee-for-service Medicare Part A or Part B. The Anthem Medicare Advantage Rate shall not include any bonus payment or settlement amount paid to Provider by CMS outside of the Medicare per claim payment process, unless otherwise set forth in the Medicare Advantage reimbursement terms of this Agreement. Unless Anthem notifies Provider otherwise, in the event CMS changes payment to Provider due to a CMS directive, Act of Congress, Executive Order, or Regulatory Requirement, the amount payable to Provider hereunder will automatically be changed as soon as reasonably practicable, as described herein, in the amount specified by CMS as a result of such directive or change in law, or in the absence of such specification, in the same percentage amount as payment is changed by CMS to Provider.
Certain confidential information contained in this document, marked by [**], has been omitted because American Well Corporation has determined that the information (i) is not material and (ii) is the type that American Well Corporation customarily and actually treats as private or confidential.
Wisconsin Provider Agreement PCS © 2022 July - Blue Cross Blue Shield of Wisconsin AHP 1587 –Rev. Jan 2022 Enterprise Multi-StateProvider Agreement © 2022 - AnthemInsurance Companies, Inc. NY Only(07/15/2019), DOH ID# 1291 11/09/2022 | 201 | 1841672798 #1350526454 |