QUALCARE
AMENDMENT TO PROVIDER NETWORK
PARTICIPATION AGREEMENT
This AMENDMENT (the “Amendment”) amends that certain Provider Network
Participation Agreement (the “Agreement”) by and between QualCare and Group.
WHEREAS, QualCare and Group each agree to amend the Agreement in order to
conform the Agreement to changes in applicable federal and state laws, rules and regulations,
and to incorporate other administrative changes to the Agreement.
NOW, THEREFORE, in consideration of the premises and the mutual promises,
covenants and conditions herein contained and for other good and valuable consideration, the
receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows:
I.
DEFINITIONS. All defined terms not specifically defined in this Amendment shall
have the meanings set forth in the Agreement.
II.
AMENDMENTS.
A.
The second WHEREAS paragraph of the Agreement is hereby deleted in its
entirety and amended as follows:
WHEREAS, Group is a health care professional or facility that is duly licensed, certified, or
otherwise authorized to practice his/her profession in the applicable jurisdiction where Covered
Services will be furnished hereunder; and
B.
Article 1 of the Agreement is hereby amended to include the following:
"Adverse Benefit Determination" means a denial, reduction or termination of, or a failure to
make payment (in whole or in part) for, a benefit, including a denial, reduction or termination of,
or a failure to provide or make payment (in whole or in part) for, a benefit resulting from
application of any utilization review, as well as a failure to cover an item or service for which
benefits are otherwise provided because the Carrier determines the item or service to be
experimental or investigational, cosmetic, dental rather than medical, excluded as a pre-existing
condition or because the Carrier has rescinded the coverage.
C.
The following definitions in Article 1 of the Agreement are hereby deleted in their
entirety and amended as follows:
“Carrier” means an insurance company authorized to transact the business of insurance in New
Jersey and doing health insurance business in accordance with N.J.S.A. 17B:17-1 et seq., a
hospital service corporation authorized to transact business in accordance with N.J.S.A. 17:48-1,
et seq., a medical service corporation authorized to transact business in accordance with N.J.S.A.
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17:48A-1, et seq., a health service corporation authorized to transact business in accordance with
N.J.S.A. 17:48E-1, et seq., or a health maintenance organization authorized to transact business
pursuant to N.J.S.A. 26:2J-1, et seq.
“Clean Claim” means the claim is for a service or supply covered by the Health Benefits Plan
that has been delivered to the proper billing address and has no defect or impropriety, including
any lack of required substantiating documentation, or particular circumstance requiring special
treatment that otherwise prevents timely payment being made on the claim. Providers shall be
entitled to reimbursement on “Clean Claims” if: (a) The health care provider is eligible at the
date of service; (b) The Member who received the health care service was covered on the date of
service; (c) The claim is for a service or supply covered under the Health Benefits Plan; (d) The
claim is submitted with all the information requested by the Payor on the claim form or in other
instructions that were distributed in advance to the health care provider or Member in
accordance with the provisions of section 4 of P.L.2005, c.352 (C.17B:30-51); and (e) The
Payor has no reason to believe that the claim has been submitted fraudulently.
“Covered Services” means, with respect to Health Benefits Plans, Medically Necessary
services or supplies provided to a Member under the applicable Health Benefits Plan for which
the Payor is obligated to pay benefits or provide services.
“Health Benefits Plan” or “Plan” means a policy or contract for the payment of benefits for
hospital and medical expenses or the provision of hospital and medical services delivered or
issued for delivery in New Jersey by an applicable Payor.
“Material Change” means any change or amendment taken by QualCare or Payor, as applicable,
that could reasonably be expected to have a material adverse impact on either the aggregate level
of reimbursement to Participating Provider or the administrative expenses incurred by
Participating Provider in complying with such change or amendment.
“Participating Hospital” means a general acute care facility licensed by the Commissioner of
Health pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), including rehabilitation, psychiatric and
long-term acute facilities, that has entered into an agreement with QualCare to provide Covered
Services to Members.
“Participating Physician” means a physician licensed pursuant to Title 45 of the New Jersey
Revised Statutes, who has entered into an agreement with QualCare to provide Covered
Services to Members, and who has privileges to admit patients to the acute care facilities of at
least one Participating Hospital, if necessary or required.
“Participating Provider” means a Participating Hospital, Participating Physician and/or
another health care provider that, under a contract with QualCare, has agreed to provide Covered
Services or supplies to Members for a predetermined fee or set of fees.
“Payor” means a Carrier, third party administrator, or self-funded plan that is contractually
obligated under the applicable Health Benefits Plan to make payment on behalf of Members
with respect to Covered Services.
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“Provider” means any physician, other health care professional, hospital, health care facility, or
any other person or entity who is licensed, certified, or otherwise authorized to provide health
care or other services within the scope of his/her/its license, certification, or authorization in the
state or jurisdiction in which the services are furnished.
“Urgently Needed Services” means services for a non-life-threatening condition that requires
care by a provider within twenty-four (24) hours.
D.
follows:
Article 3.2.1 of the Agreement is hereby deleted in its entirety and amended as
is duly licensed, certified, or authorized to practice his/her profession without restriction or
limitation within the applicable jurisdiction where Covered Services will be furnished hereunder;
and
E.
Article 3.2 of the Agreement is hereby amended to include the following new
Article 3.2.12:
has identified on the signature page all tax identification number(s) under which Participating
Provider will submit claims for Covered Services rendered on behalf of Members hereunder.
F.
follows:
Article 4.5 of the Agreement is hereby deleted in its entirety and amended as
Member Identification Cards; Verification. QualCare shall assist Payor in providing each of its
Members with an identification card that indicates his/her enrollment in Payor’s Health Benefits
Plan. This identification card shall include the QualCare logo, a description of the network to be
accessed, the applicable telephone number(s) for eligibility, benefits and UM questions, the
Payor identification number, and other information as may be required by the applicable Payor.
G.
follows:
Article 4.7 of the Agreement is hereby deleted in its entirety and amended as
No Liability for Covered Services. QualCare shall not be obligated to perform or be liable for
the performance of any Covered Services required to be performed by Participating Provider
pursuant to any Payor Agreement. QualCare shall not be liable for any payment of any claims
for furnishing Covered Services to Members, and QualCare shall not be an insurer, guarantor, or
underwriter of the responsibility or liability of any Payor to provide benefits pursuant to any
Health Benefits Plan.
H.
follows:
Article 5.11 of the Agreement is hereby deleted in its entirety and amended as
Notice of Changes. Participating Provider shall provide QualCare with at least thirty (30) days
advanced written notice, or otherwise use its/his/her best efforts to provide such written notice, in
the event of any change in the Participating Provider’s status, including without limitation
changes to Participating Provider’s tax identification number(s), and/or changes or limitations on
new patients, office hours, office locations, and scope of services.
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I.
follows:
Article 6.1 of the Agreement is hereby deleted in its entirety and amended as
Establishment. QualCare or Payor, as applicable, or its representative shall establish UM and
QM programs to review and monitor the quality, Medical Necessity, and appropriateness of
Covered Services furnished by Participating Provider on an inpatient and outpatient basis. To
the extent that QualCare is responsible for establishing UM or QM programs, QualCare shall
establish appropriate medical committees to assure effective utilization and quality of care for
Members and a multidisciplinary committee for continuous quality improvement (CQI) to
monitor the quality of the UM program. Such committees will assist QualCare in the
development, implementation, administration, and monitoring of QualCare’s UM and QM
programs, as applicable.
J.
follows:
Article 6.3.2.a of the Agreement is hereby deleted in its entirety and amended as
Adverse Benefit Determinations of the UM and QM committee may be used to deny or reduce
payment for those Covered Services provided to Members. A Member may not be billed for the
amount of any such payment that is so denied. Reimbursement will not be denied retroactively
for a Covered Service provided to a Member where Participating Provider relied upon the written
or oral Authorization of QualCare or Payor, as applicable, prior to providing services to the
Member, except in cases of misrepresentation or fraud, or in cases of Member ineligibility under
the applicable Plan.
K.
follows:
Article 6.3.2.b of the Agreement is hereby deleted in its entirety and amended as
Adverse Benefit Determinations made under the UM and QM programs are for purposes of
determining whether services are Covered Services under the terms and conditions of the
applicable Health Benefits Plan and the extent to which benefit payments will be made. Unless
otherwise expressly set forth below, Adverse Benefit Determinations shall be made as required
by the exigencies of the situation – within seventy two (72) hours of receipt of a claim for
Urgently Needed Services, within fifteen (15) days of receipt of a claim for all other nonUrgently Needed Services, such as pre-authorizations, and within thirty (30) days of receipt of a
post-service claim. Adverse Benefit Determinations shall be provided within two (2) business
days. Such Adverse Benefit Determinations shall in no way affect the responsibility of
Participating Provider to provide appropriate services to Members.
L.
Articles 6.4.1, 6.4.1.a, and 6.4.1.b of the Agreement are hereby deleted in their
entirety and amended as follows:
Participating Provider, acting on behalf of the Member with the Member’s consent, may appeal
any Adverse Benefit Determination resulting in a denial, termination, or limitation of services or
the payment of benefits therefor under the applicable internal appeal processes of Carrier.
a.
For group and individual Plans, under a stage 1 internal appeal,
Participating Provider, acting on behalf of the Member with the Member’s consent, shall have
the right to speak, regarding an Adverse Benefit Determination, with the Carrier’s medical
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director, or the medical director’s designee who rendered the Adverse Benefit Determination.
Stage 1 appeals shall be concluded as required by the exigencies of the situation – within
seventy-two (72) hours of receipt of the stage 1 appeal for any Urgently Needed Services,
Emergency services, admissions, availability of care, continued stay and health care services for
which the Member received Emergency services but has not been discharged from a facility, or
within ten (10) calendar days in the case of all other stage 1 appeals. As applicable, at the
conclusion of a stage 1 internal appeal, Carrier shall include a written explanation of the right to
a further internal or external appeal, including the applicable time limits, if any, for making the
appeal, and to whom the appeal should be addressed.
b.
For group Plans, under a stage 2 internal appeal, Participating Provider,
acting on behalf of the Member with the Member’s consent, shall have the right to pursue
his/her/its appeal before a panel of physicians and/or other providers selected by Carrier who
have not been involved in Adverse Benefit Determination at issue. Stage 2 appeals shall be
concluded as required by the exigencies of the situation – within seventy-two (72) hours of
receipt of the stage 2 appeal for any Urgently Needed Services, Emergency services, admissions,
availability of care, continued stay and health care services for which the Member received
Emergency services but has not been discharged from a facility, or within twenty (20) business
days in the case of all other stage 2 appeals. As applicable, at the conclusion of a stage 2 internal
appeal, Carrier shall include a written explanation of the right to a further external appeal,
including the applicable time limits, if any, for making the appeal, and to whom the appeal
should be addressed.
M.
follows:
Article 6.4.2 of the Agreement is hereby deleted in its entirety and amended as
External Appeals. Participating Provider acting on behalf of a Member with the Member’s
consent, may appeal a final internal Adverse Benefit Determination, except where the final
internal Adverse Benefit Determination was based on eligibility, including rescission, or the
application of a contract exclusion or limitation not related to Medical Necessity, through the
Independent Health Care Appeals Program to an independent utilization review organization
(“IURO”). Any stage 3 external appeal through the Independent Health Care Appeals Program
must be filed within four (4) months of receipt of the final internal Adverse Benefit
Determination. The external appeal request shall be filed on the forms provided in accordance
with N.J.A.C. 11:24A-3.5(k)4 and mailed to the Department of Banking and Insurance,
Consumer Protection Services, Office of Managed Care, P.O. Box 329, Trenton, New Jersey
08625-0329.
N.
follows:
Article 7.4.3 of the Agreement is hereby deleted in its entirety and amended as
An overdue payment shall bear simple interest when required by law. The Carrier shall pay
interest, to the extent required by applicable law, at the time the overdue payment is made. If
Carrier fails to make payment to Participating Provider in the manner, amount, or time provided
for pursuant to law, rule, or regulation, in accordance with the Agreement, or otherwise fails to
discharge its obligations to Participating Provider, QualCare may, in its sole discretion, use
whatever contractual remedies QualCare possesses against Carrier to remedy the defaults.
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QualCare shall exercise its remedies in the manner it determines is reasonable. QualCare has no
other obligations to Participating Provider under this Agreement with respect to any claim,
liability, damage or expense that Participating Provider may incur as a result of the failure of
Carrier to discharge its obligations under this Agreement or any agreement between QualCare
and Carrier or Payor, as applicable. In the event of such default, nothing in this Agreement shall
be construed to limit Participating Providers ability to seek from such Carrier or Payor, as
applicable, such legal remedies as may be available to Participating Provider and which
Participating Provider may deem appropriate.
O.
The first paragraph of Article 10.4 of the Agreement is hereby deleted in its
entirety and amended as follows:
Continuation of Services. Termination hereunder shall result in immediate cessation of the
Agreement on the effective date of such termination; provided, however, that (except where this
Agreement was terminated for a Serious Breach or pursuant to Article 10.2.5), Participating
Provider and QualCare shall continue to abide by the terms and conditions of the Agreement, as
may be amended from time to time, and Provider shall:
P.
Article 10.4 of the Agreement is hereby amended to include the following after
Article 10.4.5:
Except as otherwise may be required under Articles 10.4.1 through 10.4.5 above, if the
Participating Provider terminates this Agreement, the Participating Provider shall continue to
furnish Covered Services as set forth hereunder for those Members who were treated by the
Participating Provider prior to the effective date of such termination for the greater of either (a) a
period of thirty (30) days, or (b) a period of four (4) months if it is Medically Necessary for the
Member to continue his/her course of treatment with the Participating Provider.
Q.
Article 11.1 of the Agreement is hereby deleted in its entirety and the remaining
articles of Article 11 are correspondingly renumbered.
R.
Article 11.1 (previously Article 11.2), entitled Amendment, of the Agreement is
hereby deleted in its entirety and amended as follows:
Amendment. This Agreement may be amended at any time by mutual consent of the parties.
QualCare may amend this Agreement, the Provider Manual or the Payor’s or QualCare’s policies
and procedures, as applicable, upon ninety (90) days advance written notice if the amendment
results in a Material Change, or upon thirty (30) days advance written notice for all other
amendments. If an amendment results in a Material Change, Participating Provider may
terminate this Agreement only by providing QualCare with notice of its/his/her intent to
terminate this Agreement within thirty (30) days of delivery of the notice of amendment, in
which event this Agreement shall terminate on the effective date provided in the notice of
amendment. Notwithstanding the foregoing, such notice shall not be required in the event the
amendment is required due to a change in the applicable federal or state laws, rules, or
regulations.
S.
Article 11.2 (previously Article 11.3), entitled Notices, of the Agreement is
hereby deleted in its entirety and amended as follows:
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Notices. Except as otherwise expressly required under this Agreement or by applicable law,
rule, or regulation, notices or other written communications required or permitted hereunder may
be effectuated if sent by letter, facsimile, electronic mail, or other generally accepted media.
Notices required under Article 10 shall be made by either overnight mail and shall be effective
on the date of receipt or one (1) business day from such overnight mailing, whichever is earlier,
or by certified mail, return receipt requested, and shall be effective on the date of receipt or three
(3) business days from such mailing, whichever is earlier.
T.
Article 11.11.4 (previously Article 11.12.4) of the Agreement is hereby deleted in
its entirety and amended as follows:
This Article 11.11 shall survive the termination or expiration of this Agreement.
III.
GENERAL PROVISIONS.
A.
Effect of Amendment. In all other respects, all other terms, covenants, and
conditions set forth in the Agreement are hereby unmodified and shall apply in full force and
effect.
B.
Resolution of Inconsistencies. In the event of a conflict or inconsistency between
the provisions set forth in this Amendment and the Agreement, the terms, covenants, and
conditions set forth in this Amendment shall control and be binding on the parties.
C.
Governing Law. This Amendment shall be governed by and construed and
enforced in accordance with the internal laws of New Jersey without giving effect to the
principles of conflicts laws.
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