State Sponsored Programs
Medi-Cal Managed Care Program
PARTICIPATING PHYSICIAN GROUP AGREEMENT
This AGREEMENT is entered into by and between BLUE CROSS OF CALIFORNIA dba ANTHEM BLUE
CROSS and Affiliates ("BLUE CROSS") and ______________________________ (”CENTER").
CENTER Tax I.D.: ___________________
CENTER and BLUE CROSS hereby agree as follows:
I.
CENTER is a federally qualified health center and a nonprofit public benefit corporation that is
organized under the laws of the State of California, which employs and contracts with
physicians. CENTER hereby agrees to abide by all terms and conditions of the BLUE CROSS' MediCal Managed Care Program (MCMCP) PARTICIPATING PHYSICIAN AGREEMENT (the “MCMCP
Participating Physician Agreement”) attached hereto and incorporated herein by this reference that are
applicable to CENTER and its physicians pursuant to the terms thereto, and subject to the terms of this
Agreement. CENTER further agrees that every physician within CENTER will, individually, abide by
the terms of the MCMCP PARTICIPATING PHYSICIAN AGREEMENT. CENTER further agrees to
notify BLUE CROSS in writing of the deletion of any physician from CENTER within one hundred and
twenty (120) working days prior to deletion. CENTER further agrees to provide a completed
application for any physicians(s) added by registering each physician with CAQH UPD to enable
BLUE CROSS to consider the qualifications of such added physician(s) for participation in the BLUE
CROSS' MCMCP. CAQH UPD as set forth in Section 2.14 of the enclosed MCMCP Participating
Physician Agreement can be accessed through internet website at www.caqh.org. CENTER agrees to
abide by BLUE CROSS’ decision regarding a physician’s participation in the BLUE CROSS’ MCMCP.
II.
CENTER hereby agrees to enter into a separate MCMCP Participating Physician Agreement for each tax
i.d. under which CENTER receives compensation.
III.
BLUE CROSS hereby agrees to abide by all the terms of the MCMCP Participating Physician
Agreement that are applicable to BLUE CROSS with respect to Medical Services performed under the
MCMCP Participating Physician Agreement by CENTER or any physician within CENTER.
IV.
For purposes of this AGREEMENT, the word "PHYSICIAN", wherever it appears in the AGREEMENT,
will mean "CENTER" and “CENTER’s physicians” unless the context requires otherwise.
V.
The following provisions of the MCMCP Participating Physician Agreement are hereby modified as
follows:
(1) Section 2.2 is deleted in its entirety and replaced with the following: "2.2 'Benefit Agreement(s)'
means the 'Member Services Guide/Evidence of Coverage', which describes and explains the health care
benefits that BLUE CROSS provides, indemnifies, or administers for Members, or administers pursuant
to [MCMCP][a Government Contract]."
(2) Section 2.6 is deleted in its entirety and replaced with the following: "2.6 'Medical Necessary' refers to
the definition set forth in the applicable Benefit Agreement, Government Contract or MCMCP."
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(3) Section 2.8 is deleted in its entirety and replaced with the following: "2.8 'Member(s)' means 'Eligible
Beneficiaries', as defined in the contract between BLUE CROSS and the State Department of Health
Services, who have enrolled in the MCMP."
(4) A new Section 2.16 is added after Section 2.15, as follows: "2.16 'Government Contract' means a
contract between BLUE CROSS and a governmental authority or government authorized entity for BLUE
CROSS to provide health benefits coverage under the MCMCP."
(5) Section 3.7 is deleted in its entirety.
(6) Section 3.8 is deleted in its entirety.
(7) Section 4.1 is deleted in its entirety and replaced with the following: "4.1 PHYSICIAN shall provide
to Members Medical Services which are Medically Necessary and which are in accordance with the
applicable Benefit Agreement and this Agreement. PHYSICIAN agrees to render such services within
the scope of PHYSICIAN’s license (including its scope of project as a (federally qualified health
center)(rural health center)) and its physicians’ licensure and qualifications, in accordance with all Federal
and State law and requirements, and in a manner consistent with accepted standards of medical practice.
Member-specific benefit information can be obtained by logging on to BLUE CROSS’ web site at
provideraccess.bluecrossca.com or by calling BLUE CROSS customer service. "
(8) Section 4.2 is deleted in its entirety and replaced with the following: "4.2 PHYSICIAN shall, to the
extent possible, seek, accept and maintain evidence of assignment of benefits for the payment of Medical
Services provided to Members by PHYSICIAN under the applicable Benefit Agreement, Government
Contract or MCMCP."
(9) Section 4.3 is deleted in its entirety and replaced with the following: "4.3 PHYSICIAN agrees to
admit or arrange for admission of Members only to Participating MCMCP Hospitals except in case of
Emergency services, when Member self-referral is permitted, as permitted in the Provider Operations
Manual regarding utilization management, or agreed to in writing by BLUE CROSS. In case of an
Emergency, as that term is defined in this Agreement, PHYSICIAN agrees to use a Participating MCMCP
Hospital whenever possible. Other exceptions to the use of Participating MCMCP Hospitals shall be
approved pursuant to the provisions of Section 7."
(10) Section 4.4 is deleted in its entirety and replaced with the following: "4.4 PHYSICIAN agrees to
refer Members to other Participating MCMCP Providers and not to non-Participating MCMCP Providers
except in case of Emergency services, when Member self-referral is permitted, as permitted in the
Provider Operations Manual regarding utilization management, or agreed to in writing by BLUE
CROSS."
(11) [Section 4.5(2) is deleted in its entirety.][COMPARE DUTY WITH PROVIDER MANUAL]
(12) Section 4.5(3) is deleted in its entirety and replaced with the following: "(3) That unless BLUE
CROSS explicitly agrees otherwise, he or she is a Participating MCMCP Provider at all locations and
under all tax i.d. numbers and/or NPI numbers provided by PHYSICIAN to BLUE CROSS. Furthermore,
PHYSICIAN agrees to notify BLUE CROSS in writing of each separate tax i.d. number and/or NPI
numbers under which PHYSICIAN receives compensation."
(13) Section 4.6 is modified by adding the phrase "Section 7" immediately before ".5" in the last line of
the Section.
(14) Section 4.10 is modified with the addition of the following at the end of the Section: "BLUE CROSS
shall provide PHYSICIAN with a copy of the formulary prior to the execution of this Agreement and
shall promptly notify PHYSICIAN of any planned changes to the formulary prior to the effective dates of
such changes."
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(15) Section 4.17 is modified with the addition of the following at the end of the Section:
"Notwithstanding the foregoing, PHYSICIAN and BLUE CROSS acknowledge PHYSICIAN’s patient
obligations under Federal and State law and PHYSICIAN’s scope of project as a [federally qualified
health center][rural health clinic], and in case of conflict between this Section 4.17 and PHYSICIAN’s
other patient obligations, the parties shall cooperate in resolving such conflict and/or agreeing to a carveout.
(16) Section 5.7 is deleted in its entirety and replaced with the following: "5.7 Notwithstanding any other
provision herein to the contrary, BLUE CROSS agrees to give PHYSICIAN at least ninety (90) business
days prior notice of any change by BLUE CROSS of a material term of this Agreement (except for any
change necessary to comply with state or federal law or regulations whereby a shorter timeframe for
compliance is required, in which case a shorter notice period is permitted).
If PHYSICIAN desires to negotiate the change (except for any change necessary to comply with state or
federal law or regulations), PHYSICIAN shall notify BLUE CROSS in writing within thirty (30) business
days after receipt of BLUE CROSS’ notice. If (a) PHYSICIAN does so notify BLUE CROSS and the
parties are unable to agree to such change or (b) PHYSICIAN does not exercise his/her right to negotiate
the change, PHYSICIAN may provide BLUE CROSS with written notice that it desires to terminate this
Agreement within ninety (90) business days after receipt of BLUE CROSS’ notice. PHYSICIAN agrees
that BLUE CROSS may withdraw its notice of change at least 25 calendar days prior to the effective date
of the change thereby canceling PHYSICIAN’s election to terminate this Agreement. If PHYSICIAN
provides BLUE CROSS with a written termination notice pursuant to this paragraph and BLUE CROSS
does not so withdraw its notice of change, this Agreement shall terminate as of the effective date of such
change, notwithstanding the provisions of Section XII of this Agreement. If PHYSICIAN does not so
elect to terminate this Agreement, PHYSICIAN shall be subject to the change ninety (90) business days
after the date of BLUE CROSS’ notice (except for any change necessary to comply with state or federal
law regulations whereby a shorter timeframe for compliance is required, in which case a shorter notice
period is permitted)."
(17) Sections 6.1 and 6.2 are deleted in their entirety and replaced with the following: [TBD] [CENTER
SHOULD RECONCILE WITH PAYMENT PROVISIONS OF MEDI-CAL PROGRAM, AND AS
NEGOTIATED WITH BLUE CROSS.
(18) Section 6.3 is modified with the addition of the following at the end of the Section: " BLUE CROSS
shall, upon request of PHYSICIAN, provide or make available to PHYSICIAN, when contracting or
renewing this Agreement with PHYSICIAN, the payment of fee schedule or other information sufficient
to enable PHYSICIAN to determine the manner and amount of payments under this Agreement for
PHYSICIAN’s services prior to the final execution or renewal of this Agreement."
(19) Section 6.4 is modified with the addition of the following at the end of the Section: "If PHYSICIAN
is compensated by capitation, PHYSICIAN shall submit information and data for covered Medical
Services provided to a Member within ___ days of the last day of the month in which the covered
Medical Services were provided, or such shorter period necessary for BLUE CROSS to comply with laws
or MCMCP requirements.
(20) Section 6.6 is deleted in its entirety.
(21) Section 7.4 is modified by the addition of the phrase "Section 7" immediately before ".2" in the last
line of the Section.
(22) Section 8.1 is modified by deleting the second paragraph of the Section and replacing it with the
following: " Subject to all applicable laws relating to privacy, confidentiality, and privileged documents
and communications, including federal and State laws, and HIPAA, PHYSICIAN shall only make a
Member’s information including but not limited to medical records available upon reasonable request to
Medi-Cal Participating Physician Group Agreement
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each physician or practitioner treating the Member, for Utilization Review purposes, and to BLUE
CROSS or as consented by the Member or an authorized representative of the Member."
(23) Section 9.2 is deleted in its entirety and replaced with the following: PHYSICIAN is covered by the
Federal Tort Claims Act (FTCA) which obviates the requirement that PHYSICIAN carry private
malpractice insurance for any damages to property or for personal injury or death caused by the
negligence or wrongful act or omission of employees or contractors of PHYSICIAN acting within the
scope of their employment or engagement. Nothing in this Agreement shall be interpreted to authorize or
obligate any PHYSICIAN employee or contractor to perform any act outside the scope of his/her
employment or engagement. PHYSICIAN shall not be required to acquire insurance, provide
indemnification, or guarantee that BLUE CROSS will be held harmless from liability."
(24) Section 9.3 is deleted in its entirety and replaced
evidence of such FTCA coverage to BLUE CROSS
promptly notify BLUE CROSS if, any time during
employee or contractor is no longer eligible for, or
circumstance that would jeopardize, FTCA coverage."
with the following: "PHYSICIAN shall provide
at any time upon request. PHYSICIAN shall
the term of this Agreement, any PHYSICIAN
if PHYSICIAN becomes aware of any fact or
(25) Section 11.2 is deleted in its entirety and replaced with the following:"11.2 In the event that any
problem or dispute concerning the terms of this Agreement, other than a Utilization Review decision as
provided for in Section VII, is not satisfactorily resolved, BLUE CROSS and PHYSICIAN agree to meet
and confer in good faith to seek resolution of the claim or dispute. If a party desires to initiate the
procedures under this section, the party shall give notice (a “Dispute Initiation Notice”) to the other
providing a brief description of the nature of the dispute, explaining the initiating party’s claim or position
in connection with the dispute, including relevant documentation, and naming an individual with
authority to settle the dispute on such party’s behalf. Within 20 days after receipt of a Dispute Initiation
Notice, the receiving party shall give a written reply (a “Dispute Reply”) to the initiating party providing
a brief description of the receiving Party’s position in connection with the dispute, including relevant
documentation, and naming an individual with the authority to settle the dispute on behalf of the receiving
party. The parties shall promptly make an investigation of the dispute, and commence discussions
concerning resolution of the dispute within 20 days after the date of the Dispute Reply. If a dispute has
not been resolved within 30 days after the parties have commenced discussions regarding the dispute,
either party may submit the dispute to arbitration subject to the terms and conditions herein. Such
arbitration shall be initiated by either party making a written demand for arbitration on the other party.
The arbitration will be conducted by the American Health Lawyers Association, unless otherwise
mutually agreed in writing by BLUE CROSS and PHYSICIAN. PHYSICIAN and BLUE CROSS agree
that the arbitration results shall be binding on both parties. The award of the arbitrator or panel may be
confirmed or enforced in any court having jurisdiction. Each party shall assume its own costs related to
the arbitration, including costs of subpoenas, depositions, transcripts, witness fees, and attorneys’ fees.
The compensation and expenses of the arbitrator and administrative fees or costs of the arbitration shall
be borne equally by the parties."
(26) Section 12.2 is modified by deleting the reference to "one hundred twenty (120) days" and replacing
it with "one hundred eighty (180) days."
(27) Section 12.4 is deleted in its entirety and replaced with the following: "12.4 In the event of
termination of this Agreement by either party, PHYSICIAN shall cease making any representations to
Members that PHYSICIAN is a Participating MCMCP Provider."
(28) Section 13.1 is deleted in its entirety and replaced with the following; "13.1 No assignment of the
rights, duties, or obligations of this Agreement shall be made by any party without the express written
approval of a duly authorized representative of the other party. Any attempted assignment in violation of
this provision shall be void as to party whose approval was not obtained. Notwithstanding the
aforementioned, the parties agree that any assignment or delegation of this Agreement shall be void
unless prior approval is obtained from the Department of Health Services."
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(29) Section 13.11 is deleted in its entirety.
(30) Exhibit B is deleted in its entirety and is replaced with the attached Exhibit B.
(31) [Exhibit C is deleted in its entirety and is replaced with the attached Exhibit C.]
(32) Exhibit D is modified by deleting the reference to JAMS and replacing it with the American Health
Lawyers Association.
This AGREEMENT becomes effective on _____________________.
(REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK)
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IN WITNESS WHEREOF, BLUE CROSS and PHYSICIAN GROUP have executed this AGREEMENT on the dates set
forth for the parties below.
FOR BLUE CROSS OF CALIFORNIA
______________________________
Signature
FOR CENTER
____________________________
Signature
______________________________
Name
______________________________
Title
________________________________
Date
____________________________
Name
___________________________
Title
____________________________
Tax ID Number
_____________________________
Date
When signing on behalf of a group, please attach the resolution granting
AUTHORITY TO SIGN ON BEHALF OF CENTER.
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State Sponsored Programs
MEDI-CAL MANAGED CARE PROGRAM
AUTHORIZATION
TO SIGN ON BEHALF OF CENTER
Date: ___________________
Name: __________________________________________.
Mailing Address:
___________________________________________________________
___________________________________________________________
Individual Representing Center: ___________________________________________
Title: ___________________________________________
I, the Secretary of [_________] (the “Center”), hereby certify that the individual listed above is authorized by
the Center’s Board of Directors to sign the MCMCP Participating Physician Agreement on behalf of the
Center:
Name (please print)
__________________________________
Signature
________________________________
State Sponsored Programs
MEDI-CAL MANAGED CARE PROGRAM
*PARTICIPATING GROUP INFORMATION
Please type or print neatly. Application must be complete.
Medi-Cal Participating Physician Group Agreement
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*GroupName_____________________________________________________________
QUALITY MANAGEMENT CONTACT PERSON:______________________________________________________
Name
Title
______________________________________________________________________________________________________
__
Address
City
State
Zip
County
______________________________________________________________________________________________________
__
TELEPHONE NUMBER:
GROUP TAX IDENTIFICATION NUMBER:
OFFICE MANAGER:
______________________________________________________________________________________________________
__
ADMINISTRATIVE OFFICE ADDRESS:
______________________________________________________________________________________________________
__
Address
City
State
Zip
County
______________________________________________________________________________________________________
__
TELEPHONE NUMBER:
GROUP TAX IDENTIFICATION NUMBER:
OFFICE MANAGER:
______________________________________________________________________________________________________
__
PRACTICE LOCATION
#1
OFFICE STREET ADDRESS:
______________________________________________________________________________________________________
__
Address
City
State
Zip
County
______________________________________________________________________________________________________
__
TELEPHONE NUMBER:
GROUP TAX IDENTIFICATION NUMBER:
OFFICE MANAGER:
______________________________________________________________________________________________________
__
PRACTICE LOCATION
#2
OFFICE STREET ADDRESS:
______________________________________________________________________________________________________
__
Address
City
State
Zip
County
______________________________________________________________________________________________________
__
TELEPHONE NUMBER:
GROUP TAX IDENTIFICATION NUMBER:
OFFICE MANAGER:
______________________________________________________________________________________________________
__
BILLING ADDRESS:
________________________________________________________________________________________________________
Address
City
State
Zip
County
______________________________________________________________________________________________________
__
TELEPHONE NUMBER:
GROUP TAX IDENTIFICATION NUMBER:
OFFICE MANAGER:
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*PLEASE SUBMIT A CURRENT ROSTER OF MEDI-CAL PHYSICIANS PARTICIPATING WITHIN
THE GROUP.
Medi-Cal Participating Physician Group Agreement
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EXHIBIT B
PHYSICIAN REIMBURSEMENT
Medi-Cal
SAMPLE ALTERNATIVE
1. The compensation rates set forth in this Exhibit apply for Benefit Agreements under MCMCP.
Compensation shall be subject to and in accordance with the terms and conditions of the Agreement,
including this Exhibit.
2. Compensation. Fee for service compensation for covered Medical Services provided to Members
shall be the lesser of the (a) actual fees or charges of PHYSICIAN, (b) any applicable State, federal or
other mandated fee schedule, or (c) the then current Medi-Cal fee schedule of BLUE CROSS, which
provides the following:
i. Primary Care Services:
100 percent of BLUE CROSS’ Medi-Cal physician rate schedule, based on the MCMCP physician
fee schedule on the date the covered Medical Services are rendered, as adjusted in this Exhibit.
ii. Specialty Physician Services:
100 percent of BLUE CROSS’ Medi-Cal physician rate schedule, based on the MCMCP physician
fee schedule on the date the covered Medical Services are rendered, as adjusted in this Exhibit.
3. Payment of compensation is subject to coordination of benefits and subrogation activities and
adjustments.
4. BLUE CROSS shall process claims and pay or deny a Clean Claim [NEED TO BE DEFINED IN
AGREEMENT] within 30 days of its receipt of the Clean Claim. The date of receipt of a Clean Claim
shall be the date BLUE CROSS receives the Clean Claim electronically, or for paper claims as
indicated by BLUE CROSS’ date stamp on the Clean Claim. The date of payment shall be the date of
the electronic funds transfer, check or other form of payment.
5. BLUE CROSS may automatically update BLUE CROSS’ Medi-Cal rate schedules without notice to
PHYSICIAN or amendment to the Agreement to include successor code numbers for the same
services or delete retired codes, as such are revised or implemented by the Department. Upon request
of PHYSICIAN, BLUE CROSS will provide to PHYSICIAN BLUE CROSS’ applicable Medi-Cal
rate schedules with then current codes no more frequently than annually. BLUE CROSS will include
in BLUE CROSS’ Medi-Cal rate schedules those covered Medical Services and corresponding rates
that are not included in the MCMCP rate schedule.
6. BLUE CROSS will implement and prospectively apply changes to BLUE CROSS’ Medi-Cal rate
schedules based on the Department’s MCMCP rate changes (a) on the MCMCP effective date, if the
Department publishes the rate change at least 45 days prior to the MCMCP effective date, or (b) no
more than 45 days after the date the Department publishes the rate change, if the publication date is
less than 45 days before or after the MCMCP effective date. BLUE CROSS will not retrospectively
apply increases or decreases to BLUE CROSS’ Medi-Cal rate schedule.
ADD LANGUAGE RE MEDI-CAL RECONCILIATION
CONSIDER ADDING INCENTIVE COMPENSATION PROGRAM
Medi-Cal Participating Physician Group Agreement
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EXHIBIT C
UTILIZATION REVIEW PROCEDURES
[IF CHANGES ARE TO BE MADE.]
Medi-Cal Participating Physician Group Agreement
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CPCA/1067675/14711147v.1
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