Common use of Network Access Services Clause in Contracts

Network Access Services. (A) Aetna shall provide Plan Participants with access to Aetna's network hospitals, physicians and other health care providers ("Network Providers") who have agreed to provide services at agreed upon rates and who are participating in the applicable Aetna network covering the Plan Participants. (B) Contracted rates with Network Providers may be based on fee-for-service rates, case rates, per diems and in some circumstances, include performance-based contract arrangements, risk-adjustment mechanisms, quality incentives, pay-for-performance and other incentive and adjustment mechanisms. These mechanisms may include payments to physicians, physician groups, health systems and other provider organizations, including but not limited to organizations that may refer to themselves as accountable care organizations and patient-centered medical homes, in the form of periodic payments and incentive arrangements based on performance. Such payments may be more specifically described in an addendum to the Agreement. The details of such payment arrangements are available upon request. Retroactive adjustments are occasionally made to Aetna’s contract rates. Retroactive adjustments may occur, for example, when the federal government does not issue cost of living data in sufficient time for an adjustment to be made on a timely basis, or because contract negotiations were not completed by the end of the prior price period or due to contract dispute settlements. In all cases, Aetna shall adjust the Customer’s payments accordingly. The Customer’s liability for all such adjustments shall survive the termination of the Agreement. (C) Aetna may contract with vendors who in turn are responsible for contracting with the providers who perform the health care services, and potentially for certain other services related to those providers such as claims processing, credentialing, and utilization management. Under some of these arrangements, the (D) Aetna reserves the right to set a minimum plan benefit design structure for in-area network claims to which the Customer must comply in order to access a particular Aetna network. (E) Aetna shall maintain an online directory containing information regarding Network Providers. Upon request and for an additional charge, Aetna shall provide the Customer with paper copies of physician directories. (F) Aetna makes no guarantee and disclaims any obligation to make any specific health care providers or any particular number of health care providers available for use by Plan Participants or that any level of discounts or savings will be afforded to or realized by the Customer, the Plan or Plan Participants. (G) ▇▇▇▇▇▇ Health and Affiliates, the dominant health system in much of northern California, uses its bargaining power to insist on unique requirements to participate in the Aetna network. Aetna’s contract with Sutter requires payment of claims that might otherwise be denied, such as those not medically necessary or experimental or investigational (but does not require payment for services the Plan expressly excludes from coverage, such as for cosmetic surgery). Aetna will charge the Plan for these claims in order to be able to continue providing Plan Participants with access to ▇▇▇▇▇▇’▇ services on an in-network basis. Consult your SPD text to ensure that the description of ▇▇▇▇▇’s services accommodates such arrangements. ▇▇▇▇▇▇ also requires that the Customer agree to be bound by the terms of ▇▇▇▇▇’s contract with ▇▇▇▇▇▇, including, but not limited to, the dispute resolution and binding arbitration provisions. The Customer agrees to be bound by the terms of the ▇▇▇▇▇▇ contract, including future amendments. The Customer may request a copy of the ▇▇▇▇▇▇ contract for its own use, upon completion of a confidentiality agreement. If a copy is furnished to the Customer, the Customer will hold the terms of the ▇▇▇▇▇▇ agreement in strict confidence in accordance with its confidentiality provisions. The Customer must sign an attestation letter agreeing to these conditions; otherwise ▇▇▇▇▇▇ providers will be excluded from the Customer’s network.

Network Access Services. (A) A. Aetna shall provide Plan Participants Members with access to Aetna Signature Administrators Network, Aetna's network hospitals, physicians and other health care providers ("Network Providers") who have agreed to provide services at agreed upon rates and who are participating in the Plan covering the Members. Aetna shall also make available to Members the same credentialing of Network Providers and quality assurance services carried out by the applicable Aetna network covering affiliate. B. When a claim is submitted for services incurred after the Effective Date, covered by the Plan, and performed by a Network Provider, Aetna will permit access on behalf of Customer for those services in an amount determined in accordance with the Aetna contract with the Network Provider (“Contract Rates”) and the Plan Participants. (B) Contracted rates with benefits. Network Providers may be based are also compensated on fee-for-service the basis of case rates and per diems. Upon receipt of claims from Participating Providers, TPA will submit the claims to Aetna for application of Contract Rates. TPA will apply the applicable Contract Rates and pay these Participating Providers at the Contract Rates. TPA shall apply no other rates, case rates, per diems and in some circumstances, include performancereductions or administrative fees other than Contract Rates to claims from Participating Providers for in-based contract arrangements, risk-adjustment mechanisms, quality incentives, pay-for-performance and other incentive and adjustment mechanisms. These mechanisms may include payments to physicians, physician groups, health systems and other provider organizations, including but not limited to organizations that may refer to themselves as accountable care organizations and patient-centered medical homes, in the form of periodic payments and incentive arrangements based on performance. Such payments may be more specifically described in an addendum to the Agreement. The details of such payment arrangements are available upon requestnetwork services under Customer’s plan. Retroactive adjustments are occasionally made to Aetna’s contract rates. Retroactive adjustments may occurrates (e.g., for example, when because the federal government does not issue cost of living data in sufficient time for an adjustment to be made on a timely basis, basis or because contract negotiations were not completed by the end of the prior price period or due to contract dispute settlementsperiod). In all cases, Aetna shall direct TPA to adjust the Customer’s 's payments accordingly. The Customer’s 's liability for all such adjustments shall survive the termination of the this Services Agreement. (C) Aetna C. Customer specifically understands that certain participation agreements with Participating Providers may contract with vendors who in turn are responsible for contracting with the providers who perform the health care services, and potentially for certain other services related to those providers such as claims processing, credentialing, and utilization management. Under some of these arrangements, the (D) Aetna reserves the right to set be negotiated on a minimum plan benefit design structure for in-area network claims to which the Customer must comply in order to access a particular Aetna network. (E) Aetna shall maintain an online directory containing information regarding Network Providers. Upon request and for an additional charge, Aetna shall provide the Customer with paper copies of physician directories. (F) Aetna makes no guarantee and disclaims any obligation to make any specific health care providers or any particular number of health care providers available for use case by Plan Participants or that any level of discounts or savings will be afforded to or realized by the Customer, the Plan or Plan Participants. (G) ▇▇▇▇▇▇ Health and Affiliates, the dominant health system in much of northern California, uses its bargaining power to insist on unique requirements to participate in the Aetna network. Aetna’s contract with Sutter requires payment of claims that might otherwise be denied, such as those not medically necessary or experimental or investigational (but does not require payment for services the Plan expressly excludes from coverage, such as for cosmetic surgery). Aetna will charge the Plan for these claims in order to be able to continue providing Plan Participants with access to ▇▇▇▇▇▇’▇ services on an in-network case basis. Consult your SPD text Therefore, Customer shall and shall require TPA to ensure that the description of ▇▇▇▇▇’s services accommodates such arrangements. ▇▇▇▇▇▇ also requires that the Customer agree to be bound by comply with the terms of ▇▇▇▇▇Aetna’s contract general Participating Provider agreements, as well as with ▇▇▇▇▇▇, the terms of specific Participating Provider agreements (including, but not limited to, the dispute resolution those terms related to retrospective audits, arbitration, and binding arbitration provisionsprecertification requirements). The Customer agrees understands that Contract Rates may include value based contracting terms, risk share components and/or other similar arrangements that may, from time to be bound by time, result in additional payments to Participating Providers in accordance with the terms of the ▇▇▇▇▇▇ contracttheir network participation agreements. Customer understands that, including future amendments. The Customer may request a copy of the ▇▇▇▇▇▇ contract among other things, failure to comply with such requirements and/or failure to adjudicate and pay Clean Claims within fifteen (15) days for its own use, upon completion of a confidentiality agreement. If a copy is furnished to the Customer, the Customer will hold the terms of the ▇▇▇▇▇▇ agreement in strict confidence in accordance with its confidentiality provisions. The Customer must sign an attestation letter agreeing to these conditions; otherwise ▇▇▇▇▇▇ providers will be excluded from the Customer’s network.electronic claims and thirty

Network Access Services. (A) Aetna shall provide Plan Participants with access to Aetna's network hospitals, physicians and other health care providers ("Network Providers") who have agreed to provide services at agreed upon rates and who are participating in the applicable Aetna network covering the Plan Participants. (B) Contracted rates with Network Providers may be based on fee-for-service rates, case rates, per diems and in some circumstances, include performance-based contract arrangements, risk-adjustment mechanisms, quality incentives, pay-for-performance and other incentive and adjustment mechanisms. These mechanisms may include payments to physicians, physician groups, health systems and other provider organizations, including but not limited to organizations that may refer to themselves as accountable care organizations and patient-centered medical homes, in the form of periodic payments and incentive arrangements based on performance. Such payments may be more specifically described in an addendum to the Agreement. The details of such payment arrangements are available upon request. Retroactive adjustments are occasionally made to Aetna’s contract rates. Retroactive adjustments may occur, for example, when the federal government does not issue cost of living data in sufficient time for an adjustment to be made on a timely basis, or because contract negotiations were not completed by the end of the prior price period or due to contract dispute settlements. In all cases, Aetna shall adjust the Customer’s payments accordingly. The Customer’s liability for all such adjustments shall survive the termination of the Agreement. (C) Aetna may contract with vendors who in turn are responsible for contracting with the providers who perform the health care services, and potentially for certain other services related to those providers such as claims processing, credentialing, and utilization management. Under some of these arrangements, thethe vendor bills Aetna directly for those services by its network of providers at the vendor’s contracted rate with Aetna, and Aetna pays the vendor for those services. In certain cases, the amount billed by the vendor to Aetna, paid pursuant to the plan, includes an administrative fee for delegated services by the vendor. As a result, the amount the vendor pays to the health care provider through the vendor’s contract with the provider may be different than the amount paid pursuant to the Plan because the allowed amount under the Plan will be Aetna’s contracted rate with the vendor, and not the contracted amount between the vendor and the health care provider. (D) Aetna reserves the right to set a minimum plan benefit design structure for in-area network claims to which the Customer must comply in order to access a particular Aetna network. (E) Aetna shall maintain an online directory containing information regarding Network Providers. Upon request and for an additional charge, Aetna shall provide the Customer with paper copies of physician directories. (F) Aetna makes no guarantee and disclaims any obligation to make any specific health care providers or any particular number of health care providers available for use by Plan Participants or that any level of discounts or savings will be afforded to or realized by the Customer, the Plan or Plan Participants. (G) ▇▇▇▇▇▇ Health and Affiliates, the dominant health system in much of northern California, uses its bargaining power to insist on unique requirements to participate in the Aetna network. Aetna’s contract with Sutter requires payment of claims that might otherwise be denied, such as those not medically necessary or experimental or investigational (but does not require payment for services the Plan expressly excludes from coverage, such as for cosmetic surgery). Aetna will charge the Plan for these claims in order to be able to continue providing Plan Participants with access to ▇▇▇▇▇▇’▇ services on an in-network basis. Consult your SPD text to ensure that the description of ▇▇▇▇▇Aetna’s services accommodates such arrangements. ▇▇▇▇▇▇ Sutter also requires that the Customer agree to be bound by the terms of ▇▇▇▇▇Aetna’s contract with ▇▇▇▇▇▇Sutter, including, but not limited to, the dispute resolution and binding arbitration provisions. The Customer agrees to be bound by the terms of the ▇▇▇▇▇▇ Sutter contract, including future amendments. The Customer may request a copy of the ▇▇▇▇▇▇ Sutter contract for its own use, upon completion of a confidentiality agreement. If a copy is furnished to the Customer, the Customer will hold the terms of the ▇▇▇▇▇▇ Sutter agreement in strict confidence in accordance with its confidentiality provisions. The Customer must sign an attestation letter agreeing to these conditions; otherwise ▇▇▇▇▇▇ Sutter providers will be excluded from the Customer’s network.