Common use of Qualification Standards Clause in Contracts

Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain all of the following Qualification Standards at each primary and branch site: • Provider must provide physical therapy services, and may also provide occupational therapy and/or speech and language pathology services; • Provider has current Medicare certification as a rehabilitation agency for outpatient physical therapy services, or current Medicare participation as a comprehensive outpatient rehabilitation facility (CORF), and can demonstrate it provides services that are restorative and rehabilitative in nature; • Provider, or at least one licensed physical therapist on staff, must have membership in a local or national physical therapy professional organization; • Provider has a Michigan licensed physical therapist on site whenever physical therapy is provided, a Michigan licensed occupational therapist on site whenever occupational therapy is provided, and a Michigan licensed speech therapist on site whenever speech-language pathology therapy is performed, except as may be otherwise permitted in BCBSM’s published policies. If the state of Michigan has not released license applications or has not issued licenses for Speech-Language Pathologists, then a Certificate of Clinical Competence from the American Speech and Hearing Association is an acceptable alternative until the state issues licenses; • Provider has written policies and procedures that meet generally acceptable standards for outpatient physical therapy to assure the quality of patient care, and Provider demonstrates compliance with such policies and procedures; • Provider can demonstrate that it conducts program evaluation and utilization review to assess the appropriateness, adequacy and effectiveness of the program’s administrative and clinical components; • Provider’s outpatient physical therapy program has been in operation for six months prior to application to BCBSM for participation as an Outpatient Physical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • Provider meets BCBSM’s Evidence of Necessity (EON) requirements, as applicable; • Provider complies with Certificate of Need (CON) requirements of the Michigan Public Health Code, as applicable; • Provider has a governing board that is legally responsible for the total operation of the facility, and for ensuring that quality care is provided in a safe environment; • Provider has an absence of inappropriate utilization or practice patterns, as identified through valid subscriber complaints, audits and peer review; and • Provider has an absence of fraud or illegal activities. Addendum C REIMBURSEMENT METHODOLOGY For Covered Services performed that are within Provider’s scope of practice, BCBSM will pay the lesser of the billed charge or the published maximum payment level per service, less any Deductible or Copayment for which the Member is responsible. The published maximum payment is set forth in BCBSM’s Maximum Payment Schedule (“Payment Schedule”). BCBSM will make the Payment Schedule available to Providers via web-DENIS. Most of the maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) system developed by the Centers for Medicare and Medicaid Services, in which services are ranked according to the resource costs needed to provide them. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM- specific conversion factor to determine overall payment levels. Other factors that may be used in setting maximum payment levels include comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Nationally imposed changes to the nomenclature and national coding system (HCPCS) for procedural codes, and corrections of typographical errors may result in immediate modifications to the Payment Schedule without prior notice. No other modification to the Payment Schedule will become effective until after 90 days have elapsed from the date of BCBSM’s notice to Providers. Notice may be provided either in written or electronic form. Written form shall include publication in the Record or other appropriate BCBSM provider publication. Electronic notice shall include, but not be limited to, publication on web-DENIS. BCBSM will review Provider reimbursement levels periodically and may adjust them if BCBSM determines modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX MEMBER Provider may xxxx Member for:

Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain all of the following Qualification Standards at each primary and branch siteApproved Site: • Provider must provide physical therapy services At a minimum, a multidisciplinary staff consisting of a board-certified or board-eligible psychiatrist, a fully licensed psychologist, and a clinical licensed master’s social worker (CLMSW) with a master’s degree in social work;  A community governing or advisory board;  A comprehensive range of mental health services offered to the community including individual and group psychotherapy, family counseling, and psychological testing. Additional services required by patients and the community may also provide occupational therapy and/or speech and language pathology servicesbe included. Emergency services are available on a 24 hour basis through program staff or referral to other appropriate community agencies; • Provider has  Proof of current Medicare certification as a rehabilitation agency for outpatient physical therapy serviceslicensure, registration, or current Medicare participation as a comprehensive outpatient rehabilitation facility (CORF), and can demonstrate it provides services that are restorative and rehabilitative in naturecertification at all times of Professional Providers on staff; • Provider, or  Accreditation by at least one licensed physical therapist national accreditation organization approved by BCBSM, such as, but not limited to the following:  The Joint Commission (TJC),  Council on staffAccreditation of Services for Families and Children (COA), must have membership  Commission on Accreditation of Rehabilitation Facilities (CARF), or  American Osteopathic Association (AOA);  Significant involvement by a psychiatrist on staff to assure that the psychiatrist assumes overall responsibility for coordinating the care of all patients. Significant involvement by a psychiatrist in a local or national physical therapy professional organization; • Provider has a Michigan licensed physical therapist on site whenever physical therapy an Outpatient Psychiatric Care facility includes, but is providednot limited to: approval of the initial evaluation, a Michigan licensed occupational therapist on site whenever occupational therapy is providedcertification of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatment, and a Michigan licensed speech therapist on site whenever speech-language pathology therapy is performed, except as may be otherwise permitted in BCBSM’s published policies. If the state of Michigan has not released license applications or has not issued licenses approval for Speech-Language Pathologists, then a Certificate of Clinical Competence from the American Speech and Hearing Association is an acceptable alternative until the state issues licenses; • Provider has written policies and procedures that meet generally acceptable standards for outpatient physical therapy to assure the quality of patient care, and Provider demonstrates compliance with such policies and procedures; • Provider can demonstrate that it conducts program evaluation and utilization review to assess the appropriateness, adequacy and effectiveness of the program’s administrative and clinical components; • Provider’s outpatient physical therapy program has been in operation for six months psychological testing prior to application to BCBSM administration;  Michigan licensure for participation as an psychiatric partial hospitalization for Outpatient Physical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • Provider meets BCBSM’s Evidence of Necessity (EON) requirementsPsychiatric Care facilities providing psychiatric day treatment, as applicable; • Provider complies with Certificate of Need (CON) requirements of the Michigan Public Health Code, as applicable; • Provider has a governing board that is legally responsible for the total operation of the facility, and for ensuring that quality care is provided in a safe environment; • Provider has an absence  Absence of inappropriate utilization or practice patterns, practices as identified through valid proven subscriber complaints, audits audits, and peer review; and • Provider has an absence , and,  Absence of fraud or and illegal activities. Addendum C REIMBURSEMENT METHODOLOGY For each Covered Services performed that are within Provider’s scope of practiceService performed, BCBSM will pay Provider the lesser of the billed charge charges or the published maximum payment level per service, less any Deductible or Copayment for which the Member is responsible. The published maximum payment is set forth in BCBSM’s Maximum Payment 's published Outpatient Psychiatric Care Rate Schedule (“Payment Rate Schedule”). BCBSM will make the Payment Schedule available to Providers via web-DENIS. Most of the maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) system developed by the Centers for Medicare and Medicaid ServicesServices (CMS), in which services are ranked according to is a schedule of relative procedure values that reflect the resource costs needed cost required to provide themperform each service. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insuranceinsurance costs. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM- BCBSM-specific conversion factor to determine overall payment levels. For procedure codes that have no CMS derived RBRVS value, BCBSM’s maximum payment level may be based on BCBSM’s medical consultants’ determination. Other factors that may be used in setting maximum payment levels include include, but are not limited to, comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Nationally imposed changes to Additionally, the nomenclature and national coding system (HCPCS) maximum payment levels indicated on the Rate Schedule for procedural codeseach type of Professional Provider may vary, and corrections commensurate with the rendering provider’s level of typographical errors may result in immediate modifications to the Payment Schedule without prior notice. No other modification to the Payment Schedule will become effective until after 90 days have elapsed from the date of BCBSM’s notice to Providers. Notice may be provided either in written or electronic form. Written form shall include publication in the Record or other appropriate BCBSM provider publication. Electronic notice shall include, but not be limited to, publication on web-DENISlicensure. BCBSM will periodically review Provider Outpatient Psychiatric Care facility reimbursement levels periodically and may adjust them to determine if BCBSM determines modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX MEMBER Provider may xxxx Member for:

Qualification Standards. In order CRNA must meet and continue to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain meet all of the following Qualification Standards at each primary and branch sitequalifications in order to be eligible for participation pursuant to this agreement: • Provider must provide physical therapy services, and may also provide occupational therapy and/or speech and language pathology servicesCurrent Michigan Licensure as a Registered Nurse (RN); • Provider has current Medicare with specialty certification as a rehabilitation agency for outpatient physical therapy services, Nurse Anesthetist issued by the Michigan Board of Nursing. • Current certification from the Council on Certification of Nurse Anesthetists; or current Medicare participation as a comprehensive outpatient rehabilitation facility (CORF), and can demonstrate it provides services that are restorative and rehabilitative in nature; • Provider, or at least one licensed physical therapist on staff, must have membership in a local or national physical therapy professional organization; • Provider has a Michigan licensed physical therapist on site whenever physical therapy is provided, a Michigan licensed occupational therapist on site whenever occupational therapy is provided, and a Michigan licensed speech therapist on site whenever speech-language pathology therapy is performed, except as may be otherwise permitted in BCBSM’s published policies. If the state of Michigan has not released license applications or has not issued licenses for Speech-Language Pathologists, then a Certificate of Clinical Competence certification from the American Speech and Hearing Association is an acceptable alternative until the state issues licenses; Council on Recertification of Nurse Anesthetists. • Provider has written policies and procedures that meet generally acceptable standards for outpatient physical therapy to assure the quality of patient care, and Provider demonstrates compliance with such policies and procedures; • Provider can demonstrate that it conducts program evaluation and utilization review to assess the appropriateness, adequacy and effectiveness of the program’s administrative and clinical components; • Provider’s outpatient physical therapy program has been in operation for six months prior to application to BCBSM for participation as an Outpatient Physical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • Provider meets BCBSM’s Evidence of Necessity (EON) requirements, as applicable; • Provider complies with Certificate of Need (CON) requirements of the Michigan Public Health Code, as applicable; • Provider has a governing board that is legally responsible for the total operation of the facility, and for ensuring that quality care is provided in a safe environment; • Provider has an absence Absence of inappropriate utilization or practice patternspatterns as defined by established practice protocols, as that are identified through valid proven subscriber or professional peer complaints, audits and peer review; , and utilization management. • Provider has an absence Absence of fraud or and illegal activities. Addendum C activities REIMBURSEMENT METHODOLOGY For Covered Services performed that are within Provider’s scope of practiceServices, BCBSM will pay the lesser of the billed charge charges or the published maximum payment level per servicefee (Fee), less any Deductible or Copayment for which the Member is responsiblecopayments and deductibles. The published maximum payment anesthesia formula is set forth in BCBSM’s Maximum Payment Schedule (“Payment Schedule”). BCBSM will make the Payment Schedule available to Providers via web-DENIS. Most sum of the maximum payment levels are time reported (in 15-minute increments) plus the Anesthesia Base Units (ABUs) multiplied by the BCBSM regional conversion factor. A percentage (Percentage) based on the Resource Based Relative Value Scale reported modifier is then applied to the formula. The Percentage is 40% when the service is performed under the medical direction of a Physician who is responsible for anesthesia services and who is not the operating surgeon, and 85% when the service is performed without medical direction of a Physician who is responsible for anesthesia services and who is not the operating surgeon. The resulting Fee is then compared to CRNA’s charge and then copayments and/or deductibles are applied, as indicated below: The Fee = (RBRVS# time units + ABUs) system developed by x BCBSM regional conversion factor x Percentage (i.e., 40% or 85%) CRNA’s payment = the Centers lesser of the Fee or CRNA’s charge, less copayments and deductibles. ABUs are obtained from the Center for Medicare and Medicaid ServicesServices (CMS), in which services are ranked according however, BCBSM retains the option to the resource costs needed to provide themmodify them at its discretion. The resource costs of anesthesia formula, the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM- specific BCBSM regional conversion factor to determine overall payment levels. Other factors that may be used in setting maximum payment levels include comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Nationally imposed changes to the nomenclature and national coding system (HCPCS) for procedural codesfactors, and corrections the number of typographical errors may result in immediate modifications to the Payment Schedule without prior notice. No other modification to the Payment Schedule ABUs associated with each anesthesia procedure code will become effective until after 90 days have elapsed from the date of BCBSM’s notice to Providers. Notice may be provided either in written or electronic form. Written form shall include publication published in the Record or other appropriate BCBSM provider publication. Electronic notice shall include, but not be limited to, publication on web-DENISMaximum Payment Schedule. BCBSM will review Provider the reimbursement levels periodically and may adjust them to determine if BCBSM determines modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX MEMBER Provider may xxxx Member for:Modifications to ABUs, procedure codes, and nationally imposed changes to the nomenclature and national coding system for procedure codes which result in changes to the Fee will become effective upon notice to CRNA. All other modifications to the Fee or to BCBSM’s reimbursement methodology will become effective 90 days from the date of notice by BCBSM to CRNA. Any required notice of reimbursement changes may, at BCBSM’s discretion, be published in the appropriate BCBSM publication (e.g., The Rec o rd ).

Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain all of the following Qualification Standards at each primary and branch site: • Provider has a current participation agreement with BCBSM as a Traditional Outpatient Physical Therapy facility; • Provider must provide physical therapy services, and may also provide occupational therapy and/or speech and language pathology services; • Provider has current Medicare certification as a rehabilitation agency for outpatient physical therapy services, or current Medicare participation as a comprehensive outpatient rehabilitation facility (CORF), and can demonstrate it provides services that are restorative and rehabilitative in nature; • Provider, or at least one licensed physical therapist on staff, must have membership in a local or national physical therapy professional organization; • Provider has a Michigan licensed physical therapist on site whenever physical therapy is provided, a Michigan licensed occupational therapist on site whenever occupational therapy is provided, and a Michigan licensed speech therapist on site whenever speech-language pathology therapy is performed, except as may be otherwise permitted in BCBSM’s published policies. If the state of Michigan has not released license applications or has not issued licenses for Speech-Language Pathologists, then a Certificate of Clinical Competence from the American Speech and Hearing Association is an acceptable alternative until the state issues licenses; • Provider has written policies and procedures that meet generally acceptable standards for outpatient physical therapy to assure the quality of patient care, and Provider demonstrates compliance with such policies and procedures; • Provider can demonstrate that it conducts program evaluation and utilization review to assess the appropriateness, adequacy and effectiveness of the program’s administrative and clinical components; • Provider’s outpatient physical therapy program has been in operation for six months prior to application to BCBSM for participation as an Outpatient Physical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • Provider meets BCBSM’s Evidence of Necessity (EON) requirements, as applicable; • Provider complies with Certificate of Need (CON) requirements of the Michigan Public Health Code, as applicable; • Provider has a governing board that is legally responsible for the total operation of the facility, and for ensuring that quality care is provided in a safe environment; • Provider has, at the time of initial application to and affiliation in the TRUST OPT Facility Network, the capacity to provide Covered Services to new patients that are Members and to continue to provide Covered Services to existing patients that are Members. • Provider can satisfactorily demonstrate sound financial stability, as determined by BCBSM, during the last five years. • Provider can satisfactorily demonstrate, as determined by BCBSM, an ability to cooperate with BCBSM, its customer groups and Members, and the general provider community. • Provider can satisfactorily demonstrate, as determined by BCBSM, that it is free of conflicts of interest relative to BCBSM, its customer groups, and Members. • Provider has an absence of inappropriate satisfactory, as determined by BCBSM, utilization history or practice patterns, as identified through BCBSM’s use management programs, valid subscriber complaints, or audits and peer review. • During the prior five year period, Provider, its officers, directors, owners and all those with significant authority and responsibility cannot have any of the following if related to the provision of or payment for health care, or if BCBSM determines that they affect Provider’s ability to provide Covered Services to Members; exclusions from state or federal programs, convictions, guilty pleas, nolo contendere pleas, remands to diversion programs, or civil judgments or settlements of civil actions. • If Provider, its officers, directors, owners and • all those with significant authority and responsibility have a history of Medicare certification revocations, suspensions, surrenders, disciplinary limitation, probations, state or federal program exclusions, or have been subject to a Corporate Integrity Agreement or found to have been non-compliant with anti- kickback laws and regulations, then Provider has an absence of fraud will be considered for network affiliation, or illegal activitiescontinued affiliation, at BCBSM’s sole discretion. Addendum C REIMBURSEMENT METHODOLOGY For Covered Services performed that are within Provider’s scope of practice, BCBSM will pay the lesser of the billed charge or the published maximum payment level per service, less any Deductible or Copayment for which the Member is responsible. The published maximum payment is set forth in BCBSM’s Maximum Payment Schedule or Freestanding Outpatient Physical Therapy Facility Fee Schedule (“Payment Schedule”). BCBSM will make the Payment Schedule available to Providers via web-DENIS. Most of the maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) system developed by the Centers for Medicare and Medicaid Services, in which services are ranked according to the resource costs needed to provide them. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM- specific conversion factor to determine overall payment levels. Other factors that may be used in setting maximum payment levels include comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Nationally imposed changes to the nomenclature and national coding system (HCPCS) for procedural codes, and corrections of typographical errors may result in immediate modifications to the Payment Schedule without prior notice. No other modification to the Payment Schedule will become effective until after 90 days have elapsed from the date of BCBSM’s notice to Providers. Notice may be provided either in written or electronic form. Written form shall include publication in the Record or other appropriate BCBSM provider publication. Electronic notice shall include, but not be limited to, publication on web-DENIS. BCBSM will review Provider reimbursement levels periodically and may adjust them if BCBSM determines modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX BILL MEMBER Provider may xxxx bill Member for: