Common use of Qualification Standards Clause in Contracts

Qualification Standards. Ambulance Operators must have and maintain the following qualifications to be eligible for participation under this Agreement: Air Ambulance • A valid Federal Aviation Association (FAA) number, and • A Michigan license as a Life Support Agency for air ambulance services Ground Ambulance • A Michigan license as a Life Support Agency for ground ambulance services In addition to the above qualification(s), Ambulance Operators must have and maintain the following: • Absence of inappropriate utilization practices as identified through proven subscriber complaints, medical necessity audits and peer review. • Absence of fraud and illegal activities For Covered Services, BCBSM and BCN will pay Provider the lower of Provider’s billed charge or the BCBSM and BCN maximum payment level for ambulance services, less any applicable Member copayments and/or deductibles. The billed charge refers to the actual charge indicated on the claim form submitted by Provider. BCBSM a n d B C N will review the maximum payment levels on an annual basis and may adjust them as necessary. BCBSM a n d B C N do not warrant or guarantee that the review process will result in increased reimbursement. The appropriateness of any adjustment will be based upon a variety of factors, which may include, but are not limited to: • The inflationary index used by Medicare • The National Hospital Input Price Index (NHIPI) • Cost and access • Competitor payment levels • BCBSM and BCN participation rates • Unusual circumstances and economic factors that may unduly influence the cost of services provided by ambulance providers in Michigan (e.g., gasoline). If services are billed infrequently, performed by a limited number of providers, or incorporate new technology and medical techniques, maximum payment levels may be set by comparing them to maximum payment levels for procedures with similar complexity and risk. These payment levels may also be reviewed by professional consultants who have the technical expertise to recommend adjustments. BCBSM and BCN will give Provider not less than 90 days prior written notice of any material change to the Reimbursement Methodology. Notice may, at BCBSM’s and BCN’s discretion, be published in the appropriate BCBSM or BCN provider publication(s) e.g., The Record.

Qualification Standards. Ambulance Operators CRNA must have meet and maintain continue to meet all of the following qualifications in order to be eligible for participation under pursuant to this Agreementagreement: Air Ambulance • A valid Federal Aviation Association (FAA) number, and • A Current Michigan license Licensure as a Life Support Agency for air ambulance services Ground Ambulance • A Michigan license Registered Nurse (RN); with specialty certification as a Life Support Agency for ground ambulance services In addition to Nurse Anesthetist issued by the above qualification(s), Ambulance Operators must have and maintain Michigan Board of Nursing. • Current certification from the following: Council on Certification of Nurse Anesthetists; or current certification from the Council on Recertification of Nurse Anesthetists. • Absence of inappropriate utilization practices or practice patterns as defined by established practice protocols, that are identified through proven subscriber or professional peer complaints, medical necessity audits and peer review, and utilization management. • Absence of fraud and illegal activities For Covered Services, BCBSM and BCN will pay Provider the lower lesser of Provider’s billed charge charges or the BCBSM and BCN maximum payment level for ambulance servicesfee (Fee), less any applicable Member copayments and/or and deductibles. The billed charge refers anesthesia formula is the sum of the 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 reported modifier is then applied to the actual 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 on below: The Fee = (# time units + ABUs) x BCBSM regional conversion factor x Percentage (i.e., 40% or 85%) CRNA’s payment = the claim form submitted by Providerlesser of the Fee or CRNA’s charge, less copayments and deductibles. ABUs are obtained from the Center for Medicare and Medicaid Services (CMS), however, BCBSM retains the option to modify them at its discretion. The anesthesia formula, the BCBSM regional conversion factors, and the number of ABUs associated with each anesthesia procedure code will be published in the BCBSM Maximum Payment Schedule. BCBSM a n d B C N will review the maximum payment reimbursement levels on an annual basis and may adjust them as periodically to determine if modifications are necessary. BCBSM a n d B C N do does not warrant or guarantee that the review process will result in increased reimbursement. The appropriateness of any adjustment 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 be based become effective upon a variety of factors, which may include, but are not limited to: • The inflationary index used by Medicare • The National Hospital Input Price Index (NHIPI) • Cost and access • Competitor payment levels • BCBSM and BCN participation rates • Unusual circumstances and economic factors that may unduly influence notice to CRNA. All other modifications to the cost of services provided by ambulance providers in Michigan (e.g., gasoline). If services are billed infrequently, performed by a limited number of providers, Fee or incorporate new technology and medical techniques, maximum payment levels may be set by comparing them to maximum payment levels for procedures with similar complexity and risk. These payment levels may also be reviewed by professional consultants who have the technical expertise to recommend adjustments. BCBSM and BCN BCBSM’s reimbursement methodology will give Provider not less than become effective 90 days prior written from the date of notice by BCBSM to CRNA. Any required notice of any material change to the Reimbursement Methodology. Notice reimbursement changes may, at BCBSM’s and BCN’s discretion, be published in the appropriate BCBSM or BCN provider publication(s) publication (e.g., The RecordRec o rd ).

Qualification Standards. Ambulance Operators In order to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain all of the following qualifications 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 be eligible 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 under this Agreement: Air Ambulance as an Outpatient Physical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • A valid Federal Aviation Association Provider meets BCBSM’s Evidence of Necessity (FAAEON) numberrequirements, 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; • A Michigan license 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 a Life Support Agency for air ambulance services Ground Ambulance determined by BCBSM, during the last five years. • A Michigan license Provider can satisfactorily demonstrate, as a Life Support Agency for ground ambulance services In addition determined by BCBSM, an ability to cooperate with BCBSM, its customer groups and Members, and the above qualification(s)general provider community. • Provider can satisfactorily demonstrate, Ambulance Operators must have as determined by BCBSM, that it is free of conflicts of interest relative to BCBSM, its customer groups, and maintain the following: Members. • Absence of inappropriate Provider has satisfactory, as determined by BCBSM, utilization practices history or practice patterns, as identified through proven BCBSM’s use management programs, valid subscriber complaints, medical necessity or audits and peer review. • Absence During the prior five year period, Provider, its officers, directors, owners and all those with significant authority and responsibility cannot have any of fraud 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 illegal activities 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 will be considered for network affiliation, or continued affiliation, at BCBSM’s sole discretion. For Covered ServicesServices performed that are within Provider’s scope of practice, BCBSM and BCN will pay Provider the lower lesser of Provider’s the billed charge or the BCBSM and BCN published maximum payment level for ambulance servicesper service, less any applicable Deductible or Copayment for which the Member copayments and/or deductiblesis responsible. The billed charge refers 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. Nationally imposed changes to the actual charge indicated 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 the claim form submitted by Providerweb-DENIS. BCBSM a n d B C N will review the maximum payment reimbursement levels on an annual basis periodically and may adjust them as if BCBSM determines modifications are necessary. BCBSM a n d B C N do does not warrant or guarantee that the review process will result in increased reimbursement. The appropriateness of any adjustment will be based upon a variety of factors, which may include, but are not limited to: • The inflationary index used by Medicare • The National Hospital Input Price Index (NHIPI) • Cost and access • Competitor payment levels • BCBSM and BCN participation rates • Unusual circumstances and economic factors that may unduly influence the cost of services provided by ambulance providers in Michigan (e.g., gasoline). If services are billed infrequently, performed by a limited number of providers, or incorporate new technology and medical techniques, maximum payment levels may be set by comparing them to maximum payment levels for procedures with similar complexity and risk. These payment levels may also be reviewed by professional consultants who have the technical expertise to recommend adjustments. BCBSM and BCN will give Provider not less than 90 days prior written notice of any material change to the Reimbursement Methodology. Notice may, at BCBSM’s and BCN’s discretion, be published in the appropriate BCBSM or BCN provider publication(s) e.g., The Record.