Common use of Stop Loss Program Clause in Contracts

Stop Loss Program. (1) For the Stop Loss Program Charges set forth in Part D below, Blue Shield shall reimburse Group for eighty percent (80%) of that portion of the Allowable Costs (as described herein) of Capitated Professional Services provided during any one (1) Agreement Year to any one (1) Member which exceeds the Attachment Level and which are Group’s financial responsibility under the Agreement. (2) In addition to the defined terms of the Agreement, the following terms have the following meanings for this Stop Loss Program: (i) The Attachment Level is ten thousand dollars ($10,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Commercial Member (including POS Members) in any one (1) Agreement Year. The Attachment Level is fifteen thousand dollars ($15,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Blue Shield 65 Plus Member in any one (1) Agreement Year. (ii) Allowable Costs (both for determining the Attachment Level and Stop Loss Program reimbursement after the Attachment Level is reached) are the lesser of the amount actually paid (other than capitation payments) by Group for such Capitated Professional Services, or ninety percent (90%) of the Blue Shield’s PPO Physician Allowances in effect at the time. Allowable Costs are reduced by: (a) the Member’s applicable Copayments; and (b) any amount for which Group is entitled to reimbursement or payment from any other source. (3) Group shall submit to Blue Shield any claims for Stop Loss Program reimbursement within ninety (90) days of the end of the Agreement Year in which the services, for which Stop Loss Program reimbursement is claimed, were provided. Blue Shield may deny any claims not submitted within said time period. Claims shall be in such form, containing such information, and provided to Blue Shield as set forth in the Provider Manual. (4) Stop Loss Program reimbursement is provided only for Capitated Professional Services which are provided to an eligible Member in conformity with the terms and conditions of the Agreement, including, without limitation, any provisions requiring Authorizations and case management program notification and cooperation. Without limiting the foregoing, Stop Loss Program reimbursement is not paid for any monetary compensation payable to a Member for any reason, including Group’s negligence in providing or arranging or failing to provide services. (5) Group shall promptly notify Blue Shield of all cases for which the Attachment Level is reached or for which it is reasonably likely that the Attachment Level will be reached. (6) Group shall, as a condition of such Stop Loss Program reimbursement, provide to Blue Shield all information necessary for Blue Shield to determine its Stop Loss Program obligation hereunder. (7) Stop Loss Program reimbursement shall be payable by Blue Shield at the later occurring of: (i) the date of the Shared Savings Settlement described in Exhibit D to the Agreement; or, (ii) ninety (90) days following the timely, complete, and uncontested submission to Blue Shield of Group’s Stop Loss Program reimbursement claim. (8) Blue Shield reserves the right to audit Group’s Stop Loss Program claims and other information provided pursuant to this Exhibit H. In the event such audit determines that there has been an underpayment in Stop Loss Program reimbursement, Blue Shield shall pay to Group the amount of such underpayment within forty-five (45) working business days thereafter. In the event such audit determines that there has been an overpayment in Stop Loss Program reimbursement, Group shall pay to Blue Shield the amount of such overpayment within forty-five (45) working business days thereafter. Alternatively, Blue Shield may, at its election, offset such overpayment from any amount then or thereafter owed by Blue Shield to Group.

Stop Loss Program. (1) For the Stop Loss Program Charges set forth in Part D below, Blue Shield shall reimburse Group for eighty percent (80%) *** of that portion of the Allowable Costs (as described herein) of Capitated Professional Services provided during any one (1) Agreement Year to any one (1) Member which exceeds the Attachment Level and which are Group’s financial responsibility under the Agreement. (2) In addition to the defined terms of the Agreement, the following terms have the following meanings for this Stop Loss Program: (i) The Attachment Level is ten thousand NA dollars ($10,000NA) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Commercial Member (including POS Members) in any one (1) Agreement Year. The Attachment Level is fifteen thousand NA dollars ($15,000NA) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Blue Shield 65 Plus Member in any one (1) Agreement Year. (ii) Allowable Costs (both for determining the Attachment Level and Stop Loss Program reimbursement after the Attachment Level is reached) are the lesser of the amount actually paid (other than capitation payments) by Group for such Capitated Professional Services, or ninety one-hundred percent (90100%) of the Blue Shield’s PPO Physician Allowances in effect at the time. Allowable Costs are reduced by: (a) the Member’s applicable Copayments; and (b) any amount for which Group is entitled to reimbursement or payment from any other source. (3) Group shall submit to Blue Shield any claims for Stop Loss Program reimbursement within ninety (90) days of the end of the Agreement Year in which the services, for which Stop Loss Program reimbursement is claimed, were provided. Blue Shield may deny any claims not submitted within said time period. Claims shall be in such form, containing such information, and provided to Blue Shield as set forth in the Provider Manual. (4) Stop Loss Program reimbursement is provided only for Capitated Professional Services which are provided to an eligible Member in conformity with the terms and conditions of the Agreement, including, without limitation, any provisions requiring Authorizations and case management program notification and cooperation. Without limiting the foregoing, Stop Loss Program reimbursement is not paid for any monetary compensation payable to a Member for any reason, including Group’s negligence in providing or arranging or failing to provide services. (5) Group shall promptly notify Blue Shield of all cases for which the Attachment Level is reached or for which it is reasonably likely that the Attachment Level will be reached. (6) Group shall, as a condition of such Stop Loss Program reimbursement, provide to Blue Shield all information necessary for Blue Shield to determine its Stop Loss Program obligation hereunder. (7) Stop Loss Program reimbursement shall be payable by Blue Shield at the later occurring of: (i) the date of the Shared Savings Settlement described in Exhibit D to the Agreement; or, (ii) ninety (90) days following the timely, complete, and uncontested submission to Blue Shield of Group’s Stop Loss Program reimbursement claim. (8) Blue Shield reserves the right to audit Group’s Stop Loss Program claims and other information provided pursuant to this Exhibit H. I. In the event such audit determines that there has been an underpayment in Stop Loss Program reimbursement, Blue Shield shall pay to Group the amount of such underpayment within forty-five (45) working business days thereafter. In the event such audit determines that there has been an overpayment in Stop Loss Program reimbursement, Group shall pay to Blue Shield the amount of such overpayment within forty-five (45) working business days thereafter. Alternatively, Blue Shield may, at its election, offset such overpayment from any amount then or thereafter owed by Blue Shield to Group.

Stop Loss Program. (1) For the Stop Loss Program Charges set forth in Part D below, Blue Shield shall reimburse Group for eighty percent (80%) of that portion of the Allowable Costs (as described herein) of Capitated Professional Services provided during any one (1) Agreement Year to any one (1) Member which exceeds the Attachment Level and which are Group’s financial responsibility under the Agreement. (2) In addition to the defined terms of the Agreement, the following terms have the following meanings for this Stop Loss Program: (i) The Attachment Level is ten thousand dollars ($10,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Commercial Member (including POS Members) in any one (1) Agreement Year. The Attachment Level is fifteen thousand dollars ($15,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Blue Shield 65 Plus Member in any one (1) Agreement Year. (ii) Allowable Costs (both for determining the Attachment Level and Stop Loss Program reimbursement after the Attachment Level is reached) are the lesser of the amount actually paid (other than capitation payments) by Group for such Capitated Professional Services, or ninety percent (90%) of the Blue Shield’s PPO Physician Allowances in effect at the time. Allowable Costs are reduced by: (a) the Member’s applicable Copayments; and (b) any amount for which Group is entitled to reimbursement or payment from any other source. (3) Group shall submit to Blue Shield any claims for Stop Loss Program reimbursement within ninety (90) days of the end of the Agreement Year in which the services, for which Stop Loss Program reimbursement is claimed, were provided. Blue Shield may deny any claims not submitted within said time period. Claims shall be in such form, containing such information, and provided to Blue Shield as set forth in the Provider Manual. (4) Stop Loss Program reimbursement is provided only for Capitated Professional Services which are provided to an eligible Member in conformity with the terms and conditions of the Agreement, including, without limitation, any provisions requiring Authorizations and case management program notification and cooperation. Without limiting the foregoing, Stop Loss Program reimbursement is not paid for any monetary compensation payable to a Member for any reason, including Group’s negligence in providing or arranging or failing to provide services. (5) Group shall promptly notify Blue Shield of all cases for which the Attachment Level is reached or for which it is reasonably likely that the Attachment Level will be reached. (6) Group shall, as a condition of such Stop Loss Program reimbursement, provide to Blue Shield all information necessary for Blue Shield to determine its Stop Loss Program obligation hereunder. (7) Stop Loss Program reimbursement shall be payable by Blue Shield at the later occurring of: (i) the date of the Shared Savings Settlement described in Exhibit D to the Agreement; or, (ii) ninety (90) days following the timely, complete, and uncontested submission to Blue Shield of Group’s Stop Loss Program reimbursement claim. (8) Blue Shield reserves the right to audit Group’s Stop Loss Program claims and other information provided pursuant to this Exhibit H. In the event such audit determines that there has been an underpayment in Stop Loss Program reimbursement, Blue Shield shall pay to Group the amount of such underpayment within forty-five (45) working business days thereafter. In the event such audit determines that there has been an overpayment in Stop Loss Program reimbursement, Group shall pay to Blue Shield the amount of such overpayment within forty-five (45) working business days thereafter. Alternatively, Blue Shield may, at its election, offset such overpayment from any amount then or thereafter owed by Blue Shield to Group.

Stop Loss Program. (1) For the Stop Loss Program Charges set forth in Part D below, Blue Shield shall reimburse Group for eighty percent (80%) of *** that portion of the Allowable Costs (as described herein) of Capitated Professional Services provided during any one (1) Agreement Year to any one (1) Member which exceeds the Attachment Level and which are Group’s financial responsibility under the Agreement. (2) In addition to the defined terms of the Agreement, the following terms have the following meanings for this Stop Loss Program: (i) The Attachment Level is ten thousand dollars ($10,000) *** of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Commercial Member (including POS Members) in any one (1) Agreement Year. The Attachment Level is fifteen thousand dollars ($15,000) *** of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Blue Shield 65 Plus Member in any one (1) Agreement Year. (ii) Allowable Costs (both for determining the Attachment Level and Stop Loss Program reimbursement after the Attachment Level is reached) are the lesser of the amount actually paid (other than capitation payments) by Group for such Capitated Professional Services, or ninety percent (90%) *** of the Blue Shield’s PPO Physician Allowances in effect at the time. Allowable Costs are reduced by: (a) the Member’s applicable Copayments; and (b) any amount for which Group is entitled to reimbursement or payment from any other source. (3) Group shall submit to Blue Shield any claims for Stop Loss Program reimbursement within ninety (90) days of the end of the Agreement Year in which the services, for which Stop Loss Program reimbursement is claimed, were provided. Blue Shield may deny any claims not submitted within said time period. Claims shall be in such form, containing such information, and provided to Blue Shield as set forth in the Provider Manual. (4) Stop Loss Program reimbursement is provided only for Capitated Professional Services which are provided to an eligible Member in conformity with the terms and conditions of the Agreement, including, without limitation, any provisions requiring Authorizations and case management program notification and cooperation. Without limiting the foregoing, Stop Loss Program reimbursement is not paid for any monetary compensation payable to a Member for any reason, including Group’s negligence in providing or arranging or failing to provide services. (5) Group shall promptly notify Blue Shield of all cases for which the Attachment Level is reached or for which it is reasonably likely that the Attachment Level will be reached. (6) Group shall, as a condition of such Stop Loss Program reimbursement, provide to Blue Shield all information necessary for Blue Shield to determine its Stop Loss Program obligation hereunder. (7) Stop Loss Program reimbursement shall be payable by Blue Shield at the later occurring of: (i) the date of the Shared Savings Settlement described in Exhibit D to the Agreement; or, (ii) ninety (90) days following the timely, complete, and uncontested submission to Blue Shield of Group’s Stop Loss Program reimbursement claim. (8) Blue Shield reserves the right to audit Group’s Stop Loss Program claims and other information provided pursuant to this Exhibit H. In the event such audit determines that there has been an underpayment in Stop Loss Program reimbursement, Blue Shield shall pay to Group the amount of such underpayment within forty-five (45) working business days thereafter. In the event such audit determines that there has been an overpayment in Stop Loss Program reimbursement, Group shall pay to Blue Shield the amount of such overpayment within forty-five (45) working business days thereafter. Alternatively, Blue Shield may, at its election, offset such overpayment from any amount then or thereafter owed by Blue Shield to Group.

Stop Loss Program. (1) For the Stop Loss Program Charges set forth in Part D below, Blue Shield shall reimburse Group for eighty percent (80%) of that portion of the Allowable Costs (as described herein) of Capitated Professional Services provided during any one (1) Agreement Year to any one (1) Member which exceeds the Attachment Level and which are Group’s financial responsibility under the Agreement. (2) In addition to the defined terms of the Agreement, the following terms have the following meanings for this Stop Loss Program: (i) The Attachment Level is ten thousand dollars ($10,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Commercial Member (including POS Members) in any one (1) Agreement Year. The Attachment Level is fifteen thousand dollars ($15,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Blue Shield 65 Plus Member in any one (1) Agreement Year. (ii) Allowable Costs (both for determining the Attachment Level and Stop Loss Program reimbursement after the Attachment Level is reached) are the lesser of the amount actually paid (other than capitation payments) by Group for such Capitated Professional Services, or ninety percent (90%) of the Blue Shield’s PPO Physician Allowances in effect at the time. Allowable Costs are reduced by: (a) the Member’s applicable Copayments; and (b) any amount for which Group is entitled to reimbursement or payment from any other source. (3) Group shall submit to Blue Shield any claims for Stop Loss Program reimbursement within ninety (90) days of the end of the Agreement Year in which the services, for which Stop Loss Program reimbursement is claimed, were provided. Blue Shield may deny any claims not submitted within said time period. Claims shall be in such form, containing such information, and provided to Blue Shield as set forth in the Provider Manual. (4) Stop Loss Program reimbursement is provided only for Capitated Professional Services which are provided to an eligible Member in conformity with the terms and conditions of the Agreement, including, without limitation, any provisions requiring Authorizations and case management program notification and cooperation. Without limiting the foregoing, Stop Loss Program reimbursement is not paid for any monetary compensation payable to a Member for any reason, including Group’s negligence in providing or arranging or failing to provide services. (5) Group shall promptly notify Blue Shield of all cases for which the Attachment Level is reached or for which it is reasonably likely that the Attachment Level will be reached. (6) Group shall, as a condition of such Stop Loss Program reimbursement, provide to Blue Shield all information necessary for Blue Shield to determine its Stop Loss Program obligation hereunder. (7) Stop Loss Program reimbursement shall be payable by Blue Shield at the later occurring of: (i) the date of the Shared Savings Settlement described in Exhibit D to the Agreement; or, (ii) ninety (90) days following the timely, complete, and uncontested submission to Blue Shield of Group’s Stop Loss Program reimbursement claim. (8) Blue Shield reserves the right to audit Group’s Stop Loss Program claims and other information provided pursuant to this Exhibit H. I. In the event such audit determines that there has been an underpayment in Stop Loss Program reimbursement, Blue Shield shall pay to Group the amount of such underpayment within forty-five (45) working business days thereafter. In the event such audit determines that there has been an overpayment in Stop Loss Program reimbursement, Group shall pay to Blue Shield the amount of such overpayment within forty-five (45) working business days thereafter. Alternatively, Blue Shield may, at its election, offset such overpayment from any amount then or thereafter owed by Blue Shield to Group.