1
EXHIBIT 10.17
Portions of this Exhibit have been omitted pursuant to a request for
confidential treatment. The omitted portions, marked by an * and [ ], have been
separately filed with the Commission.
HMO
Physician Network
Form Code: GRPXXY050892
PHYSICIAN NETWORK
PARTICIPATION AGREEMENT
This Agreement is effective as of July 1, 1994 and is entered into between
Atlanta-AHP, Inc. ("Physician Network") and Aetna Health Management, Inc.
("AHM"). Upon acceptance of sufficient application from Physician Network's
member physicians, Physician Network may participate in various Aetna health
benefits products in accordance with the terms and conditions stated below.
I. DEFINITIONS
1.1 MEMBER means a person eligible to receive benefits under a Plan.
1.2 COVERED SERVICES are those services for which benefits may be provided
under the terms of a Plan.
1.3 CAPITATED SERVICES means services listed in Attachment A-1 that are
also Covered Services.
1.4 Network PHYSICIAN means a member of Physician Network whose
application has been accepted by AHM.
1.5 NON-CAPITATED SERVICES means services in Attachment A-2 that are also
Covered Services.
1.6 PARTICIPATING PROVIDER means a facility, physician or other health
care provider under agreement to participate in a provider Network administered
by AHM or its affiliates. This term does not include members of Physician
Network whose applications have not been accepted by AHM.
1.7 PAYOR means an entity liable for funding of benefit payments under a
Plan which uses a provider Network administered by AHM or its affiliates. A
Payor may be a health maintenance organization ("HMO"), insurer, employer or
other entity, depending on the Plan. A Payor's liability for funding benefit
payments is governed by the terms of its Plan. AHM will inform Physician Network
of the Payor liable for benefit payments under a specific Plan on request. AHM
is not a Payor.
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1.8 PCP FEATURE means that in order to obtain maximum benefits under a
Plan, the Member chooses a personal physician, known as a "Primary Care
Physician," or "PCP," and is required to contact the PCP to arrange for
non-emergency services in order to receive maximum benefits.
1.9 PLAN means a health benefits plan which encourages or requires Members
to use a Participating Provider in order to receive maximum benefits.
II. PHYSICIAN NETWORK'S AGREEMENTS AND OBLIGATIONS
General
2.1 Physician Network agrees to provide those Covered Services to Members
without discriminating against Members on the basis of source of payment, race,
color, religion, national origin, health status or disability.
2.2 Physician Network consents to references to the status of Physician
Network and of Network Physicians as a Participating Provider in marketing and
other materials.
2.3 Physician Network will maintain medical, financial and administrative
records concerning services provided to Members and will keep these records for
at least five years from the date the service was rendered. Physician Network
agrees that AHM or Payors, their authorized representatives, and duly authorized
third parties such as government or regulatory agencies, will have the right to
inspect, review and receive copies of records directly related to services
rendered to Members, upon reasonable notice, during regular business hours.
Physician Network will provide, upon request, a copy of Member operative reports
free of charge and agrees to accept payment for copies of other records at the
rate of $1 per page. Physician Network further agrees to obtain any necessary
releases from Members with respect to their records and the information
contained therein.
2.4 Physician Network agrees not to delegate Physician Network's duties
under this Agreement without prior written consent of AHM. This paragraph does
not prohibit the expected performance of Physician Network obligations by
Network Physicians.
2.5 Physician Network agrees to make referrals to and arrange back-up
coverage, with Participating Providers unless medically inappropriate. Physician
Network agrees to obtain pre-certification from Member's Primary Care Physician
for any referrals to physicians outside the Physician Network.
2.6 Physician Network agrees to participate in the Utilization Management
program ("UM programs") and Quality Management program ("QM program") applicable
to each Plan, including initiating utilization review. For Plans with a PCP
Feature, Physician Network agrees to follow the referral management program.
Failure to comply with the applicable UM/QM programs may result in reductions in
payment or in termination of this Agreement.
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2.7 Physician Network agrees to comply with and participate in any
applicable appeal/grievance procedure, including any applicable Member grievance
system.
2.8 For Plans with a PCP Feature, upon Network Physician's election and
AHM's approval, individual Network Physicians shall be designated either a
Primary Care Physician or a Specialist Physician. Specialist Physician agrees to
inform referring Primary Care Physician of findings and/or treatment plan orally
or in writing.
Billing and Compensation
2.9 Physician Network agrees to accept the amounts provided for in
Attachments X, X-0, X-0 and A-3 as payment in full for Covered Services.
Physician Network agrees that if Physician Network reduces the amount Physician
Network will accept as payment in full for Non-Capitated Services, e.g. through
forgiveness of coinsurance, copayments or deductibles, Physician Network will
xxxx Xxxxx at the reduced amount and will accept payment from Payor based on the
reduced amount.
2.10 If Physician Network's failure to participate in the UM/QM programs,
or if Physician Network's failure to submit a timely claim, results in a denial
or reduction of payment from Payor, Physician Network agrees not to charge
Members for the resulting unpaid charges. Physician Network agrees not to charge
Members for services which UM review indicates may not be covered unless a) the
Member has been informed prior to receiving the services that the services may
not be covered under Payor's Plan and b) the Member has agreed in writing to pay
for the services. Except or the preceding two sentences, nothing in this
Agreement is intended to restrict Physician Network's right to charge Members
for non-covered services.
2.l1 Physician Network agrees to file claims on behalf of Members for
Non-capitated Services. Physician Network also agrees to obtain assignment of
benefits for such claims when appropriate.
2.12 Physician Network agrees to submit an itemized claim for
Non-capitated Services using the HCFA-1500 billing form (or a billing form
containing equivalent information) within 90 days from the date of service, or,
in those instances in which the Payor is secondary, 90 days from the date that
notice of payment decision is received from the primary payor. Payors will not
be obligated to pay claims which are submitted after that time.
2.13 Physician Network agrees to cooperate in claims payment
administration including, but not limited to, coordination of benefits,
subrogation, checking coverage, prior certification and record keeping
procedures. For Non-capitated Services, if Payor pays Physician Network more
than is provided for in Payor's Plan, or if Payor pays Physician Network on the
basis of an assignment of benefits which is successfully contested, Physician
Network agrees to return such amounts to Payor or to Payor's agent.
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2.14 If Payor is a HMO, Physician Network agrees that in no event,
including but not limited to non-payment by the HMO, HMO insolvency or breach by
AHM of this Agreement, shall Physician Network xxxx, charge, collect a deposit
from, seek compensation, remuneration or reimbursement from, or have any
recourse against HMO's Members for Covered Services. This provision does not
prohibit collection of supplemental charges or copayments on HMO's behalf made
in accordance with HMO's Plan. Physician Network further agrees that this
paragraph shall be construed to be for the benefit of HMO's Members and that
this paragraph supersedes any oral or written contrary agreement now existing or
hereafter entered into between Physician Network and HMO's Members or persons
acting on such Members' behalf.
Credentialing
2.15 Physician Network agrees to provide the information required under
AHM's credentialing and quality management programs ("C/QM programs"); Physician
Network agrees that Physician Network's participation and the participation of
individual Network Physicians under this Agreement may be terminated or
suspended pursuant to these programs. Physician Network represents and warrants
that the information provided in accordance with the C/QM programs, including
but not limited to the information provided in each Network Physician's
application, continues to be true and complete. Physician Network agrees to
notify AHM immediately of changes in that information.
2.16 Physician Network and each Network Physician shall maintain
comprehensive general and professional liability insurance in adequate amounts
("adequate" as determined by AHM), shall provide documentary evidence of such
coverage to AHM upon request, and shall notify AHM immediately of any change in
coverage.
2.17 Physician Network represents and warrants that Physician Network has
and will maintain all licenses necessary to provide the services contemplated
under this Agreement. Physician Network shall notify AHM immediately of any
action to suspend, revoke or restrict its license(s) and/or any other
accreditation or certification that is necessary or useful for providing the
services contemplated by this Agreement.
Network Terms
2.18 Physician Network represents and warrants that it is in good standing
under applicable laws and regulations governing its existence and operation,
that this Agreement has been executed by its duly authorized representative, and
that Physician Network has the authority to bind Network Physicians to the terms
of this Agreement.
2.19 Physician Network agrees that an application will be submitted to AHM
for every physician who is presently a member of Physician Network or who
becomes a member of Physician Network during the term of this Agreement.
Physician Network agrees to notify AHM immediately if any Network Physicians
cease to be members of Physician Network.
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III. AHM AGREEMENTS AND OBLIGATIONS
3.1 AHM agrees to provide descriptions of Aetna health benefits products
to Physician Network.
3.2 AHM shall arrange for the distribution of identification cards to
Members; each card will include a toll-free number that Physician Network may
use during normal business hours to check eligibility for coverage and to obtain
general coverage information.
3.3 AHM agrees to inform Physician Network of the UM/QM procedures and the
billing procedures for each Plan.
3.4 AHM shall implement a means for Physician Network to identify other
Participating Providers.
3.5 AHM will instruct Payor to pay its portion of Physician Network's
bills for Non- capitated Services, within 30 days of receipt, or such shorter
period as required by law, when such bills are accurate, complete, in the
agreed-upon form, when Payor is primary and when the bills do not require any
further investigation.
IV. TERM AND TERMINATION
4.1 Term. This Agreement shall continue in effect until terminated.
4.2 Termination. This Agreement may be terminated:
a) without cause by either party upon 90 days prior written notice
to the other.
b) for material breach if 30 days prior written notice specifying
the material breach has been given to the breaching party and if at the end of
the thirty days the dispute remains unresolved. This Agreement may then be
terminated immediately by written notice to the breaching party.
c) upon notice by AHM pursuant to AHM's C/QM programs.
d) upon notice by AHM if insufficient numbers of Physician Network's
members are Network Physicians.
4.3 Obligations Following Termination. Physician Network shall continue to
provide Covered Services to Members receiving active treatment at the time of
termination until the course of treatment is completed or until ARM makes
reasonable and medically appropriate arrangements to have another physician
provide the services. The terms of this Agreement continue to apply after
termination to such Covered Services and to Covered Services provided
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before termination. Physician Network agrees to inform Members seeking medical
care after the date of termination that Physician Network is no longer a
Participating Provider.
V. MUTUAL OBLIGATIONS
5.1 Amendments. This Agreement may be amended by AHM upon written notice
to Physician Network if necessary in order to comply with applicable law. It may
also be amended by AHM upon 30 days prior written notice to Physician Network,
unless Physician Network objects to the proposed amendment in writing within 15
days of the date the notice of amendment was sent.
5.2 Independent Contractors. Physician Network, AHM and Payors are
independent contractors and are not responsible for the acts or omissions of
each other. Physician Network and Network Physicians continue to be solely
responsible for treatment decisions; claim determinations and determinations
made in connection with utilization review in no way affect the responsibility
of Physician Network and Network Physicians to provide or arrange for
appropriate services for Members.
5.3 Dispute Resolution. If a dispute should arise with respect to the
terms of this Agreement, the parties agree to attempt to resolve the matter
through informal discussion, or, if informal discussion does not resolve the
matter, through mediation. Where pursuing mediation, the parties shall attempt
to take no longer than 30 days to agree upon a mediator.
5.4 Notice. Any written notice required by this Agreement shall be sent by
certified mail, return receipt requested, to the address given below or to such
later address as may be specified in writing. Any prior written notice periods
required by this Agreement shall be deemed to start on the day that written
notice was sent.
Attn: Xxxxx X. Xxxxx, M.D. Aetna Health Management. Inc.
Atlanta-AHP, Inc. Contracts Administration
0000 Xxxxxxxxx-Xxxxxxxx Xxxx 0000 Xxxxxx Xxxxxx XX0X
Xxxxx 000 Xxxxxxxxxx, XX 00000
Xxxxxxx, XX 00000
and
Attn: Xxxxxx X. Xxxxx, Ph.D.
000 Xxxxxxx Xxxxx, Xxxxx 000
Xxxxxxx, XX 00000
5.5 Trademarks. Neither party may use the other party's trademarks or
servicemarks without the express written consent of the other party. Neither
party may use any trademark or servicemark of any Payor without the express
written consent of that Payor.
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5.6 Waiver of Breach. The waiver of any breach of this Agreement will not
be deemed to waive any other breach.
5.7 Entire Agreement. This Agreement, including its attachments,
constitutes the entire agreement between the parties with respect to the matters
addressed herein and supersedes all prior oral and written understandings
between the parties.
ATLANTA-AHP, INC. AETNA HEALTH MANAGEMENT, INC.
By:____________________________ By:__________________________________
Printed Name:__________________ Printed Name:________________________
Title: ________________________ Title:_______________________________
Date:__________________________ Date:________________________________
Tax I.D.: _____________________
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A
Compensation Schedule
Full Capitation, Risk Share
I. Reimbursement Rate
A. For in-area HMO Members, Physician Network's reimbursement for
Capitated Services shall be based on [*] per Member per month for the initial
year of the contract. Total Physician Network's reimbursement is subject to the
risk share arrangement and implementation clause described in Section IV and V,
respectively.
The reimbursement rate is subject to renegotiation annually and shall be
negotiated on or about 30 days prior to, and effective on, the contract
anniversary date.
Physician Network shall be responsible for providing all Capitated
Services. Physician Network shall provide these services directly or arrange for
the provision of any necessary services required by Members. If physicians other
than Network Physicians are used to provide such services, Physician Network
shall be responsible for making payments directly to such providers.
B. For Non-capitated Services provided to Members Physician Network's
Reimbursement Rate shall be the lesser of:
1. The maximum fee for the particular Covered Service as determined
by HMO, or
2. Physician Network's usual and customary charge for such service.
Physician Network shall provide HMO with data on a quarterly basis
relating to payments made for Physician Network Covered Services. Physician
Network shall also provide HMO with summary data on magnetic tape, floppy disk,
or hard copy in a format acceptable to HMO within 45 days after the end of the
quarter. This format, at a minimum, shall include: (1) Member name, (2) Member
I.D. number, (3) date of service, (4) CPT Code/ICD-9 code, (5) billed
amount/paid amount, (6) Member's Primary Care Physician, (7) provider rendering
service if other than Primary Care Physician and (8) coordination of benefits
and third party recoveries information.
Physician Network shall provide HMO a quarterly balance sheet, income
statement and year-to-date income statement on a timely basis. Within 120 days
of the end of each Physician
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Network fiscal year, Physician Network shall provide HMO a current financial
statement or audited financial statement if available. Physician Network shall
permit HMO to perform a financial audit of Physician Network's financial
records, at HMO's expense, upon 30 days written notice by HMO.
II. Compensation: Payor
A. For Capitated services, the compensation payable by Payor to Physician
Network shall be equal to the Capitation Rate described above, subject to the
terms of this Agreement and the applicable Plan.
B. For Non-capitated Services, the compensation per claim payable by Payor
to Physician Network, subject to the terms of this Agreement and the applicable
Plan, shall be equal to:
1. The Reimbursement Rate,
2. Minus any applicable copayments, coinsurance and/or deductibles.
C. Capitation payments will be paid to Physician Network by Payor on or
before the 10th day of each month.
D. For the purposes of calculating Capitation payments due under this
Attachment, the number of Members will be determined as of the first day of the
month. No payment adjustments will be made for Members entering or leaving the
applicable health benefits plan after the first day of the month. All Capitation
payments shall be subject, for a period not to exceed three months, to
subsequent adjustment as required to reflect delayed enrollment information
received by HMO from HMO's contractholders.
III. Compensation: Member
Physician Network agrees that Physician Network will not xxxx Members for
amounts in excess of the deductibles, copayments and/or co-insurance provided
for in Member's Plan.
IV. Risk Share Arrangement
Except for the first year arrangement described in V. below, the
Capitation payments made under this Agreement are subject to adjustment on an
annual basis, as determined by the following reconciliation process:
Within 60 days of the anniversary date of this contract, Physician Network
shall provide HMO a reconciliation showing the following amounts:
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1. Total capitation payments paid to Physician Network by HMO for
the preceding contract year plus applicable copayments, COB recoveries and other
third party recoveries related to HMO Members.
2. Total Capitated Services provided during the preceding contract
year multiplied by the HMO fee schedule in effect as of the first day of the
preceding contract year.
If the amount described in number one above is greater than the amount in
number two, Physician Network shall reimburse HMO 100 percent of the surplus. If
the amount in number one above is less than 60 percent of the amount in number
two, HMO shall pay Physician Network the difference.
Any risk share payments shall be paid within 30 days after the
reconciliation. The reconciliation shall be provided by Physician Network to HMO
on magnetic tape, floppy disk or hard copy in a format acceptable to HMO. All
supporting detail information shall be included in the reconciliation.
V. First Year Risk Share Arrangement
During the first year after the contract effective date, the Capitation
payments made under this Agreement are subject to adjustment, as determined by
the following reconciliation process:
A. Within 180 days of the contract effective date, Physician Network shall
provide HMO a reconciliation showing the following amounts:
1. Total capitation payments paid to Physician Network by HMO for
the first two months of this contract plus applicable copayments, COB recoveries
and other third party recoveries related to HMO Members.
2. Total Capitated Services provided during the first two months of
this contract multiplied by the HMO fee schedule in effect as of the first day
of this contract (Attachment A-3).
If the amount described in number one above is greater than 80 percent of the
amount in number two, Physician Network shall reimburse HMO 100 percent of the
surplus. If the amount in number one is less than 60 percent of the amount in
number two, HMO shall pay Physician Network the difference.
Any risk share payments shall be paid within 30 days after the
reconciliation. The reconciliation shall be provided by Physician Network to HMO
on magnetic tape, floppy disk or hard copy in a format acceptable to HMO. All
supporting detail information shall be included in the reconciliation.
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B. Within 60 days of the first anniversary date of this contract,
Physician Network shall provide HMO a reconciliation showing the following
amounts:
1. Total capitation payments paid to Physician Network by HMO for the last
ten months of the first year of this contract plus applicable copayments, COB
recoveries and other third party recoveries related to HMO Members.
2. Total Capitated Services provided during the last ten months of the
first year of this contract multiplied by the HMO fee schedule in effect as of
the first day of this contract.
If the amount described in number one above is greater than the amount in
number two, Physician Network shall reimburse HMO 100 percent of the surplus. If
the amount in number one above is less than 60 percent of the amount in number
two, HMO shall pay Physician Network the difference.
Any risk share payments shall be paid within 30 days after the
reconciliation. The reconciliation shall be provided by Physician Network to HMO
on magnetic tape, floppy disk or hard copy in a format acceptable to HMO. All
supporting detail information shall be included in the reconciliation.
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Attachment A-1
Capitated Services
I. Capitated Services shall include the following services unless specifically
excluded on Attachment A-2:
1. All professional services that are typically performed by
otolaryngologists in the Atlanta market. This includes services, procedures,
surgeries, etc. performed in hospitals, surgical centers, offices, or other
locations; and
2. Laboratory and radiology services normally rendered in the office of
Network Physicians.
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PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-2
Compensation Schedule
Non-Capitated Services
I.CPT PROCEDURE CODES
IMPLANTS
--------
69710 IMPLANTATION/REPLACEMENT OF ELECTROMAGNETIC BONE
CONDUCTION HEARING DEVICE IN TEMPORAL BONE
69711 REMOVAL/REPAIR OF ELECTROMAGNETIC BONE CONDUCTING
HEARING DEVICE IN TEMPORAL BONE
69930 COCHLEAR DEVICE IMPLANTATION
GRAFTS
15570 DERMA FAT FASCIA
21235 EAR CARTILAGE GRAFT TO EAR
20926 TISSUE GRAFT
15100 SPLIT GRAFT
69320 RECONSTRUCTION EXTERNAL AUDITORY CANAL
61526 CRANIECTOMY
69725 DECOMPRESSION FACIAL NERVE/INCLUDING MEDIAL TO
GENICULATE GANGLION
69720 DECOMPRESSION FACIAL NERVE
95937 NEUROMUSCULAR JUNCTION TESTING
63707 REPAIR OF DURAL/CSF LEAK
69310 MEATOPLASTY
42425 EXCISION OF PAROTID TUMOR
60252-60254 THYROIDECTOMIES
60220-25-45-56 THYROIDECTOMIES
60260 THYROIDECTOMIES
00000-00-00 THYROIDECTOMIES
60254 THYROIDECTOMIES
31365 RADICAL NECK
31390 PHARYNGOLARYNGECTOMY, W/RADIAL NECK DISSECTION, W/
XXXXXXXX.
00000 XXXXXXXXXXXXXXXXXXXX, X/XXXXXX NECK DISSECTION, W/O
XXXXXXXX.
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00
00000 XXXXXX (UNLISTED PROCEDURE)
31360 LARYNGECTOMY/TOTAL WITHOUT NECK DISSECTION
31365 LARYNGECTOMY/TOTAL WITH RADICAL NECK
31367 SUBTOTAL SUPRAGLOTTIC WITH RADICAL NECK
31368 SUBTOTAL SUPRAGLOTTIC WITHOUT RADICAL NECK
SKULL BASE
----------
61518-61521 CRANIECTOMY
61526 CRANIECTOMY, BONE FLAP CRANIOTOMY
61530 COMBINED WITH MIDDLE/POSTERIOR FOSSA
61590
61591
61595-61598
61600-61613
61615-61619
62100
62120
62121
62140
II. OTHER PROCEDURES
LAB AND RADIOLOGY SERVICE THAT ARE NOT TYPICALLY PERFORMED IN
THE OFFICE OF NETWORK PHYSICIANS
HOME HEALTH SERVICES
III. OTHER
FACILITY FEES FOR SURGERY, EMERGENCY ROOM AND HOSPITAL STAYS
HEARING AIDS
DME ITEMS
EMERGENCY ROOM CLAIMS
ALL OUT-OF-AREA CLAIMS
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
11100 BIOPSY OF LESION [*]
11440 REMOVAL OF SKIN LESION
11441 REMOVAL OF SKIN LESION
11442 REMOVAL OF SKIN LESION
11443 REMOVAL OF SKIN LESION
11446 REMOVAL OF SKIN LESION
11620 REMOVAL OF SKIN LESION
11642 REMOVAL OF SKIN LESION
20000 * INCISION OF ABCESS
20670 * REMOVAL OF SUPPORT IMPLANT
21235 EAR CARTILAGE GRAFT
21255 RECONST. ZYGOMATIC ARCH & GLENOID
21320 TREATMENT OF NOSE FRACTURE
21330 REPAIR OF NOSE FRACTURE
21365 REPAIR CHEEK BONE FRACTURE
21557 RADICAL RESCONS. TUMOR NECK
21557A RADICAL RECONS. TUMOR NECK ASSI
26445A AST SURG/RELEASE HAND/FINGER
30100 INTRANASAL BIOPSY
30110 REMOVAL OF NOSE POLYP(S)
30115 REMOVAL OF NOSE POLYP(S)
30117 REMOVAL OF INTRANASAL LESION
30130 REMOVAL OF TURBINATE BONES
30140 REMOVAL OF TURBINATE BONES
30200 * INJECTION TREATMENT OF NOSE
30420 RECONSTRUCTION OF NOSE
30520 REPAIR OF NASAL SEPTUM
30620 RECONSTRUCTION INNER NOSE
30630 REPAIR NASAL SEPTUM DEFECT
30801 CAUTER/ABLAT MUCOSA OF TURBINA
30802 CAUTER/ABLAT MUCOSA OF TURBINA
30901 * CONTROL OF NOSE BLEED
30903 * CONTROL OF NOSE BLEED
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
30930 THERAPY FRACTURE OF NOSE [*]
31000 * IRRIGATION MAXILLARY SINUS
31020 EXPLORATION MAXILLARY SINUS
31070 EXPLORATION OF FRONTAL SINUS
31090 EXPLORATION OF SINUSES
31250 DIAGNOSTIC NASAL ENDOSCOPY
31252 NASAL ENDOSCOPY W/POLYPECTOMY
31254 NASAL ENDOSCOPY W/ETHMOIDECTOM
31255 NASAL ENDOSCOPY W/ETHMOIDECT
31256 NASAL ENDOSCOPY W/MAX. ANTROSTO
31267 MAXILLARY SINUS ENDOSCOPY, W/
31275 SPHENOID ENDOSCOPY-SURGICAL
31285 SINUS ENDOSCOPY; TWO OR MORE
31505 DIAGNOSTIC LARYNGOSCOPY
31525 DIAGNOSTIC LARYNGOSCOPY
31526 DIAGNOSTIC LARYNGOSCOPY
31535 OPERATIVE LARYNGOSCOPY
31536 OPERATIVE LARYNGOSCOPY
31541 OPERATIVE LARYNGOSCOPY
31570 LARYNGOSCOPY WITH INJECTION
31575 FIBERSCOPIC LARYNGOSCOPY
31579 LARYNGOSCOPY W/STROBOSCOPY
31600 INCISION OF WINDPIPE
00000 XXXXXXXXXXXXX W/OUT CELL WASH
00000 XXXXXXXXXXXX XXXX BIOPSY
31750 REPAIR OF WINDPIPE
33511A ASST SURG/CORONARY ARTERIES BY
36415 * VENIPUNCTURE
38500 BIOPSY/REMOVAL OF LYMPH NODE
38720 REMOVAL XX XXXXX XXXXX,XXXX
00000 BIOPSY OF LIP
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
40806 INCISION OF LIP FOND [*]
40808 BIOPSY OF MOUTH LESION
40810 EXCISION OF MOUTH LESION
40812 EXCISE/REPAIR MOUTH LESION
40819 EXCISE LIP OR CHEEK FOLD
41010 EXCISION OF TONGUE LESION
41105 BIOPSY OF TONGUE
41110 EXCISION OF TONGUE LESION
41113 EXCISION OF TONGUE LESION
41115 EXCISION OF TONGUE FOLD
41140 REMOVAL OF TONGUE
42145 PALATOPHAYNGOPLASTY
42310 * DRAINAGE OF SALIVARY GLAND
42326 CREATE SALIVARY CYST DRAIN
42400 * BIOPSY OF SALIVARY GLAND
42405 BIOPSY OF SALIVARY GLAND
42415 EXCISE PAROTID GLAND/LESION
42420 EXCISE PAROTID GLAND/LESION
42420A ASST SURG/EXCISE XXXXXXX XXXXX
00000 EXCISION SUBMAXILLARY GLAND
42700 * DRAINAGE OF TONSIL ABSCESS
42800 BIOPSY OF THROAT
42804 BIOPSY OF UPPER NOSE/THROAT
42809 REMOVE PHARYNX FOREIGN BODY
42810 EXCISION OF NECK CYST
42820 REMOVE TONSILS AND ADENOIDS
42821 REMOVE TONSILS AND ADENOIDS
42825 REMOVAL OF TONSILS
42826 REMOVAL OF TONSILS
42830 REMOVAL OF ADENOIDS
42835 REMOVAL OF ADENOIDS
42950 RECONSTRUCTION OF THROAT
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The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
42960 CONTROL THROAT BLEEDING [*]
43200 ESOPHAGUS ENDOSCOPY
43202 ESOPHAGUS ENDOSCOPY, BIOPSY
60100 * BIOPSY OF THYROID
60220 PARTIAL REMOVAL OF THYROID
60220A ASST SURG PARTIAL REMOVAL OF T
60280 REMOVE THYROID DUCT LESION
67971A RECONSTRUCTION XXXXXX/XXXX XXX
00000 * TREAT EYELID BY INJECTION
68770 CLOSE TEAR SYSTEM FISTULA
69200 CLEAR OUTER EAR CANAL
69205 CLEAR OUTER EAR CANAL
69210 REMOVE IMPACTED EAR WAX
69220 CLEAN OUT MASTOID CAVITY
69399 OUTER EAR SURGERY PROCEDURE
69401 INFLATE MIDDLE EAR CANAL
69420 * INCISION OF EARDRUM
69424 REMOVE VENTILATING TUBE
69433 * CREATE EARDRUM OPENING
69436 CREATE EARDRUM OPENING
69436A CREATE EARDRUM OPENING/ASST SU
69540 REMOVE EAR LESION
69610 REPAIR OF EARDRUM
69631 REPAIR EARDRUM STRUCTURES
69641 REVISE MIDDLE EAR & MASTOID
69660 REVISE MIDDLE EAR BONE
69661 REVISE MIDDLE EAR BONE
69799 MIDDLE EAR SURGERY PROCEDURE
70210 X-RAY EXAM OF SINUSES
70220 X-RAY EXAM OF SINUSES
70360 X-RAY EXAM OF NECK
70380 X-RAY EXAM OF SALIVARY GLAND
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19
The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
70480 CAT SCAN OF SKULL [*]
71020 X-RAY EXAM OF CHEST
74220 CONTRAST X-RAY EXAM, ESOPHAGUS
76499 RADIOGRAPHIC PROCEDURE
76536 ECHOGRAPHY HEAD NECK
76805 ECHO XXXX XX XXXXXX
00000 PROVIDE RADIOISOTOPE(S)
80019 19 OR MORE BLOOD/URINE TESTS
81000 URINALYSIS WITH MICROSCOPY
81002 ROUTINE URINE ANALYSIS
82785 RIA ASSAY GAMMAGLOBULINE
84435 ASSAY THYROXINE (T-4)
84439 RIA ASSAY, FREE THYROXINE
84443 RIA ASSAY OF TS HORMONE
84703 GONADOTROPIN, CHORIONIC
85002 BLEEDING TIME TEST
85018 HEMOGLOBIN, COLORIMETRIC
85023 HEMOGRAM & PLATELET COUNT
85610 PROTHROMBIN TIME
85651 RBC SEDIMENTATION RATE
85730 THROMBOPLASTIN TIME, PARTIAL
86235 ENA ANTIBODY
86331 IMMUNODIFFUSION OUCHTERLONY
86430 RHEUMATOID FACTOR TEST
86580 TB INTRADERMAL TEST
86592 BLOOD SEROLOGY, QUALITATIVE
87060 NOSE/THROAT CULTURE, BACTERIA
87070 CULTURE SPECIMEN, BACTERIA
87081 BACTERIA CULTURE SCREEN
87186 ANTIBIOTIC SENSITIVITY, MIC
87210 SMEAR, STAIN & INTERPRET
88150 CYTOPATHOLOGY, PAP SMEAR
-19-
20
The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
88304 SURGICAL PATHOLOGY, COMPLETE [*]
88305 SURGICAL PATHOLOGY, COMPLETE
90782 INJECTION OF MEDICATION
90784 INJECTION OF MEDICATION (IV)
90844 INDIVIDUAL PSYCHOTHERAPY
92504 EAR MICROSCOPY EXAMINATION
92506 SPEECH & HEARING EVALUATION
92507 SPEECH/HEARING THERAPY
92508 SPEECH/HEARING THERAPY
92511 NASOPHARYNGOSCOPY
92532 POSITIONAL NYSTAGMUS STUDY
92533 CALORIC VESTIBULAR TEST
92541 SPONTANEOUS NYSTAGMUS TEST
92542 POSITIONAL NYSTAGMUS TEST
92543 CALORIC VESTIBULAR TEST
92544 OPTOKINETIC NYSTAGMUS TEST
92545 OSCILLATING TRACKING TEST
92546 TORSION SWING RECORDING
92547 SUPPLEMENTAL ELECTRICAL TEST
92551 PURE TONE HEARING TEST, AIR
92552 PURE TONE AUDIOMETRY, AIR
92553 AUDIOMETRY, AIR & BONE
92555 SPEECH THRESHOLD AUDIOMETRY
92556 SPEECH AUDIOMETRY, COMPLETE
92557 COMPREHENSIVE AUDIOMETRY
92560 BEKESY AUDIOMETRY, SCREEN
92563 TONE DECAY HEARING TEST
92567 TYMPANOMETRY
92568 ACOUSTIC REFLEX TESTING
92569 ACOUSTIC REFLEX DECAY TEST
92572 STAGGERED SPONDAIC WORD TEST
92582 CONDITIONING PLAY AUDIOMETRY
-20-
21
The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
92583 SELECT PICTURE AUDIOMETRY [*]
92584 ELECTROCOCHLEOGRAPHY
92585 BRAINSTEM EVOKED AUDIOMETRY
92589 AUDITORY FUNCTION TEST(S)
93000 ELECTROCARDIOGRAM, COMPLETE
93005 ELECTROCARDIOGRAM, TRACING
93875 NON-INVASIVE PHYSIOLOGIC STUDI
97010 HOT OR COLD PACKS THERAPY
97110 THERAPEUTIC EXERCISES
97112 NEUROMUSCULAR REEDUCATION
97116 GAIT TRAINING THERAPY
97530 KINETIC ACTIVITIES
97752 MUSCLE TESTING WITH EXERCISE
99025 INITIAL SURGICAL EVALUATION
99201 OFFICE/OUTPATIENT VISIT, NEW
99202 OFFICE/OUTPATIENT VISIT, NEW
99203 OFFICE/OUTPATIENT VISIT, NEW
99204 OFFICE/OUTPATIENT VISIT, NEW
99205 OFFICE/OUTPATIENT VISIT, NEW
99211 OFFICE/OUTPATIENT VISIT, ESTAB
99212 OFFICE/OUTPATIENT VISIT, ESTAB
99213 OFFICE/OUTPATIENT VISIT, ESTAB
99214 OFFICE/OUTPATIENT VISIT, ESTAB
99215 OFFICE/OUTPATIENT VISIT, ESTAB
99221 INITIAL HOSPITAL CARE
99222 INITIAL HOSPITAL CARE
99223 INITIAL HOSPITAL CARE
99231 SUBSEQ HOSPITAL CARE
99241 OFFICE CONSULTATION
99242 OFFICE CONSULTATION
99243 OFFICE CONSULTATION
99244 OFFICE CONSULTATION
-21-
22
The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission.
PHYSICIAN NETWORK PARTICIPATION AGREEMENT
Attachment A-3
HMO Fee Schedule
CODE CPT NAME FEE
---- -------- ---
99251 INITIAL INPAT CONSULTATION [*]
99252 INITIAL INPAT CONSULTATION
99253 INITIAL INPAT CONSULTATION
99272 CONFIRMATORY CONSULT
99274 CONFIRMATORY CONSULT
99283 EMERGENCY DEPT. VISIT
99284 EMERGENCY DEPT. VISIT
99395 PERIODIC REEVAL ESTAB ADULT
-22-
23
Physician Group
JGPXXN050892
PHYSICIAN NETWORK
HMO ACCESS AGREEMENT
This Access Agreement is effective as of July 1, 1994 and is entered into
by and between Atlanta-AHP, Inc. ("Physician Network"), Aetna Health Plans of
Georgia, Inc. ("HMO") and Aetna Health Management, Inc. ("AHM").
WHEREAS, Physician Network and AHM have entered into a Participation
Agreement so that Physician Network may participate in various Aetna health
benefits products ("Participation Agreement"), and
WHEREAS, HMO offers one or more of said products, and
WHEREAS, it is the intention of all the parties for Physician Network and
its Network Physicians to be Participating Providers in HMO's provider Network,
NOW, THEREFORE, in consideration for the mutual promises made herein and
for other good and valuable consideration, the parties agree as follows:
1. All terms shall have the meanings given to them in the Participation
Agreement, unless defined below.
2. HMO agrees that to the extent it is a Payor, it will comply with the
Payor terms of Participation Agreement, including paying for Covered Services in
accordance with HMO's Plans.
3. AHM agrees to HMO's participation as a Payor and user of Physician
Network's services under the Participation Agreement.
4. Physician Network agrees that its Network Physicians will serve as
Participating Providers in HMO's provider Network in accordance with the terms
and conditions of the Participation Agreement and this Access Agreement. The
parties agree that if any of the terms of the Access Agreement conflict with any
of the terms in the Participation Agreement, the terms of this Access Agreement
shall prevail with respect to services provided to HMO's Members.
5. This Access Agreement shall terminate:
a. Upon 90 days prior written notice by HMO or by Physician Network
to the other parties. The parties agree that the "Obligations Following
Termination" provision of
-23-
24
the Participation Agreement shall continue to bind the parties following
termination of this Access agreement.
b. Immediately upon the termination of the Participation Agreement.
The parties agree that the "Obligations Following Termination" provision of the
Participation Agreement shall continue to bind the parties following termination
of this Access Agreement. AHM agrees to notify HMO immediately of any
termination of the Participation Agreement.
c. Immediately upon the termination of the Management Agreement
between AHM and HMO. Should said Management Agreement terminate, HMO and
Physician Network agree that:
I. They shall continue to abide by the terms of the
Participation Agreement and the additional terms of this Access Agreement for
those Plans underwritten or administered by HMO.
II. HMO shall abide by the duties of AHM under the
Participation Agreement for those Plans underwritten or administered by HMO.
6. The parties recognize that neither termination of this Access Agreement
nor termination of the Management Agreement between AHM and HMO will terminate
the Participation Agreement between AHM and Physician Network.
7. This Agreement and the Participation Agreement constitute the entire
agreement among the parties with respect to the participation of Physician
Network in HMO's provider Network and supersedes all prior oral and written
understandings between HMO and Physician Network.
IN WITNESS WHEREOF, the parties have executed this Access Agreement below:
ATLANTA-AHP, INC.
By:___________________________
Printed Name:___________________
Title:___________________________
Date:___________________________
-24-
25
AETNA HEALTH PLANS OF GEORGIA, INC.
By:_______________________________
Printed Name:___________________
Title:___________________________
Date:___________________________
AETNA HEALTH MANAGEMENT, INC.
By:_______________________________
Printed Name:___________________
Title:___________________________
Date:___________________________
-25-
26
The information below marked by * and [ ] has been omitted pursuant to a request
for confidential treatment. The omitted portion has been separately filed with
the Commission
Aetna Health Plans of GA, Inc.
Hospital Risk Share Agreement
Base Period Analysis
# @ RISK $ PAID/
PATIENTS $ PAID PATIENT PMPM
-------- ------ ------- ----
INPATIENT
(ALL CAPITATED PHYSICIANS):
[*] [*]
TOTAL INPATIENT, ALL PAR. CAP.
OUTPATIENTS:
PAR. CAP.:
[*] [*]
SUBTOTAL, OUTPATIENT, PAR. CAP.
NON-PAR CAP. ([*])
TOTAL, OUTPATIENT
TOTAL FACILITY CHARGES
-26-
